Every finding on record at Newport House

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, interview, and record review the facility failed to ensure food stored in the kitchen's refrigerators and freezers were labeled, dated and/or sealed. The facility census was 92.Findings are:A record review of the facility's Food Storage General Guidelines policy with a revision date of 3/8/2024 revealed the following:1) All foods are labeled and dated.9) Food is stored in clean, approved containers that are covered, labeled and dated. This includes foods stored in refrigerators, freezers, and pantries. A record review of the FDA Food Code 2022, revealed that food packages shall be in good condition and protect the integrity of the contents so that food is not exposed to adulteration or potential contaminants. An observation of the large reach-in freezer on 1/26/2026 at 7:15 AM revealed the following: 1 clear bag of small round brown substance was not labeled and sealed. 1 clear bag of large, flat, tan/brown substance was not labeled and sealed. 2 brown bags of yellow, elongated substance was not sealed. 1 brown bag of tan round substance was not sealed. An observation of the walk-in refrigerator on 1/26/2026 at 7:15 AM revealed the following: 1 package of open sliced cheese that was not sealed. An observation of the walk-in freezer on 1/26/2026 at 7:15 AM revealed the following: 1 large sheet pan with round, colorful, tan substance that was not labeled, dated, or sealed. In an interview on 1/27/2026 at 12:20 PM the Sous Chef (SC) confirmed the following: 1 clear bag of small round brown substance was not labeled or sealed and should have been. 1 clear bag of large, flat, tan/brown substance was not labeled or sealed and should have been. 1 brown bag of yellow, elongated substance that SC referred to as French fries was not sealed and should have been. 1 brown bag of tan round substance that SC referred to as Tator tots was not sealed and should have been. 1 box of tilapia was not sealed and should have been. 1 box of open wild Alaskan seafood was not sealed and should have been. In an Interview on 1/27/2026 at 12:20 PM the Team Lead Food Nutrition Services (TLFNS) confirmed the following: 1 large sheet pan of round, colorful, tan substance in the walk-in freezer that was not labeled, dated, or sealed and should have been. 1 package of open sliced cheese in the walk-in refrigerator that was not sealed and should have been.

Licensure Reference Number 175 NAC 12.006.18(B)Licensure Reference Number 175 NAC 12.006.18(D)Licensure Reference Number 175 NAC 12.006.19(A)(i)Licensure Reference Number 175 NAC 12.006.18(C)(i) Based on observation, interview, and record review, the facility failed to ensure Hoyer lifts (mechanical full body lifts) were sanitized before or after each use, gowns were worn during high contact cares on Resident 14, Resident 7's nebulizer (neb)(a machine used to deliver aerosolized medications to the lungs) administration kit was cleaned after each use, handle linens used for perineal (peri)(area between the genitals and rectum) care in a manner to prevent the potential for cross contamination for Resident 84, failed to perform hand hygiene with glove changes during perineal care for Resident 84, store oxygen tubing and a Bilevel Positive Airway Pressure Device (BiPAP)(a machine used to treat apnea or high carbon dioxide levels) mask in a manner to prevent the potential for cross contamination, and failed to ensure the nebulizer kit and oxygen humidification were labeled with a date for Resident 9. The facility census was 92. Findings are:A. A record review of the facility's undated Transmission-Based Precautions Guidelines revealed equipment handling for standard precautions was to disinfect equipment before and after each use. An observation on 01/27/2026 at 10:22 AM revealed that Registered Nurse (RN)-H and Nursing Assistant (NA)-G entered Resident 7's room to transfer the resident from the wheelchair to the bed. NA-G exited the room and got the Hoyer lift from the hallway and brought it into the resident's room without disinfecting the Hoyer lift. NA-G and RN-H transferred the resident from the wheelchair to the bed using the Hoyer lift and then NA-G took the Hoyer lift from the room and placed it against the wall in the 200 hallway. NA-G then removed gloves, went to the nurse's station and performed hand hygiene. Observation between 10:22 AM and 10:45 AM revealed the Hoyer lift had not been disinfected. An observation on 01/28/2026 at 9:41 AM revealed that NA-I and NA-J retrieved the Hoyer lift from the 200 hallway and took it into Resident 7's room without disinfecting the Hoyer lift. NA-I and NA-J used the Hoyer lift to transfer Resident 7 from the bed to the wheelchair. NA-A then took the Hoyer lift back into the 200 hallway without disinfecting it. An observation on 01/28/2026 at 10:07 AM revealed NA-I and NA-J took the Hoyer lift that was used on Resident 7 and had not been disinfected into resident room [ROOM NUMBER], Resident 70's room, and transferred that resident without disinfecting the Hoyer lift. In an interview on 01/28/2026 at 10:24 AM, NA-I confirmed that the Hoyer lift was not disinfected prior to or after using it to transfer Resident 7 or prior to using it on Resident 70. In an interview on 01/28/2026 at 9:54 AM, RN-H confirmed there were 3 residents on the 200 hall that required Hoyer lift transfers. In an interview on 01/28/2026 at 3:27 PM, the Director of Nursing (DON) confirmed the staff should have disinfected the Hoyer lift before or after use. B. A record review of the facility's undated Transmission-Based Precautions Guidelines revealed that for standard precautions a gown should have been worn if soiling was likely and that if a resident was in Enhanced Barrier Precautions (EBP), staff should have applied a gown prior to high-contact resident care activities such as dressing, bathing, toileting, transferring, providing hygiene (cleaning), device care or use such as urinary catheter, feeding tube and any skin opening requiring a dressing. A record review of Resident 14's Care Plan with an admission date of 09/23/2024 revealed the resident had a Ileostomy (a surgically created opening in the stomach area that allows waste and gas to bypass damaged colon into an external bag) and a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube placed directly into the stomach to allow nutrients, fluids, and medications to be administered) for tube feedings. The Care Plan had a focus area that the resident was in EBP and an intervention that staff should have worn gowns and gloves during high-contact resident care activities. An observation on 01/27/2026 at 8:29 AM revealed a round EBP magnet on the right side of the door frame. RN-H entered Resident 14's room, performed hand hygiene, gloved, pulled back the PEG tube dressing and looked at the site, flushed the resident's PEG tube, removed gloves, exited the room and performed hand hygiene all without wearing a gown. An observation on 01/27/2026 at 11:44 AM revealed a round EBP magnet on the right side of the door frame. NA-K entered Resident 14's room and performed hand hygiene, checked Resident 14's Ileostomy, put on gloves, retrieved a graduate cylinder (a container used to measure fluid contents) and propped the graduate cylinder between resident's Ileostomy and NA-K's leg. NA-K then opened the Ileostomy bag and drained the waste into the graduate cylinder. NA-K emptied and rinsed the graduate cylinder, removed gloves, performed hand hygiene and exited the room, all without having a gown on. In an interview on 01/28/2026 at 7:56 AM, RN-H confirmed the resident was in EBP and RN-H did not wear a gown during Resident 14's PEG tube cares on 01/27/2026 at 8:29 AM, and RN-H and NA-K should have had a gown on with PEG tube and Ileostomy cares. C. A record review of the facility's Medication – Nebulizer Treatment policy dated 07/26/2017 revealed the staff should rinse the nebulizer administration kit pieces after each use. A record review of Resident 7's Medication Administration Record (MAR) dated January 2026 revealed that the resident had orders for Albuterol/Ipratropium (a medication used to relax the muscles in the lungs) nebulizer treatments twice daily and as needed (PRN). The MAR was marked that the resident received the nebulizer treatments twice per day, every day. An observation on 01/26/2026 at 10:31 AM revealed that Resident 7's nebulizer administration kit was laying on the bedside table with a residual (small, leftover) amount of liquid (presumed medication) remaining in the kit. An observation on 01/27/2026 at 7:04 AM revealed that Resident 7's nebulizer administration kit was lying on the bedside table with a residual amount of liquid (presumed medication) remaining in the kit. An observation on 01/27/2026 at 10:22 AM revealed RN-H removed the nebulizer administration kit from Resident 7's mouth and placed it on the bedside table prior to assisting NA-G with transferring the resident to bed. RN-H did not rinse the nebulizer administration kit. At 10:45 AM the kit was lying on the overbed table with a residual amount of medication still in the kit. An observation on 01/28/2026 at 6:27 AM revealed that Resident 7's nebulizer administration kit was laying on the bedside table with a residual amount of liquid (presumed medication) remaining in the kit. In an interview on 01/29/2026 at 7:18 AM, RN-F confirmed that staff should have cleaned Resident 7's nebulizer administration kit after each use. D. Record review of the facility policy titled Hand Hygiene and Glove Usage dated 03-09-2021 revealed it is the policy of the facility that hand hygiene for residents and staff will be performed to avoid the spread of pathogens. Hand Hygiene is required before putting on gloves and after removing gloves. Record review of Resident 84's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-17-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required total assistance with dressing, hygiene, toileting, bed mobility and transfers. -was frequently incontinent of bowel and bladder. An observation conducted on 01-28-2026 at 6:15 AM of Nursing Assistant (NA) C performing incontinence care for Resident 3 revealed NA C with gloved hands removed the soiled brief and performed perineal care (cleaning of the genital and anal area) then removed gloves and reapplied new gloves without performing hand hygiene. An interview conducted on 01-28-2026 at 6:50 AM with NA C confirmed hand hygiene was not performed in between glove changes and should have been. E. Record review of the facility policy titled Personal Laundry and Clean Linen dated 04-13-2022 revealed infection prevention principles was a key consideration related to procedures related to on-site laundry services. Linens will be collected following infection control standards. An observation conducted on 01-28-2026 at 6:15 AM of NA C providing facial hygiene for Resident 3 revealed NA C went to the bathroom turned on the sink, obtained a washcloth and held it under the running water, wringed it out and then placed it on the bedside table on top of Resident 3's belongings without a barrier and proceeded to wash Resident 3's face with the wash cloth. After completing facial hygiene, NA C went to the bathroom, placed the dirty washcloth in the laundry basket, obtained another washcloth, held it under the running water and then squeezed out the excess water by pressing the washcloth against the inside of the sink basin, then placed the washcloth on the bedside table without a barrier and proceeded to perform perineal care. An interview conducted on 01-28-2026 at 6:50 AM with NA C confirmed the washcloth was placed on the bedside table without a barrier and confirmed the washcloths touched the inside of the sink basin. An interview conducted on 01-28-2026 at 7:00 AM with Registered Nurse (RN) F confirmed washcloths touching the bedside table without a barrier and washcloths touching the inside of the sink could cause cross contamination. F. Record review of the facility policy entitled Policy – Medication – Nebulizer Treatment dated reviewed 11/15/2021 revealed: -C. Change tubing and administration kit weekly. Record review of the facility policy entitled SOP – Medication Provision – Oxygen dated reviewed 08/10/2022 revealed: -c. Humidifiers -i. Care and use of prefilled disposable humidifiers: -8. Label humidifier with date and time opened. Bottle is good for 72 hours. Record review of Resident 9's Census List revealed the facility admitted the resident on 08/08/2023. Record review of Resident 9's Diagnosis Report revealed Resident 9 had conditions that included acute and chronic respiratory failure, interstitial pulmonary disease (chronic inflammation and scarring of the lung tissue), hypoventilation (breathing too slow or too shallow to meet the body's needs), and shortness of breath. Record review of Resident 9's MDS dated [DATE] revealed Resident 9 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Further review of Resident 9's MDS revealed Resident 9 used oxygen and a non-invasive mechanical ventilator (BiPAP). Record review of Resident 9's Order Summary Report (OSR) revealed the following orders: -ipratropium and albuterol solution one vial per nebulizer every four to six hours as needed for congestion dated 12/14/2025. -O2 (oxygen) at three liters per nasal cannula continuously for interstitial disease dated 06/04/2024. -Oxygen low flow nasal cannula bled into BIPAP while asleep dated 07/15/2025. -BiPAP settings at 6 centimeters (cm) CPAP (continuous positive airway pressure, delivers a steady stream of pressurize air to keep the airway open while asleep)/EPAP (expiratory positive airway pressure, the lower, baseline pressure provided during exhalation, designed to keep airways open) and 12 cm inspiratory positive airway pressure (IPAP, higher pressure during inhalation). Provide the device with heated humidification and mask to achieve best patient comfort and compliance. Oxygen 4 liters per minute per BIPAP device dated 07/15/2025. Observation on 01/27/2026 at 8:19 AM revealed a BiPAP mask lying on the resident's bedside table with no barrier beneath. Observation on 01/27/2026 at 10:50 AM revealed a BiPAP mask lying on the resident's bedside table with no barrier beneath. Further in-room observations revealed a nebulizer machine and nebulizer kit sitting in the windowsill with the nebulizer kit/tubing undated; an undated disposable O2 humidification bottle connected to the O2 concentrator; and the O2 bleed-in tubing for the BiPAP was stored on the floor. Observation on 01/28/2026 at 12:58 PM revealed the nebulizer kit and machine were sitting in the window and the nebulizer kit/tubing were undated; an undated disposable humidification bottle was attached to the O2 concentrator; the O2 bleed-in tubing for the BiPAP was stored on the floor; and a BiPAP mask lying on the resident's bedside table with no barrier beneath. An interview on 01/28/2026 at 1:02 PM with Licensed Practical Nurse (LPN)-L confirmed the nebulizer kit/tubing and O2 humidification bottle were undated, the O2 bleed-in tubing for the BiPAP was stored on the floor, and the BiPAP mask was stored on the bedside table with no barrier beneath. LPN-L confirmed the nebulizer kit and O2 humidification bottle should have been dated, the BiPAP bleed in tubing should have been stored off the floor, and the BiPAP mask should have been stored with a barrier beneath. An interview on 01/29/2026 at 11:38 AM with the Assistant Director of Nursing (ADON) who also acted as the facility's Infection Preventionist confirmed the undated nebulizer kit and humidification bottle, the O2 bleed-in tubing for the BiPAP stored on the floor, and BiPAP mask stored on the bedside table with no barrier created potential for cross-contamination.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview, the facility failed to notify the medical practitioner of 10 consecutive days of refusal of scheduled bowel medications for 1 (Resident 4) of 1 sampled residents. The facility staff identified a census of 92.Findings are:Record review of a facility policy entitled Notification to Physician/ Family of Change in Resident Health Status dated reviewed 08/27/2018 revealed the following: - Policy Statement: The Care Communities will notify the resident's physician or designee the resident's legal representative when there is: - A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences or ineffectiveness and/or need to implement a new form of treatment). - Definitions: - C. A need to alter treatment significantly such as a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or need to initiate a new form of treatment to deal with a problem (e.g., the use of any medical procedure or therapy that is not currently ordered. - Procedure: - A. Notification tool - SBAR [SBAR, a structured communication framework used in healthcare to provide clear, concise, and complete information. SBAR is divided into four parts situation (what is happening now), background (relevant history), assessment (professional evaluation), and recommendation (what action is suggested)] - 3. In non-emergent or non-urgent situations, such as notification of a fall without injury, the SBAR can be faxed to the physician's or designee's office. - 4. The SBAR serves as documentation of the information provided and is filed in the Physician's Order section of the chart. - B. Notification - 1. The Care Communities will attempt to contact the resident's physician or designee with changes in resident's health status. - a. If the resident has one or more consulting physicians, the primary physician or designee will be contacted unless there are other specific instructions. - b. After hours, the on-call physician or designee will be responsible for emergency care. - c. In the event that the on-call physician or designee is not available, the house supervisor/designee will contact the Medical Director or send the resident to the Emergency Department.Record review of Resident 4's Census List revealed the facility admitted the resident on 06/20/2022.Record review of Resident 4's Diagnosis Report revealed Resident 4 had conditions which included cerebral infarction (stroke), hemiplegia (total or partial paralysis on one side of the body that results from disease or injury to the motor centers of the brain) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following cerebral infarction affecting the right dominant side, and difficulty in walking.Record review of Resident 4'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 12/16/2025 revealed Resident 4 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 7. According to the MDS manual, a score of 7 indicated the resident had moderate cognitive impairment. Further review of the MDS identified Resident 4 had rejected care during one to three days of the assessment period and had constipation. Record review of Resident 4's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed the following interventions related to bowel elimination: -Monitor for constipation dated 08/29/2022. -Monitor bowel and bladder pattern every shift dated 08/29/2022. -Continue to educate importance of bowel management. Resident often states it's normal for them to go a lengthy amount of time between bowel movements dated 01/02/2023. -At times Resident 4 will refuse bowel protocol because of [gender's] past profession where it was necessary to go days without access to facilities where [gender] felt comfortable in moving bowels. Resident 4 understood the risk of doing this, dated 07/01/2024.Record review of Resident 4's Order Summary Report revealed the following orders: -Medical Director may visit, examine, and treat as indicated dated 06/20/2022. -Prune products for bowel needs as needed (PRN), every 12 hours PRN, and every 24 hours PRN dated 06/20/2022. - Document in nursing notes characteristic bowel sounds, abdomen characteristic if flat or distended and firm or soft daily, dated 02/12/2025. -Milk of magnesia suspension (saline laxative) 400 mg in 5 milliliters (mL) by mouth once daily as needed for constipation dated 07/28/2022. -Senna-time tab (stimulant laxative) 8.6 mg take 2 tablets by mouth every evening dated 07/08/2025. -Bisacodyl suppository (fast acting stimulant laxative) 10 milligrams (mg) insert 1 suppository per rectum once daily as needed for constipation dated 08/15/2025. -Motegrity tab (a medication that works by stimulating colon muscle contractions to relieve chronic idiopathic [unknown cause] constipation) 2mg take 1 tablet by mouth daily dated 11/12/2025. -Miralax powder (saline laxative), mix 17 grams with 8 ounces of water/juice and drink twice daily dated 12/03/2025.Record review of Resident 4's December 2025 and January 2026 Medication Administration Records (MAR) revealed Resident 4 refused docusate sodium 15 out of 20 scheduled administrations from 12/29/2025 through 01/07/2026: -12/29/2026 evening dose; -12/30/2026 morning and evening doses; -12/31/2026 morning and evening doses; -01/01/2026 morning and evening doses; -01/02/2026 morning dose; -01/03/2026 evening dose; -01/04/2026 morning dose; -01/05/2026 morning and evening doses; -01/06/2026 morning and evening doses; and -01/07/2026 morning dose.Further review of Resident 4's December 2025 and January 2026 MARs revealed Resident 4 refused Motegrity and Miralax 8 out of 10 scheduled administrations from 12/29/2025 through 01/07/2026: -12/30/2025, 12/31/2025, 01/01/2026, 01/03/2026, 01/04/2026, 01/05/2026, 01/06/2026, and 01/07/2026.Further review of Resident 4's December 2025 and January 2026 MARs revealed Resident 4 refused senna-time tab 2 out of 10 scheduled administrations on 12/31/2025 and 01/04/2026.Record review of Resident 4' s Progress Notes (facility based) dated 12/29/2025 through 1/7/2026 revealed the following: -12/30/2025 resident refused docusate sodium, Registered Nurse (RN) educated on importance of taking bowel medications. Resident stated understanding and still refused. -12/31/2025 refused senna and docusate, was educated and verbalized understanding but still refused; -12/31/2025 resident refused docusate sodium - will not take bowel meds. RN educated on importance of having more frequent BM (bowel movements), resident stated understanding and still refused. -01/01/2026 Resident day 7 without BM and continue to refuse any bowel protocol order by provider. Denies pain and discomfort while palpating abdomen. Bowel sound Ax4 [active times 4 quadrants] at this time. -01/03/2026 Resident is going on day eight without having a BM. The nurse asked if Resident 4 would like something for bowels and Resident 4 refused despite education on bowel obstructions and other health concerns. Resident 4 had active bowel sounds in four quadrants. Resident 4 had no complaints of pain or discomfort. -01/04/2026 at 2:49 PM Resident 4 was administered ondansetron (a medication used to reduce nausea and vomiting) due to vomiting. -01/04/2026 at 3:33 PM the resident returned from an outing. Resident 4 had a large emesis of suspected root beer and noodles. Vital signs were obtained, resident had active bowel sounds on the right side, hypoactive left side and denied abdominal pain or feelings of constipation. The resident was believed to have a UTI and pink eye infection, but the facility was waiting on the provider's office as they had no on-call service.Record review of Resident 4's physician visit dictation dated 01/07/2026 and signed by Resident 4's medical practitioner revealed [gender] has not been taking (gender) bowel regimen as [gender] does not like to take the medications. Further review of the Progress Note revealed the following updated plan of care for chronic constipation: - Continue on Miralax twice daily, docusate daily, senna 2 tabs nightly, and Motegrity 2 mg daily. Previously was on linaclotide but unable to swallow capsule. Emphasized to [gender] the importance of taking (gender) medications as directed. I will also add magnesium citrate for (gender) to use as needed for intermittent constipation. Orders: Colonoscopy to schedule.Record review of Resident 4's progress notes, scanned documents, and physical chart did not reveal evidence of notification to Resident 4's medical practitioner regarding refusals of medications. Further review of the medical record to include physician's orders and the care plan did not identify parameters for notification of refusal of medications.An interview on 01/29/2026 at 1:00 PM with the Registered Nurse Team Lead (RNTL)-M with the Director of Nursing (DON) present revealed the facility did not have evidence that an SBAR communication form was sent to the provider regarding Resident 4's refusal of bowel medications from 12/29/2025 through 01/07/2026.An interview on 01/29/2026 at 2:35 PM with the DON confirmed the facility did not have evidence at the time of survey exit of notification to the provider for Resident 4's refusal of bowel medications from 12/29/2025 through 01/07/2026.

Licensure Reference Number 175 NAC 12-006.05(G) Based on interview and record review, the facility failed to ensure a rational (based on clear thought and reason) was provided to continue as needed (PRN) Lorazepam (a medication used to treat anxiety) greater than 14 days. This affected 1 (Resident 7) of 5 sampled residents. The facility census was 92. Findings are:A record review of Resident 7's Clinical Census dated 01/27/2026 revealed the resident was admitted to the facility on [DATE] and elected to receive hospice services on 10/03/2025. A record review of Resident 7's Medical Diagnosis dated 01/27/2026 revealed the resident had diagnoses of Chronic Diastolic (Congestive) Heart Failure (CHF), Delirium Due To Known Physiological Condition (fluctuating disturbance in attention, awareness, and cognition), Depression, and Anxiety. A record review of Resident 7's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/06/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15, which indicated the resident was cognitively aware. The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with personal hygiene, and was dependent on staff for toileting, bathing, dressing, footwear, and transfers. The resident did not have behaviors and was on antianxiety medications. A record review of Resident 7's Care Plan with an admission date of 11/27/2023 revealed the resident had a focus area of the resident took Lorazepam for Anxiety and Insomnia. Interventions were administer medications as ordered, inform hospice of changes in mood, behaviors, or side effects from the medication, and scheduled and PRN assessments. A record review of Resident 7's Clinical Physician Orders dated 01/27/2026 revealed the resident had orders for scheduled Lorazepam .5 milligram (mg) tablet at bedtime and Lorazepam Concentrate .25 milliliters, (ml) every hour as needed for Anxiety. A record review of Resident 7's Medication Administration Record (MAR) January 2026 revealed that the PRN Lorazepam Concentrate was administered 01/13/2026 and 01/23/2026. A record review of Resident 7's Progress Notes dated 01/13/2026 and 01/23/2026 revealed the resident was administered PRN Lorazepam for Anxiety and no behaviors or non-pharmacological interventions (some done to treat behavior other than administer medications) were documented. A record review of Resident 7's Pharmacist's Recommendation To Prescriber dated 10/08/2025 revealed that the resident had an order for PRN Lorazepam Concentrate and the Center for Medicare and Medicaid Services required a 14 day stop on all PRN psychotropic (mind altering) medications unless the prescriber documented clinical rational for continued use and provided a new duration for use on the continued order. The recommendation from the pharmacy was to continue the PRN Lorazepam for a period of 6 months for Anxiety. The prescriber's response was an X on agree, a check mark beside the recommendation, and signed as CHI Hospice/(MD name) with illegible initials dated 10/17/2025. It did not reveal a clear rational for the continued use of the PRN Lorazepam. In an interview on 01/29/2026 at 8:05 AM, the Director of Nursing (DON) confirmed that the rational for Resident 7's continued PRN Lorazepam greater than 14 days was Anxiety and for a normal resident, not on hospice, there should have been a rational for continued use documented on the Pharmacist's Recommendation To Prescriber.

Licensure Reference Number 12-006.09(E)(i). Based on record review and interview, the facility failed to implement a comprehensive care plan to prevent the potential for altered nutrition for 1 (Resident 3) of 2 residents sampled. The facility census was 92. Findings are:Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-04-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-weight on admission was 173 pounds (lbs).-Brief Interview of Mental Status (BIMS) was scored as 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.-required extensive assistance with eating.-required total assistance with hygiene, dressing, bed mobility, transfers, toileting and bathing. Record review of Resident 3's Electronic Health Record (EHR) revealed a baseline care plan dated 12-31-2025 indicating Resident 3 was on a regular mechanical soft diet and required assistance with eating. Record review of Resident 3's Nutrition Assessment (NA) dated 01-04-2026 revealed the following care plan goal:-provide adequate nutrition and hydration.-improve oral intake to 75% or greater at 2 meals daily.Further review of the NA dated 01-04-2026 revealed the nutritional evaluation summary section revealed Resident 3 had no edema, was averaging 50 % of meal intake, and would follow for the need of oral nutritional supplements and had no skin breakdown. Record review of Resident 3's EHR revealed a Comprehensive Care Plan dated 01-05-2026 revealed no plan of care for altered nutrition. An interview conducted with Registered Dietician (RD) A on 01- 28-2026 at 1:00 PM confirmed a comprehensive care plan for altered nutrition should have been implemented on or before 01-20-2026 and was not implemented until 01-26-2026.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1). Based on observation, interview and record review the facility failed to evaluate, monitor and implement interventions for a significant weight loss for 1(Resident 3) of 2 residents sampled. The facility census was 92. Findings are:Record review of the facility policy titled Weight Management dated 10-10-2023 revealed it is the policy of the facility to maintain acceptable parameters of nutritional status by recognizing, evaluating, and addressing the needs of the residents at risk or experiencing impaired nutrition and hydration, unless the resident's clinical condition demonstrates that this is not possible or residents' preference indicates otherwise. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-04-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-weight on admission was 173 pounds (lbs).-Brief Interview of Mental Status (BIMS) was scored as 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.-required extensive assistance with eating.-required total assistance with hygiene, dressing, bed mobility, transfers, toileting and bathing. Record review of Resident 3's Comprehensive Care Plan (CCP) printed on 01-26-2026 revealed no care plan for nutrition. Record review of Resident 3's Hospital Inpatient Dietary Consult (HIDC) dated 12-30-2025 revealed Resident 3 was having poor oral intake, was having trouble with a regular diet and family was assisting Resident 3 with eating. Further review of the HIDC revealed the hospital dietician recommended a soft diet and Ensure (nutritional supplement) with meals three times a day. Record review of Resident 3's Order Summary (OS) printed on 01-26-2026 revealed no orders for Ensure or any other nutritional supplements. Record review of Resident 3's Medication Administration Record (MAR) for January 2026 revealed no orders for Ensure or a nutritional supplement. Record review of Resident 3's Electronic Health Record (EHR) under the section weights and vitals revealed the following weights:-01-03-2026 weight was 172.2.-01-09-2026 weight was 166.0, a loss of 6.2 lbs. or 3.6 % compared to the weight on 01-03-2026.-01-12-2026 weight was 162.0, a loss of 10.6 lbs. or 6.15 % compared to the weight on 01-03-2026, which signified a significant weight loss within 30 days.-01-23-2026 weight was 161.3, a loss of 10.9 lbs. or 6.32 % within 30 days of admission. Record review of Resident 3's Nutrition Assessment (NA) dated 01-04-2026 revealed the following care plan goal:-provide adequate nutrition and hydration.-improve oral intake to 75% or greater at 2 meals daily.Further review of the NA dated 01-04-2026 revealed the nutritional evaluation summary section revealed Resident 3 had no edema, was averaging 50 % of meal intake, and would follow for the need of oral nutritional supplements and had no skin breakdown. Record review of Resident 3's EHR, including nutritional notes, care plan, and physician's orders revealed no evaluation or implementation of interventions to address Resident 3's significant weight loss on 01-12-2026. Record review of Resident 3's Dietary Progress Note (DPN) dated 01-26-2026 revealed Resident 3 had multiple meal refusals, had lost 10.8 lbs. (6.2 %) since admission due in part to the resolution of lower extremity edema (swelling caused by excess fluid trapped in the body tissues) and in part due to oral intake and the dietician recommended Ensure twice a day. Record review of Resident 3's Progress Notes (PN) from 12-31-2025 to 01-27-2026 revealed no documentation of edema. Record review of Resident 3's PN dated 01-05-2026 revealed Resident 3 required assistance with meals and a decrease in fluid intake was noted. Record review of Resident 3's PN 01-08-2026 revealed Resident 3 had a decrease in fluid intake, had a change in appetite, and had difficulty swallowing at times. Record review of Resident 3's PN dated 01-17-2026 revealed Resident 3 had received new orders to encourage fluids, monitor for decreased appetite, weight loss, and worsening kidney function. An observation conducted on 01-27-2026 at 9:00 AM revealed Resident 3 was in bed with the head of bed elevated and Resident 3's daughter was there helping Resident 3 eat breakfast. Resident 3 ate a couple of bites of scrambled eggs and a couple of bites of toast with jelly. An interview conducted with the Registered Dietician (RD) A on 01-29-2026 at 8:45 AM confirmed Resident 3 loss of 10.8 lbs. or 6.2% in 1 month was a significant weight loss that was not identified until 01-23-2026 and interventions were not put into place until 01-26-2026 and confirmed Resident 3 had not had edema.

Licensure Reference Number 175 NAC 12-006.09(D). Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities for error. The facility medication error rate was 8 %. The facility census was 92. Findings are:Record review of the facility policy titled Medication Administration dated 03-08-2022 revealed it was the facility policy to store and administer medications and treatments in a safe and effective manner. Professional standards of medication administration are followed including the 6 rights of medication administration:-right resident-right drug-right dose-right time-right route-right documentation. An observation conducted on 01-28-2026 at 9:00 AM of Registered Nurse (RN) E administering medications to Resident 84 revealed Resident 84 was given the following medications while eating breakfast:Riluzole 50 milligram (mg) 1 tabletTylenol 500 mg 2 tabletsAspirin 81 mg tabletCyclobenzaprine hydrochloride 10 mg tabletFamotidine 20 mg tabletMultivitamin 1 tabletOxybutynin chloride 5 mg tabletVitamin D3 25 microgram (mcg) tablet Record review of Resident 84's Order Summary (OS) printed on 01-27-2026 revealed an order for Riluzole 50 mg tablet, take one tablet by peg tube twice a day, give 1 hour before or 2 hours after a meal. An interview conducted with RN E on 01-28-2026 at 12:15 PM confirmed the Riluzole 50 mg tablet was not given 1 hour before or 2 hours after a meal and should have been. An observation conducted on 01-28-2026 at 9:30 AM of RN D administering medications to Resident 52 revealed Resident 52 was given the following medication while eating breakfast:-apixaban 2.5 mg tablet-Vitamin D3 50 mcg tablet-amlodipine 10 mg tablet-omeprazole 20 mg tablet-furosemide 40 mg tablet-lacosamide 150 mg tablet Record review of Resident 52's OS printed on 01-28-2026 revealed an order for omeprazole 20 mg tablet by mouth daily, take 60 minutes before meals. An interview conducted on 01-28-2026 at 11:30 AM confirmed Resident 52 was given an omeprazole 20 mg tablet with breakfast and it should have been given 60 minutes prior to the meal.

License Reference Number NAC 12-006.12(D)(i) Based on observation, interview, and record review, the facility failed to dispose of medications in accordance with standard of practice. The facility identified a census of 94. Findings are: Observation on 8/29/24 at 7:00 AM of medication administration by Registered Nurse (RN) B, revealed RN B dropped a Tylenol 500 mg on the floor. After dropping the Tylenol 500 mg on the floor, RN B picked up the Tylenol tab and threw it away in the trash can attached to the medication cart. Interview on 8/29/24 at 7:30 AM of RN B confirmed RN B did not know how to dispose of medications. Observation on 8/29/24 at 8:21 AM of medication administration by Licensed Practical Nurse (LPN) C, revealed LPN C had placed the following medications in the medication cup: Atorvastatin (used for treatment of high cholesterol) 40 mg, Sertraline (antidepressant) 25 mg, Amlodipine (antihypertensive) 2.5 mg, memantine (used for treatment of dementia) 10 mg, Aspirin 81 mg, Carvedilol (antihypertensive) 6.25 mg, Donepezil (used for treatment of dementia) 10 mg, however, when pouring the medications in a plastic sleeve in preparation to crush the medication, all of these medications fell on the floor. LPN C picked up all the medications and threw all the medications in the trash can attached to the medication cart. Interview on 8/29/24 at 8:40 AM with LPN C confirmed LPN C did not know how to dispose of medications. Interview on 8/29/24 at 9:40 AM with Director of Nursing (DON) confirmed RN B and LPN C did not dispose of medication in accordance with facility policy. Record review of Medication Processes and Protocols (undated) revealed the following instructions for the destruction process of medications: Two staff will destroy the medications together-from prep to disposal: a. Don gloves-double glove if any medications to be destroyed are Hazardous Medications. b. Open Deterra Drug Destruction System Bag (a safe medication disposal pouch that inactivates medications with charcoal). c. Fill bag 50% (half full) with warm water. d. Keep Deterra bag open for 30-45 seconds. e. Seal Deterra bag tightly and discard in the trash bin.

Licensure Reference Number 175 NAC 12-006.17D Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between Residents 34, 20, 33, 75, 65, 13, 17, 26, 14, 11 and 57 during meal service in the dining room, failed to ensure staff changed gloves and performed hand hygiene (cleaned) after surgical mask and cell phone were touched during meal service for Resident 6 to prevent cross-contamination (transfer of bacteria from one surface to another), and failed to ensure the vent in front of the kitchen hood was clean to prevent the potential for foodborne illness (illness caused by food contamination). This had the potential to affect 90 resident who consumed (ate) food prepared in the facility kitchen. The total facility census was 91. Findings are: A. A record review of the facility's undated What's Expected of Me Quick Sheet, The Role and Responsibility of All Staff Related to Dining Service revealed that when the staff served meals, the staff was expected to perform hand hygiene before getting the resident's meal tray and in between assisting each resident. A record review of the facility's Hand Hygiene and Glove Usage policy dated 03/09/2021 revealed the staff should have worn and changed gloves between residents and performed hand hygiene after removing gloves. A record review of Resident 11's Clinical Census dated 07/25/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 11's Medical Diagnosis dated 07/25/2023 revealed the resident had a primary diagnosis of Dementia (confusion) and multiple other diagnoses. A record review of Resident 11's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's Care Plan) dated 04/25/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 3 out of 15. According to the MDS [NAME] a score of 0 to 7 indicates a resident has severe cognitive imparement. The resident needed extensive assistance with self-performance on eating and a 1-person physical assist with support on eating. A record review of Resident 14's Clinical Census dated 07/25/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 14's Medical Diagnosis dated 07/25/2023 revealed the resident had a primary diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and mental functions), and the resident had Dementia (confusion), Cerebral Infarction (Stroke), Cognitive Communication Deficit (difficulty thinking and how someone uses language), Dysphagia (difficulty swallowing), and multiple other diagnoses. A record review of Resident 14's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's Care Plan) dated 05/25/2023 revealed the resident was rarely/never understood and a BIMS score had not been completed. The resident was a 1-person physical assist with support on eating. An observation on 07/19/2023 at 11:34 AM revealed Nursing Assistant (NA-A) was seated in main dining room with Resident 11 on the right side and Resident 14 on the left side of NA-A. NA-A performed hand hygiene and donned (put on) gloves. NA-A assisted Resident 11 with drinking of a nutrition shake and assisted Resident 11 with eating the resident's Herbed Pork Loin. NA-A removed gloves, and repositioned Resident 14's wheelchair and donned gloves without having performed hand hygiene. NA-A touched Resident 14's clothing, then turned and assisted Resident 11 with eating without a glove change or hand hygiene. NA-A reached across table and moved Resident 14's stuffed dog with a gloved right hand and then back to assist Resident 11 with the gloved right hand without a glove change or hand hygiene. NA-A then gave Resident 14 a drink with the gloved right hand, then turned and gave Resident 11 a drink with the same gloved right hand without a glove change or hand hygiene. NA-A then touched Resident 14's chest with the right hand and wiped Resident 14's nasal drainage with Resident 14's cloth napkin after Resident 14 sneezed. NA-A repositioned (moved) Resident 14's glasses up the resident's nose a wipe, then repositioned Resident 11's wheelchair without a glove change or hand hygiene. NA-A then grabbed the straw at the drinking surface with a gloved right hand and gave Resident 14 a drink, then turned and grabbed Resident 11's drink, touched the drinking surface with the same right hand and gave Resident 11 a drink without a glove change or hand hygiene. NA-A grabbed Resident 11 and repositioned Resident 11 in the resident's wheelchair, removed gloves, performed hand hygiene, applied new gloves and then grabbed and checked NA-A's cell with both hands and then gave Resident 11 a drink with the gloved right hand without a glove change or hand hygiene. In an interview on 07/24/2023 at 07:36 AM, the Dietary Manager (DM) confirmed the staff in the dining room should have changed gloves and washed hands between residents and after the staffed touched any personal items including cell phones. In an interview on 07/24/2023 at 09:45 AM, the Director of Nursing (DON) confirmed that hand hygiene and glove changes should have been completed between each resident and should have performed hand hygiene after touching any personal items. B. A record review of Resident 6's Clinical Census dated 07/25/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 6's Medical Diagnosis dated 07/25/2023 revealed the resident had a primary diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and mental functions). Resident 6 also had Vascular Dementia (confusion) and multiple other diagnoses. A record review of Resident 6's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's Care Plan) dated 04/25/2023 revealed the resident was rarely/never understood and a BIMS score had not been completed. The resident was a total dependance with self-performance on eating and a 1-person physical assist with support on eating. An observation on 07/19/2023 at 12:17 PM revealed Nursing Assistant (NA)-B gloved and sat at a main dining room table to assist Resident 6 with eating. NA-B touched NA-B's cell phone multiple times and outside of NA-B's surgical mask multiple times before Resident 6's meal arrived. NA-B assisted Resident 6 with a utensil to eat the resident's Cherry Bar without a glove change or hand hygiene. NA-B then grabbed Resident 6's Dinner Roll with gloved hands, buttered the Dinner Roll, and continued to assist Resident 6 with eating the residents Herbed Pork Loin and Dinner roll. NA-B then touched the outside of NA-B's surgical mask and then tore apart Resident 6's Herbed Pork Loin with the same gloved hands and continued to assist the resident with eating without a glove change or hand hygiene being performed. At 12:42 PM, NA-B was observed as NA-B touched the outside of the surgical mask with the left hand, grabbed the resident's Dinner Roll with the left hand and used a knife to cut the Dinner Roll into pieces with the right hand without a glove change or hand hygiene and assisted resident with taking a bite of the Dinner Roll. NA-B then tore up Resident 6's Herbed Pork Loin with gloved hands and placed the Herbed Pork Loin in the resident's mouth with NA-B's gloved hand without a glove change or hand hygiene. In an interview on 07/24/2023 at 07:36 AM, the Dietary Manager (DM) confirmed the staff in the dining room should have changed gloves and washed hands after the staffed touched any personal items including surgical masks and cell phones. In an interview on 07/24/2023 at 09:45 AM, the Director of Nursing (DON) confirmed that the staff should have performed glove changes and hand hygiene after touching any personal items and before touching a resident's food. C. An observation on 07/20/2023 at 07:48 AM revealed Food Service Associate (FSA)-C was in the main dining room and got a cup of soda and a cup of water for Resident 34 and placed a clothing protector around Resident 34's neck while touching the resident. FSA-C then went to the kitchen serving area, pulled a pen from the staff member's pants pocket and completed a dining ticket, FSA-C then picked up 2 plates of food and delivered the 2 plates to Resident 33 and Resident 20. FSA-C went and poured beverages and delivered to Resident 75, returned to the serving area, and placed hands on the counter. FSA-C then delivered a plate of food to Resident 65, returned to the serving area, got a plate of food, and delivered to Resident 13. FSA-C then returned to the serving area, picked up a plate of food, and delivered to Resident 17. FSA-C delivered a plate of food to Resident 26, then went and touched another resident's wheelchair before FSA-C returned to the kitchen counter, went in the kitchen and got several additional assistive eating utensils, came back to dining room and placed into a bin. FSA-C placed hands on the kitchen counter, got a pen from pants pocket, completed a dining ticket, got a plate from the serving area and delivered to Resident 57. FSA-C went back to the kitchen counter, placed hands on the counter, and then got a plate from the serving area and delivered to Resident 75. FSA-C did not perform hand hygiene during the entire observation. In an interview on 07/24/2023 at 07:36 AM, the Dietary Manager (DM) confirmed the staff in the dining room should have washed hands between residents and after the staffed touched any personal items. In an interview on 07/24/2023 at 09:45 AM, the Director of Nursing (DON) confirmed that hand hygiene should have been completed between each resident and the staff should have performed hand hygiene after touching any personal items. D. An observation on 07/19/2023 at 07:06 AM revealed a gray fuzzy substance was hanging from the vent located in the ceiling in front of the entire length of the kitchen exhaust hood. This vent was above the cooking and food preparation areas. An observation on 07/20/2023 at 10:48 AM revealed a gray fuzzy substance was hanging from the vent located in the ceiling in front of the entire length of the kitchen exhaust hood. This vent was above the cooking and food preparation areas. An observation on 07/20/2023 at 11:56 AM with the Dietary Manager (DM) revealed a gray fuzzy substance was hanging from the vent located in the ceiling in front of the entire length of the kitchen exhaust hood. This vent was above the cooking and food preparation areas. In an interview on 07/20/2023 at 11:56 AM, the DM confirmed there was a gray fuzzy substance was hanging from the vent located in the ceiling in front of the entire length of the kitchen exhaust hood. The DM confirmed the DM thought that was an item that should have been cleaned when the kitchen exhaust hood was cleaned by an outside company on 07/12/2023. In an interview on 07/20/2023 at 01:04 PM, the DM confirmed that the vent in the ceiling in front of the kitchen exhaust hood was not included in the kitchen hood cleaning process that was completed by an outside company on 07/12/2023 and the vent had not been cleaned since the build was built. In an interview on 07/25/2023 at 09:17 AM. The DM confirmed the vent in the ceiling in front of the kitchen exhaust hood was in a location that could have potentially allowed the gray fuzzy substance to dislodge and fall in uncovered food products during cooking or food preparation.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A Based on observation, record review and interview, the facility staff failed to ensure water was provided and fluid intake was sufficient to meet resident needs for 4 (Residents 17, 37, 78 and 181) of 5 residents reviewed for hydration. The facility staff identified a census of 79. Findings are: A. Record review of facility policy for Hydration dated 3-04-2022 revealed the following information: -Policy Statement: -The facility will offer sufficient fluid intake to maintain proper hydration and health to the extent possible following the residents care plan and providers orders. B. Record review of an undated and unsigned facility Hydration Protocol revealed the following information: -Hydration is an important area of consideration in caring for the elderly. It is recognized that hydration impacts mental functioning, skin integrity, bowel and bladder status, resistance to infections, reactions to medications, and much more. Some issue related to good hydration include availability of fluids, need for assistance with taking fluids, swallowing, hesitancy to drink fluids because of fear of incontinence or difficulty getting to the bathroom and the lack of fluid reserves in the elderly. C. Observation on 4-25-2022 at 9:54 AM revealed there was not water at Resident 17's bedside or within reach. Observation on on 4-25-2022 at 2:01 PM revealed there was not water at Resident 17's bedside or within reach. Record review of Resident 17's Nutrition Short Term/Quarterly assessment dated [DATE] revealed the facility Registered Dietician (RD) evaluated Resident 17 as requiring total dependence for eating and identified Resident 17 would need 2055 milliliters (ml) of fluid a day. Record review of Resident 17's Comprehensive Care Plan (CCP) dated 2-22-2022 revealed staff were to monitor and record Resident 17's intake at each meal. Record review of Resident 17's Documentation Survey Report (DSR) v2 sheet printed on 4-26-2022 revealed Resident 17's fluid intake for the following dates: -April 19th , fluid intake was identified as 930 ml's for the day. -April 20th, fluid intake was identified as 730 ml's for the day. -April 21st, fluid intake was identified as 300 ml's for the evening shift, there were no amounts identified for the breakfast or lunch time frames. -April 22nd, fluid intake was identified as 1120 ml's for the day. -April 23rd, fluid intake was identified as 990 ml's for the day. On 4-26-2027 at 7:20 AM an interview was conducted with the facilty RD. During the interview the facility RD reported water should be at the residents bedside and within reach. On 4-26-2022 at 2:30 PM a follow up interview was conducted with the facility RD. During the interview review of Resident 17's DSR vs sheet for April 2022 was reviewed. The facility RD confirmed the fluid intakes record April 19th through April 23rd did not meet Resident 17's daily fluid needs. D. Observation on 4-25-2022 at 10:01 PM revealed Resident 37 did not have water at bed side or within reach. Observation on 4-26-2022 at 7:22 AM revealed resident 37 was in bed and did not have water within reach. Record review of Resident 37's Nutrition Short Quarterly Assessment (NSQA) sheet dated 2-21-2022 revealed the facility RD assessed required total dependence for eating and required 1845 ml's of fluid per day. Record review of Resident 37's CCP dated 4-23-2022 revealed the facility staff were to monitor and record Resident 37's meal intake for each meal. Record review of Resident 37's DSR V2 reported for April 2022 revealed the fluid intake recorded for Resident 37: -April 19th, fluid intake was identified as 830 ml's for the day. -April 20th, fluid intake was identified as 1000 ml's for the day. -April 21st, fluid intake was identified as 420 ml's for the day. The lunch amount of fluid intake was not identified. -April 22nd, fluid intake was identified as 730 ml's for the day. -April 23rd, fluid intake was identified as 1160 ml's for the day. -April 24th, fluid intake was identified as 900 ml's for the day. On 4-26-2027 at 7:20 AM an interview was conducted with the facilty RD. During the interview the facility RD reported water should be at the residents bedside and within reach. On 4-26-2022 at 2:45 PM a follow up interview was conducted with the facility RD. During the interview review of Resident 37's DSR v2 sheet for April 2022 was reviewed. The Facility RD confirmed during the interview the record fluid amounts from April 19th 2022 through April 24th 2022 would not meet Resident 37's fluid needs per day. E. Observation on 4-25-2022 at 10:13 AM revealed water was not within reach of Resident 78. Observation on 4-25-2022 at 2:02 PM revealed water was not within reach for Resident 78. Record review of Resident 78's CCP dated 4-23-2022 revealed the facility staff were to monitor and record Resident 78's intake. Record review of Resident 78's Nutrition assessment dated [DATE] revealed the facility RD required 1431 ml's of fluid per day. Record review of Resident 78's DSR v2 sheet dated for April 2022 revealed the fluid intakes recorded for Resident 78 for the following dates: -April 19th, fluid intake was recorded as 600 ml's for the day. -April 20th, fluid intake was recorded as 995 ml's for the day. -April 21st, fluid intake was recorded as 780 ml's for the day. -April 22nd, fluid intake was recorded as 480 ml's for the day. On 4-26-2022 at 2:10 PM an interview was conducted with the facility RD. During the interview review of Resident DSRv2 report for April 2022 was reviewed. During the interview the facility RD confirmed based upon the amount of fluids documented would not meet Resident 78's daily fluid needs. F. Observation on 4-25-2022 at 11:22 AM revealed there was not water at Resident 181's bedside. Observation on 4-26-2022 at 7:20 AM with the facility Director of Nursing (DON) revealed water was not at Resident 181's bed side. The DON confirmed water was not at Resident 181's bedside. Record review of Resident 181's Nutrition assessment dated [DATE] revealed the facility RD assessed Resident 181's daily fluid needs as 1557 ml's per day. Record review of Resident 181's DSRv2 report for April 2022 revealed Resident 181's fluid intake as follows: -April 19th, fluid intake was identified as 560 ml's for the day. -April 20th, fluid intake was identified as 840 ml's for the day. -April 22nd, fluid intake was identified as 750 ml's for the day. -April 23rd, fluid intake was identified as 850 ml's for the day. -April 24th, fluid intake was identified as 540 ml's for the day. -April 25th, fluid intake was identified as 800 ml for the day. On 4-26-2022 at 3:00 PM an interview was conducted with the facility RD. During the interview the facility RD reported the amount of fluid intake from April 19th through April 25th would not meet Resident 181's daily fluid needs.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A Based on observation, record review and interview; the facility staff failed to follow the lunch menu for 40 residents who ate regular textured meals in the North Dinning room. The facility staff identified a census of 79. Findings are: Record review of a Diet Spreadsheet for week 5 printed on 4-27-2022 revealed for the lunch meal on 4-27-2022 the residents were to receive food items that included 3 ounces (oz) of beef pot roast. Observation on 4-27-2022 at 11:42 AM of the lunch meal service in the North Dinning room revealed Cook H prepared and served the [NAME] items that included sliced beef pot roast. Further observations revealed the sliced pot roast looked to be thin. Cook using the facility scale weighed a slice of the beef pot roast revealing the weight to be 0.10 of a pound of beef pot roast. Cook H obtained a second slice of the beef pot roast revealing a weight of 0.12 pounds. On 4-27-2022 at 11:55 AM an interview was conducted with the Dietary Manager (DM). During the interview the DM reported the weight of 0.10 of a pound was less than 2 oz's and the weight of 0.12 pound was about 2 oz's. The DM confirmed the menu was resident were to receive 3 oz's of the beef pot roast and what was being served to the residents was not enough of the beef pot roast.

Based on observation, interview and record review, the facility failed to maintain the dignity of Resident 26 by not ensuring the bedroom door was closed while the resident was using the toilet room area which exposed the resident's thigh and peri area. Findings are: An observation on 4/25/2022 at 09:06 AM revealed Resident 26 seated in a wheelchair with pants and brief around Resident 26's upper thighs and a towel over the lap. When Resident 26 was asked if the resident was waiting for help, Resident 26 said help was not needed. The door to the room was open to the hall way and Resident 26 was visible from the dining area. An observation on 04/25/2022 at 09:35 AM revealed Resident 26 still seated in a wheelchair with pants and brief around upper thighs. An observation on 04/25/2022 at 09:55 AM revealed Resident 26 had pants and brief pulled up around waist. An interview with RN-C (Registered Nurse) on 04/25/2022 at 11:22 AM revealed Resident 26 frequently takes self to bathroom and transfers self to a wheelchair with pants and briefs around thighs. An interview with Nurse Aide-F (NA-F) on 04/25/2022 at 01:25 PM confirmed if Resident 26's call light is not answered quickly when the resident is on the toilet, Resident 26 will transfer self to wheelchair. Resident 26 is unable to pull up their pants by themselves so Resident 26 will remain in the wheelchair with the pants and briefs around the Resident's thighs until someone helps to pull them up. An observation on 04/26/2022 at 07:42 AM revealed Resident 26 getting out of bed. Nurse Aide G (NA-G) placed a wheelchair beside Resident 26's bed and locked the wheels. NA-G placed gait belt around Resident 26's upper chest. Resident 26 swung their legs to the edge of the bed and used the hand rail to pull themself up. NA-G had one hand on the gait belt to guide Resident 26. Resident 26 shuffled their feet to the side and reached back with one hand while holding the hand rail with the other hand and lowered self into wheelchair. NA-G pushed the resident into the toilet. Resident 26 locked the wheelchair brakes, grasped the hand rails around the toilet and pulled self upright. NA-G lowered Resident 26's briefs and Resident 26 turned self around and lowered self to the toilet. An interview on 04/26/2022 at 07:56 AM with Registered Nurse H (RN-H) confirmed Resident 26 does not always wait for help when Resident is done on the toilet. Resident 26 will transfer self to a wheelchair but is not able to pull up their briefs and pants completely. RN-H confirmed the expectation is that staff is to help the resident with the resident's clothes as soon as it is noticed. RN-H confirmed that being partially undressed is a dignity issue. Record review of the facility's Resident Rights Policy dated 03/04/2022 revealed A Resident is to be treated with dignity and respect in full recognition of the resident's individuality.

Based on record review and interview, the facility failed to provide a written notice of the reason for transfer to a hospital to the resident / representative for 1 (Resident 32) of 3 residents reviewed for hospitalization /transfer. The facility census was 79. Findings are: A. Record review of a facility policy entitled Discharge Plan of Care and Discharge Transfer Summary dated 11/16/21 revealed that a notice of transfer or discharge will be given to the resident and representative within 24 hours of discharge. B. Record review of Resident 32's Discharge Tracking MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 11/13/21 revealed that Resident 32 had a unplanned discharge from the facility to an acute care hospital on 11/13/21. Record review of Resident 32's Entry Tracking Record dated 11/16/21 revealed that Resident 32 was readmitted to the facility from an acute care hospital on 11/16/21. Record review of Resident 32's Electronic Medical Record [EMR] revealed no written information related to the reason for transfer to the hospital on 11/13/21 had been provided to the resident or their representative at the time of the transfer or within 24 hours of the residents discharge from the facility. Record review of Resident 32's Discharge Tracking MDS dated [DATE] revealed that Resident 32 had a unplanned discharge from the facility to an acute care hospital on 1/10/22. Record review of Resident 32's Entry Tracking Record dated 1/14/22 revealed that Resident 32 was readmitted to the facility from an acute care hospital on 1/14/22 . Record review of Resident 32's Electronic Medical Record [EMR] revealed no written information related to the reason for transfer to the hospital on 1/10/ 22 had been provided to the resident or their representative at the time of the transfer or within 24 hours of the residents discharge from the facility. C. Interview on 04/26/22 at 2:08 PM with the Director of Nursing confirmed that no written notice of the reason for the transfer to the hospital had been provided to the resident or representative at the time of the transfer or within 24 hours on 11/13/21 or 1/10/22 for Resident 32.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to identify interventions to prevent falls on the baseline care plan for 2 (Resident 70 and Resident 182) of 5 sampled residents. The facility staff identified a census of 79. The findings are: A. Record review for Resident 182 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Falls Risk Assessment for Resident 182 dated 3/28/22 revealed a score of 15 indicating high risk. The assessment further instructed that if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Review of the baseline care plan for Resident 182 dated 3/28/22 revealed a history of falls and fall related injury fracture of the femur. No interventions for falls were identified on the baseline care plan. Interview on 4/27/22 at 07:40 AM with MA (Medication Aid) A and RN (Registered Nurse) B confirmed there were no interventions for falls on Resident 182's baseline care plan and also confirmed that there should be interventions in place on admission when a resident is identified as risk for falls. B. Record Review for Resident 70 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Fall Risk Assessment for Resident 70 dated 4/13/22 revealed the resident scored a 13 indicating the resident was at risk for falls. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Review of the baseline care plan for Resident 70 dated 4/13/22 revealed history of falls. No interventions for falls were identified on the baseline care plan. Interview on 4/27/22 at 07:40 AM with MA (Medication Aid) A and RN (Registered Nurse) B confirmed there were no interventions for falls on Resident 70's baseline care plan and also confirmed that there should be interventions in place on admission when a resident is identified as risk for falls. Review of the policy for Accidents-Falls dated 1/19/22 revealed the procedure for all residents was a fall risk assessment is conducted upon admission, upon readmission from the hospital, quarterly with MDS assessment, annually, and with any significant change to the residents status which puts them at a great risk for falls. A plan of care to reduce fall risk will be developed for residents whose assessment indicate that they are at risk for falls/accidents. The plan of care is communicated to all appropriate staff.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, record reviews and interview; the facility staff failed to ensure the dishwashing machine maintained a rinse cycle temperature to sanitize dishes to prevent the potential for food borne illness. This practice had the potential to effect all residents who ate meals from the kitchen. The facility staff identified a census of 136. Findings are: Observation on 12-04-2018 at 2:38 PM with Registered Dietician (RD) F revealed the dishwasher obtained 170 degrees during the rinse cycle. Review of the instructions on the dishwashing machine revealed the rinse cycle was to obtain a temperature of 180 degrees. Record review of a log to record the temperature of the rinse cycle for (MONTH) (YEAR) revealed the following: -Breakfast Rinse Temperatures. -12-01-2018, 170 degrees. -12-02-2018, 169 degrees. -12-03-2018, 169 degrees, -12-04-2018, 169 degrees. -Lunch Rinse Temperatures. -12-01-2018, 170 degrees. -12-02-2018, 171 degrees. -12-03-2018, 170 degrees. Further review of a log to record the temperature of the rinse cycle for (MONTH) (YEAR) revealed at the bottom of the log sheet was information identifying the rinse cycle was to be 180 degrees. On 12-04-2018 at 2:38 PM an interview was conducted with RD F. RD F confirmed the dishwasher rinse cycle had not reached 180 degrees to sanitize the dishes and should have.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D The facility failed to ensure mechanically altered cold meat sandwich storage temperatures were maintained at a temperature to prevent the potential for food borne illness for 15 residents receiving mechanically altered diets. The facility staff identified a census of 136. Findings are: Observation on 12-04-2018 at 11:40 AM revealed the facility kitchen staff had prepared the lunch meal for the residents of the facility. The food items prepared included a pureed cold meat sandwich and a mechanical ground cold meat sandwich. Cook J obtained the temperature of the foods including the mechanical ground and pureed cold meat sandwiches. Cook J using the facility thermometer revealed the temperature of the mechanical ground and the pureed sandwiches were both 39 degrees. Observation on 12-04-2018 at 12:55 PM with the Dietary Services Manager (DSM) of the food temperatures revealed the DSM using the facility thermometer, that had been calibrated, revealed the mechanical ground and the pureed meat sandwich temperatures was 50 degrees. In 12-04-2018 at 1:05 PM an interview was conducted with the DSM. During the interview, the DSM confirmed the mechanical ground and pureed sandwich were too warm.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D The facility failed to ensure mechanically altered cold meat sandwich storage temperatures were maintained at a temperature to prevent the potential for food borne illness for 15 residents receiving mechanically altered diets. The facility staff identified a census of 136. Findings are: Observation on 12-04-2018 at 11:40 AM revealed the facility kitchen staff had prepared the lunch meal for the residents of the facility. The food items prepared included a pureed cold meat sandwich and a mechanical ground cold meat sandwich. Cook J obtained the temperature of the foods including the mechanical ground and pureed cold meat sandwiches. Cook J using the facility thermometer revealed the temperature of the mechanical ground and the pureed sandwiches were both 39 degrees. Observation on 12-04-2018 at 12:55 PM with the Dietary Services Manager (DSM) of the food temperatures revealed the DSM using the facility thermometer, that had been calibrated, revealed the mechanical ground and the pureed meat sandwich temperatures was 50 degrees. In 12-04-2018 at 1:05 PM an interview was conducted with the DSM. During the interview, the DSM confirmed the mechanical ground and pureed sandwich were too warm.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on interviews and record reviews the facility staff failed to provide a bath 2 times per week as requested for 1 of 1 sampled residents Resident 67. The facility staff identified a census of 136. The findings are: Interview conducted on 11/29/18 at 11:26 AM with Resident 67 revealed that Resident 67 prefers a bath twice a week and had not had a bath in a week. Interview conducted on 12/3/18 at 09:55 AM with Resident 67 revealed that Resident 67 had not had a bath all last week. Care Plan review dated 10/3/18 revealed that Resident 67 had a preference for bathing two times a week. On 12/3/18 Record Review of the bath schedule for the month of (MONTH) (YEAR) revealed the last bath that Resident 67 received was on 11/22/18 and not received a bath on 11/26 or 11/29/2018. Interview with RN C on 12/4/18 at 09:05 AM confirmed that the Resident 67 was to receive a bath on 11/26 and 11/29 and had not received a bath on 11/26 or 11/29/2018.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observations, record reviews and interview, the facility staff failed to implement interventions to prevent pressure ulcer development for 1 (Resident 9) of 1 sampled resident. Findings are: Record Review of Admission Record revealed that Resident 9 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of current Physician order [REDACTED]. Review of the Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/15/18 revealed resident was at risk for pressure ulcers. Review of Current Comprehensive Care Plan dated 11/15/18 identifies Resident 9 at risk for skin breakdown related to extensive assist with bed mobility and transfers. Observation on 11/29/18 at 08:21 AM Resident 9 was sitting in the wheelchair with a sling in the chair, under the resident's body. Observation on 12/3/18 at 08:02 AM Resident 9 was sitting in the wheelchair with a sling in the chair, under the resident's body. Observation on 12/4/18 at 08:55 AM Resident 9 was sitting in the wheelchair with a sling in the chair, under the resident's body. An interview conducted 12/4/18 at 09:00 AM with RN C confirmed that there was a sling in Resident 9's wheelchair, under the resident's and that there was an order dated 7/23/18 for no sling under (resident's) body when up in chair for pressure relief.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record reviews and interviews; the facility staff failed to evaluate significant weight loss for 1 (Resident 126 ) of 4 sampled residents. The facility staff identified a census of 136. Findings are: Record review of Resident 126's Comprehensive Care Plan (CCP) printed on 12-03-2018 revealed Resident 126 had [DIAGNOSES REDACTED]. Further review of Resident 126's CCP printed on 12-03-2018 revealed Resident 126 had a history of [REDACTED]. Record review of Resident 126's Weights and Vitals Summary sheet revealed Resident 126 weight were as follows: -8-22-2018,weight was 158.2 lbs. -9-19-2019, weight was 149.2 lbs. A loss of 9 lbs or 5.68% within 30 days. Review of the Resident record revealed there was no evidence the facility staff had evaluated the significant weight loss. On 12-03-2018 at 12:56 PM a interview was conducted with Registered Dietician (RD) E and RD F. During the interview RD F confirmed an evaluation of Resident 126 significant weight loss had not been completed

LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D2b Based on observation, record review and interview; the facility staff failed to evaluate nutritional requirements and casual factors for the development of a pressure ulcer for 1 (Resident 118). The facility staff identified a census of 147. Findings are: Record review of a Face Sheet dated [DATE] revealed Resident 118 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of Resident 118's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed the facility staff assessed the following about the resident: -Resident 118 had short and long term memory deficits. -Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -Incontinent of bowel and bladder. -Resident 118 was at risk for skin breakdown. Record review of a Braden scale (tool used for predicting pressure sore risk) dated [DATE] revealed Resident 118 had scored a 13. According to the information on the Braden Scale form, a score of 13 placed Resident 118 at moderate risk for the development of a pressure ulcer. Record review of Resident 118's Comprehensive Care Plan (CCP) dated [DATE] revealed Resident 118 was at risk for alteration in skin integrity. The goal for Resident 118 was to be free from alteration in skin integrity. Interventions listed on the CCP to prevent skin breakdown included performing a nutritional screening and to adjust diet supplements as indicated to reduce the risk of skin breakdown. Record review of Resident 118's Clinical Notes Report (CNR) dated [DATE] revealed Resident 118 was identified as having " breakdown to coccyx..." Record review of Resident 118's CNR dated [DATE] revealed Resident 118 had had a "slit area in coccyx..." Record review of a Wound Care Addendum (WCA) sheet dated [DATE] revealed Resident 118 was evaluated as having an abrasion to the lower left buttocks. The WCA sheet did not have measurements of the abrasion. The treatment was identified as a cream being applied. Record review of Resident 118's WCA sheet dated [DATE] revealed Resident 118 was assessed as having a pressure ulcer to the right lower buttocks that measured 2.50 cm (centimeters) by 1.50 cm with a depth of 0.10 cm. The pressure ulcer was not staged on the WCA sheet. Record review of Resident 118's WCA sheet dated [DATE] revealed the wound and treatment were unchanged from the [DATE] assessment. Record review of Resident 118's WCA sheet dated [DATE] revealed Resident 118's pressure ulcer to the lower right buttocks measured 1.50 cm by .30 cm with a depth of 0.10 cm with the wound bed being described as pink. Record review of Resident 118's WCA sheet dated [DATE] revealed the pressure ulcer to Resident 118's right lower buttocks measured 3.20 cm's, by 1.60 cm's with a depth of 0.20 cm. The pressure ulcer was assessed as a stage 2 ( According to the facility Skin assessment policy dated ,[DATE], identified a stage 2 as partial thickness loss of dermis presenting a shallow open ulcer with a red/pink wound bed without slough."). According to the documentation on the WCA sheet, the pressure ulcer had "...almost doubled in size since last week-red moist non-healing wound bed with open edges and sl (slight) periwound redness. Scant amount of drainage. Will place on air mattress". Record review of Resident 118's WCA sheet dated [DATE] revealed the pressure ulcer to Resident 118's right lower buttocks measured 2.80 cm, by 1.50 cm, with a depth of 0.20 cm and was assessed as a stage 2. The wound bed was assessed as having 30 percent slough, yellow in color. According to the wound documentation, the wound bed had adherent slough with scant drainage. The facility staff were to request a treatment change. According to the facility policy for Skin assessment dated ,[DATE], identified a stage 3 as a pressure ulcer with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle no exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. Observation on [DATE] at 10:35 AM of the pressure ulcer treatment to Resident 118's lower right buttocks revealed Register Nurse (RN) B removed the dressing to the pressure ulcer and cleansed the wound. RN B measured the pressure ulcer to Resident 118's right lower buttocks as 1.7 cm's, by 0.6 cm's. The depth of the wound was not measured by RN B. When asked how deep the wound was, RN B stated 0.2 cm's and stated "yes" when asked if the pressure ulcer had developed in the facility. Observations of the wound revealed the wound bed had whitish tissue that covered the base of the wound. No odors of the wound were noticed during the wound treatment. On [DATE] at 10:54 AM an interview was conducted with RN B. When asked what caused the pressure ulcer, RN B stated " moisture, pressure and shearing". When asked to stage the wound, RN B stated " it has gone from a 2 to a stage 3", the pressure ulcer "...has gotton worse". When asked if the wound bed of the pressure ulcer could be seen, RN B stated "no'. RN B then identified Resident 118's pressure ulcer as unstageable. According to the facility policy for Skin assessment dated ,[DATE] an Unstageable is a "full thickness tissue loss in which the base of the ulcer is covered with slough (yellow, tan, gray or brown) and/or eschar (tan, brown, or black) in the wound bed. Record review of Resident 118's medical record did not contain evidence of an evaluation of casual factors for the development of the pressure ulcer and did not contain any evidence that Resident 118's nutrition status had been evaluated and interventions implemented when the pressure ulcer developed on [DATE] and again when the pressure ulcer condition declined on [DATE]. An interview was conducted with Registered Dietician (RD) C on [DATE] at 2:39 PM. During the interview, RD C reported being unaware that Resident 118 had developed a pressure ulcer on [DATE] and the status of the pressure ulcer had declined on [DATE]. When asked if a nutritional evaluation had been completed when the pressure ulcer was identified on [DATE] and again, when the pressure ulcer condition had declined on [DATE], RD C stated "no". When asked if Resident 118's nutritional needs were being meet for wound healing needs, RD C reported (gender) "was not sure" if Resident 118's needs were met for wound healing. A follow up interview on [DATE] at 11:48 AM was conducted with RD C. RD C reported no evaluation had been conducted for nutritional requirements for pressure ulcer healing on [DATE] and when the pressure ulcer condition declined on [DATE]. Record review of the facility policy and procedure for Skin assessment dated ,[DATE] revealed the following: -Purpose; -To establish guidelines for assessment and maintenance of skin integrity and management of skin alteration. -Guidelines; -D3, If skin integrity is impaired as a result of pressure, the pressure ulcer will be staged according to the Agency of Health Care Policy and Research (AHCPR) or MDS definitions. -F, Measurements of wounds include: -F1. Length by width by depth in centimeter utilizing a measuring guide. Record review of the facility Pressure Ulcer Protocol dated ,[DATE] revealed the following: -Nutritional deficit; -Contact dietician for resident consult and/or recommendation. -Investigate factors that compromise residents dietary intake ( especially protein or calories) and offer them support with eating. Cross reference to F325, The facility failed to evaluate nutritional needs and implement interventions to prevent significant weight loss.

Licensure Reference: 175 NAC 12-006.09D8b Based on observations, interview, and record review; the facility failed to evaluate nutritional needs and implement interventions to prevent significant weight loss for 2 residents (Residents 118 and 95). The facility had a total census of 147 residents. Findings are: A. Resident 118's Care Plan revealed a goal of meeting 100% of Resident 118's nutrition and hydration needs. The nutritional care plan was up dated on 1/2014 to state Resident 118's weight was 140.3 which was down 6.2% in the past 180 day and was not significant. The Care plan up-date indicated Resident 118 was eating 85% of meals. A review of Resident 118's tray card indicated Resident 118 was to be offered carnation instant breakfast at all meals. Observations on 2/12/14 between 12:22 PM -12:38 PM revealed Resident 118 being fed lunch in bed. Resident 118 ate 100% of meal but did not receive carnation instant breakfast. Observations on 2/13/14 at 8:40 AM revealed Resident 118 being fed breakfast in bed. Resident ate 100% of meal but did not receive carnation instant breakfast. A review of Resident 118's weight report and weekly weight record revealed Resident 118's weight was 151 lbs. on 8/8/13, 142.7 lbs. on 12/11/13 and 134.9 lbs during the week of 1/22/14. This reflects a weight loss of 16.1 lbs. (10.6 %) in 6 months and 7.8 lbs. (5.4%) in 1 month. A review of a Wound Care Addendum revealed Resident 118 developed a pressure ulcer measuring 2.5 cm in length, 1.5 cm in width, and .10 cm in depth to right lower buttocks on 1/8/14. According to the Wound Care Addendum, Resident 118's pressure sore was determined to be a stage II on 1/23/14 and had increased in size to 3.2 cm in length, 1.60 cm in width, and had a depth of .2 cm. In an interview on 2/13/14 at 2:45 AM, Registered Dietitian C reported being unaware of Resident 118's pressure sore until the day before. Registered Dietitian C reported that development of a pressure sore should be followed up with a nutrition assessment and interventions to ensure nutritional needs are being met. In a follow up interview on 2/18/14 at 11:53 AM, Registered Dietitian C reported waiting for a reweigh of Resident 118 from the weight the week of 1/22/14. Registered Dietitian C reported it took 2 weeks to get the re-weigh. A notification of Resident 118's significant weight loss was sent to Resident 118's physician on 2/14/14. B. Resident 95's Care Plan revealed a goal that Resident 95 would maintain a weight between 87 and 107 lbs. (pounds). The Care Plan was updated in 1/2014 to state Resident 95's weight was stable at 89.2 lbs and Resident 95 was eating 90% of meals. Resident was to be offered Ensure Complete 2 times per day and Resident 95 wanted to be fed at all meals. A review of a Weekly Weight Record revealed Resident 95 weighed 92.8 lbs. during the first week of January and 81.2 lbs. during the first week of February. This reflects a significant weight loss of 11.6 lbs. (12.5%) in one month. Observations on 2/12/14 between 11:59 AM and 12:29 PM revealed Resident 95 feeding self in the main dining room. Resident 95 ate all of the lettuce with cottage cheese and none of the macaroni and cheese. Resident 95 was observed to receive only set up assist with the meal and received no assistance with eating. Resident 95 had difficulty getting food on to the spoon. A review of the meal intake record for Resident 95 revealed an intake of 100% for lunch meal on 2/12/14. Observations on 2/13/14 between 8:20-8:34 AM revealed Resident 95 feeding self in the main dining room. Resident 95 received set up assistance with the meal including adding thickener to malt'o meal and coffee. Resident 95 ate all of malt'o meal but did spill some of the cereal. Resident 95 did not receive any assistance with eating. A review of the meal intake record for Resident 95 revealed an intake of 75% for the lunch meal on 2/13/14. In an interview on 2/13/14 at 8:52 AM, Resident 95 reported receiving assistance with meals at times. Resident 95 reported spilling food on self. In an interview on 2/13/14 at 2:30 PM, Registered Dietitian C reported Resident 95 had requested full assist with meals at last care plan meeting. In an interview on 2/13/14 at 3:28 PM, Unit Coordinator LPN (Licensed Practical Nurse) D reported Resident 95 was being assisted to eat as of last week and this was communicated in a verbal report to staff. A review of an email from Registered Dietitian C dated 2/7/14 revealed a request for a reweigh of Resident 95. In an interview on 2/18/14 at 11:45 AM, Registered Dietitian C reported it had taken a week to get a re weigh on Resident 95. Registered Dietitian C reported wanting reweighs to be completed within 48 hours. A review of the Weekly Weight Report revealed Resident 95 had a weight of 86.2 lbs during the second week of February. A notification of Resident 95's significant weight loss was sent to Resident 95's physician on 2/17/14. C. A review of facility policy titled weight management with an effective date of 3/11 revealed the following; -"Weights that appear to be inaccurate are reviewed by a nurse with a "reweigh" completed within 24 hours."

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to evaluate the ability of residents to safely drink hot fluids for 3 (Resident 1, 2 and 3) residents. The facility census was 146. Findings are: A. Record review of a Face Sheet dated 1-17-2012 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated as completed on 10-14-2013 revealed the facility staff assessed the following about the resident; -Resident 1 rarely/never understood or able to understand. -Required extensive assistance with bed mobility and eating. -Dependant for transfers, locomotion, dressing, toilet use and personal hygiene. Record review of a Rapid Skin Assessment (RSA) sheet dated 11-03-2013 revealed Resident 1 had a "blister and Reddened areas" to the left upper thigh. According to the information on the RSA sheet. Resident 1 "..has on occasion reached for table mates food/drink". The RSA sheet also contained information that Resident 1 " spilled cup with brown liquid onto clothing on 11/02/2013". Interventions directed that "all hot liquids to be served in cups w(with) lids. Table mates liquids to be moved out of reach. Supervise when drink hot liquids". Record review of a Change in Skin Integrity (CISI) sheet dated 11-03-2013 revealed the sizes of the blistered areas on the left upper thigh were as follows: -5.0 cm (centimeters) by 3 cm. -5.2 cm by 1.2 cm. -1.2 cm by 1.2 cm. -0.4 cm by 0.8 cm. -0.4 cm by 0.4 cm. -3.0 cm by 2.0 cm. The resident's physician was notified and orders given for treatment. Record review of a Doctor's Orders/Progress Notes sheet dated 11-08-2013 revealed Resident 1's physician had seen the wound areas to the left upper hip. The physician diagnosed the area as "scald burn". Record review of an education sheet dated 11-07-2013 titled "Mandatory Read and sign" revealed staff were to read and sign how to provide hot liquids to Resident 1. The mandatory education sheet contained the following information: -All hot liquids should be served in a cup with a lid and handle. -(Resident 1) needs supervision anytime (gender) is drinking a hot liquid. -(Resident 1) may at times reach for tablemate's drink, so always place tablemate's drink outside of Resident 1's reach. -When( Resident 1) is done with (gender) meal, please return (gender) to (gender) neighborhood, as (gender) can become sleepy after eating. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 11-06-2013 revealed staff were to keep all hot liquids out of Resident 1's reach and when Resident 1 was drinking any hot liquids, Resident 1 must use a cup with lid and be supervised. Observation on 11-14-2013 at 11:42 AM revealed Resident 1 was placed at a table by Licensed Practical Nurse (LPN) B. Resident 1's table mate had coffee within reach of Resident 1. No staff were supervising Resident 1. Observation with the Director of Nuring (DON) on 11-14-2013 at 12:01 PM of temperatures of the following items revealed: -Decafanated coffee temperature in the server was 162 degrees. -Regular coffee temperature in the server was 155 degrees. -Hot water in the server was 157 degrees. On 11-14-2013 at 12:09 PM an interview was conducted with LPN A, the unit manager for Resident 1. When asked if everyone on the unit for Resident 1 had signed the mandatory education sheet that contained the new intervention to prevent further injuries, LPN A stated "no". When asked who had not signed the education sheet, LPN A identified several staff members including LPN B who was in charge of Resident 1. Observation of the wound area to Resident 1's upper thigh area was completed with LPN B on 11-14-2013 at 12:19 PM. Resident 1's wound measured approximately 12 cm by 5 cms's irregular shaped. The wound base had yellowish white tissue with a peppering of red areas. No odors or drainage was observed. An interview was conducted with LPN B. on 11-14-2013 at 12:22 PM. During the interview when asked if LPN B was aware of the new interventions to prevent additional injuries for Resident 1. LPN B stated the (gender) "...was not aware" of the new interventions. An interview was conducted with LPN A on 11-14-2013 at 9:42 AM . When asked if the facility staff evaluate the residents to determine their ability to safely drink hot liquids, LPN A " we do not do that'. An interview was conducted with the DON on 11-14-2013 at 1:18 PM. During the interview when asked if the facility had a policy and procedure for evaluating a the resident's ability to safely dink hot liquids, the DON stated "no, we have not evaluated any of the residents". B. Record review of a Face sheet dated 10-03-2013 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 2's MDS dated as completed on 8-23-2013 revealed the facility staff assessed the following about the resident; -Resident 2 was sometimes understood and sometimes would understand. -Required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. Observation on 11-14-2013 at 8:35 AM revealed Resident 2 was in the dining room for breakfast. Resident 2 was observed to have coffee in a cup and there was not a lid on it. Observation on 11-14-2013 at 11:47 AM, Resident 2 was in the dining room for lunch. Resident 2 was observed to have coffee in a cup that did not have a lid on it. Further observations revealed that as Resident 2 was taking a drink, Resident 2's hand shook. Record review of Resident 2's medical chart did not contain evidence of an evaluation of Resident 2's ability to safely drink hot liquids. Review of Resident 2's CCP did not have information for staff on how to provide hot liquids safely for Resident 1. C. Record review of a Face sheet dated 2-17-2013 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's MDS dated as completed on 9-06-2013 revealed the facility staff assessed the following about the resident: -Resident 3 scored an 11 on the Brief Interview for Mental Status (BIM's). According to the MDS Manuel, a score of 11 indicates moderately impaired cognition. -Required supervision with eating. -Required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Record review of an Ocular Progress Notes dated 8-21-2013 revealed Resident 3 was legally blind. Observation on 11-14-2013 at 8:40 AM revealed Resident 3 was in the dining room for breakfast. Resident 3 was observed to have a cup of brown liquid in a cup without a lid. Observation on 11-14-2013 at 11:46 AM Resident 3 was in the dining room for lunch. Resident 3 was drinking hot chocolate in a cup without a lid. Record review of Resident 3 medical chart did not contain evidence that an evaluation of Resident 3's ability to safely drink hot liquids. Record review of Resident 3's CCP reviewed on 8-28-2013 revealed it did not have instructions for staff to safely provide hot liquids for Resident 3. An interview on 11-14-2013 at 2:25 PM was conducted with Registered Nurse (RN) C, who assited in completing the MDS asessment. When asked if Residents1, 2, and 3 were evaluated for the ability to safely drink hot liquids, RN C stated "none of the residents were evaluated". According to information at www.antiscald.com an exposure to a temperature of 140 degrees for 3 seconds would result in a 2nd degree burn with no irreversible damage. Exposure to 140 degrees for 5 seconds would result in a 3rd degree burn with full thickness injury.

Licensure reference: 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to ensure that residents were transferred with assist of 2 staff members for 1 (Resident 1) of 7 residents which resulted in a fractured clavicle. The facility had a total census of 152 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] according to the resident's Face Sheet. A review of the facility Investigation Report for the incident on 3/3/13 revealed Resident 1 was being toileted with the use of a sit/stand mechanical lift when Resident 1 slid their arms out of the sling and started to slide down. Resident 1 was lowered to the ground by the nurse tech. X-ray on 3/5/13 showed the resident had a non-displaced fracture of clavicle. The Investigation Report listed an immediate intervention of change Resident 1 to a full body lift and educate staff on care plan changes. A review of Resident 1's 3/3/13 nursing assessment revealed the safest way to transfer Resident 1 from one surface to another was with the EZ stand lift. In an interview on 3/26/13 at 3:33 PM, the DON (Director of Nursing) confirmed Resident 1 was to be transferred with the EZ stand lift at the time of the incident. In an interview on 3/26/13 at 4:26 PM, Nurse Aide A reported when Resident 1 was done on the toilet, Nurse Aide A lifted up Resident 1 and pulled lift away. Resident 1 fell out of the lift. Nurse Aide A reported the resident fell to the floor. Nurse Aide A reported no one had been assisting with the lift at the time. Nurse Aide A reported normal procedure was to have a second staff person help with the transfer. In an interview on 3/26/13 at 6:02 PM, Nurse Aide B reported hearing a call for help. When Nurse Aide B reached the bathroom, Resident 1 was half in and half out of the lift. Nurse Aide A was behind the resident with Nurse Aide B's arms around the resident. Nurse Aide B reported Nurse Aide B had not been asked to assist with the transfer of Resident 1 on or off the toilet. Nurse Aide B reported 2 staff members were supposed to attend when lifting a resident. Nurse Aide B reported Nurse Aide B had not been asked to assist with transferring resident on or off the toilet. In an interview on 3/26/13 at 4:42 PM, the DON reported wanting both staff members in the room when transferring a resident with the EZ stand lift. In an interview on 3/26/13 at 7 PM, the Administrator reported two staff members were to be present in the room when a resident was transferred using a lift. Facility Skills Demonstration for EZ Stand Transfers updated on 1/13 stated the following: - "Do NOT leave resident's side when resident is in standing position." - "ALWAYS USE 2 TO TRANSFER!!!"