Every finding on record at Northfield Retirement Communities Care Center

Licensure Reference Number 175 NAC 12-006.09(J) Based on record review, observation, and interview, the facility failed to ensure 1 (Resident 46) of 2 sampled residents' nutritional needs were met per their orders and plan of care. The facility identified a census of 60.Findings Are:A.A record review of Resident 46's Facesheet dated 7/9/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior)) with behavioral disturbances, nausea, and progressive supranuclear ophthalmoplegia (a rare brain disease that affects movement, balance, vision, and swallowing).A record review of Resident 46's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 4/30/2026 revealed the resident's Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 10, which indicated they had moderately impaired cognition. The resident required supervision or touching assistance with eating and required substantial/maximal assistance with oral hygiene, toileting hygiene, dressing, personal hygiene, bed mobility, and transfers. Staff documented that the resident had a weight loss of 5% or more in the last month or 10% loss in the last 6 months and was not on a physician-prescribed weight-loss regimen.A record review of Resident 46's undated Care Plan revealed the resident was at nutritional risk related to their diagnoses of progressive supranuclear ophthalmoplegia, depression, iron deficiency, age-related physical debility, and past knee surgery (both knees). The resident had been coughing/choking with meals and Speech had recommended a pureed diet, but the resident did not like it so per their family they were to have minced moist texture even though choking still occurred. The resident had a goal stating Resident 46's weight is 94 pounds, will avoid significant weight changes as possible. Interventions related to meeting their nutritional needs were a regular, mince/moist texture diet, providing super cereal as ordered, giving supplements as ordered, and encourage oral intake of food and fluids. In the Activities of Daily Living (ADL, tasks related to personal care, such as dressing, eating, and mobility) section of Resident 46's Care Plan, it stated the resident required extensive to dependent assist with their ADLs; this section was last reviewed/revised on 5/9/2026.An interview on 7/6/2026 at 11:46 AM with Resident 46's representative revealed they had tried different altered textures for the resident and that they felt the resident's choking was a swallowing problem related to their progressive supranuclear ophthalmoplegia rather than a chewing difficulty.A record review of Resident 46's Weights Detail Report dated 7/8/26 revealed the following information:-On 1/17/26 the resident weighed 99 pounds.-On 2/25/26 the resident weighed 95 pounds.-On 3/25/26 the resident weighed 93.8 pounds.-On 4/23/26 the resident weighed 94 pounds.-On 5/27/26 the resident weighed 87 pounds.-On 6/17/26 the resident weighed 82.4 pounds.-On 7/1/26 the resident weighed 79.6 pounds.Based on the recorded weights, Resident 46 had an 8.5 % weight loss in one month from 5/27/2026 to 7/1/2026. Resident 46 had a 15.1% weight loss in three months from 3/25/2026 to 7/1/2026. Resident 46 had a 19.6% weight loss in six months from 1/17/2026 to 7/1/2026.A record review of Resident 46's Dietary Progress Notes revealed:-On 2/4/2026 the Registered Dietitian (RD) documented the resident's weight was 99 pounds, with no significant changes. The resident was to receive Mighty Shakes, 4 oz four times a day and Super Cereal at breakfast. The RD stated they recommended investigating some higher calorie supplements for the resident based upon the weight loss looking back at the 90-day and 180-day marks. The resident had seen Speech Therapy and been given a recommendation to have a pureed diet. RD was to communicate with the Dietary Manager about this to determine what the resident would accept. Later on 2/4/2026 the RD documented they would trial the resident on a mechanical soft diet for three days and trial a Magic Cup (a high-calorie, high-protein nutritional supplement designed for people who need to gain weight or are at risk of malnutrition) at dinner to see if the resident would consume this.-On 2/12/2026, The RD documented that the resident's diet was changed to mechanical soft.-On 4/28/2026, the RD documented the resident's weight was 94 pounds, down from 106 pounds 180 days prior. The resident was to receive Mighty Shakes, 4 oz four times a day and Super Cereal at breakfast. The RD recommended a new weight be obtained.-On 6/1/2026, the RD documented that the resident's weight was 88 pounds, down from 94 pounds which was 6.3% loss in 30 days and a 7.3% loss in 90 days. The resident was to receive Mighty Shakes, 4 oz four times a day and Super Cereal at breakfast. The RD wrote that they recommended Speech Therapy be consulted regarding the use of thickened liquids or other techniques to reduce choking.-On 6/16/2026, the CDM documented that the resident continued to have choking at meals and was eating less than 50% of meals.-On 6/23/2026, the RD documented that the resident had a 6% weight loss in the prior 30 days, a 13% weight loss in 90 days, and an 18% weight loss in 180 days. There was no evidence of new recommendations being made by the RD during this review.A record review of Resident 46's Active Orders revealed:-An order for their diet to be regular texture, minced and moist (mechanical soft). This order had a start date of 2/25/2026.-An order for Mighty Shakes (a fortified, high-calorie nutritional beverage designed to help individuals-particularly older adults, hospital patients, or those recovering from illness-prevent unintended weight loss or malnutrition) 4 ounces between meals, four times a day. Staff were to record the actual amount taken in. This order was received on 2/18/2025 and started on 4/28/2025.-An order for Super Cereal (a recipe that combines different ingredients and nutrients that when combined, makes a high-calorie, nutritious, and fortified cereal) at breakfast daily. Staff were to record the amount eaten. This order had a start date of 4/28/2025.An observation on 7/7/2026 beginning at 8:00 AM revealed Resident 46 sitting at the dining room table with a plate of scrambled eggs in front of them, the resident was not feeding themself. A staff person sat down with the resident at this time and fed them a bite of food and gave them a drink of liquid. At 8:04 AM the staff got up from beside the resident and left the room. At 8:11 AM another staff person sat down beside this resident and began feeding the resident some yogurt. The resident was not observed to have any choking episodes during this meal.A continuous observation on 07/08/2026 beginning at 7:47 AM revealed Resident 46 sitting at a table in the dining room in their wheelchair. The resident had a hot liquid cup that was full of a liquid, an 8-ounce (oz) plastic cup full of a clear liquid, a 4 oz plastic cup full of a yellow/orange liquid, and a 4 oz plastic cup with a brown liquid that was 3/4 empty. -At 7:54 AM, Resident 46 was observed taking drinks of the brown liquid and of the yellow/orange liquid.-At 8:03 AM, Resident 46 received their breakfast which consisted of yogurt, scrambled eggs, and ground meat. Staff put the foods on the table and then walked away from the resident. Resident 46 attempted to take a bite of food using their fork but the fork was empty before the resident got it to their mouth. The resident then took a couple of bites of eggs using their fingers, dropping portions of it before it got to their mouth.-At 8:18 AM, Resident 46 took a drink of their clear liquid. No staff had reapproached the resident and the resident had not eaten any more food.-At 8:27 AM, Resident 46 took a drink from their hot liquid cup. No staff had reapproached the resident and the resident had not eaten any more food.-At 8:30 AM, Medication Aide (MA)-R sat down next to Resident 46. Another MA walked over at this time and gave Resident 46 their crushed medications and then a drink of the brown liquid. MA-R then began giving Resident 46 bites of their yogurt.-At 8:42 AM, MA-R left the table, then another staff approached Resident 46, said something to them and then took the resident to their room. At this time, Resident 46's plate still contained the majority of the eggs and meat, the yogurt was empty, and the brown liquid was 80% empty. There was no evidence of Resident 46 being provided Super Cereal with their breakfast and the resident was not observed to have any choking episodes.An interview on 7/8/26 at 8:24 AM with a resident who sits at the same table as Resident 46 revealed they neglect that poor old (gender) in the yellow shirt, they won't even help (gender). They aren't helping (gender) eat at all. I'm going to call my lawyer.An observation on 7/8/2026 beginning at 11:56 AM revealed Resident 46 sitting at the dining room table drinking a brown liquid from a 4 oz cup, the resident did not have any food.-At 12:02 PM, Resident 46 had drunk approximately 50% of the brown liquid and had not yet received their lunch meal.An interview on 7/8/26 at 12:05 PM with Dietary Aide (DA)-S confirmed it was the dietary department's responsibility to give residents their drinks at mealtimes, including the supplements (such as Mighty Shakes) and also confirmed that the brown liquid Resident 46 had been drinking was their Mighty Shake. An observation on 07/08/2026 at 12:39 PM revealed Resident 46 had finished drinking all of their Mighty Shake and staff had begun assisting them with eating their food. The resident was not observed to have any choking episodes with this meal.A continuous observation on 7/9/2026 beginning at 7:58 AM revealed Resident 46 sitting at a table in the dining room with a full hot liquid cup, an 8 oz cup of clear liquid and a 4 oz cup of yellow/orange liquid. Resident 46 was drinking the yellow/orange liquid and had consumed about 75% at that time.-At 8:02 AM, Resident 46 was given their breakfast meal which consisted of scrambled eggs and ground meat on a plate and a cup of yogurt. Staff placed these items in front of the resident and then walked away. Resident 46 picked the cup of yogurt, brought it to their mouth, and was using their tongue to lick the yogurt from the cup.-At 8:06 AM, Resident 46 picked up some scrambled egg with their hand and placed it in their mouth.-At 8:20 AM, Resident 46 had finished their yellow/orange liquid, and they had placed a spoon in their yogurt cup. The majority of their food remained on their plate, and no staff had approached the resident since their food was delivered.-At 8:24 AM, Resident 46 picked up the yogurt cup and attempted to drink from it with the spoon still in the cup. The resident then put the cup down, wiped their face with a napkin and then tried to take a bite of yogurt using the spoon, but could not get the food end of the spoon to their mouth.-At 8:35 AM, Resident 46 turned their plate around and picked up some of the ground meat with their fingers and placed it in their mouth, dropping some of it in the process. No staff have approached the resident.-At 8:40 AM, Resident 46 took a bite of their yogurt.-At 8:49 AM, Resident 46 picked up some of the ground meat with their fingers and put it in their mouth. A staff comes and sits across the table from the resident and talks with the residents at the table but does not offer or attempt to assist Resident 46 with eating.-At 8:52 AM, the staff got up and left the table, then another staff went and sat down in the vacated seat.-At 8:57 AM, this staff person got up and then sat down beside Resident 46 and began to feed the resident their yogurt.There was no evidence of a Mighty Shake or Super Cereal being given to Resident 46 and resident was not observed to have any choking episodes.An interview on 7/9/2026 at 9:03 AM with Nurse Aide (NA)-T confirmed the Mighty Shakes and Super Cereal were to be distributed by the dietary staff. NA-T confirmed Resident 46 had not received either of these items that morning.An interview on 7/9/2026 at 9:03 AM with DA-C confirmed they had not given Resident 46 their supplements that morning. DA-C stated Resident 46 won't eat the Super Cereal, so I just don't give it to (gender). They don't eat their sausage either so I'm about to just not give (gender) that either.An interview on 7/9/26 at 9:45 AM with the Certified Dietary Manager (CDM) confirmed the dietary staff was responsible for distributing Mighty Shakes and Super Cereal to the residents; and that Mighty Shakes were distributed any time within that mealtime. CDM confirmed the Mighty Shake order for Resident 46 stated it was to be given between meals, not with meals. CDM stated Resident 46 sometimes refused these supplements, but staff should still be offering it to the resident as ordered. CDM confirmed the dietary staff should not be withholding the supplements when they are ordered for the residents.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observations, interviews, and record review, the facility failed to date and seal opened food items and failed to perform proper hand hygiene and change gloves while preparing and distributing food to prevent the potential for cross contamination and food-borne illness. The facility identified a census of 60. This had the potential to affect all residents who ate out of the kitchen. Findings are:A.During initial tour on 7/5/2026 from 6:10 PM until 6:53 PM, the following concerns were identified:-The walk-in refrigerator was found to have an opened, and sealed, block of sliced orange cheese with no expiration or opened date located.-The walk-in freezer was found to have a box of breakfast sausage links with the cardboard and plastic bag in the box opened. The plastic bag was not sealed, and the links were exposed. A box of frozen carrots was found with the cardboard and plastic bag in the box opened. The plastic bag was not sealed, and the carrots were exposed. A box of frozen peas was found with the cardboard and the plastic bag in the box opened. The plastic bag was not sealed, and the peas were exposed.-In the dry-food storage, a shelf of individual packets of sauces, honey, salt, pepper, mayo, and powder creamer were found in trays that were not the original boxes, and no dates were located on the packets or the trays.Interview with the Certified Dietary Manager (CDM) and Cook-G on 7/5/2026 at 6:37 PM confirmed the undated block of sliced cheese, the exposed frozen food items, and the undated individual packets. B.During an observation of meal prep on 7/8/2026 at 9:02 AM until 9:49 AM, Cook-E had dumped a container of cooked, cubed chicken into a griddle with gloves on. Cook-E removed their gloves and washed their hands for 5 seconds with soap outside running water. Cook-E put on new gloves and stirred the chicken with a spatula. With the same gloved hands, Cook-E grabbed a clean strainer and placed it by the sink. Cook-E opened the fridge door with same gloved hands and grabbed a bag of lettuce. Cook-E dumped the lettuce into the strainer and rinsed the lettuce in the sink. Cook-E did not touch the lettuce with their gloved hands. Cook-E removed their gloves and washed their hands with soap for 7 seconds outside of running water. With new gloves, Cook-E stirred the chicken. Cook-E removed their gloves and washed their hands with soap for 11 seconds outside of running water. Cook-E applied new gloves and measured the temperature of the chicken. Cook-E wrote that temperature in the temperature log and removed their gloves. Cook-E washed their hands for 7 seconds with soap outside of running water, applied gloves, and scooped chicken into a bowl with the spatula. After removing their gloves, washing their hands, and applying gloves, Cook-E touched the outside of the bag of tortillas and grabbed tortillas with their gloved hands and placed them on a baking pan. Cook-E proceeded to assemble a wrap. Cook-E opened the fridge door with their same gloved hands and grabbed a box of cheese and placed it on the counter. Cook-E removed their gloves and washed their hands for 10 seconds with soap outside of running water. Cook-E applied gloves and proceeded to assemble the wraps. When finished with the first bag of tortillas, Cook-E opened another bag of tortillas but didn't grab any tortillas. Cook-E washed their hands with soap outside of running water for 9 seconds. Cook-E covered a pan of wraps cut in half with foil, labeled the pan and placed it in the fridge. Cook-E washed their hands with soap for 7 seconds outside of running water.An observation during the meal prep on 7/8/2026 at 9:50 AM revealed CDM had washed their hands with soap for 2 seconds outside of running water. Dietary Aide(DA)-C had washed their hands for 3 seconds with soap outside of running water.A continued observation of Cook-E preparing wraps on 7/8/2026 at 10:00 AM revealed Cook-E, with gloved hands, had opened a tortilla bag and grabbed tortillas out of the bag with same gloved hands. Cook-E proceeded to make wraps and wrapped the wraps with same gloved hands. Cook-E removed gloves and washed hands with soap for 10 seconds outside of running water.An observation of Cook-G and CDM preparing lasagna on 7/8/2026 at 10:06 AM revealed CDM had applied soap then washed hands under running water. CDM did not scrub their hands with soap outside of running water. CDM applied gloves and stirred ground beef and cans of spaghetti sauce together. CDM removed gloves and washed hands with soap for 2 seconds outside of running water. CDM layered lasagna noodles onto spaghetti sauce in pan, and Cook-G used green-handled scoop to layer noodles with beef sauce. CDM dropped a noodle, picked it up with same gloved hands, threw it away, removed gloves, and washed hands with soap for 10 seconds outside of running water.An observation on 7/8/2026 at 11:20 AM revealed Cook-E preparing mechanical soft and pureed food. Cook-E washed hands with soap for 7 seconds outside of running water. Cook-E used chicken broth and vegetable broth to process with the menu items.An observation on 7/8/2026 at 11:45 AM until 12:37 PM revealed DA-F in the satellite kitchen preparing for the meal service. DA-F had touched a trash can lid with their hand and then put gloves on. DA-F opened the kitchen door with gloved hands, went in and out of the kitchen, walked back into the satellite kitchen, dropped a steak knife, and picked it up. With same gloved hands, DA-F flipped through the temperature log binder, opened the kitchen door, walked into and out of the kitchen, then removed gloves. Without washing their hands, DA-F applied new gloves and started cutting the foil off the steam table pans with the food in them and began scooping food out and serving. With same gloved hands, DA-F touched the kitchen door handle, but then turned around and went back to serving. DA-F then opened kitchen door again with same gloved hands and went into and out of the kitchen. DA-F came back into the satellite kitchen and proceeded to serve and touched a chicken wrap with same gloved hands.Record review of Policy & Procedure Manual: Hand Washing revealed staff should wash hands after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks; before donning disposable gloves for working with food and after gloves are removed; and after engaging in other activities that contaminate the hands. The procedure also revealed staff should scrub with soap for a minimum of 10 to 15 seconds within the 20 seconds hand washing procedure and rinse with clean, running warm water.An interview with CDM on 7/9/2026 at 9:55 AM confirmed that the kitchen staff should have washed their hands for at least 15 seconds outside of running water and should have changed gloves between tasks.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure 2 of 5 sampled Nurse Aides completed 12 hours of ongoing in-service training and at least 4 hours of dementia care training. This had the potential to affect all residents who resided within the facility. The facility identified a census of 60.Findings Are:A record review of the Facility Assessment Tool, last updated on 7/3/26 revealed that Nurse Aides (NA) must complete no less than 12 hours of in-service training per year and the training would include dementia management training. The in-service training would address areas of weakness as determined in NA's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.A record review of an undated and untitled facility-provided document revealed NA-B was hired on 3/6/23 and NA-D was hired on 7/2/25.A record review of NA-B's Training Hours dated 7/7/26 revealed NA-B had completed 11.8 hours of ongoing training and 2.25 hours of dementia care training.A record review of NA-D's Training Hours dated 7/7/26 revealed NA-d had completed 6.3 hours of ongoing training and 1.25 hours of dementia care training.An interview on 7/7/26 at 2:23 PM with Licensed Practical Nurse (LPN)-U confirmed there was no evidence of NA-B or NA-D completed any additional ongoing training or dementia care training.

Licensure Reference Number 175 NAC 12-006.05(D)&(E) Based on record review and interview, the facility failed to ensure residents or their representatives were informed in advance of the risks and benefits of a medication, the treatment alternatives or other options prior to the use of psychotropic medication for 7 (Residents 2, 8, 10, 24, 54, 57, and 62) of 7 sampled residents. The facility identified a census of 60.Findings are:Record review of psychotropic medication use policy with a revision date February 2025 revealed: Prior to initiating psychotropic medication, the staff will obtain documented consent from the resident or representative. A. Record Review of Resident 2's Face sheet dated 7/9/26 revealed an original admission date of 12/5/25 with the following relevant diagnosis: -Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Record review of Resident 2's Medications Administration History dated 6/10/26 through 7/9/26 revealed an order for: risperidone tablet 0.5milligrams (mg); take one tablet by mouth twice a day (BID) as needed (PRN) for agitation. The start date on this order was 6/9/26. The order was discontinued on 7/8/26. Record review of Resident 2's Medication Order with a start date of 6/5/2026 revealed an order for fluoxetine capsule, 20 mg, take 1 capsule by mouth once a day for dementia with agitation. There was no end date listed for this order. Record review of Resident 2's Medications Administration History from 6/10/26-7/9/26 revealed that Resident 2 received 6 doses of the PRN risperidone. Record review of Resident 2's paper chart and electronic medical record revealed there was no informed consent signed by the Resident or their Representative before the risperidone and fluoxetine medications were started. A document received from the facility on 7/7/26 labeled psychotropic medication consent revealed the names of the medications ordered (risperidone and fluoxetine), the name of the Resident's representative, with a date written as 7/7/26, and an unidentified staff signature with a date written as 7/7/26. This document also revealed that the consent was received by the representative via phone. An interview on 7/7/26 at 2:57 PM with the Director of Nursing (DON) confirmed there was no informed consent completed before 7/7/26 for Resident 2's Risperidone or Fluoxetine orders. B. Record review of Resident 8's face sheet dated 7/7/26 revealed an original admission date of 2/6/26 with the following relevant diagnoses: -Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; -Depression, unspecified; -Anxiety disorder, unspecified. Record review of Resident 8's medication orders revealed an order for escitalopram oxalate (an SSRI antidepressant prescribed to treat major depressive disorder and generalized anxiety disorder) tablet, 20mg, take 1 tablet by mouth once a day. This order started on 2/6/26. There was an additional order for: Vraylar capsule, 1.5mg, take 1 capsule by mouth once a day given for depression. This order started on 2/6/26. Record review of Resident 8's medications administration history from 2/6/26-3/6/26 revealed that Resident 8 received the escitalopram and the Vraylar every day between 7:00 and 10:00 AM. Record review of Resident 8's EMR and paper chart revealed no informed consent signed by the Resident or their representative before the escitalopram or Vraylar were started. A document received from the facility on 7/7/26 labeled psychotropic medication consent revealed the names of the medications ordered (Vraylar and escitalopram) and their doses, the name of the resident's representative with a date listed of 7/7/26, and two unidentified staff signatures with a date listed of 7/7/26. This document also revealed that the consent was received by the representative via phone. An interview at 2:57 PM on 7/7/26 with the DON confirmed there was no informed consent completed before 7/7/26 for Resident 8's Vraylar and escitalopram. C. Record review of Resident 10's face sheet dated 7/7/26 revealed an original admission date of 11/10/2023 with the following relevant diagnoses: - Anxiety disorder, unspecified; - Depression, unspecified. Record review of Resident 10's orders revealed an order for mirtazapine (atypical tetracyclic antidepressant. It is primarily used to treat major depressive disorder) tablet, 30mg, take 2 tablets by mouth, daily at bedtime. This order had a start date of 1/22/26. There was an order for: clonazepam (a prescription benzodiazepine used to treat panic disorders and certain seizure disorders) tablet, 1mg, take 1 tablet by mouth as needed, daily. This order had a start date of 5/14/26. There was an additional order for: clonazepam tablet, 1mg, take one tablet by mouth twice a day. This order had a start date of 5/29/26. Record review of Resident 10's medication administration history from 1/22/26-2/21/26 revealed that Resident 10 received their Mirtazapine medication every day between 7:00-10:00 PM. Continued record review of Resident 10's administration records from 5/11/26-6/10/26 revealed that Resident 10 received their scheduled clonazepam daily as ordered, and they received their PRN clonazepam 3 times. Record review of Resident 10's EMR and paper chart revealed there was no informed consent signed by the resident before their mirtazapine and clonazepam were started. A document received by the facility labeled Psychotropic Medication Consent received from the facility on 7/7/26 revealed 1 of the Residents relevant medications order (mirtazapine), a note that reads: [gender]'s [gender] own person, no resident name or signature, and an unidentified staff signature with a date written as 6/10/25. An additional document received from the facility also lists the resident's medication (mirtazapine) with the resident's name written in and a date listed as 1/22/26, and an unidentified staff signature with a date written as 7/9/26 with a line through it. Another document received from the facility on 7/9/26 revealed one of the Residents medications (clonazepam 1mg twice a day and PRN) with the resident's name and a date written as 7/14/26 with the 7 marked out and a 5 written next to it, and an unidentified staff signature with a date written as 7/14/26 with the 7 marked out and a 5 written next to it. An interview with Resident 10 at 12:28 PM confirmed that they don't recall receiving the psychotropic medication consents, their signature is not on it, and the hand-written name is not in their own handwriting. D: Record review of Resident 54's admission face sheet revealed an original admission date to the facility on 3/6/24 with the following relevant diagnoses: Other sexual disorders; Unspecified dementia (a decline in cognitive function that intervenes with daily life, including memory, thinking, reasoning, and behavior). Record review of Resident 54's active orders printed 7/8/26 revealed an order for donepezil (medication used to treat dementia by improving memory, attention, and daily functioning) which was initiated 4/26/25, fluoxetine (medication used to treat certain mental health conditions) which was initiated 4/26/25, and paroxetine (medication used to treat conditions by increasing serotonin levels in the brain) which was initiated 06/17/2025. Record review of Resident 54's medication order revealed an order for haloperidol (an antipsychotic medication used to treat psychiatric conditions) which was initiated 7/2/26. Record review of Resident 54's paper chart and electronic health record (EHR) revealed there was no informed consent for donepezil, fluoxetine or paroxetine. An informed consent for haloperidol was identified with a date of 07/07/2026. Interview with DON 07/07/2026 at 2:57 PM confirmed there was no informed consent completed before 07/07/2026. E: Record review of Resident 57's admission face sheet revealed an original admission date to the facility on [DATE] with the following relevant diagnoses: Unspecified dementia (a decline in cognitive function that interferes with daily life, including memory, thinking, reasoning, and behavior); Anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident 57's orders printed 7/8/26 revealed an order for: donepezil (medication used to treat dementia by improving memory, attention, and daily functioning) which was initiated 1/20/26, quetiapine (an antipsychotic medication used to treat mental health conditions) which was initiated 4/4/26, and duloxetine (medication used to treat depression and anxiety) which was initiated 2/17/26. Record review of Resident 57's paper chart and EHR revealed there was no informed consent for donepezil. An informed consent for quetiapine and duloxetine was identified with a date of 07/07/2026. Interview with DON 07/07/2026 at 2:57 PM confirmed there was no informed consent completed before 07/07/2026. F. Record review of Resident 62's Resident Face Sheet dated 7/9/2026 revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 4/17/2025. Record review of Resident 62's Order History printed 7/9/26 revealed an order for Lexapro (escitalopram oxalate) tablet once a day. This medication started on 3/21/2025 and discontinued 4/2/2025. Record review of Resident 62's Resident Progress Notes revealed a note dated 3/20/2025 regarding a medication review with a Nurse Practitioner for continued behaviors. The note revealed an order for Lexapro 10mg by mouth once a day and to discontinue Seroquel as needed (PRN). The note did not reveal the Power of Attorney (POA)/Legal Guardian was notified of this change and new medication. Further record review of Resident 62's Progress Notes revealed a note dated 4/1/2025 for a request for Lexapro to be discontinued due to refusals and the POA stated that Resident 62 did not want nor need that medication. Record review of Resident 62's electronic medical record revealed no evidence of the facility contacting the POA about starting Resident 62 on Lexapro. Interview with the Director of Nursing (DON) on 7/9/2026 at 12:25 PM confirmed the facility did not have any documentation notifying Resident 62's POA for starting Lexapro. G. A record review of Resident 24's Facesheet dated 7/9/26 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 24's Active Orders revealed the resident had the following psychotropic medication orders: -alprazolam (an anti-anxiety medication) 0.25 mg, to be given daily at bedtime. This medication had a start date of 1/7/26. -paroxetine (an antidepressant medication) 30 mg daily. This order had a start date of 6/5/26. -Zyprexa (an antipsychotic medication) 2.5 mg, to be given three times a day. This order had a start date of 5/8/26. A record review of a Psychotropic Medication Consent form for Resident 24 revealed the facility provided this form to the resident's representative with information on the risks and benefits of their paroxetine and Zyprexa via telephone on 7/7/26. A record review of Resident 24's medical records revealed no evidence of informed consent being obtained from the resident or their representative related to their alprazolam medication. There was also no evidence of informed consent being obtained from the resident or the representative prior to 7/7/26 for their paroxetine or Zyprexa. An interview on 7/7/26 at 2:57 PM with the DON confirmed there was no informed consent completed before 7/7/26.

Licensure reference number: 175 NAC 12-006.09(D) Based on record review, interview and observation, the facility failed to submit accurate minimum data set (MDS, a federally mandated clinical assessment tool used in Medicare and Medicaid-certified nursing facilities to evaluate a resident's physical, cognitive and psychosocial health status and dictates individualized care plans and determines facility Medicare and Medicaid reimbursements) for 1 (Resident 43) of 3 residents sampled. The facility identified a census of 60 residents. Findings are:Record review of Resident 43's quarterly MDS assessment dated [DATE] revealed the following:Section N (medications) coded the resident as receiving an antibiotic during the look-back period. Review of physician orders and the medication administration record (MAR) revealed the resident was not receiving an antibiotic. The resident had been prescribed methenamine Hippurate since 08/20/2025, which is an anti-infective urinary antiseptic and is not classified as an antibiotic according to the Federal Drug Administration.Section O (special treatment, procedures, and programs) coded the resident as having intravenous IV) access during the assessment reference period.During an interview on 07/08/2026 at 1:08 PM, the MDS Coordinator reviewed the MDS documentation and confirmed the inaccurate codings in Section N and Section O.

Licensure reference number 175 NAC 12-006.05(G) Based on record reviews and interviews, the facility failed to ensure physician follow up and provide clinical rationale for the continued use of as needed antipsychotic medication for 1 (Resident 2) out of 5 sampled residents. The facility showed a census of 60. Findings are:Record review of Resident 2's face sheet dated 7/7/26 revealed an original admission date of 12/5/2025 with the following relevant diagnosis:-Dementia in other diseases classified elsewhere, unspecified severity, with agitation.Record review of Resident 2's undated Continuity of Care Document, revealed an order for: risperidone (atypical antipsychotic medication) 0.5 milligram (mg) tablet, take one tablet as needed twice a day for agitation. The start date on this order was 6/9/26 and this medication was last administered on 7/1/26 at 8:16 PM.Record review of Resident 2's administration record from 6/10/26-7/9/26 revealed Resident 2 received 6 doses of risperidone.Record review of Resident 2's Electronic Medical Record (EMR) and paper chart revealed no documentation of in-person physician visits every 14 days, no documentation of the order being renewed every 14 days, and no informed consent signed by the resident or their representative before the medication was started. A document received from the facility on 7/7/26 revealed Resident 2's name, the relevant medication order, the resident's representative name with a date of 7/7/26, an unidentified staff member's signature, and a date of 7/7/26. This document also revealed that consent was received from the resident's representative via phone.An interview with the DON at 9:15 AM on 7/9/26 confirmed they do not have a clinical rationale for the PRN risperidone that explains why there is no stop date or clinical rationale for having the medication over 14 days, and that they have contacted the prescriber to provide them with a clinical rationale.An interview with the DON at 11:35 AM on 7/9/26 confirmed that they do not have documentation of revisits with the prescribing provider for the PRN risperidone or any order renewals for this medication every 14 days.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to notify Adult Protective Services (APS) of alleged resident-to-resident abuse for Resident 54. failed to notify APS within the required timeframe of an injury of unknown origin for Resident 6, and failed to submit an investigation report to the State Agency within the required timeframe for Residents 54 and 6. The sample size was 4 and the facility identified a census of 60. A record review of the facility policy Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating with a revision date of July 2026 revealed all allegations of resident abuse (including injuries of unknown source), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations). A. A record review of Resident 54's Facesheet dated 7/8/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior)) with behavioral disturbances, other sexual disorders, and high risk heterosexual behaviors. A record review of Resident 54's Progress Notes from June 2025 through July 8, 2026, revealed the following resident to resident incidents documented: -On 6/3/2025 this resident and another resident were whispering to each other at the dining room table. Resident 54 was holding onto the other resident's forearms and the nurse witnessed Resident 54 grope the other resident's breasts. The nurse reported the incident to the Director of Nursing (DON), Adult Protective Services (APS) and the Power of Attorney (POA) were notified, and staff were to keep the residents separated at all times. -On 6/4/2025, Resident 54 continued to make contact with and hold the hands of the resident from 6/3/2025. -On 6/8/2025, another resident went to sit by Resident 54. Resident 54 yelled, Get up at the other resident while giving them dirty looks. The other resident got up and left the area upset. The nurse told Resident 54 that this wasn't kind, and to be nice and leave the other resident alone when they aren't bothering anyone. -Later in the day on 6/8/2025, Resident 54 was being assisted to their room when they saw another resident, who asked them, where are you going? This resident replied, I am going to bed, you should come to bed with me. Staff documented the charge nurse was aware. -On 9/6/2025, Resident 54 wheeled themself over to another resident and attempted to grab/touch them. Staff redirected Resident 54, took them to their room, and told them it is not appropriate to touch other residents. -On 11/23/2025, Resident 54 was making inappropriate gestures towards another resident. Resident 54 was removed from the area, and staff discussed the importance of appropriate communication with other residents. -On 12/26/2025, Resident 54 was observed going up to another resident and grabbing the other resident's breasts. The nurse advised Resident 54 to stop and keep hands to self. -On 3/26/2026, facility staff contacted Resident 54's psych provider as this resident had placed their hands on another resident's buttocks and attempted to grab another resident. -On 4/27/2026, Resident 54 grabbed another resident's hand and attempted to place their hand on Resident 54's genital area. Staff intervened and separated the residents. Staff explained to Resident 54 that they are not allowed to touch staff or other residents, the resident responded stating Oh, why? I like it. The nurse explained to Resident 54 that this is a violation and sexual assault and if they continued, legal action may be taken. Resident 54 stated but I like to touch. The nurse reinforced the education and alerted the DON and Social Services. The note then stated the plan of care was ongoing and the resident was watching television with their spouse in the south living room. Later this same morning, Resident 54 saw another resident walking by and attempted to touch them. Staff intervened, removed the other resident, then took this resident to activities. -Later on 4/27/2026, Resident 54 was attempting to grab another resident's breast, making a squeezing action. Staff intervened, took Resident 54 to their room, and educated the resident about appropriate behavior. Resident 54 did not believe they had done anything wrong stating that is not exactly what I was doing. The resident then stated to another resident Let me see your tittys. The nurse again took Resident 54 to their room and educated them on appropriate behavior. -On 4/30/2026, Resident 54 was sitting in the commons area and stated come here so I can rub your tummy to another resident as they walked past. Staff intervened and removed the resident from the situation. A short time later, the same resident walked in front of Resident 54 in the dining room and Resident 54 yelled get (gender) out of here. -On 5/6/2026, Resident 54 was walking to the dining room, approached a resident of the opposite gender, and forcefully grabbed their hand and attempted to place the other resident's hand between (gender) crotch. A nurse aide hollered no and stopped Resident 54 from placing the other resident's hand on them. Staff separated the two residents and moved Resident 54 to a different room for closer observation. Messages left for Resident 54's provider and POA. DON and Social Services were made aware. This incident was reported to the State. -On 5/18/2026, Resident 54 was found by staff attempting to lift up another resident's shirt. Staff intervened and Resident 54 stated, What, I was just trying to feel them up. Resident was removed from the room, and the nurse attempted to explain why this behavior was inappropriate, to which the resident stated, I just can't help myself. -On 5/28/2026, Resident 54 was reaching for a resident of the opposite gender, got ahold of the resident's hands and attempted to pull the resident closer to them. Staff intervened and asked Resident 54 what they were doing. The resident replied, I wanted to touch (gender) titties. The other resident was moved away from this resident. -On 6/27/2026, Resident 54 was moved away from another resident due to Resident 54 rubbing their hands on the other resident's breast. Resident 54 was talked to about keeping their hands to themself and the charge nurse was notified. -On 6/28/2026, Resident 54 had been making sexual comments to staff and other residents. The resident was also making attempts to grab staff's buttocks and breasts. The resident was educated about being appropriate, redirected, and distraction interventions were used which was successful at the time of the incident(s). Resident 54 stated they did not understand why they could not touch people or make comments. The resident was educated again and continued to have sexual behaviors. Later this same day, Resident 54 was moved to their room to watch television due to sexual comments being made to staff and other residents. Resident 54 had also been reaching to touch another resident. Resident 54 was educated, their POA and the administrator were notified. An interview on 7/8/26 at 4:45 PM with the facility Administrator confirmed the facility had no further information aside from the Progress Notes regarding Resident 54's resident-to-resident incidents over the prior year. An interview on 7/9/26 at 8:10 AM with the facility Administrator confirmed the resident-to-resident incidents documented in Resident 54's Progress Notes on 6/8/2025, 9/6/2025, 11/23/2025, 12/26/2025, 3/26/2026, 4/27/2026, 4/30/2026, 5/18/2026, 5/28/2026, 6/27/2026, and 6/28/2026 should have been reported to the State and were not. A record review of a facility provided fax document revealed the facility attempted to fax an Investigation Report for Resident 54's resident-to-resident sexual behaviors that occurred on 5/6/2026, on 5/8/2026. The document stated the fax was not sent, the result: Communication failed because the line is busy at the fax destination, etc. Wait a moment, then try again. There was no evidence provided of the facility attempting to re-fax or send the document through another means. An interview on 7/8/26 at 12:00 PM with the facility Administrator revealed the facility was not able to locate evidence of their investigative report for the resident-to-resident incident that occurred on 5/6/26 being successfully sent to the State Agency as required. B. Record Review of Resident 6's Resident Face Sheet dated 7/7/2026 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Dementia with Behavioral Disturbance (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior] with non-cognitive symptoms like agitation, aggression, wandering, and hallucinations). Record review of Resident 6's Resident Progress Notes revealed a note dated 10/8/2025 at 1:19 PM regarding a bruise noted to Resident 6's right forearm. The bruise was dark purple in color and measured 10 centimeters (cm) by (x) 10 cm. The note revealed Resident 6 was unable to state what happened and the nursing staff member stated Resident ambulates throughout facility, may have bumped gender arm somewhere. The note revealed that a referral was made to the Nurse Practitioner and a message left for Resident 6's Power of Attorney (POA). Further record review of Resident 6's Progress Notes revealed a note dated 10/18/2025 at 2:22 PM a bruise on right lower arm (RLA) of Resident 6 and was measured to be 11x12 cm and still has purple, blue, and green bruising to area. Record review of Resident 6's NRC Weekly Skin Observation dated 10/18/2025 at 3:57 PM revealed Resident 6's bruise was purple, blue, and had some yellow which indicated healing. Unknown how pt (resident) received bruise to RLA as pt is unable to report how (gender) received it. Record review of Adult Protective Services (APS) Intake Worksheet with date received at 10/20/2025 at 2:49 PM revealed the facility reported Resident 6's bruise of unknown origin that measured about 11x12cm, with purple and green hues, on right lower arm. The report revealed that Resident 6 was unable to tell the reporter where Resident 6 got the bruise due to their cognitive impairment. Interview with Administrator (ADM) on 7/9/2026 at 9:31 AM confirmed that the initial bruise was 10/8/2025, and the report was made to APS on 10/20/2025. ADM confirmed that this was past the two hours to report.

Licensure Reference Number 175 NAC 12-006.08Based on record review and interviews, the facility failed to ensure 1 (Resident 3) of 2 sampled residents' provider was notified of their significant weight loss. The facility identified a census of 60. Findings are: Record review of Resident Face Sheet dated 7/7/2026 revealed that Resident 3 was admitted to the facility on [DATE]. Record review of Corp - Weights Detail Report revealed Resident 3's weights from 2/2026 through 5/2026 as followed:- 2/25/2026 106 pounds (lbs),- 3/11/2026 112 lbs,- 3/25/2026 107.8 lbs,- 4/01/2026 94 lbs,- 4/23/2026 94 lbs,- 4/29/2026 94 lbs,- 5/6/2026 93.4 lbs,- 5/20/2026 94 lbs,- 5/27/2026 96 lbs. Resident 3's weight of 107.8 lbs on 3/25/2026 and 94 lbs on 4/1/2026 was a 12.8% weight loss in 1 week. Resident 3's weight of 106 lbs on 2/25/2026 and 96 lbs on 5/27/2026 was a 9.4% weight loss in 3 months. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities), dated October 2025, revealed that in Chapter 3, Section K, weight changes of 5% in 1 month or 7.5% in 3 months should prompt thorough assessment of the resident's nutritional status. It also revealed that if the resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Record review of Resident Progress Notes pertaining to Resident 3 revealed a dietary note from 3/11/2026 at 12:25 PM signed by the dietician. This note revealed that there was no significant weight changes noted at that time because of left hip surgery and femur fracture. The resident had a readmission date of 3/5/2026 from that hospital stay. The note stated that the facility would continue to monitor weekly weights and there were no changes to recommend at that time. Further record review of Resident 3's Progress Notes revealed that between 4/1/2026 and 4/8/2026 there was no evidence of the provider being notified of Resident 3's 12.8% weight loss from the week 3/25/2026 to 4/1/2026. Further record review of Resident Progress Notes revealed a dietary note written by the dietician from 4/8/2026 at 10:09 AM. The note revealed that Resident 3 had an 11% weight loss in 30 days and change of 14.5% in 90 days. It was noted that staples were discontinued to the left hip on 3/26/2026. Their recommendation was to update nutritional care plan. Record review of Care Plan (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), undated, revealed a problem of nutritional status, started 12/9/2025. An approach to this problem was to notify the physician of significant weight loss/gain, started 12/9/2025. The last revision date was 6/26/2026. Record review of Order History for the dates of 3/1/2026 to 7/9/2026 revealed that Resident 3 was never ordered a diuretic between those dates. Resident 3 was ordered to start Ensure, in-between meals, twice a day starting on 5/14/2026. Record review of The Residency Continuity of Care Document, dated 7/7/2026, revealed that Resident 3 was not ordered a diuretic that would have been started in March 2026. Interview with Certified Dietary Manager (CDM) on 7/9/2026 at 11:25 AM confirmed that Resident 3 was not on a diuretic between March 2026 and April 2026. CDM revealed that they requested a reweight from the nurse aides on 4/13, but a reweight was never completed. CDM confirmed that the dietician would refer to the charge nurse or MDS coordinator to contact the provider. CDM confirmed that the provider was not notified of Resident 3's weight loss. Interview with the Director of Nursing (DON) on 7/9/2026 at 12:28 PM confirmed that there was no evidence of the provider being notified of Resident 3's significant weight loss. Interview with Nurse Consultant (NC)-L on 7/9/2026 at 12:35 PM confirmed that the 12.8% loss was a significant weight loss and the provider should have been notified.

Licensure Reference Number 175 NAC 1-005.06(C) Based on record review and interview, the facility failed to ensure the use of an antibiotic was clinically indicated for 1 (Resident 24) of 2 sampled residents. The facility identified a census of 60.Findings Are:A record review of facility policy Antibiotic Stewardship with a revision date of December 2016 revealed when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.A record review of facility policy Antibiotic Stewardship-Orders for Antibiotics with a revision date of December 2016 revealed appropriate indications for use of antibiotics include:a. criteria met for clinical definition of active infection or suspected sepsis; andb. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).A record review of Resident 24's Facesheet dated 7/9/2026 revealed the resident was admitted to the facility on [DATE].A record review of Resident 24's undated Care Plan revealed the resident had a history of Urinary Tract Infection (UTI) and had an intervention stating to report signs of UTI to provider: acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine.A record review of Resident 24's Progress Notes for June and July 2026 revealed:-On 6/16/2026 staff notified Resident 24's provider that the resident had been lethargic and not wanting to get up. The provider ordered a urinalysis (UA) with possible culture. Later that same day, the UA was obtained via clean catch (a method characterized by cleaning the genital area and catching only the midstream portion of the urine flow) and taken to the laboratory.-On 6/18/2026, Resident 24 was exit seeking and upset, stating they were being held against their will and was kidnapped. The facility placed a Wander Guard on the resident's walker for their safety.-On 6/19/2026, Resident 24's provider was in the facility and reviewed the UA results. Provider gave an order for cephalexin (an antibiotic medication) 500 milligrams (mg) to be given twice daily for seven days.-On 6/20/2026, staff documented that Resident 24 had no adverse effects from their antibiotic and there was no increased confusion noted. A short time later, staff documented that the resident was confused while taking their medications and required reassurance and step by step instructions on how to take the medications.Further record review of Resident 24's medical records revealed no evidence of the resident having symptoms of an infection.A record review of a Centers for Disease Control (CDC) document titled NHSN Long-term Care Facility Component-Urinary Tract Infection and dated January 2025 revealed in Figure 1: Criteria for Defining Non-Catheter Associated Symptomatic Urinary Tract Infection (SUTI) that one of the required criteria for a urinary tract infection was a positive urine culture with no more than 2 species of microorganisms, at least one of which is a bacterium of greater than or equal to 100,000 CFU/ml (colony-forming units per milliliter, a unit of measurement used in microbiology to estimate the number of viable (living and reproducing) bacteria or fungal cells in a liquid sample). The document also revealed that mixed flora often represents contamination.A record review of Resident 24's Clinical Laboratory Results revealed a urinalysis (UA) was collected from the resident on 6/16/2026. The Urine Culture section dated 6/18/2026 revealed a final result of greater than 100,000 CFU/mL Mixed Bacteria. The comments section just below this revealed Mixed Flora- more than 3 organisms isolated. Please review specimen collection procedure and consider resubmitting specimen if clinically indicated. Resident 24's provider handwrote on this page an order for cephalexin 500 mg twice a day for 7 days and to encourage hydration, with a date of 6/19/2026. There was no evidence of the provider requesting a repeat UA to be done. A record review of Resident 24's medical records revealed no evidence of the facility requesting a repeat UA or addressing that the prescribed antibiotic was not clinically indicated. An interview on 07/08/2026 at 1:04 PM with the Director of Nursing (DON) revealed their process for antibiotic stewardship was to print off the order when a resident was placed on an antibiotic. The DON did not indicate that they conducted follow up with the providers when there was a question of the medication not being clinically indicated.

Licensure Reference Number 175 NAC 12-006.05(H) Based on record review and interview, the facility failed to protect other residents from 1 (Resident 54) of 1 sampled resident's adverse behaviors. The facility identified a census of 60.Findings Are:A record review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program with a revision date of April 2021 revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy stated objectives to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and to protect residents from any further harm during investigations.A record review of Resident 54's Facesheet dated 7/8/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior)) with behavioral disturbances, other sexual disorders, and high risk heterosexual behaviors.A record review conducted on 7/8/2026 of Resident 54's Care Plan revealed the resident had physical and verbal behavioral symptoms toward others; this had a start date of 3/25/2024. There was additional information stating that on 5/6/2026, the resident had grabbed another resident and forcefully tried to put the other resident's hand in their crotch and that staff had intervened. There were no other resident-to-resident incidents listed in the care plan. The interventions for this area were:-Assess whether the behavior endangers the resident and/or others, intervene if necessary. This had a start date of 3/25/2026.-Maintain a calm environment and approach to the resident. This had a start date of 3/25/2026.-When Resident 54 has physical or verbal behaviors, keep distance between resident and others (e.g. staff, other residents, visitors). This had a start date of 3/25/2026.-Notify Resident 54's provider as needed. This had a start date of 5/9/2026. A record review of Resident 54's Observations revealed the following Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) scores:-On 11/4/2025 the resident had a score of 12/15, indicating the resident had moderately impaired cognition.-On 2/2/2026 the resident had a score of 12/15, indicating the resident had moderately impaired cognition.-On 5/1/2026 the resident had a score of 11/15, indicating the resident had moderately impaired cognition. A record review of Resident 54's Progress Notes from June 2025 through July 8, 2026, revealed the following resident to resident incidents documented:-On 6/3/2025 this resident and another resident were whispering to each other at the dining room table. Resident 54 was holding onto the other resident's forearms and the nurse witnessed Resident 54 grope the other resident's breasts. The nurse reported the incident to the Director of Nursing (DON), Adult Protective Services (APS) and the Power of Attorney (POA) were notified, and staff were to keep the residents separated at all times.-On 6/4/2025, Resident 54 continued to make contact with and hold the hands of the resident from 6/3/2025.-On 6/5/2025, the facility contacted Resident 54's provider and requested a psychiatric consultation for the resident's sexual behaviors.-On 6/6/2025, the facility received an order for Resident 54 to be evaluated by the psychiatric provider as soon as possible. Scheduling had been notified of this order.-On 6/8/2025, another resident went to sit by Resident 54. Resident 54 yelled, Get up at the other resident while giving them dirty looks. The other resident got up and left the area upset. The nurse told Resident 54 that this wasn't kind, and to be nice and leave the other resident alone when they aren't bothering anyone.-Later in the day on 6/8/2025, Resident 54 was being assisted to their room when they saw another resident, who asked them, where are you going? This resident replied, I am going to bed, you should come to bed with me. Staff documented the charge nurse was aware.-On 6/9/2025, the facility was notified that Resident 54 would be seen by the psych provider at the facility on 6/17/2025.-On 6/17/2025, Resident 54 was seen by the psych provider and the facility received orders to discontinue their fluoxetine (an antidepressant medication) and to start paroxetine (an antidepressant medication) 40 milligrams (mg) daily for inappropriate sexual behaviors such as touching other residents' breasts. The resident was to see the provider again in one month.-On 8/22/2025, Resident 54 was seen by a psych provider. The progress note stated the resident was started on gabapentin (an anticonvulsant medication) 10mg in 4/2024 which was not effective. Then was placed on fluoxetine, then switched to paroxetine 40 mg, which was not effective. The facility was to do a gradual dose reduction of the paroxetine and reduce it to 20 mg every morning and add medroxyprogesterone (a synthetic form of the hormone progesterone) 5 mg for management of inappropriate sexual behaviors.-On 9/6/2025, Resident 54 wheeled themself over to another resident and attempted to grab/touch them. Staff redirected Resident 54, took them to their room, and told them it is not appropriate to touch other residents.-On 11/7/2025, Resident 54 was seen by their provider with no changes made to their medication regimen.-On 11/23/2025, Resident 54 was making inappropriate gestures towards another resident. Resident 54 was removed from the area, and staff discussed the importance of appropriate communication with other residents. The staff also discussed the incident with other staff, so they were aware of the situation and this resident's placement near other residents.-On 11/26/2025, staff documented that Resident 54 was having an increase in inappropriate sexual behaviors and a referral was made to their provider. Later that same day, the provider wrote an order for paroxetine 30 mg daily for inappropriate sexual behaviors.-On 12/26/2025, Resident 54 was observed going up to another resident and grabbing the other resident's breasts. The nurse advised Resident 54 to stop and keep hands to self.-On 1/8/2026, staff documented Resident 54 was seen by the psych provider and that the resident would be monitored for two months.-On 2/3/2026, Resident 54 was observed during an activity holding hands with another resident. Staff separated the residents and then while the staff was telling Resident 54 it was inappropriate to hold other residents' hands, the resident reached up and grabbed the staff's breast. The resident was removed from the situation and educated.-On 2/18/2026, Resident 54's psych provider wrote a new order for Provera (a synthetic form of the hormone progesterone) 5mg twice daily for sexual disinhibition.-On 3/4/2026, Resident 54 was in a resident of the opposite gender's room while the other resident was sleeping, looking at the other resident. Staff removed Resident 54 from the room.-On 3/26/2026, facility staff contacted Resident 54's psych provider as this resident had placed their hands on another resident's buttocks and attempted to grab another resident. The provider placed an order for Depakote (a mood stabilizing medication) 125 mg twice daily.-On 4/4/2026, Resident 54 was seen by the psych provider and received an order to increase the Depakote to three times a day for sexual disinhibitions.-On 4/27/2026, Resident 54 grabbed another resident's hand and attempted to place their hand on Resident 54's genital area. Staff intervened and separated the residents. Staff explained to Resident 54 that they are not allowed to touch staff or other residents, the resident responded stating Oh, why? I like it. The nurse explained to Resident 54 that this is a violation and sexual assault and if they continued, legal action may be taken. Resident 54 stated but I like to touch. The nurse reinforced the education and alerted the DON and Social Services. The note then stated the plan of care was ongoing and the resident was watching television with their spouse in the south living room. Later this same morning, Resident 54 saw another resident walking by and attempted to touch them. Staff intervened, removed the other resident, then took this resident to activities.-Later on 4/27/2026, Resident 54 was attempting to grab another resident's breast, making a squeezing action. Staff intervened, took Resident 54 to their room, and educated the resident about appropriate behavior. Resident 54 did not believe they had done anything wrong stating that is not exactly what I was doing. The resident then stated to another resident Let me see your (breasts). The nurse again took Resident 54 to their room and educated them on appropriate behavior.-On 4/28/2026, the facility documented that on 4/27/2026, the facility contacted law enforcement and had the police officer meet with Resident 54 regarding their inappropriate physical contact with others. The officer spoke with the resident, who stated they understood the concern and would keep their hands to themself going forward. Resident 54's POA was also contacted and the POA requested the facility contact the resident's psych provider.-On 4/28/2026, the facility received orders from a provider to discontinue Resident 54's finasteride (an androgen inhibitor medication), gabapentin, singulair (a cold medication), and Myrbetriq (a medication used to treat overactive bladder). Later that day, the facility received orders from Resident 54's psych provider to reduce their Depakote over the following 8 days, then discontinue; and to increase their medroxyprogesterone to 10 mg twice daily.-On 4/30/2026, Resident 54 was sitting in the commons area and stated come here so I can rub your tummy to another resident as they walked past. Staff intervened and removed the resident from the situation. A short time later, the same resident walked in front of Resident 54 in the dining room and Resident 54 yelled get (gender) out of here.-Later on 4/30/2026, Resident 54 was sitting in the commons area with their hand in their pants, touching their genitals. The nurse told the resident to remove their hand from their pants, which the resident did.-On 5/6/2026, Resident 54 was walking to the dining room, approached a resident of the opposite gender, and forcefully grabbed their hand and attempted to place the other resident's hand between (gender) crotch. A nurse aide hollered no and stopped Resident 54 from placing the other resident's hand on them. Staff separated the two residents and moved Resident 54 to a different room for closer observation. Messages left for Resident 54's provider and POA. DON and Social Services were made aware. This incident was reported to the State. -On 5/8/2026, Resident 54 was seen by their psych provider and orders were received to discontinue their Aricept (a medication used to treat dementia), medroxyprogesterone, and paroxetine. A new order was received to start cimetidine (a medication that reduces stomach acid production) 200 mg four times a day.-On 5/18/2026, Resident 54 was found by staff attempting to lift up another resident's shirt. Staff intervened and Resident 54 stated, What, I was just trying to feel them up. Resident was removed from the room, and the nurse attempted to explain why this behavior was inappropriate, to which the resident stated, I just can't help myself.-On 5/28/2026, Resident 54 was reaching for a resident of the opposite gender, got ahold of the resident's hands and attempted to pull the resident closer to them. Staff intervened and asked Resident 54 what they were doing. The resident replied, I wanted to touch (gender) (breasts). The other resident was moved away from this resident.-On 6/5/2026, Resident 54 was seen by their psych provider. The provider wrote to discontinue the cimetidine, medroxyprogesterone, and to start trazodone (an antidepressant medication) 50 mg four times a day. The provider also wanted a valproic acid level drawn and would follow up in 1 month.-On 6/27/2026, Resident 54 was moved away from another resident due to Resident 54 rubbing their hands on the other resident's breast. Resident 54 was talked to about keeping their hands to themself and the charge nurse was notified.-On 6/28/2026, Resident 54 had been making sexual comments to staff and other residents. The resident was also making attempts to grab staff's buttocks and breasts. The resident was educated about being appropriate, redirected, and distraction interventions were used which was successful at the time of the incident(s). Resident 54 stated they did not understand why they could not touch people or make comments. The resident was educated again and continued to have sexual behaviors. Later this same day, Resident 54 was moved to their room to watch television due to sexual comments being made to staff and other residents. Resident 54 had also been reaching to touch another resident. Resident 54 was educated, their POA and the administrator were notified.-On 6/30/2026, Resident 54 had been trying to follow another resident around even after Resident 54 was told the other resident did not want followed. Resident 54 was not easily redirected.-On 7/7/2026, Resident 54 was seen by their psych provider. The resident was to continue their current medication regimen, and they would add Haldol (an antipsychotic medication) 5 mg twice a day. The provider would follow up with the resident in 1 month.An interview on 7/8/26 at 4:45 PM with the facility Administrator confirmed educating a resident with cognitive impairment, like Resident 54, was not an effective intervention for resident-to-resident behaviors. The Administrator also confirmed the facility had no further information aside from the Progress Notes regarding Resident 54's resident-to-resident incidents or interventions over the prior year. An interview on 7/9/26 at 8:00 AM with the facility Administrator confirmed the medication changes were not working to mitigate Resident 54's behaviors toward other residents. An interview on 7/9/2026 at 8:00 AM with the Director of Nursing revealed we would be calling State three times a day if we called each time Resident 54 had a behavior.

Licensure Reference Number 175 NAC 12-006.04(A)(iii) Based on record review and interview, the facility failed to conduct a criminal background check prior to the start date of 1 of 5 sampled employees. This had the potential to affect all residents who resided within the facility. The facility identified a census of 60. Findings Are:A record review of an undated New Hire Checklist for Nurse Aide (NA)-A revealed the NA had a start date of 5/21/2026.A record review of a Background Screening Report for NA-A revealed the report was ordered on 5/28/2026 and was completed on 5/29/2026, 8 days after the NA's start date. There were no adverse findings on this report.An interview on 7/7/26 at 11:20 AM with Human Resources (HR) confirmed NA-A's background check was completed on 5/29/2026, which was after their start date.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1),(3), & (4)Based on record review, interview and observation, the facility failed to identify causal factors and implement interventions to prevent falls, and ensure resident safety for 4 (Resident 1, 5, 3, and 7) out of 7 sampled residents. The facility showed a census of 55.Findings are: A. Record review of Resident 1's Census dated 3/10/2026 revealed an admission date of 1/2/2026. A record review of Resident 1's Care plan revealed the following diagnoses: -Unspecified systolic congestive heart failure, -Unspecified atrial fibrillation, -Unspecified combined systolic and diastolic heart failure, -Atypical atrial flutter, -Weakness, -Dizziness and giddiness. Record review of Resident 1's progress note at 12:04 PM on 1/2/2026 revealed the facility received report from the discharging facility and the resident required the assistance of 1 person and their walker for ambulation and transfers, and that the resident had confusion at times. A progress note from 12:30 on 1/2/2026 revealed resident does appear disoriented at times. Progress note written at 10:16 on 1/3/2026 revealed therapy recommended one staff member to provide assistance for mobility in Resident 1's room with use of 4 wheeled walker and gait belt, and use of manual wheelchair for mobility outside resident room. A record review of Resident 1's Minimum Data Set (MDS)(a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate residents' physical, functional, and psychological capabilities) dated 1/9/2026 revealed a Brief Interview for Mental Status (BIMS) (a tool used to screen for cognitive impairment) revealed a score of 13 indicating the resident is cognitively intact. The MDS also revealed Resident 1 was taking anticoagulants. Record review of Resident 1's undated care plan revealed a problem start date of 2/11/2026 for the category of 'Delerium; Resident experiencing delirium as evidenced by: Fluctuating cognition and alertness, Periods of confusion, reports of vivid dreams and difficulty distinguishing dreams from reality'. Record review of a progress note from 7:20 PM on 1/31/2026 revealed a nurse was called into Resident 1's room to assess the resident after an unwitnessed fall. Record review of Fall investigation packet revealed a brief description of the fall indicating Resident 1 went to the bathroom alone and did not use their call light. Resident 1 fell in the bathroom, sustaining injury to the head, and aides found the resident on the floor after hearing the resident yelling. Record review of Resident 1's care plan revealed 1/31/2026 self-transfer, self-ambulation to BR, fell. Hematoma to back of head. To ER, admitted with brain bleed. Additional record review of Resident 1's care plan revealed a problem start date of 1/20/2026 for a category of 'falls' with approach start dates of 1/20/2026 for the following interventions: -See that Resident 1 has footwear on that does not slip, slide. -Make sure floor is free of glare, liquids, foreign objects. -Leave night light on in room. -Keep personal items and frequently used items within reach. -Dycem (a non-slip, and antimicrobial materials used for gripping, stabilizing objects, and controlling contamination) to recliner cushion. Further record review of Resident 1's care plan revealed following additional interventions: Approach start date 2/3/2026 -Sign in room to call for assistance. -Frequent checks. Record review of Resident 1's progress note revealed Resident 1 had a fall at 6:45 PM on 2/19/2026 with major injury. Fall Investigation Packet revealed Resident one was last seen between 6:00 and 6:15 PM when their dinner tray was taken by staff. The fall investigation packet revealed Resident was self-transferring when they lost balance. The fall investigation packet does not include a reason for Resident 1 self-transferring. The fall investigation packet shows a care plan update and staff educated to continue frequent checks, an immediate measure taken as 'bed alarm'. Root cause of fall is listed as: -Amount of assistance in effect. -Environmental factors/ items out of reach walker/ wheelchair by window. -Footwear. Further record review of Resident 1's care plan revealed no evidence of a 'bed alarm' being implemented. Another record review of Resident 1's care plan revealed: 2/19/2026 Did not have footwear on the did not slip, slide. Lost balance, fell on lt (left) side. Laceration to head. Sent to ER for c/o pain lt wrist, LT hip.Fell on left side. admitted for lt femur fx (fracture), lt wrist fx. Record Review of Resident 1's progress notes from 10:15 AM in 2/21/2025 revealed Received call from RWMC with report on patient (pt). Resident will be returning to facility via EMS. (Gender) will be coming back comfort cares. A progress note from 2/21/2026 at 2:02 PM revealed Resident has a 4-centimeter (cm) laceration to left side of scalp that has 6 staples. Resident is having labored breathing. A progress note from 10:16 AM on 2/22/2026 revealed At 0955 (9:55 AM) went to check resident, noted no lung sounds, no heart rate, and no Blood Pressure (BP). Charge nurse notified. Interview at 1:24 PM on 3/10/2026 with MDS Coordinator/RN (MDS) confirmed there is no way to look at charting to see what time a Resident was last brought to the bathroom. Interview at 2:14PM on 3/10/2026 with Medication Aide (MA)-C confirmed that Resident 1 was found in the bathroom on 1/31/2026 after falling because (gender) took (gender) to the bathroom without assistance. Resident 1 was last toileted around 4:00 PM on 1/31/2026. MA-C also confirmed Resident 1 was toileted about every 2 hours to help prevent falls because (gender) refused to use the call light due to embarrassment of being in the facility with (gender) family as apart of the staff. B. Record Review of Resident 5's census, dated 3/10/2026, revealed an admission date of 1/13/2026. Record review of Resident 5's undated care plan revealed the following listed diagnoses: -Unspecified dementia, unspecified severity, with psychotic disturbance, -Generalized anxiety disorder, - Restlessness and agitation. A record review of Resident 5's MDS revealed a BIMS score of 99 indicating severe cognitive impairment. A record review of a facility document Fall tracking and trends from June 2025 through March 2026 revealed Resident 5: -Fell at 1:15 PM on 1/17/2026. Leaned forward in wheelchair (w/c), fell, don't leave alone in dining room (DR). There was no injury noted. -Fell at 7:00 PM o 1/17/2026. In w/c, fell forward, hit head/dycem and gel cushion, w/c. There was a laceration to the head, and the resident was sent to the ER. -Fell at 3:10 PM on 1/22/2026. Self-transfer from recliner/ dycem to recliner cushion. There was no injury noted. -Fell at 6:45 PM on 1/25/2026. Self-transfer from w/c. fell/different/lower w/c per therapy. There was a skin tear to the left forearm. -Fell at 1:55 PM on 2/27/2026. In w/c, fire drill going on/slid from w/c / dycem again in w/c. There was no injury noted. Further record review of Resident 5's undated care plan revealed the resident needed extensive assistance with turning and positioning. The care plan also revealed the resident's cognition, mobility and safety awareness are impaired. Resident 5's care plan also revealed the following interventions with a star date of 1/20/2026: -Make sure the floor is free of glare, liquids, foreign objects. -Leave night light on in room. -Keep personal items and frequently used items in reach. -Keep bed in lowest position with brakes locked. -Dycem (a non-slip, and antimicrobial materials used for gripping, stabilizing objects, and controlling contamination) and gel cushion in wheelchair. -Don't leave Resident in DR (dinning room) alone. The following interventions had a start date of 1/27/2026: -Dycem to recliner. -Different lower wheelchair done by therapy. The following intervention has a start date of 2/11/2026: -Keep the call light in reach. Resident does not use the call light. Check routinely. The following intervention has a start date of 3/2/2026: -Therapy to check that dycem is in place in w/c. A record review of the pocket care plan (a documentation made daily for staff use regarding all facility residents and their care needs) for 3/10/2026 revealed no mention of Resident 5's fall interventions as listed above. Record review of the fall event reports from 1/17/2026, 1/22/2026, and 2/27/2026, revealed there were no immediate measures taken after the falls to prevent future falls and ensure safety. Record review of the fall event report from 1/25/2026 revealed first aid and rest as immediate measures taken. The NA fall investigation worksheet from 1/25/2026 revealed first down as the recommended intervention to prevent similar falls. Page 7 of the 'fall checklist' document revealed the root cause of this fall documented with a handwritten note that reads: I don't know. Record review of the NA investigation worksheet from 1/25/2026 revealed a recommendation of first down to prevent similar falls. Record review of the NA investigation worksheet from 2/27/2026 revealed a recommendation to make sure the resident is in the recliner as an intervention to prevent similar falls. Record review of Resident 5's progress notes revealed no mention of reevaluating interventions for appropriateness or attempts at different interventions to prevent falls and ensure safety. An interview at 1:24 PM with MDS confirmed that confused residents cannot be educated. An interview at 3:10 PM on 3/10/2026 with MA-C confirmed that the interventions in place for Resident 5 were unsuccessful in preventing falls. C. A record review of Resident 3's Facesheet revealed the resident was admitted to the facility on [DATE] and was discharged on 10/17/2025. A record review of Resident 3's undated Care Plan revealed the resident had a problem area related to falls. There were the following interventions for this problem area with a start date of 11/21/2023: -Keep bed in lowest position with brakes locked. -Keep personal items and frequently used items within reach. -Leave night light on in room. -Make sure the floor is free of glare, liquids, foreign objects. -See that Resident 3 has footwear on that does not slip, slide. -Staff to do frequent checks. There was the following intervention for this problem area with a start date of 6/13/2024: -Dycem placed on wheelchair related to Resident 3 sliding from wheelchair There was the following intervention for this problem area with a start date of 8/6/2024: -Resident 3 will try to put self on the floor when in the wheelchair. There was the following intervention for this problem area with a start date of 9/11/2024: -Place in common area after meals as Resident 3 allows. There was the following intervention for this problem area with a start date of 10/3/2024: -Staff to see that soda can is available and not on the floor. A record review of a facility document titled Fall Tracking and Trends from June 2025 through March 2026 revealed the following for Resident 3: -The resident was found on the floor by their wheelchair on 7/30/25 at 6:45 PM in the common area. The resident was trying to get out of their wheelchair. Staff were to put Resident 3 to bed after meals. -The resident was observed on the floor in front of their recliner 8/23/2025 at 4:15 PM. Staff were not to put the resident in their recliner and were to put the resident in bed. -The resident fell out of their recliner while reaching for a banana on 9/7/2025 at 6:55 AM. Staff were to put food within the resident's reach. -The resident fell out of their wheelchair in the hall on 10/3/25 at 7:30 AM. Staff were not to leave the resident in their wheelchair and were to increase checks on rounds. A record review of Resident 3's Progress Note dated 07/30/2025 revealed the resident was observed in a kneeling position in front of their wheelchair in the common area. The resident stated they were trying to get up. There were no injuries noted. Further record review of Resident 3's undated Care Plan revealed there was an intervention added to the falls problem area with a start date of 8/5/2025 that stated, Staff to put in bed after meals. A record review of Resident 3's Progress Note dated 08/23/2025 revealed the resident was observed on the floor in their room in front of their recliner with no injuries noted. Further record review of Resident 3's undated Care Plan revealed there was an intervention added to the falls problem area with a start date of 9/3/2025 that stated, Staff do not put Resident 3 in their recliner. They slide out of it. Put them in bed. A record review of Resident 3's Progress Notes dated 9/07/2025 revealed the resident had fallen out of their wheelchair and sustained a laceration above their right eye. The resident was taken to the emergency room and returned to the facility with sutures above their right eye. Further record review of Resident 3's undated Care Plan revealed there was an intervention added to the falls problem area with a start date of 9/10/2025 that stated, Staff to place food within Resident 3's reach. A record review of Resident 3's Progress Note dated 10/03/2025 revealed the resident had an unwitnessed fall in the sitting area. The resident had a laceration to their nose, an abrasion to their forehead, and a skin tear to their left forearm. The resident was sent to the emergency room for evaluation. The resident later returned to the facility with sutures to the laceration on their nose. Further record review of Resident 3's undated Care Plan revealed there was an intervention added to the falls problem area with a start date of 10/14/2025 that stated, Do not leave alone in wheelchair, increase checks. A record review of a facility document Fall Checklist revealed Resident 3 had fallen on 10/3/2025 at 7:30 AM and on page 2 of the document it stated that dietary staff had witnessed the fall. In the Fall Scene Investigation Report section it revealed the resident stated they were trying to go home and that they had last been assisted with toileting at 7:00 AM. In the final portion of this section of the document, it states Action Taken: do not leave resident in wheelchair, increase checks. On the CNA (certified nurse aide) Fall Investigation page of the document, it stated that the resident was last assisted to the bathroom before their bath that morning, around 6:15 AM. The resident had last been checked on 15 minutes prior to the fall and an intervention the staff could do to help prevent another similar fall like this was to make sure (gender) is being watched if in wheelchair more frequently. This page was signed and dated by staff. The document signed as reviewed by the Fall Risk Committee on 10/6/2025. An interview on 3/10/26 at 12:30 PM with MDS confirmed the documentation in Resident 3's Fall Checklist for the fall that occurred on 10/3/2025 was inconsistent and it was unclear what had happened, and when. MDS confirmed that the document stated the resident was checked on 15 minutes prior to the fall and to increase checking frequency would be to place the on 1:1 supervision, which the facility had not implemented. MDS also confirmed the intervention of Do not leave alone in w/c, increase checks would not be a feasible intervention as the facility could not sustain 1:1 cares for residents. MDS also stated the CNA Fall Investigation page was signed by a dietary aide who would not have known when the resident had last been checked on or toileted. MDS confirmed the intervention that was added to Resident 3's Care Plan was not put into place until 11 days after the fall, and it should have been added no later than the day after the fall was reviewed by the fall risk committee, which was on 10/6/2025. An interview on 3/10/26 at 2:30 PM with LPN-A confirmed Resident 3's Care Plan had conflicting guidance regarding whether to keep the resident in the common area or put the resident in bed after meals. D. A record review of Resident 7's Facesheet dated 3/10/2026 revealed the resident was admitted to the facility on [DATE]. A record review of a facility document Fall Tracking and Trends from June 2025 through March 2026 revealed: - fell on 7/8/2025 at 6:50 PM. No injuries. Transferring, weak, lowered to floor. 2-staff to transfer- per therapy now a total lift. - fell on 7/9/2025 at 4:00 PM. No injuries. Slid out of recliner. Keep footrest up when doing cares. - fell on [DATE] at 2:30 AM. Fell out of bed, no injuries, keep bed in low position. - fell on [DATE] at 7:30 AM. Found in doorway of room, had crawled to doorway, sent to ER r/t confusion, returned, bed in low position. ER found thyroid mass. A record review of Resident 7's undated Care Plan revealed the resident had an amputation of the left leg, below the knee. The resident required extensive assist with turning and positioning and was dependent on staff and a mechanical lift for transfers. The care plan also revealed the resident had a history of falls and had an intervention of keep bed in lowest position with brakes locked with a start date of 7/10/2025. A record review of Resident 7's Progress Note dated 12/17/2025 revealed the resident was observed sitting upright between their bed and bedside table and the bed was in a raised position. When asked what happened, the resident stated they had been sleeping and fell out of bed. Further record review of Resident 7's undated Care Plan revealed an entry 12/17/25 fell out of bed and an intervention dated 12/22/2025 that stated, Keep bed in low position. A record review of Resident 7's progress note dated 12/29/2025 revealed the resident was observed laying on the floor in the doorway of their room. The resident stated they had crawled to the doorway. A record review of a facility document Fall Checklist dated 12/29/2025 revealed that 5 minutes prior to being observed on the floor in their room doorway, Resident 7 had been laying in bed. Further record review of Resident 7's undated Care Plan revealed an entry 12/29/25 found in doorway of room on stomach, had crawled to the doorway. Unable to verbalize how (gender) fell, confused. Sent to ER and an intervention dated 12/31/2025 that stated Sent to ER r/t confusion, returned. Has thyroid mass. Bed to be in low position. An observation on 3/10/2026 at 7:30 AM revealed Resident 7 lying in their bed. The bed was in a high position, approximately 2-3 feet from the floor. An observation on 3/10/2026 at 8:35 AM revealed Resident 7 sitting up on the side of their bed with their legs dangling over the edge of the bed. Resident 7's right foot was several inches above the floor. There was an overbed table in front of the resident and the resident was eating their breakfast and watching TV. The Social Services Director entered the room at 8:36 AM and conversed with the resident, then left the room without lowering the bed. An observation on 3/10/2026 at 9:21 AM revealed Resident 7 remained in the same position on their bed with the overbed table in front of them and the bed remained in the elevated position. Licensed Practical Nurse (LPN)- B entered the room and spoke with the resident for several minutes, then left the room at 9:30 AM without lowering the bed. An observation on 3/10/2026 at 10:13 AM revealed Resident 7 lying in their bed on their back with a blanket over them. The bed had been lowered so the base of the mattress was about a foot above the ground. An observation on 3/10/2026 at 11:13 AM revealed Resident 7 sitting upright on the edge of their bed with their legs dangling. Their right foot was a few inches from the floor and the overbed table was in front of them. The resident was reading a piece of paper and watching tv. An observation on 3/10/2026 at 1:18 PM revealed Resident 7 sitting in the same position as prior observation with their foot a few inches from the floor. An interview on 3/10/26 at 2:07 PM with LPN-B confirmed that when LPN-B went into Resident 7's room while the resident was eating their breakfast, the resident's bed was not in low position. LPN-B stated the bed was not ever in low position at mealtimes as the resident sits on the edge of their bed for all meals and it would not be comfortable for the resident to eat their meal if the bed was in low position. An interview on 3/10/26 at 2:30 PM with LPN-A confirmed Resident 7's care plan had the intervention of keep bed in low position in the falls section entered on three different dates. LPN-A revealed that the facility's nurse aides did not have access to the residents' care plans and that the aides used a pocket care plan which contained pertinent information about each resident. A record review of the pocket care plan for 3/10/2026 revealed no information for Resident 7 in relation to their fall intervention of keeping their bed in low position. Further interview on 3/10/26 at 2:30 PM with LPN-A confirmed the pocket care plan reviewed by the surveyor was the document in use that day by the nurse aides and it did not reflect that Resident 7's bed was to be in low position. LPN-A stated the nurses also did not utilize the residents' care plans during their shifts. The nurses referred to a Therapy Communication binder which contained recommendations from the therapists and utilized a 24-hour report/census sheet which was updated nightly and contained information about each resident that the nurses needed to know. LPN-A confirmed that these documents also did not contain information about Resident 7's bed needing to be in low position.

Based on record review and interview, the facility failed to submit a comprehensive investigative report to the State Agency for 2 (Residents 1 and 3) of 6 sampled residents who had a fall with major injury. The facility census was 55.Findings Are: A record review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program with revision date of April 2021 revealed the facility was to investigate and report any allegations within timeframes required by federal requirements. A.A record review of Resident 1's Facesheet dated 3/10/2026 revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 2/22/2026.A record review of Resident 1's Progress Notes dated 2/20/2026 revealed the resident had a fall on 2/19/2026 which resulted in a laceration to the left side of their head, a left wrist fracture, and a left femur fracture.A record review of a Investigation Report dated 2/24/2026 revealed in the Describe the incident section that Resident 1 had fallen on 2/19/2026 at 11:29 PM in their room and was by their bed on their left side. The resident had sustained a laceration to the left side of their head, a fractured left femur, and a fractured left wrist. In the What permanent measures were put into place to prevent reoccurrence section it stated: None, resident was admitted to the hospital. Family elected not to have surgery due to heart condition and upon return resident was unresponsive. In the What was the outcome of the facility investigation section it stated: Resident non-compliant with transfers. Tried to self-transfer and fell. Resident did not call for assistance.An interview on 3/10/2026 at 3:30 PM with the Director of Nursing (DON) confirmed that the Investigation Report dated 2/24/2026 was the investigative report the facility submitted to the State Agency for Resident 1's fall on 2/19/2026 and it did not contain information regarding interventions being put into place. The DON stated the facility had implemented interventions of repositioning and rounding on the resident greater than once per hour to ensure their safety and comfort following their return to the facility from the hospital and confirmed this information should have been included in the report. B.A record review of Resident 3's Facesheet dated 3/10/2026 revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 10/17/2025.A record review of Resident 3's Progress Notes dated 10/3/2025 revealed the resident had an unwitnessed fall in the sitting area which resulted in the resident needing sutures for a laceration on their nose.A record review of a facility provided document labeled October 2025 Reportable revealed Resident 3 had an incident occur on 10/3/2025 at 7:30 AM. In the section labeled Describe the Incident the description stated: 0725 Resident was observed on the floor with bleeding to the nose and forehead. 0750 Resident left the building with EMS (emergency medical service) for further workup in the ED (emergency department). 1120 Nursing staff received call from hospital and resident has been diagnosed with a fractured nose. In the section labeled Investigation Summary and Outcome the description stated, Fall committed will meet to discuss current interventions and decide what modifications need to be made. In the section labeled What permanent steps were put into place to prevent recurrence? the description stated, Staff will increase checks on rounds while resident is in bed and resident is not to be left in wheelchair without supervision.An interview on 3/10/2026 at 3:30 PM with the DON confirmed that the investigative report submitted to the State Agency for Resident 3's fall on 10/3/2025 did not contain a thorough investigation into the resident's fall.

Licensure Reference Number NAC 175 ,d+[DATE].11(E) Based on record review, interviews, and observations the facility failed to identify and dispose of spoiled fruits and vegetables stored in the walk-in refrigerator. This had the potential to affect all residents who resided within the facility. The facility identified a census of 45. Findings are: A record review of the facility policy Dietary Policy dated [DATE] revealed staff will check for expiration dates when getting food. If food is found to be expired, discard immediately. Do not return expired foods to shelves. There was no evidence of guidance in the policy related to the monitoring and disposal of fresh fruits and vegetables. An observation on [DATE] at 6:15 PM during initial kitchen tour revealed two bags of grapes that had a greenish black fuzzy substance sticking to the grapes with a cloudy light greenish liquid substance throughout the bag. The observation further revealed an open box that contained a bag with one tomato in it. The tomato was noted to have a fuzzy greenish black substance around the stem. An interview on [DATE] at 7:00 PM with the Certified Dietary Manager (CDM) confirmed, these products should never have been in the refrigerator and should have been disposed of immediately. CDM stated that staff check foods that have expiration dates (canned or boxed items) upon removing from storage, but was unable to indicate how they monitor fresh fruits and vegetables.

Licensure Reference Number 175 NAC 12-006.04(B)(i) Based on record reviews and interviews, the facility failed to implement an effective initial training program to ensure new employees had completed training on topics of resident rights, emergency procedures, abuse/neglect, dementia care and medical emergency directives (for nursing staff) for 3 (Dietary Aide (DA) -G, Nurse Aide (NA) -B, and Medication Aide (MA) -D) of 5 sample employees. This had the potential to affect all residents residing within the facility. The facility identified a census of 45. Findings are: A record review of the facility's undated Facility Assessment Competency Tool, under the section Workforce Training, revealed high priority rating for training on abuse and neglect, emergency preparedness and resident rights and medium priority rating for dementia training. There was no evidence of the importance of training regarding medical emergency directives. A record review of an undated, facility-provided staff list revealed the following: -DA-G was hired on 4/19/2025. -NA-B was hired on 2/19/2025. -MA-D was re-hired on 1/13/2025. A record review of DA-G's personnel record revealed no evidence that initial orientation training had been completed, including on topics of resident rights, emergency procedures, or dementia. A record review of NA-B's personnel record revealed no evidence that initial orientation training had been completed on dementia or medical emergency directives. A record review of MA-D's personnel record revealed no evidence initial orientation training had been completed on dementia or medical emergency directives. An interview on 5/6/2025 at 3:40 PM with Human Resources (HR) confirmed DA-G had no evidence initial orientation training had been completed and no evidence NA-B or MA-D had completed initial orientation training on dementia or medical emergency directives.

Nebraska Revised Statute 71-6018.02(2)(a) Based on record reviews and interviews, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 45. Findings are: A record review of a Payroll-Based Journal Staffing Data Report (PBJ, a system analysis report of staffing metrics, such as excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours/day, that is based off payroll information submitted by the nursing homes) from July 1 - September 30, 2024, revealed the facility had triggered for four or more days within the quarter for no RN hours. The infraction dates were 8/10/2024, 8/11/2024, 8/16/2024, and 9/22/2024. A record review of facility-provided Timecard Reports from 8/10/2024-8/11/2024 revealed no evidence of RN hours on 8/10/2024 or 8/11/2024. A record review of facility-provided Timecard Reports from 9/22/2024 revealed no evidence of RN hours on 9/22/2024. An interview on 5/7/2025 at 12:50 PM with the Nurse Consultant (NC) confirmed the facility did not have RN hours on 8/10/2024, 8/11/2024, or 9/22/2024 but was able to provide evidence of 8-consecutive RN hours on 8/16/2024. A record review of facility-provided Individual Timecards from 2/2/2025-2/8/2025 revealed no evidence of RN hours on 2/8/2025. A record review of facility-provided Individual Timecards from 2/12/2025-2/26/2025 revealed no evidence of RN hours on 2/15/2025 or 2/16/2025. A record review of facility-provided Individual Timecards from 4/1/2025-4/12/2025 revealed no evidence of RN hours on 4/5/2025, 4/6/2025, or 4/12/2025. An interview on 5/8/2025 at 10:00 AM with the Nursing Home Administrator (NHA) revealed the facility's process for ensuring RN hours are to schedule an RN at least 8 consecutive hours every day. If a callout or unanticipated staffing shortage of the RN would occur, the RN would be responsible for attempting to find a replacement, the NHA would also attempt to find coverage. However, the facility had been having difficulty fulfilling RN hours due to vacations and other unexpected staffing turnovers. The NHA confirmed the facility had no evidence of RN hours for at least 8 consecutive hours on 2/8/2025, 2/15/2025, 2/16/2025, 4/5/2025, 4/6/2025, and 4/12/2025.

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interviews, the facility failed to ensure nurse aides (NA)/ medication aides (MA) had completed ongoing training of at least 12 hours per year on topics appropriate to the employee's job duties, abuse/neglect training, and at least 4 hours of dementia training as required for 5 (MA-H, NA-A, MA-F, MA-E, and NA-I) of 5 sample employees. This had the potential to affect all residents residing within the facility. The facility identified a census of 45. Findings are: A record review of the facility's undated Facility Assessment Competency Tool, under the section Workforce Training, revealed high priority rating for nurse aide education and training on abuse and neglect, and medium priority rating for dementia training. There was no evidence of time requirements for ongoing training. A record review of an undated facility-provided staff list revealed the following: -MA-H was hired on 6/6/2022. -NA-A was hired on 6/26/2022. -MA-F was re-hired on 6/21/2022. -MA-E was re-hired on 10/13/2023. -NA-I was hired on 3/6/2023. A record review of the facility's provided copy of MA-H's Relias Transcript with a date range of 6/6/2023-6/6/2024 revealed MA-H had completed 1.75 hours of ongoing training. There was no evidence that ongoing training on dementia had been completed. A record review of the facility's provided copy of NA-A's Relias Transcript with a date range of 6/6/2023-6/6/2024 revealed a total of 3 hours of ongoing training had been completed. NA-A had completed an additional 0.17 hours of training, but the courses of Setting Up the Steam Table, Proper Freezer Storage, and Dry Storage were unrelated to NA-A's job duties. There was no evidence NA-A had completed ongoing training on dementia. A record review of the facility's provided copy of MA-F's Relias Transcript with a date range of 6/21/2023-6/21/2024 revealed MA-F had completed 4.75 hours of ongoing training with 0.25 hours of training on dementia. There was no evidence MA-F had completed ongoing training on abuse and neglect. A record review of the facility's provided copy of MA-E's Relias Transcript with a date range of 10/13/2023-10/23/2024 revealed MA-E had completed a total of 8 hours of ongoing training had been completed with 0.25 hours of training on dementia. A record review of the facility's provided copy of NA-I's Relias Transcript with a date range of 3/6/2024-3/6/2025 revealed no evidence NA-I had completed 4 hours of ongoing training on dementia. An interview on 5/7/2025 at 8:30 AM with the Nurse Consultant (NC) confirmed the facility had not met the requirements for ongoing training for the 5 sampled staff.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on Interview and record review, the facility failed to notify the medical provider of 1 (Resident 22) of 1 resident's elevated blood pressures. The facility identified a census of 45. Findings are: A record review of a facility policy titled, Change in a resident's condition or status, last revised February 2021, revealed that the nurse will notify the resident's physician or physician on call in several situations which include the need to alter the resident's medical treatment, and a significant change in the resident's physical/emotional/mental condition. A record review of Resident 22's Continuity of Care Document, revealed Resident 22 was admitted to the facility on [DATE]. The document also revealed Resident 22 had diagnoses of dementia, hypertension, cognitive communication deficit, anxiety, and chronic pain. A record review of Resident 22's physician orders revealed an active order dated 11/19/21 which read, Blood pressure and pulse BID (twice daily) if out of parameters recheck 2 hours post B/P meds. A record review of Resident 22's care plan and physician orders revealed no evidence of recommended blood pressure range or parameter for the resident to maintain. A record review of Resident 22's vital sign records revealed the following dates, times, and blood pressure (BP) measurements: -On 5/5/25 at 8:26 AM their BP was 206/103, -On 5/5/25 at 12:17 PM their BP was 187/92, -On 5/4/25 at 4:33 AM their BP was 196/80, -On 5/3/25 at 9:07 AM their BP was 173/88, -On 4/27/25 at 5:12 AM their BP was 178/68, -On 4/20/25 at 8:19 AM their BP was 176/76 -On 4/16/25 at 8:59 AM their BP was 176/77, -On 4/15/25 at 8:29 AM their BP was 187/84, -On 4/14/25 at 7:18 AM their BP was 182/73, and -On 4/9/25 at 6:09 AM their BP was 192/81. A record review of Resident 22's nursing progress notes between 4/8/25 and 5/7/25 revealed no evidence that a physician was notified of Resident 22's high blood pressure. A record review of the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guidelines for hypertension (originally published 11/13/17) revealed that lowering BP in isolated systolic hypertension (defined as systolic BP >160 with variable diastolic BP <90, <95, or <110) is effective in reducing the risk of fatal and nonfatal stroke, cardiovascular events, and death. (Full title: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines; ahajournals.org) An interview with the Director of Nursing (DON) on 5/5/25 at 4:17 PM confirmed that nursing staff did not notify the medical provider of blood pressure values outside of Resident 22's baseline measurements (baseline is a reference point to track changes and assess the impact of treatments or interventions over time). The interview also confirmed that the nursing staff should have taken additional BP measurements to ensure Resident 22's well-being.

Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on record reviews and interviews, the facility failed to develop a baseline care plan (BCP, a resident's plan of care that includes the minimum information needed to provide effective, person-centered care immediately upon admission) within 24 hours as required for 1 (Resident 41) of 2 sample residents. The facility identified a census of 45. Findings are: A record review of a facility policy, Care Plans - Baseline with a revised date of March 2022, revealed a BCP would be developed within 48 hours of admission to meet the resident's immediate health and safety needs. There was no evidence that a BCP would be developed within 24 hours as required by state regulation. Additionally, the policy revealed a BCP is to include initial goals, physician's orders, dietary orders, therapy services, social services, and Pre-Admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) recommendations. A record review of Resident 41's Face Sheet indicated Resident 41 had been admitted to the facility on [DATE]. Resident 41 had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), Pressure-induced deep tissue damage(DTPI, a type of pressure ulcer where the damage extends beyond the skin's surface into the underlying soft tissues), Refsum's disease (an inherited condition that causes vision loss, absence of the sense of smell, and a number of other symptoms), pain, acute kidney failure, history of blood clots in the leg, atrial fibrillation (a common heart rhythm disorder characterized by an irregular and often rapid heartbeat), high blood pressure, depression, anxiety, retention of urine, and abnormal weight loss. A record review of Resident 41's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 1/31/2025 revealed the following: -Resident 41 had short/long-term memory impairment with severe impairment of their cognitive decision-making skills. -Resident 41 required moderate assistance with eating and oral hygiene; substantial assistance with personal hygiene; and was dependent for assistance with toileting, bathing, and dressing. Additionally, Resident 41 required partial assistance for bed mobility and maximum assistance for transfers. -Resident 41 had a urinary catheter and was always incontinent of bowel. -Resident 41 received scheduled and as needed pain medication. Resident 41 displayed indications of pain through non-verbal sounds (such as crying, whining, moaning, etc.), vocal complaints, and facial expression (grimaces, furrowed brow, clenched teeth, etc.) on 3-4 days during the past 5 days of the ARD. -Resident 41 had a history of falls prior to admission and had 1 fall since their admission that caused injury. -Resident 41 had an order for a mechanically altered diet. -Resident 41 had one stage 2 (partial-thickness skin loss) and two unstageable pressure ulcers. Treatments included pressure-reducing devices for their chair and bed, repositioning program, and pressure ulcer care. -Resident 41 was taking an antidepressant (a type of medicine used to treat depression), an anticoagulant (blood thinner), an antibiotic, and an opioid (prescription pain medicine). -Resident 41 required oxygen use. A record review of Resident 41's medical record revealed no evidence a BCP had been developed. An interview on 5/7/2025 at 9:30 AM with the Director of Nursing (DON) confirmed the facility had not developed a BCP and should have developed one within 24 hours as required for Resident 41.

Licensure Reference Number 175 NAC 12-006.05(G) Based on interview and record review, the facility failed to attempt gradual dose reductions or provide clinical rationale for not attempting a gradual dose reduction for 2 (Residents 19 and 24) of 5 sampled residents' psychotropic medications. The facility identified a census of 45. Findings are: Record review of a facility policy titled, Psychotropic medication use, last revised July 2022, revealed that psychotropic medications included anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics. The policy also revealed that residents on psychotropic medications receive gradual dose reductions (GDRs) unless clinically contraindicated. A. A record review of Resident 24's Continuity of care document, revealed Resident 24 was admitted to the facility on [DATE]. The document also revealed Resident 24 had diagnoses of dementia (a progressive condition marked by cognitive deficits including memory, thinking, and social abilities), falls, anxiety, drug-induced dyskinesia (uncontrolled involuntary muscle movements), and chronic pain. A record review of Resident 24's physician orders revealed active orders for the following psychotropic medications with the indications in parentheses: -Mirtazapine, an antidepressant, 15 milligrams (mg) daily at bedtime (anxiety), with the most recent order date of 10/28/24. -Quetiapine, an antipsychotic,12.5 mg daily in the morning (ordered for dementia), 25 mg at bedtime daily (ordered for anxiety). 6/19/24 and 10/28/24 were documented as start dates, respectively. A record review of Resident 24's care plan revealed a section, Psychotropic Drug Use, last revised 4/15/25 which revealed the following: Resident(name) has dementia with behaviors and anxiety. They take anti-depressants and anti-psychotic medication. The meds have been adjusted. Sees psych prn. Does have hx of TD. The care plan Approach stated that a GDR would be done if recommended by pharmacist and approved by the physician. Record review of facility document titled, Consultant pharmacist medication regimen review (MRR) and physician notification, for Resident 24 revealed a note in August 2024 which stated, If not contraindicated, would you consider a GDR (gradual dose reduction) of Lexapro or Remeron? There was no statement written in the space provided for physician response below the pharmacist's recommendation. An interview with the Director of Nursing (DON) on 5/07/25 at 9:34 AM revealed the physician did not respond to the pharmacist recommendation in August 2024. The DON also confirmed that no other pharmacist recommendations for psychotropic medication gradual dose reductions were suggested. The interview also revealed no physician documentation of clinical rationale for not attempting a GDR existed for this resident. The DON confirmed a GDR should have been attempted or a clinical rationale for not attempting a GDR should have been documented by the physician. 52169 B A record review of Resident 19's Significant Change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 02/21/2025, revealed the resident had displayed disorganized thinking continuously. Resident had difficulty following what was being said and the resident's behaviors interfered with the resident's care and affected the resident's ability to participate in activities or social interactions. The MDS also revealed the resident rejected cares at times and had physical behavioral symptoms directed towards others which included hitting, kicking, pushing, scratching, grabbing, abusing others sexually. A record review of Resident 19's Continuity of Care document revealed Resident 19 had an order for Lexapro (Antidepressant) 10 mg once a day with an indication of major depression and a start date of 03/02/2023. A record review of Resident 19's Care Plan dated 03/05/2025 stated there would be a drug reduction as recommended by pharmacist and approved by physician. A record review of Resident 19's medical records revealed no evidence of a GDR being attempted or any clinical rationale for why a GDR should not be attempted. An interview on 05/07/2025 with the DON revealed the facility does not complete any GDRs unless the pharmacist identifies to do so during monthly reviews. Additionally, the DON confirmed the facility had no evidence a GDR had been attempted or was documented by their physician as clinically contraindicated for Resident 19.

Licensure Reference Number: 175 NAC 12-006.04C3a(6) Based on record reviews and interviews, the facility failed to notify the family representative of changes in responsiveness and respiratory status for one sampled resident (Resident 6) to determine the need for further evaluation and changes in care to meet the residents' needs. The facility census was 51 with four current sampled residents and four closed records. Findings are: Review of Resident 6's Progress Notes revealed the following including: - 12/11/19 at 9:48 PM Resident noted very sleepy this shift; - 12/12/19 at 9:26 PM Remains sleepy; - 12/14/19 at 2:12 PM Hospice note - family concerned that the resident is over medicated and not getting updates, resident was minimally responsive, slurred speech, unable to chew or swallow; - 12/15/19 at 10:49 AM - Resident incoherent this morning, not eating or drinking, Hospice notified; - 12/15/19 at 1:30 PM Hospice note included that the resident's lung sounds were diminished with tracheal congestion. Further review revealed no documentation that the facility notified the family of the above changes in condition. Review of the Care Plan, goal date 3/12/20, revealed that the resident was unable to communicate clearly at times, make self understood or understand others related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the DON on 1/9/20 at 3:15 PM confirmed that there was no documentation that the nurses notified the family representative of changes in the resident's condition as described above.

Licensure Reference Number: 175 NAC 12-006.05(9) Based on record reviews and interview, the facility failed to provide interventions to prevent recurrent episodes of physical abuse for one current sampled resident (Resident 2). The facility census was 51 with four current sampled residents. Findings are: Review of the facility Verification of Investigation report, dated 11/29/19, revealed that Resident 2 had a recent stroke with right sided neglect, did not speak, had difficulty swallowing, had Alzheimer's Disease and required assistance with all activities of daily living, including eating and drinking. Further review revealed that on 11/19/19 staff observed Resident 2's spouse hit the resident's arms because the resident wouldn't eat. The IDON (Interim Director of Nurses) stated that staff reported that the spouse hit the resident at least 3 times on the Lt. [left] forearm hard. The IDON told the spouse that [gender] could not hit the resident because the resident wouldn't eat. The spouse left the facility. Further review revealed that on 11/25/19 staff reported to the IDON that, during supper, the spouse hit the resident's arm and ate the resident's food. That evening staff observed new bruises on the resident's arms. The skin assessment, dated 11/29/19 at 11:30 AM, revealed that the resident had resolving bruises to the left forearm and a new bruise on the right forearm. On 11/26/19 at 8:45 AM, the spouse was notified that [gender] was not allowed in the facility related to hitting spouse. Interview with the Director of Nursing on 1/9/20 at 2:35 PM confirmed that on 11/19/19, the IDON did not immediately report the abuse incident to the Administrator, APS (Adult Protective Services) was not notified, interventions were not into place to protect the resident from further abuse and an investigation was not done as required. Further interview confirmed that on 11/25/19, staff did not immediately report the abuse incident to the Administrator or APS and interventions were not immediately put into place to protect the resident from further abuse as required. Review of the facility Abuse Policy, not signed or dated, revealed the following including: Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. b. The Administrator, will involve key leadership personnel as necessary to assist with reporting, investigation and follow up. Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days. When making a report, the following information should be reported: . - Date, time, location and circumstances of the alleged incident. - Any obvious injuries or complaints of injury. - Steps the facility has taken to protect the resident . - The facility must include the following investigative components: - Have evidence that all alleged violations are thoroughly investigated. - Prevent further potential abuse . while the investigation is in progress.

Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to provide care to prevent recurrent bruises for one closed record (Resident 6). The facility census was 51 with four closed records and four current sampled residents. Findings are: Review of the facility Verification Of Investigation, dated 10/22/19, revealed that on 10/17/19, staff not a bruise on the resident's left forearm, approximately 7 x 6 cm. [centimeters] in size. Further review revealed hat the arm of the wheelchair was padded to prevent further injury to the arm. Review of the Progress Notes, dated 12/4/19 at 2:38 PM, revealed that the resident had a purple discoloration to the left forearm which measured about 5 x 3 cm., due to hitting the chair. Review of the Care Plan, goal date 3/12/20, revealed a problem dated 6/30/16, that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan did not include the need to pad the resident's wheelchair armrests or to assist the resident to position the arm to prevent bruising. Interview with the DON on 1/9/20 at at 3:00 PM confirmed that interventions were not in place to prevent recurrent bruising of the resident's arm.

Licensure Reference Number: 175 NAC ,d+[DATE].09D7 Based on record reviews and interviews, the facility failed to implement interventions to reduce the risk for falls and major injuries for two closed records (Residents 8 and 7) with identified changes in condition that increased the risk for falls. The facility census was 51 with four closed records and four current residents sampled. Findings are: A. Review of Resident 8's Progress Notes revealed the following: - [DATE] at 12:23 AM The resident tripped over an oxygen tank and fell . The resident complained of shoulder pain, had bruising on the right arm, hand and rib cage area; - [DATE] at 10:45 AM The resident was found on the floor with blood coming from the nose, deformity noted a the nose. The resident stated I think I broke my nose and I am choking on blood. Staff attempted to position the resident and suction the resident to clear the airway which was unsuccessful. The resident became unresponsive and expired at 11:15 AM. Review of the facility Verification of Investigation report, dated [DATE], revealed that on [DATE] at 9:00 AM and the resident was calling for help, was at the foot of the bed and almost on the floor and staff assisted the resident to bed. At 10:00 AM, staff assisted the resident to position at the head of the bed. At 10:40 AM, staff stated that the resident had been rolling around in bed from the head to the feet of the bed all morning. The resident had received medication for pain at 10:11 AM. At 10:25 AM the resident was at the foot of the bed. Further review revealed that the resident had a recent increase in pain and restlessness and pain medication was increased on [DATE] per Hospice recommendations. Review of the Care Plan, goal date [DATE], revealed that the resident was on hospice care, required assistance with turning, positioning, transfers, ambulation in room, toileting and hygiene due to a Stroke with left side weakness and [CONDITION(S)]. Further review revealed that the resident was at risk for falls due to a history of falls, self transfers and impaired safety awareness. No care plan approaches were changed, since the fall on [DATE], to address the resident's increased pain and restlessness to reduce the risk for falls and injuries. Interview with the DON (Director of Nursing) on [DATE] at 3:20 PM confirmed that the resident had a decline in condition which increased the risk for falls and injuries. Further interview confirmed that interventions were not in place to reduce the resident's risk for falls and injuries. B. Review of Resident 7's Progress Notes revealed the following including: - [DATE] at 7:31 AM Risk Management note. The resident had a recent trip to the emergency room and returned with a diagnosis of near [CONDITION(S)] ([CONDITION(S)]). No recommendations were made at this time; - [DATE] at 3:15 PM Risk Management note. The physician recently increased pain medication [MEDICATION(S)] (narcotic [MEDICATION(S)]). No recommendations were made at this time; - [DATE] at 4:37 AM The resident was found on the floor. The resident stated was trying to get to the recliner from the bed. The resident complained of left hip pain; - [DATE] at 7:07 AM The resident complained of severe hip pain with any movement. The resident was sent to the emergency room for evaluation and at 10:26 AM the hospital reported that the resident had a left hip fracture and was admitted for surgery. Review of the Care Plan, goal date [DATE], revealed that the resident had diagnoses including [CONDITION(S)], Heart Disease, required extensive assistance with mobility, transfers and supervision/assist with ambulation in the room and hall. Further review revealed no changes in approaches to address the resident's increased risk for falls related to diagnosis of [CONDITION(S)] or increased dosage of pain medication. The date of the last care plan approaches prior to the fall on [DATE] was [DATE]. Interview with the DON on [DATE] at 3:10 PM confirmed that the resident had recent increased risk factors for falls including, increased tremors and unsteadiness, diagnoses of [CONDITION(S)] and increase dosage of pain medication. Further interview confirmed that changes in care were not made as indicated to decrease the risk for falls and injuries.

Licensure Reference Number 175 NAC 12-006.09D7b(3) Based on record reviews and interview; the facility failed to identify and implement interventions to prevent recurrent falls and injuries for one current sampled resident (Resident 2). The facility census was 55 with three current sampled residents. Findings are: Review of Resident 2's Care Plan, goal date 9/17/19 and printed on 6/24/19, revealed that the resident was at risk for falls related to dementia and impaired mobility and safety awareness. The resident had a fall on 4/24/19, was found on the floor in the dining room, attempted to ambulate without assistance, sustained a hematoma (swelling) on the right side of the head and was sent to the emergency room for evaluation. The resident had a fall on 5/1/19 and had a skin tear to the right wrist. The resident transferred self on 6/10/19, was sent to the emergency room to evaluate pain and returned with a [DIAGNOSES REDACTED]. Further review revealed that new approaches were listed after each fall. Review of the Resident Progress Notes, revealed that on 6/10/19 at 11:10 PM, the resident was found on the floor in between the bedroom and the bathroom. The resident stated had hit head and complained of right wrist pain. The right wrist was noted to have a deformity. The resident was sent to the emergency room per ambulance for evaluation. Further review revealed that on 6/11/19 at 7:53 AM, the emergency room nurse reported that the resident had a complex [MEDICAL CONDITION] wrist. Review of the facility Verification of Investigation report, dated 6/10/19, revealed that the resident had Dementia and [MEDICAL CONDITION] with impaired cognition (thinking skills, memory, awareness and reasoning). The resident was found on the floor in room on 6/10/19 at 11:11 PM. The resident had transferred self and attempted to ambulate without staff assistance. Further review revealed that the resident often attempted to self transfer and ambulate without staff assistance. Interviews with the Director of Nurses and RN (Registered Nurse) - B on 6/24/19 at 11:30 AM confirmed that the resident had a history of [REDACTED]. Further interviews confirmed that effective interventions were not identified or in place to prevent recurrent falls with injuries.

Licensure Reference Number: 175 NAC ,[DATE].10D Based on record reviews and interviews, the facility failed to clarify dosage calculations prior to administering a narcotic medication to one sampled resident (Resident 5). The failure resulted in overdosing the resident resulting in the resident's death. Facility census was 47. Findings are: Record review of an undated Resident Admission Record for Resident 5 revealed the resident was admitted to the facility on [DATE]. Record review of a Palliative Care Consultation document for Resident 5 dated [DATE] revealed the resident was assessed by a Palliative Care Nurse Practitioner. The Nurse Practitioner described the resident as having steadily declined in the past 2 years since the resident fractured a hip. The resident was assessed sitting in a recliner and answered simple questions. The Nurse Practitioner recorded There are no signs of acute distress at this time. Following assessment of the resident the Nurse Practitioner ordered [MEDICATION NAME] liquid 1 mg (milligram) by mouth or sublingually (under the tongue) q (every) 12h (12 hours). Prescription sent to pharmacy. Record review of an untitled document revealed 30 cc (cubic centimeters or milliliters) of [MEDICATION NAME] was received at the facility on [DATE]. Record review of an Individual Resident's Controlled Substance Record for Resident 5 revealed 30 ml (milliliters) of [MEDICATION NAME] was received on [DATE]. Further review of the record revealed MA (Medication Aide)-J administered a 0.5 ml dose at 9:00 p.m. On [DATE], MA-F administered a 1 ml dose of [MEDICATION NAME] at 8:33 a.m. On [DATE], MA-I administered a 1 ml dose of [MEDICATION NAME] at 8:00 p.m. on [DATE]. Record review of Resident 5's Resident Progress Notes between [DATE] and [DATE] revealed no entry on ,[DATE] and an entry on [DATE] recorded at 8:41 p.m. which read: Entered room @ (at) 2030 (8:30 p.m.), resident has no noted pulse or resp (respirations) Record review of the facility's Medication Error Report forms for Resident 5 revealed the errors occurred on ,[DATE] and [DATE]. Description of the errors revealed the bottle from the pharmacy was correctly labeled c with 0.1 ml per 1 mg. Someone had blacked out the 0.1 ml (on the label). 0.5 ml (5 milligrams) was given on [DATE] @ 2100 (9:00 p.m.) by MA-J and 1 ml (10 mg) at 0830 (8:30 a.m.) by MA-F on [DATE]; and on [DATE] at 2000 (8 p.m.) by MA-I. The document recorded the Outcome to resident was Patient died at 2030 [DATE]. A separate Medication Error Report form for Resident 5 described the same incident and included a handwritten statement on [DATE] from LPN (Licensed Practical Nurse)-L which recorded I (LPN-L) marked out the label to prevent someone from giving wrong dose. MA-F asked me what dose to give as (the med aide) was confused from looking at the label. Phone interview with the Palliative Care Nurse Practitioner on [DATE] at 9:15 a.m. confirmed the Nurse Practitioner consulted for Resident 5 on [DATE] and wrote orders for [MEDICATION NAME] 1 mg to be administered every twelve hours. The Nurse Practitioner stated, that following the assessment of the resident on [DATE], the resident was not in any imminent danger from the disease process and the family and resident chose palliative care for comfort. When questioned in the Nurse Practitioner's opinion, what would affect a 5 mg dose and two subsequent 10 mg doses would have on Resident 5, the Nurse Practitioner stated due to frailty and [AGE] years of age, doses at that level would probably kill (the resident). Phone interview with the pharmacist dispensing the [MEDICATION NAME] for Resident was done on [DATE] at 9:45 a.m. The pharmacist stated having re-checked all orders and labels regarding Resident 5's [MEDICATION NAME] order. The pharmacist confirmed receiving an order from the Palliative Care Nurse Practitioner on [DATE] and verified the order called for [MEDICATION NAME] 1 mg every 12 hours. The Pharmacist verified the label sent out was on a typed label and identified to give 0.1 ml or 1 mg in the instructions. The bottle also identified the strength of the medication in the bottle was 10 mg per milliliter. When asked what a 10 mg dose of [MEDICATION NAME] would result in for Resident 2, the pharmacist replied that in a frail elderly person over [AGE] years of age and as potent as this ([MEDICATION NAME]) is that the first dose would cause some sedation but with progressive dosing accumulation would occur and likely result in death. The pharmacist stated that even a healthy young individual taking a 10 mg dose would experience severe sedation at a minimum. Interview with the facility DON (Director of Nursing) on [DATE] at 2:00 p.m. confirmed the facility staff had overdosed Resident 5 on [DATE] and [DATE]. The DON stated, from investigation, that the resident's [MEDICATION NAME] was received at the facility in a 30 ml bottle on [DATE]. The DON stated, that when logged into the computer, LPN-K had incorrectly typed in the order as 5 mg/ml rather than 10 mg/ml. When MA-J compared label to logged in order, MA-J was confused and asked for direction from LPN-K. LPN-K then directed MA-J to administer 0.5 ml (5 mg) which MA-J complied with and administered the medication at 9:00 a.m. LPN-K had not contacted the pharmacy or prescribing Nurse Practitioner for clarification of the orders. The DON stated that, on [DATE], MA-F also questioned the order and asked LPN-L for directions. LPN-L proceeded to tell MA-F the label was incorrect and crossed out the label instructing to administer 0.1 ml and changed the label to 1 ml without receiving any clarification from the pharmacy or the prescribing Nurse Practitioner. LPN-L instructed MA-F to administer 1 ml (10 mg) of the [MEDICATION NAME] with which MA-F complied at 8:33 a.m. At 8:00 p.m., MA-I administered 1 ml of [MEDICATION NAME] to Resident 5 based on the label change. The DON verified the resident was overdosed by 5 times the order on [DATE] and twice was administered 10 times the order on [DATE]. The DON verified the resident expired a half hour after receiving the third dose. Prior to the survey team exit on [DATE], the facility had terminated two employees regarding the incident. In addition, the facility's nurse consultants and DON arranged for immediate education for licensed nurses including dosing calculations for liquid medications, and review of a new policy for monitoring liquid medication dosages. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G.

Licensure Reference Number 175 NAC 12-006.07C Based on record reviews and interview, the facility failed to ensure that the QA&A (Quality Assessment and Assurance) Committee 1) developed and implemented an action plan to reduce the risk for medication errors which were identified at the annual survey and 2) identified that medication administration competencies were not completed for seven medication aides to ensure safe medication administration. The facility census was 47. Findings are: A. Review of the survey findings from the annual survey, dated 2/4/16, revealed a deficiency cited for medication errors. The medication rate was eight percent. Review of the findings for the current survey revealed that a medication error occurred during the medication pass observations and a significant medication error resulting in resident death was cited. B. Review of the findings for the current survey revealed that medication administration competencies were not completed for medication aides currently administering medications for the residents. A deficiency was cited at F 499. Review of the facility Quality Assurance Policy, dated 8/30/05, revealed that the following: Policy: The Quality Assessment/Assurance Committee shall determine opportunities for improvement, develop mechanisms that scrutinize appropriateness, effectiveness, efficiency and safety of the service rendered. Interview with the Administrator on 6/6/16 at 2:00 PM confirmed that the QA&A Committee was responsible to ensure that identified deficiencies were corrected and that staff were competent to perform their jobs.

Licensure Reference Number 175 NAC 12-006.09D Based on observations, record review and interviews; the facility failed to identify, assess and manage ongoing pain for one sampled resident (Resident 4). The facility census was 48. Findings are: Review of the Resident Admission Record revealed that Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan with a goal date of 3/3/16, revealed that the resident required assistance with repositioning to maintain level of comfort. Further review revealed that the resident had a [DIAGNOSES REDACTED]. Approaches included evaluate pain needs every shift, weekly pain observation and quarterly pain risk observations, monitor and record any complaints of pain, including alleviating and aggravating factors, and monitor and record any non verbal signs of pain such as crying, guarding, moaning, restlessness, or grimacing. Interview with the resident on 2/3/16 at 9:15 AM revealed that bottom is very sore and I shouldn't be sitting on it. Interview at 2:00 PM revealed my bottom is still very sore and it hurts so much to sit in this chair. Observations on 2/3/16 at 9:15 AM revealed the resident seated in the recliner in room with feet elevated. The resident was attempting to reposition self in the recliner and was grimacing and teary. Observation at 12:25 PM revealed the resident seated in a chair in the dining room with no seat cushion. Further observations at 10:45 AM and 2:00 PM revealed the resident seated in the recliner with feet elevated. Observation on 2/4/16 at 7:30 AM revealed the resident seated in the dining room with no seat cushion. Observation on 2/4/16 at 8:30 AM revealed the resident seated in the dining room asking for assistance to room. Further observations revealed MA (Medication Aide) - F assisted the resident to the room and to the bathroom. The resident stated that bottom is still very sore like yesterday. Observation revealed the resident's coccyx area was reddened with an open area noted. The resident complained of pain while skin care was provided and stated It hurts so bad. Interview on 2/4/16 at 9:15 AM with LPN (Licensed Practical Nurse) - G revealed that LPN-G was not aware of the resident's pain or open area on the residents' coccyx. Interview on 2/4/16 at 10:45 AM with the DON (Director of Nursing) confirmed that the staff did not evaluate the resident's pain at least every shift as directed on the care plan. Further interview confirmed that staff were to communicate pain to the charge nurse right away so that the resident's pain would be assessed, including causal factors, and then implement measures to alleviate the pain. The DON confirmed that there was no documentation of the resident's pain or skin problems and the resident did not receive any pain medication this month.

Licensure Reference Number 175 NAC 12-006.09D4 Based on observation, record reviews, and staff interview; the facility failed to identify a decline in functional range of motion and develop a program to improve or prevent further decline for one current sampled resident (Resident 12). The facility census was 39 and the Stage 2 sample was 18 current residents. Findings are: Review of the admission summary revealed that Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 5/21/12, revealed no limitations in functional range of motion. Review of the MDS, dated [DATE], revealed limitations in functional range of motion on both sides, including the upper and the lower extremities. Review of the "Physician's Telephone Orders", dated 6/4/12, revealed an order to discontinue Occupational Therapy as the resident was meeting goals. Review of the "Physician's Telephone Orders", dated 6/11/12, revealed an order to discontinue Physical Therapy and transition to Restorative Care. Review of the "Care Plans", goal date 11/22/12, revealed that the resident required limited assistance with activities of daily living. Approaches included "Restorative and walk to dine 6-11-12". Review of the facility "Preventative Maintenance Program", dated 6/11/12, revealed that the Physical Therapist recommended "Walk to Dine Program to 3 Meals a day". Further review revealed that on 7/29/12, the Restorative Nurse documented no changes were needed. Review of the "Nursing Assessment", dated 7/30/12, revealed that the resident had contractures at bilateral shoulders and knees, back, and neck and the resident ambulated independently with a walker. Further review revealed no assessment to identify the cause of the contractures or a plan to restore function or to prevent further decline. Review of the "Preventative Program" documentation, dated 7/30/12, revealed that the resident ambulated independently with walker daily, doing better with own activities of daily living, and requested staff to supervise when undressing at bedtime. Observation on 8/13/12 at 3:30 PM revealed the resident ambulated in room independently with walker. Interview on 8//16/12 at 2:30 PM with the Interim Director of Nursing confirmed no documentation that the staff identified the resident's actual decline in functional limitation in range of motion or potential causal factors. Further interview confirmed that the resident's preventative program does not address the limitation in range of motion for the upper and the lower extremities and interventions to restore function or to prevent further decline.

Licensure Reference Number 175 NAC 12-006.07C Based on record reviews and staff interview, the facility failed to ensure that the QA&A (Quality Assessment and Assurance) Committee identified quality of care issues and implemented plans of action to correct identified quality deficiencies from the previous survey. The facility census was 39. Findings: Review of the annual Recertification Survey, dated 2/14/12, revealed that deficiencies cited included the following: F 225 - Reporting Investigations of Abuse to the State Agencies; F 226 - Staff reporting allegations of abuse to the administrative staff for investigation; F 280 - Updating and revising care plans to reflect the current needs of the residents; F 282 - Implementation of the care plan approaches; F 514 - Accurate and complete documentation of the medical record. Review of the preliminary citations for the current survey revealed that these deficiencies were not corrected. Further review of the preliminary citations for the current survey revealed multiple care tags which included the following: F 157 - Physician notification of a resident's change in condition; F 241 - Care to promote dignity for the residents; F 309 - Care and treatment following a resident's fall with injuries; F 312 - Care and assistance with activities of daily living for a dependent resident; F 314 - Care and treatment for [REDACTED]. F 317 - Care and services to prevent functional limitations in range of motion; F 318 - Care and services to prevent further decline in limitations in range of motion; F 323 - Care and treatment to prevent accidents, provide safe transfers for a resident at risk for falls. Interview on 8/16/12 at 3:30 PM with the Administrator and the Interim Director of Nursing confirmed that the QA&A committee was to ensure that deficiencies from the previous survey were corrected. Further interview confirmed that the QA&A committee did not identify and correct quality of care issues in the facility.

Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews, and interviews, the facility failed to provide standard emergency care and treatment following a resident fall with head and neck injury for one sampled resident (Resident 47). Sample size was 12 current residents. Facility census was 39. Findings are: Interview with Resident 47's family member on 8/14/12 at 2:45 p.m. revealed the family member was concerned with the care and treatment following Resident 47's fall in June. The family member stated the resident was being assisted by a staff member from the bathroom and fell hitting the resident's head and bending the neck. The family member stated the resident had a prior history of spinal injuries and surgeries before the incident. The family member stated being contacted by the facility after the fall and the staff reported there were no significant injuries sustained. Upon inquiry, the facility reported the nurse aide assisting the resident placed a pillow underneath the resident's head following the incident and then summoned a nurse. The family member was concerned as to why the resident was moved and a pillow was placed under the resident's head following a head and neck injury. The family member reported that the resident continued with persisting pain for several days before any assessment by a medical practitioner. The family member stated that once the resident was sent for an evaluation and x-rays, a new neck fracture was discovered. Resident 47 was interviewed on 8/15/12 at 7:30 a.m. The resident was observed seated in a chair with an immobilizing neck brace in place. Resident 47 confirmed falling in June after being assisted to the bathroom. Resident 47 stated experiencing neck pain from the fall and described the pain as severe and persisting without relief for three days. Resident 47 confirmed reporting the pain to nursing and receiving pain medication but that the medication did not totally relieve the pain in the neck. The resident questioned why the facility waited for days before requesting medical practitioner examination. Record review of Resident 47's "Face Sheet" dated 6/6/12 revealed the resident was admitted to the faciliy on 5/29/12. A hospital History and Physical form for Resident 47 dated 5/24/12 revealed "Past Surgical History" for the resident including: "Anterior cervical fusion; and Lumbar fusion". The resident was admitted to the hospital on [DATE] for "End Stage Patellofemoral arthritis" of the right knee requiring a "right total knee arthroplasty." Record review of a facility investigation dated 6/15/12 related to an incident involving Resident 47 revealed the following information: - The incident was identified as having occurred on 6/8/12. (This date was incorrect based on review of the documentation pertaining to the events. The actual incident occurred on 6/9/12 at 4:00 a.m.) - The investigation identified Resident 47 sustained a "Fracture to neck from fall". - The investigation determined that, at 4:00 a.m., a nurse aide assisted the resident to the bathroom and upon return to the bed, "resident tipped to the right falling over and hit the wall with (his/her) head and neck." - Treatment following the fall was described as: "First aid, assessment for injury, neuro checks per policy, no exterior signs of trauma, neuoro checks remained stable with full range of motion." - The investigation listed the resident's medical history and identified: "Numerous compression fractures of neck/spine with multiple back and neck surgeries with placement of hardware . . ." - Description of the incident revealed the resident : "ambulated through the bathroom door and turned left slightly to angle towards (his/her) bed. CNA (Nurse Aide) following (resident) . . . (the resident) tipped to the right all of a sudden and fell to the floor with (resident's) back towards the wall. When (the resident) landed (the resident's) head and neck were angled up from the mop board but crunched against the wall. CNA called for assistance and put a pillow under resident's head . . . Resident has a history of chronic pain in (the resident's) neck and stated neck just felt a little stiff. Ice pack offered . . . 6/9/12 still no trauma noted and resident's c/o (complain of) stiffness only. 6/10/12 continued to c/o stiffness only, pain meds given for knee pain. 6/11/12 complains of neck hurting more today, called (name of physician) and sent to ER (emergency room ) . . . Later that day resident was admitted to (hospital) with fracture to neck . . ." Record review of nursing documentation entries for Resident 47 between 6/9/12 and 6/11/12 revealed the following entries: - 6/9/12 entry documented at 1:08 p.m. revealed a note regarding the 4 a.m. fall. The nurse documented being called into Resident 47's room "patient is on floor layig (sic) on back with pillow under (resident's) head . . . (resident) was walking back from br (bathroom) and tipped over to the side (Nurse Aide) let (the resident ) fall adn (sic) voiced that (the resident) hit (the resident's) head on the wall . . . ROM (range of motion) WNL (within normal limits) . . . provider contacted . . . faxed . . . (resident) did c/o pain in neck but voiced that has hurt even before fall but (resident) c/o being stiff . . ." Record review of the fax communication to the physician on Saturday 6/9/12(erroneously dated 6/8/12 on the form) and unsigned by the staff member, revealed the fax was "information only" and reported at 4 a.m. resident was walking with walker and tipped onto the right side falling over and hitting side of head on the wall. "ROM (range of motion) done no c/o pain". The fax stated resident "did c/o pain in neck area (Resident) was able to do ROM. Assisted back up, walked back to bed . . ." There was no documented response from the physician acknowledging receipt of the fax. Additional notes after the resident's fall included: - 6/9/12 entry documented at 9:52 p.m. the resident in pain and had [MEDICATION NAME] (narcotic) at 2:30 p.m. and 8:10 p.m. Had [MEDICATION NAME] (anti anxiety) at 8:10 as "very upset because of the pain. Polar ice placed to R (right) knee. Ice pack to neck . . ." - Medication Sheets entries documented on 6/9/12, Resident 47 was administered [MEDICATION NAME] at 1:25 a.m.; 10:20 a.m.; 2:30 p.m.; and 8:30 p.m. on 6/9/12. - Entry 6/10/12 at 12:47 p.m. read "After effects of fall- (Resident) c/o pain neck but voices (resident) feels stiff, does better once on pain meds." at 12:49 p.m. the documentation read: " . . . Need for pain medication, pain meds given per (resident) request after tried reposition up in chair no relieve . . ." - Medication Sheets entries documented on 6/10/12, Resident was administered [MEDICATION NAME] at 11 a.m.; 4 p.m., and 8 p.m. - 6/11/12 at 12:56 a.m. entry read: " . . . pain meds given with effectiveness. Amb (ambulates) with walker and 1 assist." - 6/11/12 at 11:30 a.m. entry read: " . . . Pain- Need for medication rated pain at 9 from knee and neck, Response to medications, received [MEDICATION NAME] at 1:55 a.m. and 4:30 a.m. was sleeping comfortably and asked at 6:10 a.m. about pain rated it at 5 . . ." - 6/11/12 at 11:49 a.m. entry read: " . . . Complains of increased pain/neck is hurting more as is knee . . ." - 6/11/12 at 5:17 p.m. entry read: "Dr. Notified: Why?- Has c/o increased neck and head pain since fall on 6-10 early AM; Pain is relieved by [MEDICATION NAME] and Tyl (Tylenol) #4 (Tylenol with 4 milligrams of [MEDICATION NAME]). Called physician and asked if we can send (resident) to ER. Dr. Agrees . . . To ER via faciliy van @ (at) 1620." The documentation supported that no physician was contacted personally about the events other than by a fax communication on 6/9/12 (Saturday- non business hour) until requesting a medical evaluation on 6/11/12. Record review of Resident 47's "Medication Sheets" and medication "Documentation Sheets" for June 2012 revealed the resident received Tylenol, [MEDICATION NAME], and Tylenol #4 prior to the fall on 6/9/12 for "leg pain". No neck pain was documented prior to the fall. Following the fall, the resident received Tylenol #4 once and [MEDICATION NAME] nine separate times. The medication sheets, documentation sheets, and nurses notes were contradictory with regard to the times and types of pain medications being administered to Resident 47 during the period between 6/9/12 and 6/11/12. Prior to the fall on 6/8/12, the resident had not been administered any [MEDICATION NAME]. Record review of the emergency room report dated 6/11/12 revealed the physician documented "fell at nursing home on Saturday striking the back of (resident)s) head on the windowsill and injuring (resident's) neck . . . complains of severe and worsening neck pain since the injury . . ." The physician also documented: "CT (computerized axial tomography scan) of the C-spine revealed bilateral pedicle fractures of C6 and multiple spinous process fractures which all appear to be acute. On arrival this patient was placed in a c-collar . . ." Record review of Resident 47's "Neuro surgical Consultation Report" dated 6/11/12 recorded the resident was seen in consultation following a fall at the nursing home on Saturday. The physician identified the resident hit the back of the head during the fall and was observed wearing a cervical collar during the exam. The physician reviewed a radiology scan which showed the resident had significant [MEDICAL CONDITION] and a previous C4-5 (cervical spine location) and C5-6 cervical fusion with allograft and a titanium plate. "The patient has [MEDICAL CONDITION] and arthritic changes. It appears that (the resident) suffered a fracture to the pars inerarticularis of C4 and C5 with displacement. The titanium plate was intact." An MRI (Magnetic Resonance Imaging) report dated 6/12/12 revealed the test was done based on "Trauma. Known cervical spine fractures." The report further describes "acute mild superior endplate compression fracture deformities involving C7, T1, and T2 (locations of neck and spine) along with chronic compression fractures at T3 and T4 which appeared stable. Interview with the IDON (Interim Director of Nursing) on 8/15/12 at 3:00 p.m. revealed the faciliy did not have a specified policy related to emergency treatment of [REDACTED]. This policy classified incidents with instructions related to "injury requiring immediate medical treatment" with examples specified as "Fracture, sprain, dislocation, injury to joint or spine . . ." included in the list. The IDON and Administrator were interviewed on 8/16/12 at 2:00 p.m. During the interview, the information from the faciliy investigation was reviewed. The IDON verified the facility was provided medical information on admission that Resident 47 had a history of [REDACTED]. The IDON and Administrator verified the non-licensed staff member placed a pillow under the resident's head following a fall with head and neck injury on 6/8/12. The IDON and Administrator also verified range of motion was performed on the resident by a licensed nurse following a head and neck injury. The IDON and Administrator verified the resident complained of ongoing pain requiring medication intervention with [MEDICATION NAME] following the fall and that the facility staff did not converse with or seek further medical practitioner evaluations until sent to the emergency roiagnom on [DATE]. Reference: American Institute for Preventive Medicine: Emergency & First Aid: Head, Neck & Spine Injuries 2012 at www.HealthyLife.com "Head/Neck/Spine Injuries . . . Signs & Symptoms For a Sever Injury: . . . It looks like the head, neck, or back is in an odd position. Pain is felt in the back, neck, and or head. The pain can be severe. Stiff neck . . . For a Whiplash Injury: Neck pain and stiffness . . . Treatment: If you suspect a head, neck, or back injury, you must keep the head, neck, or back injury, you must keep the head, neck, and back perfectly still until emergency medical care arrives. Any movement of the head, neck, or back could result in paralysis or death . . ." The article also provides instructions to "Get Medical Care Fast" if any of the severe injury symptoms are observed.

Licensure Reference Number 175 NAC 12-006.09D4 Based on record reviews and staff interview, the facility failed to identify a decline in functional range of motion and develop a program to improve or prevent further decline for one current sampled resident (Resident 26). The facility census was 39 and the Stage 2 Sample was 18 current residents. Findings are: Review of the admission summary revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 4/22/12, revealed that the resident had no impairment in functional range of motion at the upper extremities and had impairment on 1 side at the lower extremities. Review of the MDS, dated [DATE], revealed that the resident had impairments in functional range of motion on both sides including the upper extremities and the lower extremities. Interview on 8/15/12 at 10:00 AM with the IDON (Interim Director of Nursing) revealed that the resident was not on a restorative nursing program. Review of the "Care Plans", goal date 10/4/12, revealed that the resident was taken off the preventative program on 2/27/12 as the resident consistently refused. Interview on 8/16/12 at 2:45 PM with the IDON confirmed that the staff did not identify the resident's decline in functional range of motion and further assessment was not completed to determine the cause of the decline. Further interview confirmed that interventions were not in place to restore function or to prevent further loss of function.