Every finding on record at Parkside Manor

Based on record review and interview the facility failed to complete the required background checks for 2 or 5 sampled staff to protect residents from potential abuse. The facility census was 27. Findings are:A. Review of the undated facility policy Parkside Manor Abuse, Neglect, and Misappropriation of Resident Property revealed the following: -It was the policy of the facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background checks. -Before new employees were permitted to work with residents, references provided by the prospective employees would be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. The facility would not employ or otherwise engage individuals who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. -A criminal background check would be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background would result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation. B. Review of Nursing Assistant (NA)-J staff file revealed that NA-J had a hire on date of 8/5/25 and a Criminal Background Check had not been completed.Review of Dietary staff (DS)-L staff file revealed that DS-L had a hire on date of 9/26/25, a Criminal Background Check and Adult and Child Registry Check had not been completed. C. An interview with the Business Office Manager (BOM)-I on 3/9/26 at 3:00 PM confirmed all new employees were to have Criminal Background Checks and Adult/Child Central Registry Checks completed upon hire. Further interview with BOM-I confirmed that NA-J and DS-L did not have a Criminal Background Check completed upon hire and DS-L did not have an Adult/Child Central Registry Check completed upon hire to ensure the residents were protected from potential abuse.

Based on record review and interview the facility failed to ensure Resident 26's Antibiotic was ordered in Accordance with the facility Antibiotic Stewardship program. The facility census was 27. Findings are:A. Review of the undated facility Antibiotic Stewardship Policy revealed the following:-It was the policy of Parkside Manor to maintain an Antibiotic Stewardship Program (ASP) with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use.-To meet the Antibiotic Stewardship guidelines, orders would include dose, duration, route and indication for Antibiotics prescribed for each resident and would be tracked and kept in the medical record. B. Record review of Resident 26's March 2026 Treatment Administration Record (TAR) revealed an order for Tobradexame Suspension (steroid/antibiotic combination) instill one drop to both eyes four times daily as needed for a diagnosis of Blepharitis (inflammation of the eyelid) with a start date of 08/25/25 (no stop date indicated). Further review of Resident 26's TAR revealed that Resident 26 received the eye drop on March 4th and March 5th, 2026, for red eyes. Interview completed on 3/10/26 at 11:05 AM with the Director of Nursing (DON) confirmed that all antibiotic orders were to have a duration and Resident 26's order for Tobradexame eye drops did not have a documented duration.

Licensure Reference Number 175 NAC 006.18(B) Based on observation, record review, and interview the facility failed to Covid 19 test 6 of 6 sampled residents (Resident 10, 11, 14, 17, 21, and 26) when respiratory illness symptoms were displayed and failed to implement isolation procedures for Resident 10 when respiratory symptoms were displayed. The facility failure had the potential to effect all residents in the building. The sample size was 6 and the census was 27. Findings are: A. Review of the facility policy Upper Respiratory Illness with a revision date of 9/4/24 revealed the following: -The facility made every attempt to prevent the transmission of any upper respiratory illness from entering the facility and also reduce the transmission of illness with the facility. -To reduce the transmission of upper respiratory illness mask and sanitizer was available at the main entrances, visitors were asked to use hand sanitizer before visiting residents, staff strictly adhered to hand, respiratory, and cough hygiene, and vaccinations were offer to all staff and residents. -To reduce the transmission of upper respiratory illness within the facility staff strictly adhered to hand respiratory and cough hygiene and were encouraged to report symptoms on themselves and/or others as soon as possible, precautions were instituted in rooms where there were suspected or confirmed cases of any transmissible respiratory illness, and any person/s that had fever or symptoms of transmissible respiratory illness including but not limited to COVID and influenza, isolated for at least 5 days from onset of symptoms or the first day of positive test results. -Infected residents were isolated and closely monitored and positive cases were investigated and tracked for case origination. The Director of Nursing (DON) or designee determined who needed to be tested and to determine outbreak testing. -Staff having signs and symptoms of COVID should test to determine if they need to isolate. B. Review of Resident 10's Progress Notes revealed the following: -2/14/2025 at 9:52 AM Resident 10 was confused and required increased assistance with getting dressed and completing cares. Oxygen level was 80% on room air. Oxygen per nasal cannula was applied at 2 liters per nasal cannula. (No follow up oxygen level was charted.) -2/15/25 at 8:00 PM revealed Resident 10 had a harsh cough was noted and both eyes had yellow color drainage. Oxygen level was 91% with oxygen at 2 liters per nasal cannula. -2/16/25 at 7:00 PM revealed Resident 10 continued with a harsh moist cough. -2/17/25 9:25 AM revealed Resident 10 had a moist, harsh, non-productive cough. Crackles were noted in bilateral lungs with diminished air exchange. Oxygen level was 82% on room air, oxygen was applied at 2 liters per nasal cannula, oxygen level increased to 90%. -2/17/25 at 9:42 AM the facility staff received a physician's order for an antibiotic medication for Pneumonia. -2/18/25 at 1:52 PM revealed Resident 10 continued with a moist cough. Lung sounds were diminished in upper lobes with crackles in the lower lobes bilaterally. Observations of Resident 10 revealed the following: - 2/18/24 at 8:50 AM revealed Resident 10 was sitting in a recliner in room, voice crackled, and a loose nonproductive cough was noted. -2/19/25 10:00 AM revealed Resident 10 was in the bathroom, had loose productive cough noted and had coughed up yellow colored phlegm. C. Review of Nursing Progress Notes for Resident 11 revealed the following: -1/30/25 at 10:52 AM revealed Resident 11 had sinus and nasal congestion, both eyes were mattery and puffy under eyes. -1/30/25 at 1:59 PM revealed the facility staff received physicians order for a decongestant and cough medication. 1/31/25 at 10:36 AM revealed Resident 11 continued with nasal congestion and had a non-productive cough. -2/1/25 9:05 AM revealed Resident 11 had a productive cough, head was congested, lung sounds were diminished. -2/4/25 at 9:56 AM, Resident 11 continued with nasal congestion and complained of ears feeling full. Face was puffy with a moist nonproductive cough. Both eyes had drainage. -2/4/25 at 12:31 PM, the resident was seen by physician and received an order for an antibiotic for pneumonia. -2/5/25 at 2:50 PM, Resident 11 continued with a harsh productive cough, lung sounds were diminished bilaterally upper and lower lobes. -2/7/25 at 10:50 AM the resident continued with an occasional moist non-productive cough noted. D. Review of Nursing Progress Notes for Resident 17 revealed the following: -2/8/25 at 10:46 AM, Resident 17 complained of sinus and nasal congestion. -2/8/25 at 12:09 PM,Physician order received for Benadryl 25 milligrams (mg) every 6 hours as needed for sinus and nasal congestion. -2/9/25 at 10:56 AM, Resident 17 continued with sinus and nasal congestion. -2/10/25 at 1:06 PM, Resident 17 continued to have nasal and sinus congestion. -2/11/25 at 2:05 AM hoarse voice was noted when speaking. An interview with Registered Nurse (RN)-C, infection control nurse, on 2/18/25 at 11:55 AM verified residents 10, 11 and 17 did not have a Covid 19 test or respiratory panel completed when respiratory symptoms started. RN-C further confirmed Resident 10 was not placed in isolation when respiratory symptoms started. 42360 E. Review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning ) dated 1/1/25 revealed the resident had moderate cognitive impairment, received substantial assistance with dressing and hygiene, was incontinent of bowel and bladder, and had dementia. Review of Resident 14's Care Plan with a revision date of 10/29/24 revealed the resident had dementia with difficulty making decisions and intermittent confusion. In addition, the resident took medications to treat Congestive Heart Failure and Depression. There was no evidence of treatment for a current or recent respiratory infection. Review of Resident 14's Progress Notes revealed the following: -1/14/25 at 12:31 PM the resident was seen by the physician in the facility and had coarse lung sounds and a loose cough. The physician ordered an antibiotic and anti-inflammatory medication. -1/15/25 at 10:29 AM the resident continued to have coarse lung sounds and a cough -1/16/25 at 6:11 AM the resident continued taking an antibiotic for a respiratory infection and continued to nasal drainage and coughing. -Further review revealed there was no evidence the facility completed COVID testing when the resident presented with signs and symptoms of a potentially infectious respiratory illness. During an interview on 2/18/25 at 3:41 PM the DON revealed the facility was not routinely COVID testing residents who presented with respiratory illness signs and symptoms. The DON would check to see if a COVID-19 test was completed for Resident 14 when respiratory illness symptoms were identified on 1/15/25. During an interview on 2/19/25 at 4:47 PM the DON confirmed the facility did not complete a COVID-19 or any type of respiratory panel testing to identify which respiratory illness Resident 14 had, when the resident presented with respiratory illness symptoms on 1/15/25. F. Review of Resident 21's MDS dated [DATE] revealed the resident had pneumonia and lung disease, however the resident was offered but declined a pneumonia vaccine. Review of Resident 21's Care Plan with a revision date of 1/2/25 revealed the resident had respiratory disease, shortness of breath and dementia. The resident displayed anxiety and anxiousness when having shortness of breath. Oxygen was used as needed. There was no indication the resident had a recent respiratory infection. Review of Resident 21's Progress Notes revealed the following: -on 1/26/24 at 2:50 PM the resident complained of signs and symptoms of a cold, a loose cough and was given oxygen to help with anxiety and discomfort. -on 1/27/24 at 1:00 AM the resident had a moist cough, labored breathing, and an oxygen level of 83% (90-100% is considered normal). The resident's oxygen levels did not improve with oxygen and thus the resident was transferred to the hospital by ambulance. -Further review revealed there was no evidence the facility completed COVID testing when the resident presented with signs and symptoms of a potentially infectious respiratory illness. During an interview on 2/18/25 at 3:41 PM the DON revealed the facility was not routinely COVID testing residents who presented with respiratory illness signs and symptoms. The DON would check to see if a COVID-19 test was completed for Resident 21 when respiratory illness symptoms were identified on 1/26/24. During an interview on 2/19/25 at 4:47 PM the DON confirmed the facility did not complete a COVID-19 or any type of respiratory panel testing to identify which respiratory illness Resident 21 had, when the resident presented with respiratory illness symptoms on 1/26/24. G. Review of Resident 26's MDS dated [DATE] revealed the resident had dementia, a respiratory condition, diabetes and had taken insulin and an antibiotic in the preceding week. Review of Resident 26's Care Plan with a revision date of 1/15/25 revealed the resident had impaired cognition and required assistance with activities of daily living. In addition, the resident had a history of falling, was diabetic and received insulin daily. There was no evidence the resident had current or recent respiratory illness. Review of Resident 26's Progress Notes revealed the following: -On 12/26/24 at 3:21 PM the resident had congestion and general malaise and an occasional cough. -On 12/28/24 at 5:24 PM the resident continued to complain of head congestion and requested a room tray for dinner. -On 12/29/24 at 9:47 AM the resident congestion was not improving, and the facility called and updated the provider on the resident's symptoms. The provider ordered an anti-inflammatory medication. -On 12/30/24 at 5:17 PM the provider visited the resident in the facility and ordered an antibiotic and nebulizer (inhaled breathing) treatments. -Further review revealed there was no evidence the facility completed COVID testing when the resident presented with signs and symptoms of a potentially infectious respiratory illness. During an interview on 2/18/25 at 3:41 PM the DON revealed the facility was not routinely COVID testing residents who presented with respiratory illness signs and symptoms. The DON would check to see if a COVID-19 test was completed for Resident 26 when respiratory illness symptoms were identified on 12/26/24. During an interview on 2/19/25 at 4:47 PM the DON confirmed the facility did not complete a COVID-19 or any type of respiratory panel testing to identify which respiratory illness Resident 26 had, when the resident presented with respiratory illness symptoms on 12/26/24.

Licensure Reference Number 175 NAC 12.006(D)(vi) Based on observation, record review and interview; the facility failed to ensure insulin pens were dated when opened to ensure safe administration of insulin for Resident 17 and Resident 129. The sample size was 4 and the facility census was 27. Findings are: A. Review of the facility policy Insulin Administration with a revised date of [DATE] revealed the following: -The purpose of the Insulin Administration policy was to provide guidelines for the safe administration of insulin to residents with diabetes. -Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial. Review of Resident 129's February 2025 medication administration record (MAR) revealed an order for Aspart (rapid acting insulin)10 units in the morning. An observation on [DATE] at 7:35 AM with Licensed Practical Nurse (LPN)-G obtained Resident 129's insulin pen out of the medication cart for administration. The Aspart Insulin did not have an open date or expiration date documented. Inspection of the medication cart on [DATE] at 11:30 AM revealed Resident 17's Toujeo (long-acting insulin) insulin pen did not have an open date or expiration date documented. Review of Resident 17's February 2025 physician orders revealed an order for Toujeo 24 units at bedtime. Interview on [DATE] at 7:35 AM with LPN-G verified that the insulin pen for Resident 129 was not dated when opened or dated when expired and insulin pens were to be dated when opened and expired. Interview on [DATE] at 11:30 AM with LPN-G verified that the insulin pen for Resident 17 was not dated when opened or dated when expired.

Licensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure Resident 4's as needed antipsychotic (a type of medication which alters chemicals in the brain to effect changes in behavior, mood and emotion) medication was reviewed for continued need and renewed every 14 days as required. The sample size was 5 and the facility census was 27. Findings are: Review of the facility policy Antipsychotic Drug Use Policy, last revised 10/10 revealed the following: -all residents having antipsychotic drug orders would have a proper diagnosis, -resident behaviors would be monitored daily, -the Pharmacy would routinely monitor and request appropriate dose reductions, -the facility would utilize the lowest effective dose based on behaviors, -residents would have interventions on their care plans to assist in redirecting undesired behaviors, and -the resident's responsible party and/or the resident would be educated on the medication, diagnosis, dose changes, and side effects of the medications. Review of Resident 4's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 12/4/24 revealed the resident had severe cognitive impairment, didn't exhibit any behaviors, was dependent with toileting, dressing, and hygiene, and had a diagnosis of dementia, anxiety and depression. Review of Resident 4's Care Plan last revised 1/2/25 revealed the following: -the resident had delusions and hallucinations, -was socially inappropriate at times, -had impaired cognitive function due to dementia, -used Haloperidol (an antipsychotic medication) for behavior management, and -required assistance with toileting, dressing, and hygiene. Review of the facility form Physician Orders for Resident 4 revealed the resident had an order for Haloperidol 5 milligrams (mg) by mouth every 8 hours as needed for agitation with a start dated of 11/25/24. Review of an email the Consulting Pharmacist sent to the Director of Nursing (DON) dated 11/26/24 revealed Resident 4 had an order for Haloperidol as needed with a stop date of 5/7/25. Recommendations were that since the Haloperidol is an antipsychotic medication, it was limited to 14 days, the resident would need to be seen by the provider for an evaluation every 14 days, and a follow-up visit was needed by 12/10/24. Review of the Consultant Pharmacist's Medication Regimen Review dated 1/15/25 revealed the last documented administration of the Haloperidol 5mg as needed was on 11/28/24. Review of the facility forms for Physician Visits revealed the following: -on 10/29/24 a Physician recertification visit had an order for Haloperidol 5mg every 8 hours as needed for agitation, -a visit on 11/12/24 revealed no documentation that the as needed Haloperidol was addressed (14 days after order), -a Physician visit on 11/19/24 revealed no documentation that the as needed Haloperidol was addressed (21 days after order), -a Physician visit on 12/24/24 revealed the Physician wrote to continue the as needed Haloperidol 5 mg every 8 hours as needed for dementia with psychosis (56 days after original order), but did not document a resident specific rationale, -a Physician recertification visit on 1/7/25, the Physician wrote to continue the Haloperidol 5 mg every 8 hours as needed for psychosis but did not document a resident specific rationale, -a visit on 1/21/25 the Physician wrote the Resident still needs Haloperidol and to continue Haloperidol as needed for dementia with psychosis but did not document a resident specific rationale, -a visit on 1/28/25 the Physician wrote Haloperidol 5 mg every 8 hours as needed for diagnosis of dementia with psychosis, but did not document a resident specific rationale, -a visit on 2/4/25 there was no documentation that the as needed Haloperidol was addressed, and -a visit on 2/11/25 there was no documentation that the as needed Haloperidol was addressed (14 days since it was last renewed). Interview on 2/19/25 at 12:50 PM with Registered Nurse (RN)-C confirmed the resident had not been seen every 14 days as required for the as needed Haloperidol. Further interview confirmed the resident had not had any adverse behaviors, the resident did not need to use the medication, and had not received the medication since 11/28/24. Interview on 2/19/25 at 1:45 PM with RN-C and the DON confirmed Resident 4 was not seen every 14 days for the as needed Haloperidol.

Liscensure Reference Number 175 NAC12-006.11C Based on observation, interview and record review, the facility failed to ensure a resident's perishable food item was dated to prevent the potential of foodborne illness. The sample size was 1 and the facility census was 31. Findings are: Review of the undated facility policy Foods Brought in from Outside Sources revealed the facility will ensure food items brought in from other sources are safe and follow food safety code standards by labeling the items with the resident's name, date the item was purchased or prepared and the name of the item. In addition, perishable food items that require refrigeration will be discarded after 72 hours if the food is not consumed by the resident. An observation on 1/30/24 at 11:45 AM revealed the dining room refrigerator had a package of steak tenders stored for a resident and did not contain a date. An interview on 1/30/24 at 11:45 AM with the Dietary Manager (DM) confirmed the package of meat should have been dated and was not.

Liscensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure resident assessments had accurate information for 3 residents (Resident's 15, 13 and 28) related to; 1) Resident 15's antiplatelet medication [a blood thinner used to prevent blood cells from clumping together to form a clot] 2) Resident 13's Level II Preadmission Screening and Annual Resident Review (PASARR) status and 3) Resident 28's anticoagulant medication [a blood thinner used to slow down the process of making clots]. The sample size was 3 and the facility census was 31. Findings are: A. Review of Resident 15's Minimum Data Set (MDS- a mandatory assessment tool used to develop residents comprehensive care plans) dated 1/10/24 revealed the section related to medications had a check mark that indicated the resident received an anticoagulant medication and had not received an antiplatelet medication. Review of Resident 15's Medication Administration Record (MAR) dated January 2024, revealed the resident received Plavix [an antiplatelet medication] 75 milligrams (mg) daily. There was no evidence the resident received an anticoagulant medication in the resident's medical record. Interview with the Director of Nurses (DON) on 1/31/24 at 10:15 AM confirmed Resident 15 was not taking an anticoagulant medication and the resident assessment dated [DATE] was not accurate and should have been marked as an antiplatelet medication. 45739 B. Review of the facility policy Parkside Manor Preadmission Screening and Annual Resident Review (PASARR), undated revealed the following: -the facility would coordinate the assessment process with the PASARR program which would incorporate recommendations from the PASARR Level II determination and evaluation in the resident's assessment, care plan, and transition of care, and -an individual was considered to have a serious mental illness if the individual met the following requirements on diagnoses had schizophrenia; had mood, paranoid, panic or other severe anxiety disorder; and/or the resident did not have a primary diagnosis of dementia. Review of Resident 13's MDS dated [DATE] revealed the following: -the resident did not have a Level II PASARR determination, -the resident was cognitively intact, -the resident had a diagnosis of schizophrenia, and -the resident received an antipsychotic medication (medications that alters chemicals in the brain to effect changes in behavior, mood and emotion). Review of Resident 13's Care Plan revealed a problem that Resident 13 required a follow up for a PASARR Level II screen with an onset date of 12/4/23. Review of Resident 13's MAR dated January 2024 revealed the resident received Olanzapine (an antipsychotic medication) 2.5 mg at bedtime for a diagnosis of schizophrenia and Quetiapine (an antipsychotic medication) 25mg twice per day for paranoid schizophrenia. Review of Resident 13's PASARR screen revealed the evaluation was completed on 12/23/22 and a determination was made that the resident did have a serious mental illness and was a Level II PASARR. Interview with the DON on 1/31/24 at 10:02 AM confirmed Resident 13 did have a diagnosis of schizophrenia and a Level II PASARR determination. Further interview confirmed that the resident MDS assessment dated [DATE] was not accurately coded and should have indicated the resident did have a Level II PASARR determination. C. Review of Resident 28's MDS assessment dated [DATE] revealed the resident received an anticoagulant medication. Review of Resident 28's MAR dated November 2023 revealed no documentation the resident had received an anticoagulant medication. Interview with the DON on 2/1/24 at 12:15 PM confirmed Resident 28 did not receive an anticoagulant in November of 2023, the MDS dated [DATE] was not accurately coded and that anticoagulant should not have been marked on the resident's assessment.

Liscensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report a potential allegation of abuse to the State Agency for Resident 16. The sample size was 1 and the facility census was 31. Findings are: A. Review of the facility's undated policy Abuse, Neglect, and Misappropriation of Resident Property revealed the following: -The facility encouraged and supported residents, staff, families, visitors, volunteers and resident representatives to report any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property. -Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. -The nursing home administrator or designee will report abuse to the State Agency per state and federal requirements. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of residents, irregardless of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident. -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 working days. B. Review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment tool used to develop a resident's plan of care) dated 1/3/24 revealed the following about the resident: -moderate cognitive impairment; -diagnoses of: fracture of the left leg; heart failure, high blood pressure, elevated fat levels in the blood, dementia, anxiety, and lung disease; and -required moderate assistance with toileting, transfers, personal hygiene, and dressing. Review of Resident 16's nursing progress notes dated 11/27/23 at 4:24 PM revealed the resident reported a staff member had ripped [gender] shirt off, sprayed [gender] in [gender] face with something so [gender] couldn't see and was banging the bed board this morning before [gender] was up and Resident was upset and crying. Review of facility investigations submitted to the State Agency between 11/7/22 and 1/29/24 revealed no evidence Resident 16's allegation of potential abuse documented on 11/27/23 was reported to the State Agency as required. An interview with the Director of Nurses (DON) on 1/31/24 at 2:10 PM confirmed the facility had not reported the allegation of potential abuse that was documented in the resident's medical record on 11/27/23.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, record review and interview; the facility failed to utilize Personal Protective Equipment (PPE) according to facility policy and to wash hands and change gloves at to prevent cross contamination during the provision of care for Resident 12 and 19. The sample size was 21 and the facility census was 29. Findings are: A. Review of the undated facility policy, Hand Hygiene revealed the following; -the objective was to prevent the spread of infection through adherence to good hand hygiene, -hand hygiene was a general term that applied to handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis, and -all personnel should wash their hands with soap and water or use hand sanitizer products to prevent the spread of infections; between patient contacts, after removing gloves, after using the restroom, sneezing, combing hair, smoking, before and after meals, anytime hand were soiled, and when going from a dirty to a clean function on the same patient. B. Review of the undated facility policy, Personal Protective Equipment/ Using Face Masks revealed the objective was to prevent the transmission of infectious agents, to prevent the transmission of infections that could be spread by direct contact, to prevent the splashing of blood or body fluids into the mouth or nose, and to prevent exposure to viruses from blood or body fluids. Further review revealed that staff were to do the following; - put a face mask on before entering the room, and after cleaning hands, - be sure the face mask covered the nose and mouth while performing treatment or services for the resident, - do not remove the mask while performing treatment or services for the resident, - handle the mask only by the strings, - never touch the mask while it is in use, and - follow established handwashing techniques. C. Review of the undated facility policy, Personal Protective Equipment/Using Gloves revealed the objective was to prevent the spread of infection, protect wounds from contamination, protect hands for potentially infectious material, and to prevent exposure to viruses. Further review revealed that staff were to use disposable single use gloves for the following; - when touching excretions, secretions, blood, body fluid, mucous membranes, or non-intact skin, - when an employees' hands had scrapes, cuts, wounds, chapped skin, [CONDITION(S)] etc., - when cleaning potentially contaminated items, and - whenever in doubt. Further review revealed staff were to wash hands after glove removal, and that gloves did not replace handwashing. D. During on observation on 11/2/22 at 9:00 AM Nurse Aide (NA)-I was noted walking in the facility attending to residents and wearing a mask covering the mouth but not the nose. E. During an observation on 11/2/22 at 9:15 AM NA -I provided transfer via full body mechanical lift and positioning into bed for Resident 12. During the episode of care NA-I was wearing a face mask covering the mouth, but not the nose. After completing the care NA-I exited Resident 12's room and did not perform hand hygiene. F. During an Interview on 11/7/22 at 12:15 PM Registered Nurse (RN)-A confirmed staff should always wash hands after performing resident cares, staff are to wear surgical face masks covering both the mouth and the nose when providing care, or in resident care environments per COVID-19 protocols, and staff should not touch the surface of their facemask during the provision of care and resume care without hand hygiene. G. Observation on 11/2/22 at 12:23 PM of the facility dining room revealed NA-I was seated at a table next to Resident 19. NA-I wore a surgical mask which covered staff's mouth, but NA-I had nose completely exposed. NA-I used right hand to repeatedly touch the outside surface of the mask to pull the mask over the staff's nose. Without completing hand hygiene, NA-I would then touch the resident and/or the resident's dinnerware before again trying to adjust placement of the mask. H. During observation of incontinence care for Resident 19 on 11/4/22 at 6:44 AM, NA-C and NA-D without performing hand hygiene placed on clean gloves. NA-D lowered the resident's slacks and disposable incontinence brief which were soiled with urine and feces. NA-D provided perineal hygiene for the resident, but without removing soiled gloves, placed a clean incontinence brief, adjusted the resident's clothing and blankets and assisted to reposition the resident in bed. NA-D removed soiled gloves but failed to complete hand hygiene before lowering the resident's bed, placing the call light within the resident's reach and closing the closet door. NA-D then entered the resident's bathroom and washed hands. I. During an interview on 11/7/22 at 12:15 PM, RN-A confirmed staff were to complete hand hygiene before putting on clean gloves and when removing soiled gloves. In addition, staff should remove gloves when soiled and should place on clean gloves when completing cares.

Licensure Reference Number: 175 NAC 12-006.09D7 and 175 NAC 12-006.09D7(a) (b) Based on record review and interview; the facility failed to: 1) assess causal factors related to an incident resulting in significant bruising for Resident 19; and 2) failed to assess causal factors and to revise current interventions and/or develop new interventions to prevent ongoing falls for Resident 23. The sample size was 4 and the facility census was 29. Findings are: A. Review of a facility policy titled Falls and Neurological Assessments with a revision date of 10/2010 revealed residents were to be assessed and interventions placed to prevent injuries to the resident. A fall risk assessment form was to be completed at the time of admission, quarterly, and/or with significant changes. At the time of a fall occurrence the following procedures were to be followed: -monitor resident for injuries; -notify the resident's physician; -document in the Nurses Notes the fall occurrence; -complete a fall incident report; and -implement an intervention on the care plan to prevent another fall from occurring. B. Review of Resident 23's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/12/22 revealed diagnoses of [CONDITION(S)], [CONDITION(S)] (an irregular, rapid heart rhythm) high blood pressure, urinary tract infection in the last 30 days, arthritis, diabetes and dementia. The assessment indicated the resident was cognitively intact and required extensive staff assistance with dressing, bed mobility, transfers, toilet use and personal hygiene. The resident was frequently incontinent of urine and occasionally involuntary of bowel. No falls were identified since the previous assessment. Review of a Nursing Progress Note dated 7/3/22 at 11:30 AM revealed staff heard the resident yell, and the resident was found on the floor beside the resident's bed. The resident stated, I rolled over and out of bed. The staff were educated on need for the adjustable bed to be kept in the lowered position. Review of a Nursing Progress Note dated 7/5/22 at 2:42 AM revealed the resident's bed was to be adjusted to the lowest position, call light pendant to be in reach and a pillow was to be placed on the right side of bed to keep the resident's feet and legs in bed. Review of a Nursing Progress Note dated 7/8/22 at 3:43 PM revealed fall interventions which included a fall mat and routine toileting. Review of a Nursing Progress Note dated 8/5/22 at 1:43 AM revealed the resident was found seated on the floor next to the resident's bed. The bed was in the lowered position. The resident reported, I tried to get out of bed and then I was on the floor. The resident was assisted to the bathroom and then back into bed. Review of the resident's medical record revealed no evidence the resident's fall was assessed for causal factors, current interventions were revised, or a new fall intervention was developed to prevent further falls. Review of a Nursing Progress Note dated 8/30/22 at 1:09 PM revealed at 10:40 AM, the staff were walking by the resident's room and observed the resident lying face down on the floor in front of the resident's lift recliner. The resident had held onto the recliner remote until the resident fell face forward out of the chair. The resident had a large bump and a hematoma to the center of forehead. The resident was transferred to the emergency room . Review of an Incident Report dated 8/30/22 at 10:45 AM revealed causal factors for the resident's fall included recent urinary tract infection and upper respiratory infection with increased confusion and disorientation. Review of a Fall Care Plan revealed on 8/30/22 the resident had placed the lift recliner in the high position and the resident fell forward face planting on the floor. An intervention was identified to unplug the lift recliner or to place the controls in the side pocket of the recliner when the resident was seated in it. During interview on 11/7/22 at 11:27 AM, Registered Nurse (RN)-A confirmed the following regarding Resident 23: -had been assessed at high risk for falls; -no causal factors were identified with the resident's fall on 8/5/22 at 1:43 AM; -current fall prevention interventions were not revised, or additional interventions developed after the resident's fall on 8/5/22 and the resident had a subsequent fall with injury on 8/30/22 at 1:09 PM. C. Review of Resident 19's MDS dated [DATE] revealed diagnoses of [CONDITION(S)], anxiety, depression, and [CONDITION(S)]. The assessment indicated the resident's cognition was severely impaired and the resident had behaviors which included delusions and hallucinations. The resident required extensive staff assistance with bed mobility, transfers, dressing, personal hygiene and toilet use and the resident was frequently incontinent of bowel and bladder. Review of a Nursing Progress Note dated 10/27/22 at 4:14 PM revealed staff observed a bruise on the resident's right lateral shin to the ankle which measured 21.5 centimeters (cm) by 10 cm. The resident was unable to identify how the bruising had occurred. The note further revealed the resident had been noted in the past to have the resident's leg between the foot-rest of the recliner and the resident would move the calf pad on the resident's wheelchair also indicating the resident had been more restless. Review of the resident's medical record revealed no evidence an injury of unknown origin investigation was completed regarding the resident's 21.5 cm by 10 cm bruise to the resident's right lower leg. Review of a Nursing Progress Note dated 10/28/22 at 11:59 AM revealed the resident continued with the bruise to the right lateral calf. The note indicated the resident was able to use the mechanical sit-to-stand lift (a mobile lift that allows for patient transfers from a seated position to a standing position and designed to support only the upper body of the resident with a requirement for the resident to have some weight-bearing capability) the same as ever. Review of a Nursing Progress Note dated 10/28/22 at 11:59 PM revealed the resident was to be placed in a Broda chair for pressure relieving and comfort. Review of Resident 19's Nursing Progress Notes dated 10/30/22 (3 days after the resident's bruising to the right lower leg was identified) revealed the following: -6:38 PM dark purple discoloration from the resident's right knee to the foot. The area was edematous and warm to the touch; and -10:20 AM right lateral leg from the knee to the foot, purple in color and swollen, tender to the touch. The full sling lift to be used to transfer the resident due to complaints when the resident was stood up. Review of a Nursing Progress Note dated 10/31/22 at 2:37 PM revealed the resident used the sit-to-stand lift for toileting and the resident was able to stand for a short time. Review of Nursing Progress Notes dated 11/1/22 revealed the following: -3:15 PM the resident was seen by the physician due to increased swelling, pain and bruising to the right lower leg and an x-ray was ordered; and 5:24 PM the x-ray was completed and revealed a trimalleolar (ankle) fracture. Review of a Temporary Problem List form used for permanent documentation of temporary problems (those with anticipated duration of 14 days or less) dated 11/2/22 (6 days after the bruising was first noted to the resident's right lower leg) revealed the following approaches: -splint to right lower extremity always; -non-weight bearing with use of a full lift for all transfers; -change of seating system to the Broda chair; and Observe for signs of pain. During an interview with RN-A on 11/7/22 at 11:44 AM, RN-A verified staff were uncertain how the resident had obtained the bruising to the resident's right lower leg. Staff failed to determine causal factors and to put interventions in place to prevent a potential reoccurrence for 6 days after the bruising was first identified.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on interview and record review, the facility failed to develop and/or implement fall prevention interventions to prevent falls for Resident 14. The sample size was 2 and the facility census was 18. Findings are: Review of the undated facility policy titled Gait Belt Use revealed: -Gait belts would be used by staff to assist a resident with ambulation/transfers. -Gait belts need to be fastened securely and tight enough to provide support if the resident began to lose their balance and needed to be lowered to the floor. -Gait belts should be used at all times for assistance with ambulation/transfers. -Never grab onto a resident's clothing or extremity to move them or pull them up. -Full attention should be given to assisting the resident (eliminate distractions). -Monitoring of proper gait belt usage would be done by the supervising charge nurse or Director of Nursing (DON). Review of Resident 14's Fall Risk Evaluation dated 6/7/21 revealed a score of 17 with a score greater than 10 indicating high risk for falls. Review of Resident 14's current Care Plan with a review date of 6/22/21 revealed the resident was at risk for falls with a history of falls. The resident didn't always ask for help and had trouble with blood pressure dropping when standing. Interventions included: -Wear tennis shoes, -keep a night light on, -use high/low bed and pendant call light, -remind not to self-transfer, -use a wheelchair for mobility, -use a two person pivot transfer, and -assist to stand and wait a bit to help blood pressure and pulse adjust. Review of Resident 14's Progress Notes revealed: - On 6/7/21 the resident was admitted to the nursing home. The resident had a history of falls prior to admission. - On 6/25/21 the staff heard the resident holler for help and upon entering the room the resident had fallen. - On 6/29/21 the nurse was called to the resident's room. The resident had fallen when getting out of the recliner to go to the bathroom before breakfast. A Nursing Assistant was assisting the resident up out of the recliner when the resident fell to the side hitting the over bed table, resulting in an injury. Review of Resident 14's Resident Incident Reports revealed no evidence to indicate a Resident Incident Report was completed following the Resident's fall on 6/25/21. Review of the facility Fall Care Plans form revealed: - On 6/25/21 the resident fell in the resident's room. The intervention identified was to remind the resident to call for assist with transfers and ambulation. There was no evidence a thorough review of potential causal factors was completed. - On 6/29/21 the resident fell in the resident's room. The intervention identified was for the resident to pivot transfer to/from wheelchair with 2 assist and a gait belt. There was no evidence a thorough review of potential causal factors was completed. During an interview with the DON on 7/14/21 at 8:17 AM the DON confirmed the facility did not have a process in place to ensure causal factors were consistently reviewed post fall and the facility had not completed post fall investigations for all falls. The DON confirmed the staff member assisting Resident 14 at the time of the resident's fall on 6/29/21 was not using a gait belt.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility failed to provide care and treatment to promote healing of Resident 11's pressure ulcer. One resident was sampled for pressure ulcers, and the total facility census was 18. Findings are: A. Review of the undated Skin Policy revealed pressure ulcers were to have a pressure ulcer assessment form completed at the time of discovery. The resident's Primary Care Physician (PCP) was to be notified for treatment options and updated with every dressing change. The PCP was to be notified immediately if symptoms of infection (odor, discharge, or redness at the site) or if the pressure ulcer was not healing within a 14 day time frame. In addition, the Dietary Manager (DM) and/or the Registered Dietician (RD) were to make recommendations for nutritional interventions. B. Review of a Wound Care Policy with revision date 10/2010 revealed the following steps for completion of a dressing change; -establish a clean field and place all items to be used on a barrier; -cleanse hands and put on clean gloves; -remove dressing and soiled gloves, cleanse hands and apply clean gloves; -wear gloves when physically touching wound; and -after completion of a dressing change, remove gloves and cleanse hands before exiting the resident's room. C. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/23/21 revealed the following related to Resident 11: -severely impaired decision making skills; -required total assistance with bed mobility, transfers, toilet use, dressing, eating and personal hygiene; -was always incontinent of bowel and bladder; -had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -was at risk for the development of pressure ulcers, and currently had one Stage 4 (The staging system is a method of summarizing certain characteristics of pressure ulcers, including the extent of tissue damage. Stage 4 identified as full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A recommendation was made to continue to pack the wound daily. The resident was to return if there are any concerns regarding the wound as it was unlikely the pressure ulcer would ever fully heal. Review of Resident 11's undated current Care Plan revealed the resident was at risk for skin breakdown due to an [CONDITION(S)] disorder (an illness that occurs when the body tissues are attacked by its own immune system) with history of a pressure ulcer. The resident was unable to utilize an air mattress due to rolling self out of bed. Interventions included the following: -dressing change as ordered; -increased protein to promote wound healing; -monitor for signs of infection including redness, odor, drainage and warmth; -monitor areas of skin breakdown, measure, assess and document per facility protocol; and -reposition every 2 hours. Review of a RD Progress Note dated 4/15/21 at 12:27 PM revealed the resident continued to have a pressure ulcer to the left buttock. The note indicated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional recommendations were identified. Review of Nursing Progress Notes revealed the following: -5/6/21 at 9:56 AM the resident's pressure ulcer had a moderate amount of brown colored pus with a foul odor noted during the dressing change. A facsimile (fax) was sent to the PCP; -5/6/21 at 10:46 AM the facility received a new order for [MEDICATION(S)] (antibiotic used for treating skin infections) 500 milligrams (mg) three times a day to be given for 7 days related to a wound infection; -5/7/21 at 10:28 AM a foul odor remained with dressing change of the resident's Stage 4 pressure ulcer with yellow-brownish drainage to the old dressing. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] -5/14/21 at 9:31 AM the resident's pressure ulcer had a small amount of serosanguineous drainage (containing both serous and blood) with a depth of 4 cm and 5 cm deep tunnel (channels which extend from the wound into or through subcutaneous tissue or muscle) at 10:00 o'clock (clock terms used to describe the position of the tunnel within the wound bed); and -5/21/21 at 10:17 AM the resident's ulcer had a depth of 5 cm with a 5 cm tunnel at 10:00 o'clock. Review of a Wound Healing Progress Report dated 5/29/21 revealed the resident's pressure ulcer measured 5 cm by 5 cm with a depth of 6 cm. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note dated 6/7/21 at 9:54 AM revealed the resident had brown drainage to pressure ulcer with dressing change. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's PCP was notified of the change in drainage to the ulcer. Review of a RD Progress Note dated 6/15/21 at 2:21 PM revealed no evidence a recommendation was made for increased protein to Resident 11's diet despite the resident's Stage 4 non-healing pressure ulcer Review of a Wound Healing Progress Report dated 6/18/21 (20 days since the pressure ulcer was last measured) revealed the resident's Stage 4 pressure ulcer measured 5 by 5 cm with a depth of 6 cm. Review of a Nursing Progress Note dated 7/2/21 (2 weeks since the ulcer was last assessed) revealed the ulcer measured 6 cm by 0.5 cm with 5 cm tunneling. A small amount of red drainage was observed. Review of a Wound Healing Progress Report dated 7/9/21 revealed the resident's pressure ulcer continued to measure 6 cm by 0.5 cm with 5 cm tunneling. Review of Resident 11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 7/14/21 at 7:37 AM, Registered Nurse (RN)-A provided treatment to Resident 11's pressure ulcer to the left buttock. RN-A placed a clean barrier on the dresser next to the resident's bed. RN-A washed hands and opened the top drawer of the dresser and removed several pair of clean gloves, an Opsite dressing (transparent, adhesive film used to provide a moist wound environment for superficial wounds), a stack of 2 x (by) 2 gauze pads, a pre-packaged Q-tip, wound cleanser in a spray bottle and a container of Idoform strips then placed items on the barrier. RN-A removed a container of hand sanitizer from uniform pocket, applied to hands and placed on clean gloves. RN-A proceeded to remove the Opsite dressing, a 2 x 2 gauze pad over the wound bed and then a length of the Idoform strips which had been used to pack the pressure ulcer. The 2 x 2 gauze and the packing strips were saturated with a reddish, brown drainage without a noticeable odor. While continuing to wear the soiled gloves, RN-A sprayed the wound cleanser inside and around the perimeter of the ulcer and used several 2 x 2 clean gauze squares to pat the wound dry and to palpate the wound perimeter. RN-A removed soiled gloves, used hand sanitizer and put on clean gloves. RN-A used the Q-tip to pack the [MEDICATION(S)] strips into the wound until unable to pack any further. RN-A then turned to the open dresser drawer and removed a pair of bandage scissors. Without cleansing or sanitizing, RN-A used the scissors to cut the length of Idoform strips and then tucked the end of the strip into the wound and placed the bandage scissors in the pocket of the staff's uniform. RN-A placed a 2 x 2 gauze square over the opening of the wound followed by the Opsite dressing. RN-A removed soiled gloves and proceeded to return unused supplies (clean gloves, 2 x 2 gauze squares and wound wash) to the dresser drawer. Before exiting room, RN-A removed the bandage scissors from uniform pocket and without cleaning or sanitizing, returned to the dresser drawer with other supplies. During interview on 7/14/21 at 8:03 AM, RN-A verified the resident had a Stage 4 pressure ulcer to the resident's left buttock which the staff had been treating since 2018. RN-A further verified staff were to assess and measure the pressure ulcer and then document the assessment weekly to determine healing. If the pressure ulcer was unchanged for 2 weeks or worsened, then staff were to notify the resident's PCP. During an interview with the Director of Nursing (DON) on 7/14/21 at 11:06 AM the following was confirmed: -staff failed to assess and measure the resident's pressure ulcer weekly and to notify the PCP as needed; -the RD had not made any recommendations to increase the resident's protein intake to promote healing of the resident's pressure ulcer; and -staff failed to complete the resident's dressing change according to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on observation, record review and interview; the facility failed to assess Resident 1 for use of a potential physical restraint prior to applying a seat belt to the resident's wheelchair and to provide routine monitoring related to use of the seat belt. The sample size was 1 and the facility census was 20. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/8/19 revealed the following regarding Resident 1: -[DIAGNOSES REDACTED]. -required total assistance with bed mobility, transfers, dressing and toilet use; and -no restraint use identified. Review of Resident 1's current Care Plan (undated) indicated the resident was at risk for falls related to [DIAGNOSES REDACTED]. The resident was identified as having poor balance, increased confusion and weakness at times. Observations of Resident 1 on 12/3/19 at 10:01 AM and at 2:38 PM and on 12/4/19 at 7:45 AM and at 8:57 AM revealed the resident was positioned in an electric wheelchair. The resident had a safety belt buckled across the resident's lap at all times when seated in the chair. There was no evidence in Resident 1's medical record that an assessment for the appropriate use of the seat belt was completed prior to its use to assure Resident 1 was not physically restrained. Furthermore, there was no evidence the seat belt was routinely monitored. During interview on 12/4/19 at 9:47 AM, the Director of Nursing (DON) confirmed there were no facility policies/procedures for the assessment of residents prior to the application of seat belts as potential physical restraints, and that routine monitoring of Resident 1's seat belt was not completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to ensure incidents of potential abuse/neglect were reported to the State Agency for 5 of 6 residents reviewed (Residents 2, 17, 121, 15 and 13) for abuse/neglect. The facility census was 21. Findings are: A. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property, (Undated) included the following: -Employees must always report any abuse or suspicion of abuse immediately to the administrator; -All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated; and -If an incident or allegation was considered reportable, the Administrator or designee was to make an initial report to the State Agency and a follow-up investigation was to be submitted to the State Agency within 5 working days. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/28/18 revealed the resident was admitted to the facility 9/17/18 with [DIAGNOSES REDACTED]. -was cognitively intact; and -had physical behavioral symptoms directed toward others (such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually) on 1 to 3 days. Review of Resident 13's comprehensive Care Plan (not dated) indicated the resident displayed socially inappropriate behavior by touching or exposing self in the company of others, and trying to touch and/or kiss other residents. Review of Nurses Notes revealed the following related to Resident 13: -9/19/18 at 4:13 PM - thinks another resident (unidentified) is spouse and did kiss (the resident); -9/22/18 at 2:49 PM - noted leaning over another resident (unidentified) and rubbing the resident's leg; and -10/22/18 at 4:42 PM - Licensed Practical Nurses (LPN)-G was sitting at the nurses station. Resident 13 approached the nurses station and looked this nurse right in the eye then walked over to a (unidentified) resident who was sitting in a wheelchair and put a hand over the resident's breast on the outside of the resident's shirt. There was no evidence these incidents of inappropriate sexual behavior toward residents was reported to the authorities and/or the State Agency, or that follow up investigations were completed. C. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/10/18 revealed [DIAGNOSES REDACTED]. Review of Nurses Notes revealed Resident 15 was verbally abusive to other unidentified residents as follows: -6/1/18 at 2:26 PM-yelled .shut up, you[***] and shut up every time the resident in another room hollered out; -6/13/18 at 11:13 AM-called another resident an expletive and mimicked other residents calling them names; -7/15/18 at 5:25 PM-yelled at another resident to get out of the way and called the other resident an[***] ; -7/25/18 at 1:01 AM-after supper made unkind and mocking comments to another resident; -7/26/18 at 9:58 AM-yells at another resident to shut the hell up you freak; -8/23/18 at 2:29 PM-stated repeatedly to another resident to shut up you[***] and at meals will call other residents names; -8/27/18 at 4:38 PM-makes rude statements to another resident such as shut the hell up you dummy or be quiet[***] . Resident 15's tablemate refused to sit with Resident 15 at meals due to Resident 15 calling the tablemate names and being mean to the tablemate; -9/1/18 at 12:55 PM-made rude comments at breakfast and lunch to tablemate. Voiced to the tablemate .you have a long ugly face and your (you are) an[***] ; -9/12/18 at 3:06 PM-mocked another resident and called the other resident foul names; and -9/14/18 at 10:53 AM-called another resident a .dumb ass and mocked other residents seated in the living room. Review of facility investigations of potential abuse/neglect from 5/1/18 through 11/6/18 revealed no reports had been submitted to the State Agency regarding Resident 15's verbal abuse toward other residents. Interview with the Director of Nurses (DON) on 11/6/18 at 9:05 AM confirmed Resident 15's incidents of verbal abuse towards other residents were not reported to the State Agency. D. Review of Nurses Notes dated 10/30/18 at 2:28 AM revealed at 10:00 PM (on 10/29/18) Resident 17 was found lying on the floor with a laceration above the left eye brow. The resident was transferred to the hospital by ambulance for evaluation. Review of Nurses Notes dated 10/30/18 at 3:05 AM revealed Resident 17 returned from the hospital at 1:45 AM after receiving a CT scan (Computed tomography is a type of imaging which uses special x-ray equipment to make cross-sectional pictures of the body) of the head, a tetanus shot and the laceration above the left eye brow was closed with glue. Review of the facility investigations of potential abuse/neglect from 10/1/18 through 11/6/18 revealed no report had been submitted to the State Agency regarding Resident 17's fall with injury that required medical treatment. Interview with the DON on 11/4/18 at 4:00 PM confirmed Resident 17's fall with injury was not reported to the State Agency. E. Review of Resident 121's Nurses Notes dated 9/24/18 at 3:27 PM revealed at 1:30 PM that day, staff were attempting to transfer the resident from a wheelchair onto a sit to stand lift (a mechanical lift designed to assist caregivers in raising weight bearing patients to a standing position). Documentation indicated the resident was combative and as a staff member attempted to place the resident's legs onto the platform of the sit to stand lift, the resident stiffened which caused the wheelchair to tip over backwards. The resident fell backward hitting the back of the head and sustained a 2.5 centimeter laceration on the back of the head. There was no evidence Resident 121's fall on 9/24/18 was reported to the State Agency as an incident of potential neglect. Interview with the DON on 11/6/18 at 8:55 AM confirmed Resident 121's fall during an assisted transfer on 9/24/18 had not been reported to the State Agency as a potential incident of neglect.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview, the facility failed to ensure interventions were in place to protect residents from verbal abuse and sexual abuse involving 4 of 6 sampled residents (Residents 13, 15, 17 and 2) reviewed for abuse. The facility census was 21. Findings are: A. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property, (Undated) included the following related to Definitions of Abuse and Neglect: -Verbal abuse was the use of oral, written or gestured language that willfully included disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; and -Sexual abuse was non-consensual sexual contact of any type with a resident. The policy further indicated the facility would protect the residents from the alleged offenders. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/28/18 revealed the resident was admitted to the facility 9/17/18 with [DIAGNOSES REDACTED]. -was cognitively intact; -experienced delusions (misconceptions or beliefs that were firmly held and contrary to reality); -had physical behavioral symptoms directed toward others (such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually) on 1 to 3 days; -exhibited wandering behaviors on 1 to 3 days; and -required limited assistance with transfers and ambulation with use of a walker. Review of Resident 13's comprehensive Care Plan (not dated) indicated the resident displayed socially inappropriate behavior by touching or exposing self in the company of others, and trying to touch and/or kiss other residents, thinking they were a spouse. Review of Nurses Notes revealed the following related to Resident 13: -9/19/18 at 4:13 PM - thinks another resident (unidentified) is spouse and did kiss (the resident); -9/22/18 at 2:49 PM - noted ambulating into other unidentified resident rooms and needed redirection. Also noted leaning over another resident (unidentified) and rubbing the resident's leg; and -9/24/18 at 9:25 AM - housekeeper reported finding the resident in another unidentified resident's room. There was no evidence these incidents were investigated in an attempt to identify the residents targeted by Resident 13, and to develop interventions to prevent further invasion of their personal space and inappropriate sexual behaviors. Review of a Social Services Note dated 9/27/18 at 11:12 AM revealed staff were trying to keep Resident 13 at least an arms length from a certain (gender) resident (unidentified) that Resident 13 knew previously from home town. Documentation indicated Resident 13 sometimes gets a little too close and the unidentified resident is not cognitive enough to know. Review of Nurses Notes dated 9/30/18 at 10:59 AM revealed that prior to breakfast dietary staff observed Resident 13 fondling Resident 2 in front of the nurses station. Review of an Alleged Report of Possible Abuse/Neglect dated 10/4/18 revealed an investigation of the incident that occurred between Residents 13 and 2 on 9/30/18. The following was revealed: -Resident 2 was admitted with [DIAGNOSES REDACTED]. -At approximately 7:30 AM the Dietary Aide (DA) observed Resident 13 leaning over Resident 2, who was in a wheelchair, with 1 hand under Resident 2's shirt and the other hand in own pants; and -Resident 13 was placed on timed periodic checks every 15 minutes, an alarm was placed on Resident 13's door to alert staff when the resident entered and/or exited the room, supervision and diversional activities were increased, and an appointment for a psychiatric consult was initiated. During interviews the following was revealed: -10/31/18 at 10:54 AM - the Director of Nursing (DON) indicated Resident 2's name was removed from the room door in an attempt to prevent Resident 13 from identifying Resident 2's location and acting inappropriately with Resident 2; and -11/1/18 at 11:00 AM - Registered Nurse (RN)-A verified Resident 13 targeted Resident 2 as spouse as they did know each other previously from their home town. C. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/10/18 revealed [DIAGNOSES REDACTED]. Review of Resident 15's Care Plan (undated) revealed the following: -Becoming more verbal with other residents. Denies making fun of them or being verbal. If resident is being verbal remove from area for a short time; and -Yells at other residents or mimics them when they talk or make a noise. A goal was identified for Resident 15 to stop making fun of other residents when sitting in the living room. Interventions to prevent Resident 15's verbal behaviors included observing the resident when in the living room with other residents and removing the resident from public areas when behavior was disruptive. Review of Nurses Notes revealed Resident 15 was verbally abusive to other unidentified residents as follows: -6/1/18 at 2:26 PM-yelled .shut up, you[***] and shut up every time the resident in another room hollered out; -6/13/18 at 11:13 AM-called another resident an expletive and mimicked other residents calling them names; -7/15/18 at 5:25 PM-yelled at another resident to get out of the way and called the other resident an[***] ; -7/25/18 at 1:01 AM-after supper made unkind and mocking comments to another resident; -7/26/18 at 9:58 AM-yells at another resident to shut the hell up you freak; -8/23/18 at 2:29 PM-stated repeatedly to another resident to shut up you[***] and at meals will call other residents names; -8/27/18 at 4:38 PM-makes rude statements to another resident such as shut the hell up you dummy or be quiet[***] . Resident 15's tablemate refused to sit with Resident 15 at meals due to Resident 15 calling the tablemate names and being mean to the tablemate; -9/1/18 at 12:55 PM-made rude comments at breakfast and lunch to tablemate. Voiced to the tablemate .you have a long ugly face and your (you are) an[***] ; -9/12/18 at 3:06 PM-mocked another resident and called the other resident foul names; and -9/14/18 at 10:53 AM-called another resident a .dumb ass and mocked other residents seated in the living room. There was no evidence Resident 15's incidents of verbal abuse toward other residents were investigated in an attempt to identify the residents targeted by Resident 15. In addition, there was no evidence additional interventions were developed to protect other residents from Resident 15's verbal abuse. Interview with Nursing Assistants (NA)-B and NA-D on 11/5/18 at 9:38 AM confirmed Resident 15 made fun of Resident 17 in particular. NA-B and NA-D reported Resident 15 and Resident 17 do not sit at the same table in the dining room and staff monitor where Resident 15 sits to make sure Resident 15 is not seated in an area where the resident can make fun of other residents.

Based on record review and interview, the facility failed to ensure blood pressure readings were obtained and evaluated in accordance with physician's orders [REDACTED]. The facility census was 21. Findings are: Review of Resident 10's Medication Administration Record [REDACTED]. If the systolic blood pressure remained above 150 then prn (as needed) [MEDICATION NAME] (medication used to treat high blood pressure) .1 milligram (mg) was to be administered. Review of Resident 10's MAR indicated [REDACTED]. The order indicated the blood pressure readings were to be taken in the morning on Monday, at noon on Wednesday and at bedtime on Fridays. The order further indicated to refer to the prn [MEDICATION NAME] order if the systolic blood pressure was above 150. Review of Resident 10's MAR indicated [REDACTED] -168/82 in AM on 9/10/18; -166/60 in AM on 9/17/18; -156/72 at noon on 9/19/18; -156/62 at noon on 9/26/18; -156/80 at noon on 10/10/18; -168/80 in AM on 10/15/18; -152/88 at noon on 10/31/18; -158/70 at bedtime on 11/2/18; and -168/82 in AM on 11/5/18. There was no evidence Resident 10's blood pressure was rechecked in 1 hour after the systolic blood pressure was above 150. Interview with the Director of Nurses on 11/6/18 at 8:45 AM confirmed Resident 10's blood pressure was not re-checked when the systolic blood pressure was above 150 as ordered by the physician.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A3 Based on record review and interview, the facility failed to ensure 1 staff member was qualified to give medications before giving medications to 4 residents (Residents 24, 6, 16 and 22). The sample size was 20 and the facility census was 25. Findings are: Review of the facility undated Medication Aide (MA) Job Description revealed the education requirements for a MA included successful completion of the 40 hour MA course. Review of MA-F's Certification of Nebraska Licensure form revealed MA-F was issued a MA license on 7/28/14. However, the form indicated MA-F was not licensed as a 40 hour MA as indicated per the facility MA Job Description and in accordance with State requirements. Review of Resident 24's Medication Administration Record [REDACTED] -[MEDICATION NAME] (Tylenol) 500 milligrams (mg) at bedtime (HS); -[MEDICATION NAME] (used to treat high blood pressure) 5 mg at HS; and -[MEDICATION NAME] Sodium (used to treat constipation) 100 mg at HS. Review of Resident 6's MAR indicated [REDACTED] -Artificial tears (eye drops) one drop in each eye at HS; -Senna (used to treat constipation) one tablet in the evening; and -[MEDICATION NAME] (an anticoagulant or blood thinner) 6 mg at HS. Review of Resident 16's MAR indicated [REDACTED] -[MEDICATION NAME] (used to prevent gout and kidney stones) 300 mg at HS; -[MEDICATION NAME] (a muscle relaxer) 20 mg at HS; -[MEDICATION NAME] (used to treat high cholesterol) 160 mg at HS; -[MEDICATION NAME] (a nasal spray used to treat congestion and allergies [REDACTED]. -[MEDICATION NAME] (cough syrup) 4 milliliters at HS; -[MEDICATION NAME] (used to treat high cholesterol) 40 mg at HS; and -Tamsulosin (used to relax muscles in the prostate and bladder neck making it easier to urinate) .4 mg one capsule at HS. Review of Resident 22's MAR indicated [REDACTED] -[MEDICATION NAME] 1000 mg; -Acidophilus (dietary supplement) 1 capsule; -Atorvastatin (used to treat high cholesterol) 40 mg; -Carvedilol (used to treat high blood pressure and heart failure) 6.25 mg; -[MEDICATION NAME] (used to treat high blood pressure) .5 mg; and -Magnesium Oxide (a mineral supplement) 400 mg. Interview with the Administrator and Office Manager on 8/14/17 at 12:15 PM confirmed MA-F did not have the qualifications to administer medications as MA-F did not have a 40 hour MA license.

Licensure Reference Number: 175 NAC 12-006.09 D5 Based on observation, record review and interview; the facility failed to develop and implement interventions for the prevention of resident to resident contact between Residents 19, 25 and 6 who had a history of [REDACTED]. Findings are: A. Review of the facility policy titled Abuse, Neglect & Misappropriation of Resident Property Policy, updated November 16, 2009 revealed the following: - Employees/volunteers will identify, intervene and correct situations in which abuse, neglect and/or misappropriation of resident property could occur. This includes assessment of the resident's environment, adequate staffing to meet resident needs and supervision of staff to identify inappropriate behavior. - Residents will be continually assessed, care planned and monitored in order to identify needs and behaviors which might lead to conflict or neglect. - If abuse is initiated by a resident and directed toward another resident, a multi-disciplinary team will address a plan of care to prevent future behavioral problems. B. Review of Resident 25's current Care Plan dated 3/7/16 revealed the resident had feelings of restlessness and anxiety related to Obsessive-Compulsive Disorder (a type of mental illness), and exhibited aggressive behaviors during the provision of cares related to [MEDICAL CONDITION]. The goals for treatment included leaving other residents alone and not tripping or hitting them, and decreasing episodes of aggressive behavior by 50%. Nursing interventions included to provide reassurance and support; observe for changes in mood; place in an area where frequent observation is possible; provide diversional activities; approach with a calm and quiet demeanor; separate from other residents and keep other residents out of reach; and seat at the table so Resident 25 would not try to trip other residents. C. Review of Resident 6's current Care Plan dated 3/11/16 revealed the resident had combative behaviors related to dementia with violence directed at self and/or others. The goals for treatment were to control anger and not lash out at people, and to strike others no more than one time per month. The Care Plan further indicated Resident 6 wandered in a wheelchair and intruded on other residents' privacy, with goals to not wander into unsafe situations and not suffer injuries due to wandering. Nursing interventions included placing the resident in an area where constant observation was possible; providing diversional activities; redirecting when wandering into other residents' rooms; and approaching the resident in a positive, calm and accepting manner. D. Review of Resident 19's current Care Plan dated 3/18/16 revealed the resident wandered in the Special Care Unit (SCU-a locked area serving residents with dementia and behaviors) and had poor safety awareness related to [MEDICAL CONDITION]. The goal of treatment was to not sustain injuries while wandering. Nursing interventions included providing diversional activities; approaching in a calm and accepting manner; redirecting when entering other residents' rooms if they are not wanting visitors or having a off day; and redirecting when trying to help other residents who did not want assistance. E. Review of an Alleged Report of Possible Abuse/Neglect dated 10/27/15 revealed Resident 6 was self propelling a wheelchair into Resident 19's room as Resident 19 was exiting the room. Resident 19 reached out to push Resident 6's wheelchair out of the way and Resident 6 reaches up and makes contact with Resident 19's right cheek. Resident 19 then makes contact with Resident 6's glasses, causing a scratch and abrasion to Resident 6's nose. The residents were separated and neither resident showed further signs of agitation. The facility concluded the incident was not predictable and was witnessed by the Nurse Aide (NA) working in the SCU where both residents resided. The report further indicated both residents had Care Plans to minimize behaviors. No new interventions were developed to prevent further incidents between the 2 residents. F. Review of an Alleged Report of Possible Abuse/Neglect dated 1/18/16 revealed Resident 19 and Resident 25 were in the living room area of the SCU. Resident 19 approached Resident 25, who was seated on the sofa, and placed a hand on Resident 25's leg. Resident 25 lifted a leg as if to kick Resident 19, who then struck out with a book and hit Resident 25 in the face 2 times. Staff intervened and separated the residents. Neither resident was injured. The facility concluded the incident was not predictable and was witnessed by the NA working in the SCU. The report further indicated both residents had Care Plans to minimize behaviors. No new interventions were developed to prevent further incidents between the 2 residents. G. The following observations were made in the living room area of the SCU: - On 5/23/16 at 10:35 AM, NA-A was seated next to Resident 6 and performing range of motion exercises (moving the resident's extremities through their full range of movement) when Resident 19 approached Resident 6, poked a finger into Resident 6's abdomen, and straightened the sleeve of the sweater covering Resident 6's right arm. NA-A did not redirect Resident 19 from touching Resident 6. - On 5/23/16 at 2:46 PM, NA-A was seated next to Resident 25 and applying nail polish to the resident's fingernails. Resident 19 stood behind Resident 25's chair and stroked the resident's hair, then put a hand on Resident 25's left shoulder and started to slide the hand downward toward Resident 25's breast. Without speaking, NA-A pushed Resident 19's hand away from Resident 25, and Resident 19 left the room. - On 5/24/16 from 9:01 AM until 9:11 AM, Resident 6 and Resident 25 were seated together with no staff available in the area (10 minutes without supervision). During interviews on 5/24/16 the following were revealed: - At 2:18 PM, NA-B indicated Resident 19 was sometimes touchy with Resident 25 and/or would attempt to push Resident 6 in the wheelchair, and Resident 25 and Resident 6 didn't like these behaviors. Therefore, they set them apart, especially if it is a bad day. - At 2:45 PM, Registered Nurse (RN)-C verified NA-B's statements related to behaviors between Resident 19, Resident 25 and Resident 6, and further indicated Resident 25 would sometimes pat Resident 19 when Resident 19 got too close, which in turn upset Resident 19. The following observations were made on the SCU on 5/24/16: - From 3:05 PM until 3:08 PM, Resident 25 sat in a chair at the table playing with plastic pull-apart beads as Resident 19 stood at a counter directly behind Resident 25's chair sorting through papers. There were no staff available in the area. (3 minutes without supervision). - From 3:17 PM until 3:24 PM, Resident 6 and Resident 25 were seated in the living room area as Resident 19 ambulated in the corridor and sat in a chair immediately outside the living room door. There were no staff available in the area (7 minutes without supervision). The following observations were made on the SCU on 5/25/16: - At 7:24 AM, NA-B ambulated Resident 25 from the resident's room to the living room, passing Resident 19 who was seated in a chair immediately outside the living room door. As Resident 25 passed, Resident 19 reached out and pulled at the hem of Resident 25's shirt. - From 7:42 AM until 7:46 AM, Resident 19 remained seated in the chair immediately outside the living room door as Resident 25 was seated in a chair in the living room. No staff were available in the area (4 minutes without supervision). - From 10:29 AM until 10:38 AM, Resident 19 was unattended by staff and wandering between the courtyard and the SCU as Resident 6 was seated in a wheelchair in the corridor outside the living room door (9 minutes without supervision). - At 10:38 AM, NA-D entered the corridor, was unable to locate Resident 19, and found Resident 19 in another resident's room. Resident 19 was redirected from the room and to a chair directly next to Resident 6 who remained seated in the corridor. - From 10:40 AM until 10:44 AM, Resident 6 and Resident 19 remained seated directly next to each other in the corridor with no staff available in the area (4 minutes without supervision). During interview on 5/25/16 from 10:59 AM through 11:35 AM, the Director of Nurses (DON) verified new interventions were not developed to protect Resident 19, Resident 6 and Resident 25 from further physical altercations.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility failed to put interventions in place to promote the healing of a pressure area for Resident 23. The facility census was 32. Findings are: A. Review of Resident 23's Department Notes indicated the resident returned to the facility from the hospital on [DATE]. Review or Resident 23's Weekly Pressure Ulcer Progress Report indicated Resident 23 had 2 pressure areas. Area A measured 2 centimeters (cm) to the inner left heel and area B measured 2 cm to the outer left heel. Review of Resident 23's undated Care Plan provided by the DON (DIrector of Nurses) on 5/24/16 indicated the resident was at risk for pressure ulcers. The Care Plan had not been updated to identify the current pressure areas and did not identify any new interventions to promote wound healing. Review of Resident 23's May Treatment Administration Record and Department Notes did not indicate Resident 23 had been wearing a heel protecting boot prior to 5/24/16. B. Observation of Resident 23's left heel on 5/25/16 at 10:19 AM with NA (Nurse Aide)-I and NA-B revealed a dark purple area to the back of resident's left heel approximately 2 cm (centimeter)long and 1.5 cm wide. NA-B stated the area was mushy. C. Interview with the Director of Nursing (DON) on 5/26/16 at 8:22 AM revealed that the nurse on duty should have notified the physician, the resident's family, and the dietary department of the pressure areas to Resident 23's left heel. The DON confirmed that dietary was not notified until 5/24/16. Further interview confirmed Resident 23's Care Plan had not been updated with new interventions until 5/24/16. The DON stated the facility had a heel protector boot they were putting on the resident's left foot. Interview with NA-I on 5/25/16 at 2:24 PM revealed the resident's heel protecting boot to the left foot was a new intervention started that day. Interview with NA-L on 5/26/16 at 9:27 AM revealed NA-L had not worked the previous 3 days and was not aware Resident 23 was to wear a heel protecting boot to the left foot.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview; the facility failed to revise Care Plans related to: 1) nutritional interventions for Resident 29; and 2) interventions to promote wound healing of pressure areas for Resident 23. The facility census was 32. Findings are: A. Review of Resident 29's current Care Plan dated 3/9/16 revealed the resident had a potential for weight loss related to leaving 25 percent (%) or more of food uneaten at most meals. The Care Plan interventions included offering fortified milk (additional nutrients, protein and calories are added to milk) at all meals and extra toast at breakfast. Review of Departmental Notes dated 3/17/16 at 2:55 PM revealed Resident 29's weight was 133 pounds (an 11 pound or 6.3 % weight loss in 3 months). There was no evidence additional interventions for the prevention of weight loss were developed or implemented. Interview with the Dietary Manager (DM) on 5/25/16 at 2:20 PM confirmed Resident 29's Care Plan had not been revised to address the weight loss and additional interventions for the prevention of weight loss had not been developed.