Every finding on record at Parkview Haven Nursing Home

Licensure Reference Number 175 NAC 12-006.09(I) Based on interviews and record reviews, the facility failed to ensure safe transfers for 1 (Resident 16) of 2 sampled residents and failed to assess the resident prior to moving the resident after the fall for 1 (Resident 16) of 2 sampled residents. The facility census was 24. Findings are: Record review of Resident 16's Clinical Census Record dated 5/20/25 revealed Resident 16 admitted to the facility on [DATE]. Record review of Resident 16's diagnosis dated 5/20/25 revealed: Hemiplegia (one-sided weakness or paralysis) and Hemiparesis (one-sided muscle weakness) following Cerebral Infarction (stroke) affecting right dominant side, Other Chronic Pain, Other Specified Disorders of Bone, Upper Arm. Record review of Resident 16's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/9/25 revealed: -Section B: no speech, usually understood and usually understands -Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 99 indicating severe cognitive impairment and inattention present. -Section G: one side limitation in upper range of motion, one side limitation in lower range of motion, and uses wheelchair. Dependent for all activities of daily living, moderate assistance with repositioning, and dependent assistance for transfers. Record review of Resident 16's progress note revealed: 9/9/2024 9:32 PM Note Text: 3-11 Shift Summary- Is total assist with all aspects of ADL's. Is incontinent of both bowel and bladder. Uses wheelchair for mobility, needs to be pushed. Does try to refuse feedings at times. zero medication issues identified, takes meds per tube. No alarms or secure care. Takes routine Tylenol. Seldom indicates pain. Entirely fed by tube. Sometimes is able to communicate needs. Skin is intact, sometimes is red around tube insertion site. Hoyer for transfers. Record review of Resident 16's Care plan dated 5/20/25 revealed: -Resident is at risk for falls related to deconditioning, paralysis, history of osteoporosis, seizures, 9/18/23-Right arm swelling/wears sling Date Initiated: 10/27/22, Revision on: 4/15/25 -Interventions -3/14/24-Seen by Advanced Practical Registered Nurse (APRN) Orders activity level up as tolerated, dependent for wheelchair (w/c) mobility and use hoyer lift with transfers. Date Initiated: 3/14/24. -9/18/24-Noted increased complaints of discomfort, limited range of motion, and swelling to the right shoulder/axillary area. Seen by APRN at the facility and orders: Oxycodone 5 mg per G-tube q 6 hrs PRN for severe pain, apply envelope sling to the right arm. May send for x-ray of the right humorous/shoulder if family agrees. Date Initiated: 9/18/24. -Received fax from Dr. to keep trying to do gentle range of motion to Resident's right shoulder. Date Initiated: 09/19/2024 Revision on: 10/14/24. Record review of facility's investigation report regarding Resident 16's incident on 9/16/24 revealed: -On 9/17/24 the Restorative Aide (RA) reported to the Director of Nursing (DON) that there was something wrong with Resident 16's right arm and that resident was complaining of a lot of pain. The resident was assessed by the DON and Minimum Data Set Coordinator (MDSC) and found when resident's right arm was moved [gender] frowned and moved away from the nurse, indicating pain. The DON called the Advanced Practice Registered Nurse (APRN) to report the findings and the APRN was going to come up the next morning to examine resident. -On 9/17/24 NA-B went into the DON's office and said that during report the staff was informed that Resident 16 was having a lot of right arm pain. NA-B reported the following to the DON: that on 9/16/24 at approximately 3:30 PM, Resident 16 slipped out of the wheelchair onto the pedals. NA-B stated [gender] hooked the resident up to the Hoyer lift and lifted them off the pedals and placed the resident onto the bed. NA-B reported that (gender) told Licensed Practical Nurse (LPN)-C about the fall and that NA-B transferred Resident 16 by Hoyer lift and placed them on the bed. -On 9/17/24 The DON notified Resident 16's primary care provider and the power of attorney of the fall and potential injury to right arm (pain with movement). -On 9/17/24 at 5:00 PM, LPN-C spoke with DON and reported that LPN-C assisted NA-B to adjust the lift pad for Redsident 16 who was in bed. LPN-C reported to DON that (gender) was not aware of a fall. -On 9/17/24 at approximately 8:30 PM the Administrator (ADM) interviewed NA-B. NA-B reported that Resident 16 started to slip from wheelchair to foot pedals so NA-B hooked resident up to Hoyer lift and moved Resident 16 to bed, NA-B reported that they notified the charge nurse. -On 9/18/2024 the APRN assessed Resident 16 and ordered the following: -Oxycodone 5 mg per peg tube every 6 hours as needed for severe pain -Envelope sling to right arm - have doctor recheck sling on rounds -May send for x-ray of right humerous shoulder if family agrees. -On 9/19/24 at 1:19 PM the facility notified Adult Protective Services (APS) via on line report. -On 9/25/25 at 2:26 PM the Administrator (ADM) emailed the Internal Investigation Summary to the State Agency. Record review of Pain Level Summary revealed facility assigns a value of pain using a PAINAD or Numerical Scale. PAINAD scale is a Pain Assessment in Advanced Dementia Scale that scores: -Breathing Independent of Vocalization -Negative Vocalization -Facial Expression -Body Language -Consolability Total scores range from 0 to 10, with a higher score indicating more severe pain (0=no pain; 10=severe pain) Record Review of Resident 16's Pain Level Summary printed on 5/22/25 revealed the following: -9/10/24 at 7:41 AM Pain Value=0 -9/11/24 at 2:46 PM Pain Value=0 -9/12/24 at 8:17 AM Pain Value=0 -9/13/24 at 10:36 AM Pain Value=0 -9/14/24 at 5:40 PM Pain Value=0 -9/15/24 at 7:22 AM Pain Value=0 -9/16/24 at 2:49 PM Pain Value=0 -9/17/24 at 8:45 AM Pain Value=0 -9/17/24 at 2:20 PM Pain Value=6 -9/17/24 at 6:08 PM Pain Value=5 -9/17/24 at 7:50 PM Pain Value=3 -9/18/24 at 12:32 AM Pain Value=6 -9/18/24 at 2:48 AM Pain Value=2 -9/18/24 at 7:54 AM Pain Value=4 -9/18/24 at 12:04 PM Pain Value=7 -9/18/24 at 2:04 PM Pain Value=4 -9/18/24 at 2:44 PM Pain Value=4 -9/18/24 at 11:45 PM Pain Value=7 -9/19/24 at 5:09 AM Pain Value=2 -9/19/24 at 8:06 AM Pain Value=5 -9/19/24 at 11:50 AM Pain Value=6 -9/19/24 at 2:53 PM Pain Value=0 -9/19/24 at 4:10 PM Pain Value=0 -9/19/24 at 8:18 PM Pain Value=4 -9/19/24 at 8:57 PM Pain Value=0 -9/20/24 at 6:03 AM Pain Value=3 -9/20/24 at 10:28 AM Pain Value=0 -9/20/24 at 1:27 PM Pain Value=5 -9/21/24 at 12:07 AM Pain Value=5 -9/22/24 at 10:20 AM Pain Value=4 -9/23/24 at 4:17 PM Pain Value=7 -9/24/24 at 12:11 PM Pain Value=8 -9/25/24 at 12:10 PM Pain Value=6 -9/26/24 at 10:53 AM Pain Value=4 -9/27/24 at 05:08 AM Pain Value=4 -9/28/24 at 7:29 PM Pain Value=5 -9/29/24 at 3:18 PM Pain Value=5 -9/30/24 at 11:35 PM Pain Value=4 -10/1/24 at 11:58 AM Pain Value=5 -10/2/24 at 8:03 AM Pain Value=5 -10/3/24 at 5:32 AM Pain Value=5 -10/4/24 at 12:38 AM Pain Value=7 -10/5/24 at 10:52 AM Pain Value=3 Record review of Limited lift Policy dated October 2005 revealed: Policy: This limited lift/resident handling policy is to ensure a safe working environment for resident handlers. It is to be reviewed and signed by all staff that perform or may perform resident handling. Procedure: -Mechanical lift transfer. (Hoyer type) with two caregivers. -Should a resident fall to the floor, the resident will be first be assessed by a nurse. If the resident is deemed medically appropriate to transfer from the floor, a full size mechanical Hoyer type lift will be used. If not deemed mechanically appropriate, the rescue unit will be notified. Record review of Hoyer Lift policy undated revealed: Purpose: To provide safe and easy transfer for the resident and the staff. -Ask a coworker for help. -To lift resident from the floor: Note: The Hoyer lift should never be used by one staff person alone, period. Two or more staff should be utilized for these procedures. As indicated by the residence condition. Record review of facility's Limited Lift Policy dated October 2005 revealed NA-B was trained on Limited Lift Procedures on 3/27/24 and signed on 3/27/24 indicating being trained. Record review of facility's Employee Orientation Record, reviewed/revised 2/2023 revealed NA-B was trained on Limited Lift Procedures, Sit-to Stand, Hoyer, Gaitbelt, 1 & 2 person ambulating, Walker, Unusual Event Report, and Accident/Incident Report on 3/27/24 and signed 3/27/24 indicating being trained. Interview on 5/21/25 at 2:13 PM with the ADM confirmed that the staff should use 2 staff members when assisting residents that utilize the hoyer lift. ADM also confirmed there was no assessment done by the nurse prior to moving resident after the fall. Interview via phone call on 5/21/25 at 6:37 PM with NA-B regarding incident occurrence on 9/16/24. NA-B said that another staff was to come help NA-B transfer Resident 16 but they didn't come to the room. NA-B said, I got the resident ready, I don't know how things went wrong, it happened so fast. I don't remember everything, it happened back in August or September. The resident kept sliding out of the wheelchair. I thought [gender]was in the wheelchair good, so I went to get RN-C. When we got back to the room the resident was sitting on the pedals of the wheelchair. We got Resident 16 up with the hoyer lift and back into bed. The nurse looked resident over and we assisted [gender] to the wheelchair again using the hoyer lift. Interview on 5/22/25 at 9:49 AM via phone with RN-C that worked on 9/16/24 with NA-B revealed NA-B came and got me that evening early sometime after 5:00 PM. When I got to Resident 16's room, resident was on the bed with the lift pad underneath [gender]. NA-B hooked the lift pad to the Hoyer lift and we transferred resident to the wheelchair. The resident did not have any complaints, although [gender] is aphasic, but there were no grimaces noted. The next day the DON called me and I told the DON what had happened. I worked the next day I think, and got report about Resident 16's right arm. I did notice [gender] was guarding it and it was a little swollen. Resident 16 saw the doctor and we started using a sling.

Licensure Reference Number 175 NAC 12-007.03(E) Based on observations and interviews, the facility failed to ensure 1 resident (Resident 19) out of 6 sampled residents was able to use the bathroom sink, medicine cabinet and was able to turn on the bathroom sink faucets without struggling. The facility census was 24. Findings are: An interview on 5/19/25 at 9:30 AM with Resident 19 revealed the sink being too high up, not being able to use the medicine cabinet, and (gender) struggles to turn the faucets on to brush (gender) teeth and wash face and hands. An observation on 5/20/25 at 8:15 AM of Resident 19 in the bathroom sitting in wheelchair trying to turn on the sink faucets and to reach the medicine cabinet. Resident 19 was able to open the medicine cabinet after struggling to reach it but unable to remove any items. Resident 19 had a stand in between the sink and toilet that had (genders) personal items such as hair brush/combs, and toothbrush and toothpaste that will fall between the bars. Resident 19 revealed that once it hits the floor (gender) is unable to pick items up. An interview on 05/21/25 at 10:14 AM with Maintenance confirmed that the sink is 34 inches in height and that is code for handicap assessable, so the sink is up to code. Maintenance confirmed that the turn faucets can be changed out to a swing faucet to assist Resident 19 with easier access for turning the faucets off and on. Maintenance was not sure if the sink could be lowered to accommodate Resident 19 easier access. A record review of The Americans with Disability Act (ADA): ADA Requirements for Bathrooms: Standards and Compliance revealed the sink should have a rim height of no more than 34 inches (86.36 cm) above the floor to accommodate wheelchair users. The knee clearance should be at least 27 inches (68.58 cm) high, 30 inches (76.2 cm) wide, and 19 inches (48.26 cm) deep to allow wheelchair users to approach the sink comfortably. An interview on 5/21/25 at 11:00 AM with the Administrator confirmed that the facility dropped the ball with Resident 19's bathroom. The management team had discussed Resident 19 concerns with the sink being too high and the faucets but then forgotten about it until now. The Administrator confirmed that the facility will get the bathroom taken care of.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews, observations, and interviews, the facility failed to send an investigation report within 5 days to the State Agency for 2 (Resident 16 and Resident 17) of 6 sampled residents. The facility census was 24. Findings are: A. Record review of Resident 16's Clinical Census Record dated 5/20/25 revealed admission to the facility was 8/15/22. Record review of facility documentation titled Internal Investigation Summary for the incident on 9/16/24 indicated Nurse Aide (NA)-B transferred Resident 16 onto bed with a Hoyer lift (a mechanical lift to transfer a person) without other staff members assistance. Resident 16 received a right arm injury that resulted in pain and swelling after this transfer. Record review of facility's investigation report regarding Resident 16's incident on 9/16/24 revealed: -On 9/17/24 the Restorative Aide (RA) reported to the Director of Nursing (DON) that there was something wrong with Resident 16's right arm and that resident was complaining of a lot of pain. The resident was assessed by the DON and Minimum Data Set Coordinator (MDSC) and found when resident's right arm was moved [gender] frowned and moved away from the nurse, indicating pain. The DON called the Advanced Practice Registered Nurse (APRN) to report the findings and the APRN was going to come up the next morning to examine resident. -On 9/17/24 NA-B went into the DON's office and said that during report the staff was informed that Resident 16 was having a lot of right arm pain. NA-B reported the following to the DON: that on 9/16/24 at approximately 3:30 PM, Resident 16 slipped out of the wheelchair onto the pedals. NA-B stated [gender] hooked the resident up to the Hoyer lift and lifted them off the pedals and placed the resident onto the bed. NA-B reported that (gender) told Licensed Practical Nurse (LPN)-C about the fall and that NA-B transferred Resident 16 by Hoyer lift and placed them on the bed. -On 9/17/24 The DON notified Resident 16's primary care provider and the power of attorney of the fall and potential injury to right arm (pain with movement). -On 9/18/2024 the APRN assessed Resident 16 and ordered the following: -Oxycodone 5 mg per peg tube every 6 hours as needed for severe pain -Envelope sling to right arm - have doctor recheck sling on rounds -May send for x-ray of right humerous shoulder if family agrees. -On 9/19/24 at 1:19 PM the facility notified Adult Protective Services (APS) via on line report. -On 9/25/25 at 2:26 PM the Administrator (ADM) emailed the Internal Investigation Summary to the State Agency. Record review of the facility's Abuse Investigations policy dated/reviewed 4-25 revealed: All reports of abuse, neglect, exploitation, theft, misappropriation of resident property, accidents with serious injury, elopement and/or injuries of an unknown cause shall be promptly and thoroughly investigated. The investigation record and applicable forms will be faxed to the appropriate agency in five (5) working days of the reported incident. Interview on 5/21/25 at 2:13 PM with ADM confirmed the fall investigation for Resident 16 was not sent into the State Agency within 5 working days as required and should have been. B. Record review of Resident 17's fall investigation report dated 3/23/2025 at 8:28 AM revealed: -Resident 17 was walking in the hall with walker and suddenly became very weak and fell down. -Most of the impact of the fall was on [gender] left side of head and the left shoulder. -Resident was complaining of severe pain. -Resident was transported to the emergency room and returned to the facility at 12:35 PM. -Family reports that Resident 17 was hurt but nothing was broken. -On 3/23/25 the Administrator notified APS by email at 10:07 AM . Record review of an e-mail from Administrator, sent on 3/30/25 at 10:02 PM to the State Agency revealed that the facility was aware of being late sending in the 5-day investigation report. Record review of an email from the Administrator revealed the 5-day investigation report was emailed to the State Agency on 3/31/25 at 10:21 AM, which was considered day 6. Interview on 5/21/25 at 1:55 PM with the Administrator confirmed that a 5-day investigation report regarding a fall on 3/23/25 for Resident 17 was not sent into the State Agency until 3/31/25 and should have been sent within 5 working days as required.

Licensure Reference Number 175 NAC 12-006.19(A) Based on observations, interviews, and record reviews, the facility failed to ensure the positioning rail on the bed was secure and in a proper position to prevent potential harm to 1 (Resident 2) of 1 sampled residents. The facility census was 24. Findings are: Record review of Resident 2's Clinical census record dated 5/20/25 revealed Resident 2 admitted to the facility on [DATE]. Record review of Resident 2's Diagnoses dated 5/20/25 revealed: Alzheimer's Disease (progressive mental deterioration, due to generalized degeneration of the brain), hemiplegia (a medical condition characterized by paralysis or severe weakness on one side of body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side, aphagia (a neurological disorder that impairs a person's ability to process and understand language, affecting communication.) following cerebral infarction, and cognitive communication deficit (a type of communication disorder where difficulties stem from cognitive impairments, rather than from a primary language or speech deficit). Record review of Resident 2's Bed Rail Assessment was completed by the facility on 4/1/25 revealed that the side rail/assist bar was indicated and served as an enabler to promote independence. Record review of Parkview Haven nursing home Policy of bed rails dated 4/18/25 revealed: -Any decision regarding bed rail use or removal should be made based on the individual resident or residence assessment. If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. Before you install bed rails: -Make sure the individual is an appropriate candidate for bed rails. Bed Side rails should not be used as a substitute for proper monitoring, especially for people at high risk for entrapment. -Avoid the routine use of adult bed rails without first conducting an individual, resident or resident assessment. Bed rails should be inspected by maintenance at a minimum. Of once a month and by nursing and all other staff entering the room daily. Inspection should include the following: -Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length and/or depth, the bed frame, bedside rail, and mattress should leave no gap wide enough to entrap a resident's head or body. -Inspect, evaluate, maintain, and upgrade equipment., beds. Mattresses, bed rails to identify and remove potential fall and entrapment hazards. -Be aware that gaps can be created by movement. For compression of the mattress, which may be caused by patients' weight, patients' movement, movement or bed position. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 4/3/25 revealed the following: -Section C: Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident 2's BIMS was 99 indicating severe cognitive impairment and has inattention present. -Section E: daily wandering -Section G: one limitation in upper range of motion, one limitation in lower range of motion, and uses wheelchair. Needs supervision for eating, moderate assistance for oral hygiene, maximum assistance with toileting hygiene, maximum assistance with bathing, maximum assistance with upper body dressing, dependent assistance with lower body dressing and footwear, maximum assistance for personal hygiene, moderate assistance with repositioning and transfers, moderate assistance to roll left to right in bed, maximum assistance from sitting to standing from bed, maximum assistance from lying to sitting on the side of the bed, moderate assistance from sit to stand from sitting in bed, toilet or chair. Record review of Resident 2's Care plan dated 5/20/25 revealed: -[Gender] has an ADL self-care performance deficit relate to Activity Intolerance, Alzheimer's, dementia ( progressive cognitive decline), fatigue, hemiplegia, impaired balance, aphasia, cognitive communication deficit, history of TIA's (Transient ischemic attack -a brief or mini stroke)-Date Initiated: 06/17/2024, Revision on: 04/16/2025 Intervention: Applied fall mat beside [gender] bed due to frequent falls when trying to transfer self-unassisted into wheelchair. Date Initiated: 04/07/2025 The resident requires partial to extensive assistance by 1 staff to turn and reposition in bed 2-3 hours and as necessary. Orders to apply positioning bar to the left side of bed to assist with transfers and positioning while in bed. Date Initiated: 06/17/2024, Revision on: 08/14/2024 -[Gender] is a high risk for falls related to Confusion, Gait/balance problems, Paralysis, Poor communication/comprehension, unaware of safety needs, Vision/hearing problems. Date Initiated: 06/17/2024 Revision on: 04/16/2025 Interview on 5/21/25 at 9:33 AM with MA-E revealed Resident 2 tries to get out of bed alone sometimes and staff places a mat in front of the bed and keeps the bed in low position to prevent injuries. Observation on 5/21/25 at 9:59 AM of Resident 2 revealed resident lying in the middle of the bed asleep. The positioning bar on the left side of the bed, near the head of bed, was raised and was lose and leaning out- away from bed at an approximate 120 degree angle. The width between the mattress and rail was at least 10 inches. The bed was in low position and there was a mat on the floor beside the bed. Interview on 5/21/25 at 10:01 AM with Maintenance Supervisor revealed side rail checks are done every month but stated I might have missed it last time. Sometimes the resident is in bed, or the nurse is in there, so I go back later. Maintenance Supervisor said [gender] didn't put this positioning bar on, that is not [gender] work, but confirmed the positioning bar was not in the correct position and needed to be fixed -I will do it now. Surveyor brought Administrator into Resident 2's room on 5/21/25 at 10:05 AM. Administrator stated That's not good, the positioning bar should be upright and tight. If [gender] rolled and got their head in between the mattress and positioning bar [gender] could choke or worse. At this time the Administrator confirmed that the positioning bar was not in the correct position. Record review of side rail maintenance log for 2025 completed by maintenance staff revealed that every month was checked indicating the positioning bar for Resident 2 was OK. Observation on 5/21/25 at 10:30 AM revealed all side rails and positioning rails in the nursing home that were on any residents' beds had no gaps between the mattress and side rails.

Licensure Reference Number 175 NAC 12-006.18(D) and 12-006.18(B) Based on observations, interviews, and record review, the facility failed to ensure staff performed hand hygiene prior to donning (putting on) gloves, between glove changes, change gloves often during cares, wash hands for 20 seconds for 2 of (Residents 16 and 20) of 2 sampled residents, and failed to wear a gown during cares for 2 of (Resident 16, and 20) of 2 sampled residents. The facility census was 24. Findings are: A. Record review of Resident 20's Clinical Census record dated 5/20/25 revealed Resident 20 admitted to the facility on [DATE]. Record review of Resident 20's Diagnosis dated 5/20/25 revealed: Retention of urine. Record review of Resident 20's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/7/25 revealed: -Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was scored 10 indicating moderate cognitive impairment. -Section G: Needs setup for eating, supervision for oral hygiene, maximum assistance with toileting hygiene, maximum assistance with bathing, moderate assistance with upper body dressing, dependent assistance with lower body dressing and footwear, maximum assistance for personal hygiene, moderate assistance with repositioning, and maximum assist for transfers. Record review of Resident 20's Care plan dated 5/20/25 revealed: Functional bladder incontinence r/t Activity Intolerance, Dementia, Impaired Mobility, Physical limitations, acute kidney failure, benign prostatic hypoplasia, and neoplasm of prostrate. Interventions -Administering UTI stat 30 ml po BID for prophylaxis for history of urinary track infection's. Date Initiated: 06/14/2024. -Use enhanced barrier precautions using gown and gloves with high contact areas per CDC with cares. Date Initiated: 04/15/2024. Observation on 5/21/25 at 7:15 AM with Nurse Aide (NA)-D and Medication Aide (MA)-E completed Resident 20's peri-cares (The cleaning and maintenance of the genital and anal areas.) and Suprapubic catheter (a type of urinary catheter that is inserted directly into the urinary bladder through the abdomen, just above the pubic bone ) cares (Regular cleaning, flushing, and monitoring of the catheter and surrounding skin to prevent complications like infection.). MA-E got the wash clothes ready. NA-D and MA-E donned gloves without hand hygiene and did not put gowns on. NA-D removed Resident 20's brief, and cleansed groin with washcloth with peri-wash on it while folding cloth for each swipe, then rinsed with another wet washcloth. NA-D then cleansed resident's external genitalia with same washcloth as used on groins, folding washcloth over each time, then wiped with the other washcloth as used before to rinse area and dried with dry towel. MA-E stated the surveyor made [gender] nervous and forgot they forgot to put on the gowns. MA-E & NA-D removed their gloves, donned a gown and new gloves without completeing hand hygiene. MA-E did get a clean washcloth wet with peri-wash and a wet cloth for rinse, and a towel ready. MA-E removed the split gauze dressing around the suprapubic catheter. MA-E did not perform hand hygiene or change gloves. MA-E cleansed the skin around suprapubic catheter opening area with a clean washcloth with peri-wash and rinsed with a wet washcloth and dried the area without completeing hand hyigene. MA-E then applied split gauze dressing and taped to skin. MA-E and NA-D washed hands with soap and water x 20 seconds. Interview on 5/21/25 at 7:32 AM with MA-E confirmed [gender] did not complete hand hyigene prior to putting on gloves, when changeing gloves, and did not wear a gown during cares for Resident 20 and should have. Interview on 5/21/25 at 7:45 AM with NA-D confirmed [gender] did not complete hand hyigene prior to putting on gloves, when changeing gloves, and did not wear a gown during cares for Resident 20 and should have. Interview on 5/21/25 at 9:00 AM with the Director of Nursing (DON) confirmed staff are to wash hands prior to donning gloves, when changing gloves, and wear gown when doing per-care and catheter cares. Record review of Hand Hygiene Policy dated 9/2020 revealed: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. -Hand hygiene when using soap and water: -Wet hands with water. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis. -Apply enough soap to cover all hand surfaces. -Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. -Dry thoroughly with a single-use towel. -Use towel to shut off the faucet. -The use of gloves does not replace hand washing. Wash hands after removing gloves. Record review of Perineal care dated 7/21/24 revealed: Purpose: The perineum needs special care for some residents in order to keep skin clean and skin healthy. Procedure for: -Wash hands. -Fill Basin half-full with warm water and place on over bed table on top of the towel. -Wet the washcloth in warm water, wring out and apply soap. Fold washcloth into fourths, making it easier to use a different section of the washcloth or disposable wipe for each stroke. Do not put the washcloth into the basin of water. Change washcloths as necessary, placing use cloths in separate plastic bag. Never place used tissue or washcloth on the bed or over bed table. -Hold penis upright. -Wash the urinary meatus (the external opening of the urethra, the tube that carries urine from the bladder to the outside of the body) in a circular motion starting at the tip. Use a clean part of the washcloth for each stroke. Be sure to wash all skin folds thoroughly. Always wash away from the urinary meatus. Be sure to wash all skin folds thoroughly. (Always wash away from the urinary meatus). -Using a clean washcloth, rinse using the same process (Note: if disposable peri wipes are used, rinsing may not be necessary). -Pat the area dry in same direction used for washing. -Wet and soap a new washcloth. With downward strokes (away from the urinary meatus), wash down the shaft of the penis, then scrotum, perineum, and thigh creases. Follow by rinsing and patting dry in the same order and direction as washing. -Wash and dry the lower abdomen and over the pubic hair. -Turn the resident on the side with back towards you and legs slightly bent. Expose the resident's buttocks. Apply bed protector if not already in place. -Remove gloves and perform hand hygiene and replace gloves. -Apply incontinent brief if used and remove the bed protector and place it in plastic bag. -Remove gloves and wash hands. Record review of enhanced barrier precautions policy reference by Center for Disease Control and Prevention dated July 12, 2022 revealed: -Policy: Is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism. (MDRO), such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. -Overview: Enhanced barrier precautions will not only focus on residents with infection or colonization with MDRO's but will also address residents at risk for developing or becoming colonized. Enhanced barrier precautions are precautions that are between standard precautions and contact precautions. Enhanced barrier precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high contact. Purpose. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDRO's to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. B. Record review of Resident 16's Clinical Census Record date 5/20/25 revealed Resident 16 admitted to the facility on [DATE]. Record review of Resident 16's Diagnoses dated 5/20/25 revealed: Hemiplegia and Hemiparesis following affecting right dominant side, Aphagia following Cerebral Infarction, and Gastrostomy Status. Record review of Resident 16's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/9/25 revealed: Section K: feeding tube Observation on 5/20/25 at 1:00 PM with Liscened Practical Nurse (LPN)-A giving medication and doing Gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food.) cares for Resident 16. Resident 16 was lying in bed with head of bed at 90 degrees. LPN-A donned gown and gloves without performing hand hygiene. LPN-A checked the placement of gastrostomy tube by using a stethoscope and instilling air into the tube by a syringe and listening to the stomach for air. LPN-A flushed the gastrostomy tube with 60 milliliters of water, gave medication Gabapentin 100 milligrams (2 capsules) that was emptied into a small amount of water in a medicine cup and poured into the tube, then flushed again with water. LPN-A administered 8 ounces of Jevity into the syringe, then 75 milliliters of water. LPN-A closed the gastrostomy tube. LPN-A cleansed the skin surrounding the gastrostomy with soap and water and dried without cleansing hands or changing gloves prior. LPN-A applied a split 4x4 gauze around the gastrostomy area and taped it to skin. LPN-A lowered the bed, removed gloves and gown, then tied up trash and dirty laundry, and left the room without washing hands. LPN-A took the trash and dirty clothes to the hopper room, then went to nursing station and washed hands with soap and water x 16 seconds. Interview with LPN-A on 5/20/25 at 1:24 PM confirmed [gender] did not perform hand hygiene before applying the gloves and giving medicine, perform hand hygiene and change gloves when starting on gastrostomy cares and wash hands before leaving the resident's room, and perform hand hygiene with the soap and water for 20 seconds and should have. Interview on 5/20 at 2:30 PM with the DON revealed staff should have performed hand hygiene before applying the gloves and giving medicine, perform hand hygiene and change gloves when starting on gastrostomy cares, wash hands before leaving the resident's room, and perform hand hygiene with the soap and water for 20 seconds. Record review of Hand Hygiene Policy dated 9/2020 revealed: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. -Hand hygiene when using soap and water: -Wet hands with water. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis. -Apply enough soap to cover all hand surfaces. -Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. -Dry thoroughly with a single-use towel. -Use towel to shut off the faucet. -The use of gloves does not replace hand washing. Wash hands after removing gloves. Record review of enhanced barrier precautions policy reference by Center for Disease Control and Prevention dated July 12, 2022 revealed: -Policy: Is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism. (MDRO), such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. -Overview: Enhanced barrier precautions will not only focus on residents with infection or colonization with MDRO's but will also address residents at risk for developing or becoming colonized. Enhanced barrier precautions are precautions that are between standard precautions and contact precautions. Enhanced barrier precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high contact. Purpose. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDRO's to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids.

Licensure Reference Number 175 NAC 12-007.04(D) Based on observations, record review and interviews, the facility failed to ensure bathroom ventilation system was functioning preventing lingering odors from permeating for 10 occupied resident rooms, and the facility failed to ensure the ventilation system was free of dust in Rooms 103,104, 105, 106,107, 109, 110, 113,115, 117. This had the potential to affect all residents. The facility census was 24. Findings are: An observation on 5/19/25 at 8:59 AM revealed the bathrooms ventilation in rooms103,104,105,106,107,109,110,113,115, and 117 did not have functional ventilation as tested with a 1 ply square of toilet paper held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw and the ventilation system did not work. All vents had a white substance on the air grill, and the rooms revealed a stale ammonia odor. An observation on 5/20/25 at 8:03 AM revealed the bathrooms ventilation in rooms103,104,105,106,107,109,110,113,115, and 117 did not have functional ventilation as tested with a 1 ply square of toilet paper held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw and the ventilation system did not work. All vents had a white substance on the air grille, and the rooms revealed a stale ammonia odor. An interview on 05/20/25 at 9:03 AM with the Maintenance confirmed that the ventilations were not working for rooms 103-115 and 117 and that someone had shut off the switch. Maintenance confirmed that (gender) had not cleaned the vents yet this month. A record review of the monthly maintenance checklist for ventilation was marked yes for May 2025, that all fans are clean, free of debris and in working order. An interview on 5/20/25 at 9:14 AM with the Administrator confirmed that (gender) expectations are the ventilations are to be cleaned monthly and staff are to be checking it regularly and the ventilations are to be checked daily due to a resident shutting the switch off and with the ventilation system not working or being turned off the bathroom could have an odor build up.

Licensure Reference Number 175NAC 12-006.09D 3(5) Based on record review and interviews; the facility failed to ensure routine bowel movement for 3 (Resident 10, 13, and 21) of 3 sampled residents. The facility census was 27. Findings are: A. A review of a facility document labeled Bowel Management Protocol dated 4/1/2020 revealed the following procedures for no bowel movement: -Day 2-A dose of Prune juice or fruit and fiber will be given. -Day 3- A dose of Milk of Magnesia (MOM) will be given. -Day 4-A Bisacodyl (Dulcolax) suppository (a medication placed in the rectum) will be given. -Day 5- The provider will be contacted for further orders. A review of Resident 10's Admission Record dated 5/21/24 revealed Resident #10 admitted to the facility on [DATE]. A review of Resident 10's Medical Diagnosis list dated 5/21/24 revealed the following diagnoses: -Alzheimer's disease -Constipation A review of Resident 10's Minimum Data Set (MDS- a comprehensive assessment that is completed by long term care facilities that measures a residents health status and functional abilities) dated 5/2/24 revealed the following: - A BIMS (Brief Interview for Mental Status) score off 99 which indicated the resident was cognitivley severely impaired. - Resident 10 did have the ability to usually make themself-understood to others, and sometimes understood others. - Resident 10 required substantial assistance with oral care, personal or toileting hygiene, and lower body dressing. - Resident 10 required maximum assistance for toilet transfers or repositioning, - Resident 10 is frequently incontinent of bladder and bowel. The bowel incontinence indicator was a 9 which meant not rated due to Resident 10 did not have a bowel movement the entire 7 day look back period of the MDS. A review of Resident 10's Care Plan dated 5/21/24 (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) revealed there was not a focus, goal, or intervention related to Resident 10's diagnosis of constipation. A review of Care Plan Notes dated 5/15/24 did not address that constipation was a concern for Resident 10. A review of the residents Bowel Elimination Task report from 4/22/24 to 5/20/24 revealed that resident did not have a bowel movement documented from: - 4/25/24-4/29/24 (5 days) -5/16/24 - 5/19/24 (4 days) A review of Resident 10's Order Report dated 5/21/24 revealed the following orders: - MiraLAX Oral Packet 17 Grams (GM) (Polyethylene Glycol) Give 8.5 gram by mouth one time a day every other day scheduled related to constipation. -Day 2 with no bowel movement, 4-ounces of prune juice or fruit & fiber was to be given. -Day 3 with no bowel movement, Milk of Magnesia (MOM) 30 milliliters by mouth was to be given every 24 hours. -Day 4 without a bowel movement, a 10 milligram Bisacodyl suppository was to be given every 24 hours. A review of Resident 10's Medication Administration Record (MAR) for April 2024 revealed that no bowel care medications were provided between 4/25/24-4/28/24. On 4/29/24 a dose of MOM was given and documented ineffective. Resident 10's next documented bowel movement was day 6 per the Bowel Elimination Task report from 4/22/24-5/20/24. A review of Resident 10's MAR for May 2024 revealed that a dose of MOM was given on 5/18/24 and 5/19/24. There were no results documented and no further bowel care or assessment documented. Resident 10s next documented bowel movement was day 5 per the Bowel Elimination Task report from 4/22/24-5/20/24. An interview on 5/22/24 at 8:00 AM with Nursing Assistant-B (NA-B) revealed [gender] is given a list of residenst who have not had bowel movements and if the identified residents have a bowel movement they are to notify the nurse. An interview on 5/23/24 at 10:48 AM with the Director of Nursing (DON) confirmed that Resident 10 did not have a bowel movement or intervention between 4/25/24-4/28/24. The DON revealed the resident did not have a documented bowel movement between 5/16/24-5/19/24. The DON revealed there was no documnetation regarding an assessment, bowel interventions, or notification for Resident 10 per [gender] expectations. B. A review of the Admission Record dated 5/21/24 revealed that Resident 13 was admitted to the facility on [DATE]. A review of the Medical Diagnosis list dated 5/21/24 revealed the following diagnoses: -Diverticulitis of large intestine -Constipation A review of Resident 13's MDS dated [DATE] revealed the following: - A BIMS (Brief Interview for Mental Status) score of 9 which indicated the resident's cognition was moderately impaired. - The resident did have the ability to make self-understood to others and understands others. - Resident 13 required maximum assistance with toileting and personal hygiene and was total depedent for lower body dressing. - Resident 13 was frequently incontinent of bladder and occasionally incontinent of bowel. A review of Resident 13's Care Plan dated 4/27/23 revealed: - A focus on constipation related to decreased mobility - Notify the physician that resident had hard stools. - Encourage resident to sit on toilet to evacuate bowels if possible. - Follow facility bowel protocol for bowel management. - Monitor/document/report as needed signs and symptoms of complications related to constipation. - Record bowel movement pattern each day. Describe amount, color and consistency. A review of Resident 13's Bowel Elimination Task report from 4/22/24 to 5/20/24 revealed the resident did not have a bowel movement documented from 5/15/24-5/20/24 (6 days). A review of Resident 13s' Order Report dated 5/21/24 revealed the following orders: - Dulcolax Rectal Suppository 10 milligrams insert 1 suppository rectally every 24 hours as needed for constipation -Day 2 with no bowel movement, 4-ounces of prune juice or fruit &fiber as needed for constipation. - Milk of Magnesia (MOM) 30 milliliters by mouth every 24 hours as needed for constipation. A review of Resident 13's MAR for May 2024 revealed that a Dulcolax 10 mg suppository was given on 5/18/24 and was not effective. There were no results documented and no further bowel care documentation. Resident 13's next documented bowel movement was day 7 per the Bowel Elimination Task report from 4/22/24-5/20/24. An interview on 5/23/24 at 10:48 AM with the Director of Nursing (DON) revealed Resident 13 did not have a bowel movement between 5/15/24-5/20/24. The DON revealed one intervention was provided and was ineffective. The DON confirmed there was not a follow up assessment or provider notification per the DON expectation. C. A review of the Admission Record dated 5/21/24 revealed that Resident 21 was admitted to the facility on [DATE]. A review of the Medical Diagnosis list dated 5/21/24 revealed the following diagnosis: -Constipation A review of Resident 21's MDS dated [DATE] revealed the following: - A BIMS score of 10 which indicated the resident's cognition was moderately impaired. - Resident 21 had the ability to make themselves understood to others and could understand others. - Resident 21 required maximum assitance with upper and lower body dressing, personal and toileting hygiene. - Resident 21 was frequently incontinent of bladder and occasionally incontinent of bowel. A review of Resident 21's Care Plan dated 10/24/23 revealed: -A focus on constipation related to decreased mobility, pain, use/side effects of medication, Norco and Tramadol - Notify the physician of bowel regulation issues. - Update the physician of increase constipation. - Follow facility bowel protocol for bowel management - Encourage resident to sit on toilet to evacuate bowels daily after lunch if possible. - Follow facility bowel protocol for bowel management. - Monitor/document/report as needed signs and symptoms of complications related to constipation. - Record bowel movement pattern each day. Describe amount, color and consistency. A review of the residents Bowel Elimination Task report from 4/22/24 to 5/20/24 revealed that resident did not have a bowel movement documented from: - 4/23/24-4/25/23 (3 days), - 4/27/24-4/30/24 (4 days) - 5/12/24-5/15/24 (4 days) -5/17/24-5/19/24 (3 days). A review of Resident 21's Order Report dated 5/21/24 revealed the following orders: - Dulcolax Rectal Suppository 10 mg insert 1 suppository rectally every 24 hours as needed for constipation -Day 2 with no bowel movement, 4-ounces of prune juice or fruit &fiber as needed for constipation. -MiraLAX Oral Packet 17 gram by mouth every 24 hours as needed for constipation. -Senna oral capsule 8.6 MG give 1 capsule by mouth one time a day for constipation. A review of Resident 21s's MAR for April 2024 revealed that MiraLAX 17 GM was given on 4/30/24 and was not effective. There were no results documented and no further bowel care documentation was revealed from the dates 4/22/24-4/30/24. A review of Resident 21's MAR for May of 2024 revealed that a Bisacodyl rectal suppository was given both on 5/15/24 and 5/20/24 documented as ineffective. MiraLAX was documented as given on 5/14/24, 5/17/24, and 5/19/24 and those too were documented as ineffective. An interview on 5/23/24 at 10:48 AM with the Director of Nursing (DON) confirmed that Resident 21 did not have a bowel movement between the following dates: - 4/23/24-4/25/23 (3 days), - 4/27/24-4/30/24 (4 days) - 5/12/24-5/15/24 (4 days) -5/17/24-5/19/24 (3 days). The dates of intervention were as follows: - 4/30/24 -5/14/24 -5/15/24 -5/17/24 -5/19/24 The DON confirmed that the documentation revealed the interventions were ineffective. A confirmation was also received that there was not a follow up for these dates noted in the form of a nurses note, assessment, or physician notification per DON expectation.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1 Based on observation, interview and record review, the facility failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) assessment to reflect the resident's status for Residents 23, 2, 24, 17 and 15. This affected 5 of 14 sampled residents. The facility identified a census of 23 at the time of survey. Findings are: A. Review of Resident 23's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 6/14/23 revealed an admitted [DATE]. Falls since the prior assessment was marked no. Applications of ointments/medications other than to feet was marked yes. Prognosis was marked no and hospice received while a resident was marked no. Review of Resident 23's MDS Schedule revealed the last MDS completed for Resident 23 had an assessment reference date of 3/21/23 and was a SCSA (Significant Change in Status Assessment). There was no documentation Resident 23 was out of the facility or discharged from the facility from 3/21/23 to 6/14/23. Review of Resident 23's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for June 2023 revealed no documentation of application of dressings to the feet. Review of Resident 23's Progress Notes dated 4/28/23 revealed the following documentation: 4/28/2023 18:15 (6:15 PM): Resident 23 was found lying on their back on the floor between room and hallway. The resident residing in that room reported Resident 23 stood up and turned around and fell . Review of Resident 23's Census dated 7/10/23 revealed Resident 23's payer source was Hospice as of 3/14/2023. Interview with the BOM (Business Office Manager) on 7/10/23 at 10:31 AM revealed Resident 23's hospice services did not end and Resident 23 had been receiving hospice services the entire time since they were admitted to hospice. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.17.1 dated October 2019 revealed the following: J1400: Prognosis (cont.) Coding Instructions Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent-If this is not the first assessment/entry or reentry (A0310E = 0), the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes). Ask the resident and family about falls during the look-back period. Resident and family reports of falls should be captured here whether or not these incidents are documented in the medical record. Coding Instructions Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) item (J1900), whichever is more recent. M1200: Skin and Ulcer/Injury Treatments Review the medical record, including treatment records and health care provider orders for documented skin treatments during the past 7 days. Some skin treatments may be part of routine standard care for residents, so check the nursing facility ' s policies and procedures and indicate here if administered during the look-back period. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. M1200I Application of Dressings to the Feet (with or without Topical Medications) Includes interventions to treat any foot wound or ulcer other than a pressure ulcer/injury. Do not code application of dressings to pressure ulcers/injuries on the foot; use M1200E, Pressure ulcer/injury care. Do not code application of dressings to the ankle. The ankle is not considered part of the foot. O0100: Special Treatments, Procedures, and Programs O0100K, Hospice care Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. B. Review of Resident 2's Quarterly MDS dated [DATE] revealed an admitted [DATE]. Anticoagulant received in the last 7 days was marked 0. Review of Resident 2's Order Summary Report dated 7/10/2023 revealed an order for Rivaroxaban (Xarelto-an anticoagulant) Tablet 15 MG Give 1 tablet by mouth one time a day with an active date of 3/16/2022. Review of Resident 2's MAR for May 2023 revealed documentation the Rivaroxaban Tablet 15 MG Give 1 tablet by mouth one time a day was administered to Resident 2 for 7 days during the 7 day MDS look back period. Review of the manufacturer's website for Xarelto revealed the following: XARELTO(R) belongs to the category of blood thinners commonly called DOACs, or direct oral anticoagulants. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.17.1 dated October 2019 revealed the following: Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Interview with the ADON (Assistant Director of Nursing) on 7/10/23 at 10:19 AM revealed an outside contract company coded the medications on the MDS and completed sections N and O. The ADON confirmed the Xarelto should have been coded as an anticoagulant on the MDS. The ADON confirmed the items on Resident 23's MDS were not coded to reflect Resident 23's condition at the time the assessment was completed. Interview with RNC (Registered Nurse Consultant) on 7/10/23 at 10:57 AM confirmed the MDS assessments for Residents 23 and 2 were coded in error. 41938 C. Record review of the Admission Record dated 7/10/23 for Resident 24 revealed that Resident 24 admitted into the facility on [DATE]. Diagnoses included frequent falls, depression, and Alzheimer's Dementia. Record review of the progress note for Resident 24 dated 1/25/23 at 8:41 PM revealed that staff were going down the hall and noted Resident 24 sitting on the floor in their room. The residents' physician was notified of the fall. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/31/23 revealed Section J1800 (Any Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent). The question was answered No indicating that Resident 24 did not have any falls since admission in the facility. Interview on 7/11/23 at 4:24 PM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 24 had a fall on 1/25/23 that was not identified on the resident's 1/31/23 MDS Assessment. The ADON confirmed that the MDS should have been marked Yes to any falls since admission. D. Record review of the Admission Record dated 7/10/23 for Resident 24 revealed that Resident 24 admitted into the facility on [DATE]. Diagnoses included frequent falls, depression, and Alzheimer's Dementia. Record review of the progress note for Resident 24 dated 3/6/23 at 4:40 PM revealed that the nurse heard a scream and Resident 24 was on the floor in the dining room laying on their right side. Resident 24 told the nurse that everything hurt. The ambulance was called. Resident 24 was sent to the hospital. Interview on 7/11/23 at 8:24 AM with Registered Nurse-D (RN-D) confirmed that RN-D was the nurse that responded to Resident 24's fall in the dining room on 3/6/23. Record review of the MDS Assessment for Resident 24 dated 4/27/23 revealed Section J1800 (Any Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent). The question was answered No indicating that Resident 24 did not have any falls since the prior assessment on 1/31/23. The ADON confirmed that Resident 24 fell in the dining room on 3/6/23. The ADON confirmed that Resident 24's fall on 3/6/23 was expected to be identified on the resident's 4/27/23 MDS Assessment but was not. E. Record review of the Admission Record dated 7/10/23 for Resident 17 revealed that Resident 17 admitted into the facility on [DATE]. Diagnoses included dementia, anxiety, and history of falling. Record review of the current undated care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 17 revealed that staff were to use a pressure pad alarm (a device that contains sensors that trigger an alarm when the resident tries to get up from the chair or bed on their own) on the resident wheelchair and bed for the resident's safety. Observation on 7/10/23 at 10:30 AM revealed Resident 17 propelled themselves in the wheelchair to the nurse's station. A white chair pad alarm box hung on the back upper right of the wheelchair. The alarm was connected to the sensor pressure pad in the seat of the wheelchair. Observation on 7/11/23 at 2:39 PM in the room of Resident 17 revealed that a pressure pad alarm box hung from the bedframe at the foot of the bed. The cord from the alarm box ran to the sensor pad on the resident's bed. Observation on 7/11/23 at 2:41 PM on the facility 200 hall revealed that Resident 17 propelled themselves in the wheelchair towards the nurse's station. A white chair pad alarm box hung from the right wheelchair handle. The cord from the alarm box ran to the sensor pressure pad on the wheelchair seat. Record review of the MDS assessment for Resident 17 dated 4/14/23 revealed that section P0200 titled Alarms was marked as not used for bed alarm and chair alarm. Interview on 7/11/23 at 4:24 PM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 17 has a chair alarm and bed alarm in place since August 2022. The ADON confirmed that the alarms are expected to be identified on the resident's MDS Assessment. F. Record review of the Admission Record dated 7/10/23 for Resident 15 revealed that Resident 15 admitted into the facility on [DATE]. Diagnoses included dementia, hallucinations, and Type 2 Diabetes (a disease where the blood sugar level is too high). Record review of the MDS assessment for Resident 15 dated 4/25/23 revealed section N0350 Insulin. The number of days that insulin injections were received during the last 7 days was marked as 1 day. Record review of the Order Summary Report (a listing of all physician orders for the resident) dated 7/10/23 for Resident 15 revealed that Resident 15 had no physician ordered insulin injections. Resident 15 had an order for Trulicity 1.5 milligrams/0.5 milliliters (a non-insulin medication used to treat type 2 diabetes in combination with diet and exercise) to inject 1.5 milligrams every Tuesday. Interview on 7/11/23 at 4:24 PM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 15 does not receive insulin. The ADON confirmed that the MDS should not have identified insulin use on the 4/25/23 MDS assessment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on interview and record review, the facility failed to complete a SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) assessment as required for Resident 10. This affected 1 of 3 sampled residents. The facility identified a census of 23. Findings are: Record review of Resident 10's SCSA MDS dated [DATE] revealed an admitted [DATE]. Record review of Resident 10's Census dated 7/10/2023 revealed Resident 10's Payer source was listed as Hospice with an active date of 6/5/2023. Record review of Resident 10's MDS list revealed no documentation that a SCSA was completed after Resident 10 was admitted to Hospice on 6/5/23. Interview with the BOM (Business Office Manager) on 07/10/23 at 10:31 AM revealed the resident MDS assessments were completed by a contract company. The BOM confirmed Resident 10 had been receiving hospice services since 6/5/2023. Interview with RNC (Registered Nurse Consultant) for the MDS contract company on 07/10/23 at 10:57 AM revealed they completed a SCSA for Resident 10 on 6/2/23 due to a decline in their condition; not due to hospice. RNC confirmed a SCSA assessment had not been done when Resident 10 was admitted to hospice on 6/5/23 as required. Interview with the ADON (Assistant Director of Nursing) on 07/10/23 at 11:00 AM revealed that the facility did not let the MDS contract company know about Resident 10's SCSA MDS needing to be completed; the ADON confirmed the company had access to their EHR (Electronic Health Record) including the census that listed the change in status for Resident 10. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed the following: An RAI (MDS, CAA process, and Utilization Guidelines) must be completed for any resident residing in the facility, including: Hospice residents: When a SNF or NF is the hospice resident's residence for purposes of the hospice benefit, the facility must comply with the Medicare or Medicaid participation requirements, meaning the resident must be assessed using the RAI, have a care plan and be provided with the services required under the plan of care. This can be achieved through cooperation of both the hospice and long-term care facility staff (including participation in completing the RAI and care planning) with the consent of the resident. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. If a resident is admitted on the hospice benefit (i.e., the resident is coming into the facility having already elected hospice), or elects hospice on or prior to the ARD of the Admission assessment, the facility should complete the Admission assessment, checking the Hospice Care item, O0100K. Completing an Admission assessment followed by an SCSA is not required. Where hospice election occurs after the Admission assessment ARD but prior to its completion, facilities may choose to adjust the ARD to the date of hospice election so that only the Admission assessment is required. In such situations, an SCSA is not required. An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician ' s or medical director ' s order stating the resident is no longer terminally ill. If a resident is admitted on the hospice benefit but decides to discontinue it prior to the ARD of the Admission assessment, the facility should complete the Admission assessment, checking the Hospice Care item, O0100K. Completing an Admission assessment followed by an SCSA is not required. Where hospice revocation occurs after the Admission assessment ARD but prior to its completion, facilities may choose to adjust the ARD to the date of hospice revocation so that only the Admission assessment is required. In such situations, an SCSA is not required. The ARD must be less than or equal to 14 days after the IDT ' s determination that the criteria for an SCSA are met (determination date + 14 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than. When an SCSA is completed, the nursing home must review all triggered care areas compared to the resident ' s previous status. If the CAA process indicates no change in a care area, then the prior documentation for the particular care area may be carried forward, and the nursing home should specify where the supporting documentation can be located in the medical record. The CAA(s) completion date (item V0200B2) must be no later than 14 days after the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be the same as the MDS completion date, but not earlier than MDS completion. The care plan completion date (item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar days).

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and interview, the facility failed to identify and evaluate a change in condition resulting in hospitalization for 1 resident (Resident 1) of 1 sampled. The facility census was 25. Findings are: Record review of Resident 1's progress notes revealed: -12/10/21 at 10:52 AM Resident with Temperature of 100.0 at 10:52 AM with emesis x 1, no other s/s (signs and symptoms) of COVID. -12/10 at 8:54 PM Nauseated and vomiting today, fluids given for supper and 50% taken. Further review revealed no indication that the practitioner had been notified. -12/11/21 at 6:35 AM Patient has run a temperature most of the night, fluctuating a lot. At 4:30 AM it was 100.0 and (gender) was given Tylenol. Temperature after Tylenol was 99.3 and then at 5:30 AM it was 100.9. No emesis during the night. Further review revealed no indication that the practitioner had been notified. -12/13/21 at 09:31 AM Called to patient's room, noted that Foley catheter was draining milky colored (infection looking) fluids, patient not running a temp but is shaking. Appointment made with [NAME] County Clinic with facility to drive patient there. Further review revealed that practitioner was not notified of change in condition, facility staff scheduled appointment with the clinic staff. -12/13/21 at 10:20 AM Change of condition, patient now vomiting with possible aspiration, temp 98.2 but body is feeling very warm, skin is flushed, eyes open. Rescue unit called and they left the facility at 9:15 AM. -12/31/21 at 12:09 PM [NAME] County Health Services called and stated that patient would be admitted to the hospital acute for bladder infection and that patient would be receiving IV antibiotics. Record review of the Hospital History and Physical dated 12/13/21 at 10:02 AM revealed that Resident 1 had been experiencing emesis off and on over the weekend according to the facility staff. Staff also reported Resident 1 had a fever and very cloudy urine in catheter today with a history of UTI's (Urinary Tract Infections). The resident's lactic acid was slightly elevated as well as Procalcitonin [which is an indicator of [CONDITION(S)] (an infection that has spread to the blood]) and white blood cell count elevated at 13.0 (normal range is 4.0-10.0). Record review of the Hospital Progress Note dated 12/13/21 at 10:23 AM revealed that Resident 1 arrived by rescue squad and Resident 1 had been vomiting off and on since Friday. Urinalysis results for Resident 1 showed large amounts of blood, and large amounts of leuk est (white blood cells indicative of a urinary infection). Record review of the Hospital Progress Note dated 12/14/21 at 04:22 AM revealed that Resident 1 was admitted from the nursing home with urosepsis (an infection in the blood caused by a bacteria that has entered the bloodstream). Urine is dark and cloudy, resident admitted on Intravenous (IV) Antibiotics and had a temperature of 100. Policy Review of Notifications of Changes last revised 9/2020 revealed that the facility will notify the physician of any need to alter treatment due to a significant change in resident's physical, mental or psychosocial status, or a decision to transfer or discharge resident from the facility. Interview with the Director of Nursing (DON) on 12/15/21 at 10:20 AM confirmed that the facility staff called the [NAME] County Health Services on 12/13/21 to schedule an appointment but did not speak with the physician, and there was no other notification to the physician on Resident 1's change in condition on 12/10 or 12/11.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed monitor the condition and request a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had a census of 25. Findings are: Record review of a Physicians Order sheet signed 11-09-2021 revealed Resident 6 admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Wound Progress Note dated 9-20-2021 revealed Resident 6 had a un-stageable pressure ulcer (un-stageable Pressure Ulcer: obscured full-thickness skin and tissue loss full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue) with a rectocutaneous fistula ( opening under the skin to the rectum wall). Record review of Resident 6's Comprehensive Care Plan (CCP) dated 9-23-2021 revealed Resident 6 was identified as having an un-stageable pressure ulcer. The goal identified for the pressure ulcer was the size of the wound would decrease by 25%. The interventions identified on Resident 6's CCP included adjusting the treatment plan if no healing was occurring within 2 to 4 weeks, monitor for changes in Resident 6's skin status that may indicate the worsening of the pressure ulcer and to notify the physician. Record review of Resident 6's Minimum Data set ( MDS: a federally mandated assessment tool used for care planning) dated 9-26-2021 revealed the facility staff assessed the following about Resident 6: -Required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Had 1 un-stageable pressure ulcer. Record review of a Pressure Ulcer Daily Documentation record revealed the Resident 6's pressure ulcer was on the coccyx ( tail bone area) with the rectocutaneous fistula. The opening area of the pressure ulcer measured 2 centimeters (cm) long and 1 cm wide. There was no measurement of how deep the wound was. Record review of Resident 6's Progress notes (PN) revealed on 10-08-2021 Licensed Practical Nurse (LPN) I documented the un-stageable pressure ulcer opening measured 2.5 cm by 1.5 cm with no depth in the wound identified. Further review of Resident 6's PN revealed there was not evidence any further in monitoring the size of the opening of the un-stagebale pressure had been completed. Record review of a Fax sheet dated 11-08-2021 revealed a request to discontinue the current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the fax sheet dated 11-08-2021 the un-stageable pressure ulcer measured 4.0 cm by 2.0 cm ( an increase in wound size from measurements identified in Resident 6's PN dated 10-08-2021). No additional treatment was requested for the un-stageable pressure ulcer. On 12-14-2021 at 3:45 PM an interview was conducted with the Director of Nursing (DON). During the interview review of Resident 6's pressure ulcer treatment was review. The DON reported during the interview an assessment of the condition of the pressure ulcer should include all measurements weekly as that is the standard of care. When asked for an assessment prior to requesting a treatment change on 11-08-2021, the DON reported an assessment had not been completed and should have been. The DON reported being unsure as why the treatment was requested to be discontinued. Observation on 12-15-2021 at 9:22 AM of Resident 6's pressure ulcer revealed LPN I removed a dressing covering Resident 6's pressure ulcer. LPN I hand sanitized and applied gloves. LPN I using a wash cloth with soap, cleansed the outside of the pressure ulcer and rinsed with another wash cloth. Observation of the pressure ulcer revealed a deep opening of approximately 3.5 cm's with an opening that measured an approximately 4 cm roundish area. There was whitish tissue going around the edge of the pressure ulcer opening. LPN I obtained a dressing and applied the dressing over the top of the wound. There was not any treatment completed for the pressure ulcer. On 12-15-2021 at 9:34 AM an interview was completed with LPN I. During the interview LPN I confirmed there was not a treatment order for Resident 6's pressure ulcer. LPN I confirmed weekly evaluations of Resident 6's pressure ulcer should include measurement. LPN I reported measuring the pressure ulcer on 12-14-2021 that measured 4 cm by 2.0 cm. LPN I confirmed the condition of Resident 6's pressure ulcer had declined. On 12-15-2021 at 1:50 PM an interview was conducted with the DON. During the interview the DON reported there should have been an evaluation of Resident 6's pressure ulcer and a new treatment requested. The DON confirmed there was not a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the facility Policy and Procedure for Pressure Ulcer Documentation dated 1/2021 revealed the following information: -Policy: -All pressure ulcers will be documented on at the time they are initially identified and daily until healed according the the following guidelines: -3. Provide a description of the pressure ulcer characteristics including location, size, depth, drainage and surrounding tissue. -4. Provide the progress towards healing and identification of potential complications. -Provide a description of the dressings and treatments. Guidelines for documentation at least weekly or with dressing changes: -1. Date observed. -2. The location and staging. -6. Wound bed: the color and type of tissue/character including evidence of healing or necrosis. -Note: If a pressure ulcer fails to show some evidence of progress towards healing within 2 to 4 weeks, the area and the residents over all condition should be reassessed. The re-evaluation includes determining weather to continue or modify the current interventions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assurance Performance Improvement (QAPI) failed to identify ongoing issues relevant to F580, F660, F684, F686, F690, F758, F756, F804, F814, F868, F885, F909 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeat deficiency at F880 were corrected and the correction maintained. The facility census was 25. Findings are: Record review of the facility Quality Assurance Performance Improvement (QAPI) process updated 8-10-2021 revealed the following information: -Policy: -It is the policy of this organization to develop, implement and maintain an ongoing quality assurance and performance improvement program designed to assure the provision of consistent quality resident care through an on going system to monitor and evaluate the quality of resident care and quality of life while maintaining resident choice. -Purpose: -The primary purpose of the QAPI are: -1. To provides a means whereby resident care, resident quality of life and safety can be measured. -3. To develop monitoring tools that provide an effective mechanism to assure that each resident receives the necessary care and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. -5. To develop plans of correction and evaluated corrective actions taken to obtain the desired results. On 12-16-2021 at 8:50 AM an interview was conducted with Nursing Assistant (NA) G. During the interview when asked if NA G was aware of what the QAPI committee was and what was being worked on, NA G reported not knowing what QAPI was and what was being worked on. On 12-16-2021 at 8:52 AM an interview was conducted with H. During the interview when asked if NA H was aware of what the QAPI committee was and what was being worked on, NA H reported not knowing what QAPI was and what was being worked on. On 12-16-2021 at 8:54 AM an interview was conducted with Licensed Practical Nurse (LPN) I. During the interview LPN I reported the QAPI committee had not identified any issue to work on. On 12-16-2021 at 8:57 AM an interview was conducted with NA J. During the interview NA J reported not knowing what the QAPI committee was working on. On 12-16-2021 at 8:58 AM an interview was conducted with the Maintenance Director. During the interview the Maintenance Director reported not knowing ad did not go to the QAPI committee meetings. On 12-16-2021 at 9:50 AM an interview was conducted with the Assistant Director of nursing (ADON). During the interview the ADON reported the QAPI committee really does not have a method in resolving issues.

Licensure Reference Number NAC 12-006.18 A(2) Based on observation and interview, the facility failed to ensure that a garbage dumpster was contained and secured with a lid or cover. This has the potential to affect all residents in the facility. The facility census is 25. On 12/15/21 at 3:42pm, an observation of the dumpster where kitchen garbage is disposed of revealed that the dumpster does not have a lid or cover. An interview with Dietary Staff S confirmed that the garbage dumpster does not have a lid or cover.

Licensure Reference Number 175 NAC 12-006.17D Based on record review, observation and interview; the facility failed to utilize hand hygiene when entering and exiting resident rooms after coming in contact with the residents and the resident's personal items, and failed to complete the screening process for visitors for signs and symptoms of COVID-19 by allowing a visitor with new onset of respiratory symptoms to enter the facility. Facility census was 25. Findings are: A. Observation on 12/13/21 at 3:10 PM revealed Medication aide (MA) A passing snacks and juice and MA A went in and out of 6 resident rooms, touching the residents and their personal items in rooms and leaving without hand hygiene. No alcohol based hand sanitizer (ABHS) was available on the carts or available in resident rooms. Interview on 12/13/21 at 3:11 PM with MA A confirmed no hand hygiene was completed while MA A was passing snacks and juice. Observation on 12/14/21 at 09:59 AM revealed MA B passing fresh ice water in 4 resident rooms removing water pitchers from each room and pouring fresh ice water from a pitcher into clean glasses. No hand hygiene was observed. Interview on 12/14/21 at 10:00 AM with MA B revealed hand sanitizer is to be used between patients, and that staff would go to the hand sanitizer on the wall near the bath house. MA confirmed no hand hygiene was completed. Observation on 12/14/21 at 1:45 PM revealed Employee C, delivering clean laundry to patient rooms, touching resident items in closets and returning to cart without hand hygiene. Record review of hand hygiene policy last revised 9/2020 revealed that staff involved with direct resident contact will perform proper hand hygiene. Interview on 12/16/21 at 08:48 AM with the DON (Director of Nursing) confirmed the expectation would be that staff would do hand hygiene if touching any personal items in the resident room or the resident, prior to leaving the room. B. Record review of the facility visitor screening logs revealed that one visitor on 9/26/21 answered yes to new congestion and runny nose as well as new shortness of breath/trouble breathing. The visitor was allowed to enter the facility. Review of an undated facility Policy Novel Coronavirus revealed if a visitor answers positive to any question or has a temperature of 99.5 degrees or above or presents or reports any respiratory symptoms, the visitor will be instructed to leave the facility immediately. Interview on 12/16/21 at 10:10AM with MA A and the facility Administrator confirmed that the visitor was allowed to come into facility after MA consulted with the charge nurse.

Based on record review and interview, the facility failed to notify the resident representatives of COVID-19 status in the building weekly and failed to notify resident representatives of COVID-19 by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection in the facility. The facility census was 25. Findings are: Record review of the facility resident representative weekly notification logs from 9/12/21 to 12/15/21 revealed: -9/12/21-9/18/21 missing a weekly notification. -10/24/21-10/30/21 missing a weekly notification and a following day notification of a single positive in the facility on 10/29/21. -11/21/21-11/27/21 missing a weekly notification. -11/28/21-12/4/21 missing a weekly notification. -12/5/21-12/11/21 missing a weekly notification. Record review of staff testing logs from 9/12/21 to 12/10/21 revealed: -Employee N tested positive on 10/29/21. Record review of the facility policy, Subject: Novel Coronavirus under the Communication section, revealed Residents & Family Communications will be directed by the Administrator Service staff in cooperation with the Social Service Director and Nursing Director: All residents will receive communication, by no later than 5pm the following day, if/when any case of COVID-19 is presumed or verified in the facility. All family members will receive updated communication, at least weekly after an identified case of COVID-19 is verified within the facility, this information will include a cumulative update. Record review of Centers for Medicare & Medicaid Service (CMS) memo dated 5/6/2020 with a reference number of QSO-20-29-NH revealed on page 2: Inform residents, their representative, and families of those residing in the facility by 5PM the next calendar day following the occurrence of a single confirmed infection of COVID-19. Interview on 12/16/21 at 10:06 AM with the facility Administrator confirmed that during the 5 weeks identified, there were no updates sent to families, and during 1 of those 5 weeks there were positive staff members. Interview also confirmed that one person is not assigned to this task.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility staff failed to monitor the use of antipsychotic medications for potential side effects for 2 (Resident 6 and 21) of 5 sampled residents. The facility census was 25. Findings are: A. Record review of a Physicians Orders (PO) sheet signed on 11-09-2021 revealed Resident 6 was admitted to the facility on [DATE] with the diagnoses that included Major Depressive Disorder, Anxiety Disorder and type 2 diabetes. Further review of Resident 6's PO signed on 11-09-2021 revealed orders for medications that included [MEDICATION(S)] (an antipsychotic medication) 1 milligram at bed time. Record review of Resident 6's Comprehensive Care Plan (CCP) dated 10-06-2021 revealed Resident 6 was at risk for side effects related to antipsychotic medication use. The goal identified on Resident 6's CCP was not to have injury related to medications use and side effects. The interventions listed to meet Resident 6's goal included for staff to observe for adverse side effects, document and report. Record review of Resident 6's medical record that included progress notes, CCP, Medication Administration Records and Treatment Records for November and December 2021 revealed no indications staff were monitoring for the side effects of the [MEDICATION(S)] medication. On 12-15-2021 at 3:35 PM an interview was conducted with the Director of nursing (DON) During the interview the DON confirmed the facility staff were not monitoring Resident 6 for side effects related to the use of the [MEDICATION(S)]. B. A record review of physician orders revealed that Resident 21 is on [MEDICATION(S)] 50 milligrams (mg) at HS (hour of sleep) for Major Depressive Disorder and [MEDICATION(S)] 25mg at 4:00 PM for Generalized Anxiety Disorder. A record review of Resident 21's Medication Administration Report revealed Resident 21 was not being monitored for potential side effects related to the use of [CONDITION(S)] (medication that affects a person's mental state) medications. On 12/15/2021 at 3:58 PM an interview was conducted with Registered Nurse (RN) R. During the interview, RN R confirmed Resident 21 had not been monitored for side effects related to the use of [MEDICATION(S)].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on record review and interview; the facility Pharmacist Consultant failed to identify and report to the facility lack of monitoring for side effects for the use of an antipsychotic medication for 2 (Resident 6 and 21) of 5 sampled residents. The facility census was 25. Findings are: A. Record review of a Physicians Orders (PO) sheet signed on 11-09-2021 revealed Resident 6 was admitted to the facility on [DATE] with the diagnoses that included Major Depressive Disorder, Anxiety Disorder and type 2 diabetes. Further review of Resident 6's PO signed on 11-09-2021 revealed orders for medications that included [MEDICATION(S)] (an antipsychotic medication) 1 milligram at bed time. Record review of Resident 6's Comprehensive Care Plan (CCP) dated 10-06-2021 revealed Resident 6 was at risk for side effects related to antipsychotic medication use. The goal identified on Resident 6's CCP was not to have injury related to medications use and side effects. The interventions listed to meet Resident 6's goal included for staff to observe for adverse side effects, document and report. Record review of a Pharmacist Drug Regimen review for November 2021 revealed there was not any information notifying the facility Director of Nursing (DON) monitoring for side effects related to the use of [MEDICATION(S)] was not being completed. On 12-15-2021 at 3:35 PM an interview was conducted with the DON. During the interview, the DON reported not being notified by the Pharmacist Consultant that side effects were not being monitored for the use of the [MEDICATION(S)]. On 12-16-2021 at 9:10 AM a phone interview was conducted with the facility Pharmacist Consultant. During the interview the Pharmacist Consultant reported the monitoring for side effects for the [MEDICATION(S)] was not Resident 6's individualized Drug regimen review. B. A record review of physician orders revealed that Resident 21 had orders for [MEDICATION(S)] ( antipsychotic ) 50 milligrams (mg) at HS (hour of sleep) for Major Depressive Disorder and [MEDICATION(S)] 25mg at 4:00pm for Generalized Anxiety Disorder. On 12/06/2021 09:15am a telephone interview with the facility pharmacist confirmed that [CONDITION(S)] medications were not being monitored for side effects and the pharmacist had not informed the facility of the requirement to monitor for side effects of [CONDITION(S)] medications. A record review of Resident 21's Medication Administration Report revealed Resident 21 was not being monitored for potential side effects related to the use of [CONDITION(S)] (medication that affects a person's mental state) medications. On 12/15/21 at 3:58 PM, an interview with Registered Nurse (RN) R confirmed Resident 21 had not been monitored for side effects related to the use of [MEDICATION(S)].

LICENSURE REFERENCE NUMBER: 175 12-006.4C3a(6) Based on record review and interview, the facility failed to notify the practitioner of a change in condition for 1 resident (Resident 1) of 1 sampled. The facility census was 25. Findings are: Record review of Resident 1's progress notes revealed: -12/10/21 at 10:52 AM Resident with Temperature of 100.0 at 10:52 AM with emesis x 1, no other s/s (signs and symptoms) of COVID. -12/10 at 8:54 PM Nauseated and vomiting today, fluids given for supper and 50% taken. Further review revealed no indication that the practitioner had been notified. -12/11/21 at 6:35 AM Patient has run a temperature most of the night, fluctuating a lot. At 4:30 AM it was 100.0 and (gender) was given Tylenol. Temperature after Tylenol was 99.3 and then at 5:30 AM it was 100.9. No emesis during the night. Further review revealed no indication that the practitioner had been notified. -12/13/21 at 09:31 AM Called to patient's room, noted that Foley catheter was draining milky colored (infection looking) fluids, patient not running a temp but is shaking. Appointment made with [NAME] County Clinic with facility to drive patient there. Further review revealed that practitioner was not notified of change in condition, facility staff scheduled appointment with the clinic staff. -12/13/21 at 10:20 AM Change of condition, patient now vomiting with possible aspiration, temp 98.2 but body is feeling very warm, skin is flushed, eyes open. Rescue unit called and they left the facility at 9:15 AM. -12/31/21 at 12:09 PM [NAME] County Health Services called and stated that patient would be admitted to the hospital acute for bladder infection and that patient would be receiving IV antibiotics. Record review of the Hospital History and Physical dated 12/13/21 at 10:02 AM revealed that Resident 1 had been experiencing emesis off and on over the weekend according to the facility staff. Staff also reported Resident 1 had a fever and very cloudy urine in catheter today with a history of UTI's (Urinary Tract Infections). The resident's lactic acid was slightly elevated as well as Procalcitonin [which is an indicator of [CONDITION(S)] (an infection that has spread to the blood]) and white blood cell count elevated at 13.0 (normal range is 4.0-10.0). Record review of the Hospital Progress Note dated 12/13/21 at 10:23 AM revealed that Resident 1 arrived by rescue squad and Resident 1 had been vomiting off and on since Friday. Urinalysis results for Resident 1 showed large amounts of blood, and large amounts of leuk est (white blood cells indicative of a urinary infection). Record review of the Hospital Progress Note dated 12/14/21 at 04:22 AM revealed that Resident 1 was admitted from the nursing home with urosepsis (an infection in the blood caused by a bacteria that has entered the bloodstream). Urine is dark and cloudy, resident admitted on Intravenous (IV) Antibiotics and had a temperature of 100. Policy Review of Notifications of Changes last revised 9/2020 revealed that the facility will notify the physician of any need to alter treatment due to a significant change in resident's physical, mental or psychosocial status, or a decision to transfer or discharge resident from the facility. Interview with the Director of Nursing (DON) on 12/15/21 at 10:20 AM confirmed that the facility staff called the [NAME] County Health Services on 12/13/21 to schedule an appointment but did not speak with the physician, and there was no other notification to the physician on Resident 1's change in condition on 12/10 or 12/11.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12-006.09C2 Based on record review and interview; the facility staff failed to implement discharge planning for 1 (Resident 10) of 1 sampled resident. The facility census was 25. Findings are: Record review of Resident 10's Minimum Data Set ( MDS: a federally mandated assessment tool used for care planning) dated 10-13-2021 revealed the facility staff assessed the following about Resident 10: -Brief Interview of Mental status (BIMS) was a 15. According to the MDS manuel, a score of 13 to 15 indicate a person is cognitively intact. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. - Active discharge planning section was identified with a no. Record review of Resident 10's Comprehensive Care Plan (CCP) dated 10-20-2021 revealed Resident 10's discharge plan was to move closer to family. On 12-13-2021 at 3:26 PM an interview was conducted with Resident 10. During the interview, Resident 10 reported wanting to be closer to family in order for them to visit more often. On 12-14-2021 at 2:55 PM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON reported Resident 10's discharge is unknown. The ADON further reported not being aware Resident 10 wanted to discharge closer to family.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(2) Based on record review and interview; the facility staff failed to evaluate a toileting program for 1 (Resident 10) of 1 sample resident. The facility census was 25. Findings are: Record review of Resident 10's Minimum Data Set ( MDS: a federally mandated assessment tool used for care planning) dated 10-13-2021 revealed the facility staff assessed the following about Resident 10: -Brief Interview of Mental status (BIMS) was a 15. According to the MDS manuel, a score of 13 to 15 indicate a person is cognitively intact. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Frequently incontinent of urine and did not have a toileting program. Record review of Resident 10's Comprehensive Care plan (CCP) dated 10-04-2021 revealed Resident 10 was incontinent of bladder. Resident 10's goal was to be clean, dry and odor free. Interventions listed on Resident 10's CCP included using pull ups to control wetness and odor, using a sit/stand lift when using the bathroom and for staff to ask Resident 10 if needs to use the bathroom. Review of Resident 10's medical record that included progress notes, MDS information, and CCP revealed an evaluation for a toileting program had not been completed. On 12-14-2021 at 1:45 PM an interview was conducted with Licensed Practical Nurse (LPN) I. During the interview LPN I reported resident 10 was not on a toileting program and staff would check and change Resident 10. On 12-15-2021 at 8:40 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported the facility did not complete an evaluation of a toileting program for Resident 10.