Every finding on record at Plainview Manor

Licensure Reference Number 175 NAC 12-006.12(D)(vi)Based on observation, record review, and interview; the facility failed to label open insulin contains (vials/pens) with dates indicating when they were opened for Resident's 2, 13, and 14, to ensure the medication was not used beyond recommended use by dates. The sample size was 3 and the facility census was 34. Findings are: Review of the facility policy Storage of Medications with a revision date of November 2020 revealed the following;-The facility stored all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals used in the facility were stored in locked compartments, under proper temperatures, light, and humidity controls.-Discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed. Review of the facility policy Insulin Administration with a revision date of [DATE] revealed no evidence the facility policy addressed dating insulin once opened, based on practice standards to avoid the potential of using insulin beyond it's effectiveness.During a tour on 8/12/25 starting at 9:32 AM of the facility medication carts 4 out of 5 opened insulins vials/pens were not dated when opened. The following undated insulins were identified;Resident 2's;-Lantus 30 units every night, and -Humalog 5 units 3 times daily and per sliding scale (dose based on blood glucose level results), -Resident 13's Basaglar 22 units in the morning and 12 units in the evening, and-Resident 14's Lantus 45 units every night. During an interview on 8/12/25 at 9:35 AM Registered Nurse-L confirmed the above insulin vials/pens were not dated when opened. In addition, the facility expected insulin pens to be dated when opened to avoid using them past the recommended effective dates. During an Interview on 8/12/25 at 11:29 AM the Director of Nursing confirmed all insulin once opened, required a date to alert staff of how long opened insulin could be safely used once it was opened.

S483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in S483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.This requirement is not met as evidenced by:Licensure Reference Number 175 NAC 12-006.12Based on record review and interview; the facility failed to have a stop date for as needed (PRN) antianxiety medications for Resident's 12, 17 and 34. The facility census was 34.Findings are:A. Review of the facility policy Psychotropic Medication Use (medications that affect the mind, emotions and behavior) with a revised date of 4/14/22 revealed;-Psychotropic medications may be considered for residents only after medical, physical, functional, psychological, social and environmental causes of behavioral symptoms had been identified and addressed. Psychotropic medications would be prescribed at the lowest possible dosage for the shortest of time and are subject to gradual reduction. -Residents would not receive PRN orders for psychotropic medications beyond 14 days unless the medication was needed to treat a specific condition that was documented in the clinical record. The need to continue PRN psychotropic medications for over 14 days would need to be evaluated by the health care provider for appropriateness of medication and specific duration. Specific reasons supporting the need for the medication would be documented in the clinical record. B. Review of Resident 12's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 7/22/25 revealed the resident had delusions and mild cognition impairment. The resident had a diagnosis of Non-Alzheimer's Dementia, Anxiety and Depression and received an antianxiety medications. Review of Resident 12's Care Plan with a revision date of 4/24/25 revealed the resident had a diagnosis of Anxiety Disorder and received an antianxiety medication as needed.Review of Resident 12 August 2025 Medication Administration Record (MAR) revealed an order for:- Lorazepam (antianxiety medication) Oral Tablet 0.5 Milligrams (mg) 1 tablet by mouth every 4 hours as needed for anxiety. The resident received a dose on 8/2/25 and 8/5/25. Review of Resident 12's medical record revealed that there was no stop date for the PRN Lorazepam medication. C. Review of Resident 17's MDS dated [DATE] revealed the resident had hallucinations, delusions, behavior symptoms such as hitting, public sexual acts, screaming out and resident had severe cognition impairment. The resident had a diagnosis of Non-Alzheimer Dementia and Anxiety. Review of Resident 17's Care Plan dated 6/20/25 revealed the resident had severe cognitive impairment, was confused, forgetful and displayed sexually inappropriate language and behaviors. The resident had a diagnosis of Non-Alzheimer Dementia and Anxiety and received antianxiety medications as needed.Review of Resident 17 August 2025 MAR revealed an order for:- Lorazepam (antianxiety medication) Oral Tablet 0.5mg 1 tablet by mouth every 12 hours as needed for agitation. The resident received a dose on 8/1/25, 8/2/25, 8/3/25 and 8/5/25. Review of Resident 17's medical record revealed that there was no stop date for the PRN Lorazepam medication. D. Review of Resident 34's MDS dated [DATE] revealed the resident had delusions, verbal behaviors, rejection of cares, wandering and mild cognition impairment. The resident had a diagnosis of Non-traumatic Brain Dysfunction, Dementia, Anxiety and Depression and received anti-anxiety medications . Review of Resident 34's Care Plan with a revision date of 4/24/25 revealed that the resident was restless, had delusions and was confused. The resident had diagnosis of Anxiety Disorder, Depression and Dementia and received an antianxiety medication.Review of Resident 34 August 2025 MAR revealed an order for:- Alprazolam (antianxiety medication) 0.25 MG 1 tablet by mouth as needed for anxiousness related to Anxiety Disorder. Give daily PRN anxiousness. The resident received the last dose on 7/26/25. Review of Resident 34's medical record revealed that there was no stop date for the PRN Alprazolam medication. E. On 8/7/25 at 2:15 PM an interview with the Director of Nursing (DON) confirmed that the PRN psychotropic medications for Resident's 12, 17 and 34 did not have a stop date and should have per facility policy.

This requirement was not met as evidenced by: Licensure Reference Number 175 NAC 12-006.12Based on record review and interview; the facility failed to obtain signed informed consents for the use of psychotropic (medication medications for Residents 1,2,12,17, and 34. The sample size was 5 and the facility census was 34. Findings are: A. Review of the facility policy Psychotropic Medication Use dated 4/14/22 revealed the following; -Psychotropic medications were considered for use only after medical, physical, functional, psychological, psychiatric, social, and environmental causes of behavioral symptoms were identified and addressed. -Residents only received psychotropic medications when necessary to treat specific conditions for which they were indicated. -Residents who were admitted receiving psychotropic medications were evaluated for appropriateness and indication for use. B. Review of the facility Psychotropic Medication Review and Gradual Dose Reduction Policy dated 1/18/19 revealed the following: -Residents and/or their families were notified quarterly of the resident's medication regimen. -Change requests made by residents and/or family were addressed through psychiatric services and/or provider review. C. Review of Resident 1's Care Plan with a revision date of 8/2/25 revealed the resident had forgetfulness, confusion, impaired decision making, and took antipsychotic, antidepressant, and antianxiety medication. Review of Resident 1's Medication Orders dated 8/12/25 revealed the following psychotropic medications; -Risperidone (antipsychotic medication) Oral Tablet 0.5 Milligrams (mg) give one tablet by mouth two times a day related to Bipolar Disorder. -Lorazepam (antianxiety medication) Oral Tablet 0.5mg Give 1 tablet by mouth in the morning for Anxiety -Sertraline (antidepressant medication) HCl Oral Tablet 25mg Give 1 tablet by mouth one time a day related to Bipolar Disorder. Review of Resident 1's Medical Record revealed no evidence of signed informed consent for the use of the psychotropic medications Risperidone, Lorazepam, or Sertraline. D. Review of Resident 2's Care Plan with a revision dated 6/27/25 revealed the resident had severe cognitive impairment, a diagnosis of Alzheimer's Dementia, behavior concerns including delusions, hallucinations and inappropriate behavior. The resident took antipsychotic medication. Review of Resident 2's Medication Orders dated 8/12/25 revealed the psychotropic medication; Quetiapine Fumarate Oral Tablet 25mg Give 1 tablet by mouth at bedtime related to Alzheimer's disease with moderate psychotic disturbance. Review of Resident 2's Medical Record revealed no evidence of signed informed consent for the use of the psychotropic medication Quetiapine Fumarate. E. During an interview on 8/12/25 at 7:31 AM Registered Nurse (RN) -L revealed no awareness of any signed forms used for consent to give psychotropic medications, RN-L reported that residents/responsible parties were updated verbally or by phone for all medication changes. F. During an interview on 8/12/25 at 8:12 AM the Director of Nursing (DON) confirmed the facility had no evidence the facility had obtained resident or responsible party informed consent for the use of any or all psychotropic medications as required. G. Review of Resident 12's Care Plan with a revision date of 4/24/25 revealed the resident had a diagnosis of Non- Alzheimers Dementia, Major Depression and Anxiety Disorder, had delusions, mild cognition deficit, confused and disoriented. The resident received an antidepressant and antianxiety medications. Review of Resident 12's August 2025 Medication Administration Record (MAR) revealed the following psychotropic medications; -Escitalopram Oxalate (antidepressant medication) Oral Tablet 20mg give 1 tablet by mouth 1 time a day related to Major Depressive Disorder. -Buspirone HCl (antianxiety medication) Oral Tablet 5mg give 1 tablet by mouth 3 times a day for anxiety. -Lorazepam (antianxiety medication) Oral Tablet 0.5mg 1 tablet by mouth every 4 hours as needed for anxiety. Review of Resident 12's Medical Record revealed no evidence of signed informed consent for the use of psychotropic medication. H. Review of Resident 17's Care Plan dated 6/20/25 revealed the resident had severe cognitive impairment, was confused, forgetful and displayed sexually inappropriate language and behaviors. The resident had a diagnosis of Non-Alzheimer Dementia and Anxiety and received an antidepressant, antianxiety and antipsychotic medications. Review of Resident 17's August 2025 MAR revealed the following psychotropic medications; -Trazadone (antidepressant medication) HCl oral tablet 50 mg 1 tablet by mouth at bedtime for insomnia. -Lorazepam (antianxiety medication) oral tablet 0.5 mg 1 tablet by mouth every 12 hours as needed for agitation. -Seroquel (antipsychotic medication) oral tablet 50 mg give by mouth 2 times daily related to Dementia. Review of Resident 17's Medical Record revealed no evidence of signed informed consent for the use of psychotropic medication. I. Review of Resident 34's Care Plan with a revision date of 4/24/25 revealed the resident was restless, had delusions and was confused. The resident had a diagnosis of Anxiety Disorder, Depression, Dementia and received antidepressant and antianxiety medications. Review of Resident 34's August 2025 MAR revealed the following psychotropic medications; -Sertraline (antidepressant) HCl oral tablet 50 mg 1 tablet by mouth 1 time a day related to depression. -Alprazolam (antianxiety) oral tablet 0.25 mg 1 tablet by mouth 3 times a day for muscle spasms related to Anxiety Disorder. - Alprazolam (antianxiety) oral tablet 0.25 mg 1 tablet by mouth as needed for anxiousness related to Anxiety Disorder. Review of Resident 12's Medical Record revealed no evidence of signed informed consent for the use of psychotropic medication. J. An interview on 8/12/25 at 8:00 AM RN-L revealed of being unaware of needing a signed consent for psychotropic medications that stated the reason for the medication and side effects. RN confirmed the facility had notified the resident and families of medication changes by phone or verbally. On 8/12/25 at 8:12 AM an interview with the DON confirmed that there was no evidence the facility had obtained resident or responsible party informed consent for the use of psychotropic medications.

Licensure Reference Number 175 NAC 12-006.02 (H)Based on record review and interview; the facility failed to report a fall with major injury within the required time frame for 1 (Resident 17) of 3 sampled residents. The facility census was 34.Findings are:A. Review of the facility policy Resident Abuse and Neglect with a revision date of 1/10/25 revealed:-All employees of the facility are responsible to protect and prevent resident abuse from occurring. -Abuse means any knowing or intentional act on the part of a caregiver which results in physical injury, psychosocial harm, unreasonable confinement, cruel punishment, sexual abuse of a vulnerable adult. -Physical abuse means damage to bodily tissue including but not limited to, fractures, bruises, lacerations and internal injuries.-Any injury resulting in possible fracture, laceration, stitches must be notified to the Administrator within 2 hours and notification to Adult Protection Services (APS). B. Review of Resident 17's medical record revealed; -On 8/11/25 at 7:20 PM Resident 17 had a fall in the dining room and received a laceration to the top of the head. Resident was transferred to the hospital per emergency services transport. -On 8/11/25 at 7:35 PM The facility Administrator was notified of Resident 17's fall with major injury and that resident was transferred to the hospital. -On 8/11/25 at 9:42 PM The facility Administrator was notified that Resident 17 would be admitted to the hospital and that resident had an acute on chronic brain bleed.-On 8/12/25 at 8:42 AM the facility Administrator notified APS of Resident 17's fall with major injury.C. An interview on 8/12/25 at 10:30 AM with the facility Administrator confirmed that APS was not notified of Resident 17's fall with major injury within 2 hours of being notified of injury.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)Based on observation, record review, and interview; the facility failed to implement new measures to prevent pressure ulcer development for Resident 7 following a significant condition change. The sample size was 3 and the facility census was 34. Findings are: Review of the facility Pressure Ulcer Policy and Procedure date 1/8/2016 revealed the following: -The purpose of the procedure was to provide guidelines for the structured assessment and identification of residents at risk for developing new pressure injuries or worsening of existing pressure injuries. -Licensed nursing staff examined an individual's skin condition upon admission to the facility. This included the initial admission and readmission following hospitalizations.-The purpose of pressure injury assessment was to identify all risk factors and to determine which factors could be modified.-Once the assessment was completed the facility completed a resident centered care plan to address and modify risk for pressure injury. -Development of the care plan was based on risk factors and the resident's overall condition, and interventions were modified as the resident's condition changed, or if the interventions were deemed inadequate. Review of Resident 7's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/27/25 revealed the resident was dependent on staff assistance for bed mobility, transfers, and hygiene. In addition, the resident had functional limitations to both lower extremities. The resident had a surgical wound but no pressure ulcers. Review of Resident 7's Progress Notes revealed the following;-on 6/24/25 at 12:26 PM the resident returned to the facility from the hospital. -on 7/7/25 at 5:17 PM the resident had a fluid filled blister on the heel, approximately 4 centimeters (cm) x 4cm, secondary to left lower extremity weakness related to a left hip fracture. The facility requested an order to treat the area with betadine (liquid anti-infective agent) swabs twice daily and to have the resident wear a protective boot to keep the heel free from any pressure continuously until healed.Review of Resident 7's Care Plan with a revision date of 7/1/25 revealed the following;-The resident was at risk of falling and sustained a hip fracture from falling at the facility on 6/18/25 and underwent surgical repair on 6/19/25.-Physical and Occupation Therapy evaluation and treatment were ordered on 6/27/25 following readmission from the hip fracture. -Self-care deficit approaches were updated on 7/1/25 including increased assistance needs with hygiene, dressing, toileting, bed mobility, and ambulation. -On 4/30/24 the resident was noted to be at risk for skin impairment and staff were to monitor document, and treat any skin impairment and a pressure relief mattress was on the resident's bed , however no change in the approaches/interventions related to the skin integrity risk were added to the care plan following the resident's hip fracture until 7/8/25 (after the blister area/pressure sore developed on the residents heel) for the use of a protective heel boot. During an observation of wound care for Resident 7 on 8/7/25 at 9:10 AM Licensed Practical Nurse (LPN)-B entered the resident's room and informed the resident of the dressing change to the left foot. LPN-B then removed a heel protection boot and a foam dressing from the resident's heel exposing a golf ball sized area of blackened skin on the resident's left heel. The area did not appear to be open or draining. LPN-B then cleaned the wound with a wound cleanser and painted the area with liquid betadine (anti-infective agent) and replaced the heel boot. LPN-B confirmed the area being treated was a facility acquired pressure ulcer. During an interview on 8/11/25 at 11:15 AM the Director of Nursing confirmed the facility implemented professional therapy and increased assistance with cares (dressing, hygiene, toileting, bed mobility, and ambulation) however the facility did not address items such as keeping the resident's heels off the bed following a hip fracture. Further interview confirmed the resident did develop a pressure sore to the left heel first reported on 7/7/25. During an interview on 8/11/25 at 3:22 PM the MDS/Care Plan Registered Nurse (RN-K) confirmed Resident 7's Care Plan was not updated to include support surface changes or ways to protect the resident's heels due to loss of mobility until after a pressure area developed on the resident's heel.

Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on record review and interview; the facility failed to ensure Resident 7's Care Plan was reviewed and revised to ensure staff implemented Enhanced Barrier Precautions (EBP-infection control strategy using gowns and gloves during high contact resident care to reduce the spread of Multi-Drug Resistant Organisms (MRDO's-germ/s resistant to many antibiotics) during the provision of wound care for Resident 7. The sample size was 5 and the facility census was 34. Findings are:Review of the facility policy Care Planning with a revision date of 2013 revealed the following: -the facility interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. -The care plan is based on resident comprehensive assessment by the interdisciplinary team-The comprehensive, person-centered care plan included measurable objectives and timetable to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident -Described services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. -Incorporated identified problem areas and incorporated risk factors identified with associated problems. -Reflected currently recognized standards of practice for problem areas and conditions. -Areas of concern identified during resident assessment were evaluated before interventions were added to the care plan. -Assessment of residents were ongoing and care plans were revised as information about residents and the resident's condition changed. Review of the facility policy Enhanced Barrier Precautions with a revision date of August 2022 revealed the following: -Enhanced Barrier Precautions were utilized to prevent the spread of multi-drug-resistant organisms to residents. -EBP employed targeted gown and glove use during high contact resident care activities when contact precautions did not otherwise apply. -Gloves and gowns were applied prior to performing high contact resident care activity. -Examples of high contact care included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assistance with toileting, device care (central lines, catheters, feeding tubes, tracheostomy/ventilators, and wound care. -EBP were indicated for resident/s infected or colonized with resistant organisms, and for residents with wounds, and /or indwelling medical devices regardless of their drug-resistant status. -EBP remained in place for the duration of the resident's stay or until wound resolution or discontinuation of the indwelling medical device. During an observation on 8/6/25 at 9:30 AM there was a sign on the room door of Resident 7 indicating the resident was on EBP. During an observation of wound care for Resident 7 on 8/7/25 at 9:10 AM Licensed Practical Nurse-(LPN)-B entered Resident 7's room, while the resident was lying in bed and without putting on a gown or gloves, proceeded to remove the heel boot from the resident right foot and then put on a pair of disposable gloves. LPN-B then removed and disposed of a foam dressing from the resident's heel exposing a golf ball sized area of blackened skin on the resident heel. The area did not appear to be open or draining. LPN-B then cleaned the wound with a wound cleanser, changed gloves and painted the area with a liquid betadine (anti-infective agent) swab. LPN-B then replaced the heel boot on the resident, removed gloves and sanitized hands with Alcohol Based Hand Sanitizer (ABHR). LPN-B confirmed the area being treated was a facility acquired pressure ulcer. During an interview on 8/7/25 at 9:20 AM LPN-B revealed being unaware Resident 7 was on EBP and acknowledged that all residents on EBP require the use of gown and gloves during the provision of wound care. She confirmed she did not follow proper procedure caring for Resident 7's heel wound.During an interview on 8/7/25 at 11:36 AM Nurse Aide (NA)-E revealed being aware Resident 7 was on EBP and a gown and gloves were required during the provision of care, such as toileting, dressing, and assisting with transfers. During an interview on 8/11/25 at 3:22 PM the MDS/Care Plan Registered Nurse (RN-K) confirmed Resident 7's Care Plan was not updated to reflect the use of EBP during high contact care activities such as wound care.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review; the facility failed to complete neurological assessments (assessment of motor and sensory skills, hearing, speech, vision, coordination, and balance to determine a potential injury or change in status) after unwitnessed falls for 1 (Resident 24) of 4 sampled residents. The facility identified a census of 34. Findings are: A. Review of the Neurological Assessment Policy with a revision date of 10/2010 revealed the purpose of the policy was to provide guidelines for a neurological assessment. Assessments were to be completed: 1) upon physician order; 2) when following an unwitnessed fall; 3) after a fall with a suspected head injury; or 4) when indicated by a resident's condition. Steps in the procedure:-perform neurologic checks with the frequency as ordered or per falls protocol.-determine the resident's orientation to time, place, and person.-observe the resident's speech pattern and clarity of speech.-check the pupil's reaction. -determine motor ability.-determine sensation in extremities.-have the resident smile to determine if there is any facial drooping. Documentation:-the date and time the procedure was performed. -the name and title of the staff performing the procedure.-all assessment data obtained.-how the resident tolerated the procedure.-if the resident refuses, the reason for the refusal and interventions taken. B. Review of Resident 24's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 7/22/25 revealed the resident was admitted on [DATE] with diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression. The following was assessed regarding the resident:-cognition was moderately impaired.-frequently incontinent of urine.-one fall with injury (except major) since the previous assessment.-used a wander/elopement alarm daily. Review of an Occurrence Report dated 9/17/24 at 7:25 PM revealed Resident 24 was found on the floor. The resident reported trying to go after a spider and lost balance. In addition, the resident reported hitting their head on the floor and complained of pain to the resident's head. Review of a Neurological Check Record revealed neurological checks were to be completed every hour for 2 hours, every 4 hours x2, then every 8 hours x1. Review of the record completed after Resident 24's fall on 9/17/24 revealed documentation assessments were completed on 9/17/24 at 9:00 PM and at 11:00 PM. An assessment was completed on 9/18/24 at 1:00 AM but at 5:00 AM, the staff failed to assess and/or document the residents skin condition, hand grasps, pupil reaction, level of orientation, speech, motor response and level of consciousness. There was no indication the resident had refused the assessment. Review of an Occurrence Report dated 4/7/25 at 6:00 AM revealed the resident had rolled out of bed and was on the floor. The report identified the resident was only orientated to person (know who you are, your name, age, and other personal details) and to time (a sense of what day, month, or year it is, and even approximate time like morning, afternoon, or night) and the fall was unwitnessed. There was no evidence neurological checks were completed to assess the resident for potential injury. Review of an Occurrence Report dated 4/15/25 at 11:32 AM revealed the resident was found sitting on the floor. The fall was unwitnessed. The report indicated the resident was only orientated to person. Further review of the report revealed no evidence neurological assessments were completed after the resident's unwitnessed fall. During an interview on 8/11/25 at 9:37 AM, Registered Nurse (RN)-I confirmed if a resident had an unwitnessed fall and was not orientated to person, place, time and situation, the staff should initiate and complete neurological assessments to evaluate for a potential head injury. An interview on 8/11/25 at 10:35 AM with the Director of Nursing (DON) verified neurological assessments were not completed or were not thoroughly completed after the resident's falls on 9/17/24 at 7:25 PM, 4/7/25 at 0600 and 4/15/25 at 11:32 AM.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i)Based on record review and interview; the facility failed to develop and/or revise interventions for the prevention of ongoing falls for 1 (Residents 24) of 4 sampled residents. The facility census was 34. Findings are:A. Review of the facility Falls and Fall Risk Management policy with a revision date of 2/16/21 revealed that based on previous evaluations and current data the staff were to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications of falling. Fall risk factors included; environmental factors, conditions which may contribute to falls, and medical factors. Staff with the input of the fall risk management team, safety committee and the provider were to implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff were to implement additional interventions or different interventions or indicate why the current approach remained relevant. Monitoring Subsequent Falls and Fall Risk: -staff were to monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. -if the resident continued to fall, the staff/fall risk management team were to re-evaluate the situation and whether it was appropriate to continue or change interventions. As needed, the attending physician would help the staff reconsider potential causes that may not previously have been identified. B. Review of Resident 24's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 7/22/25 revealed the resident was admitted [DATE] with diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression. The following was assessed regarding the resident:-cognition was moderately impaired.-frequently incontinent of urine.-one fall with injury (except major) since the previous assessment. -used a wander/elopement alarm daily. Review of an Occurrence Report dated 9/17/24 at 7:25 AM revealed the resident had an unwitnessed fall. The resident reported going after a spider and lost balance. The resident was assessed as orientated to person (know who you are, your name, age, and other personal details), to time (a sense of what day, month, or year it is, and even approximate time like morning, afternoon, or night) and to situation (what is happening around them). In addition, the resident was assessed as having impaired memory and balance. An intervention was identified to provide education to the resident to call the staff for assistance when needed and for a Physical Therapy (PT) evaluation. Review of a Progress Note by the PT dated 10/17/24 (1 month after the resident's fall) revealed no new recommendations were made related to fall prevention. Review of an Occurrence Report dated 12/31/24 at 12:00 PM revealed the resident was found on the floor of the bathroom. The resident's blood pressure at the time of the fall was 67/39 (normal blood pressure for an adult is 120/60) and the resident was difficult to arouse. The resident's medications were reviewed, and a new order was received to discontinue a blood pressure medication. Review of an Occurrence Report dated 4/7/25 at 6:00 AM revealed the resident had rolled out of bed and onto the floor. A new intervention was developed to place an assist bar (a safety device which assists residents with repositioning and getting into/and out of bed) on the resident's bed. Review of an Occurrence Report dated 4/15/25 at 11:32 AM revealed the staff heard the resident calling out and found the resident on the floor next to the bed. The resident indicated trying to find something under the bed. The report identified the resident had been assessed as orientated to person only. An intervention for education to the resident was listed. No further interventions were identified. During an interview on 8/7/25 at 8:45 AM, Nursing Assistant (NA)-A reported the resident had a history of falls and remained a fall risk. The resident did walk independently with the walker and the resident roomed with the spouse. The resident was not always compliant and frequently did not remember to call for staff assistance if the resident was dizzy or needed assistance. An interview on 8/11/25 at 9:37 AM with Registered Nurse (RN)-I indicated if a resident was not orientated x4 or was identified on the Occurrence Report as having impaired memory then listing an intervention for re-education of the resident was not an effective intervention to prevent further falls. Resident 24 had a history of exit seeking and of an elopement and did not always make good decisions. Interview on 8/11/2025 at 10:35 AM with the Director of Nursing (DON) confirmed the following:-9/17/24 at 7:25 PM the resident had a fall in the resident's room when trying to get a spider. The resident was educated to call staff if another bug was found and then staff would address. The resident was evaluated by PT on 10/15/24 as part of a quarterly assessment and no new recommendations were made. -4/15/25 at 11:32 AM the resident had a fall in the resident's room as the resident was looking for something underneath of the bed. The only intervention was to educate the resident to seek staff assistance. -Resident 24's cognition was moderately impaired, and the resident did not always make good choices. Providing the resident education was not an effective intervention to prevent further falls for the resident.

This REQUIREMENT is not met as evidenced by Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to long term use of an antibiotic medication for Resident 23. The antibiotic did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 7 and the facility census was 34. Findings are: A. Review of the facility Antibiotic Stewardship Program with a revision date of 1/16/20 revealed the following:-the purpose of the program was to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. -the overall goal was to prevent undesirable outcomes related to misuse by optimizing the selection of drug, dose, route, and duration of therapy. -the leadership team was to regularly review the appropriateness of antibiotic courses and make recommendations for adjustment where necessary, establish new or revised protocols for appropriate antibiotic prescribing, monitor antibiotic use, and provide education on responsible use of antibiotics to residents, families, and healthcare workers. -all nurses were to be educated regarding proper assessment for infection prior to calling a physician. -the facility was to ensure the pharmacy reviewed all antibiotic usage for appropriateness. -the facility would monitor for any adverse reactions/outcomes related to use of antibiotics. B. Review of Resident 23's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/23/25 revealed the resident was admitted [DATE] with diagnosis of obstructive uropathy (condition affecting the urinary tract where urine flow is blocked) and diabetes. Review of Resident 23's admission Order Summary Report dated 7/14/24 revealed an order for Macrobid (antibiotic used to treat urinary tract infections)100 milligrams (mg) one capsule daily. Further review of the physician orders revealed no stop date was indicated for the Macrobid. Review of Nursing Progress Notes revealed the following:11/19/24 at 1:35 PM the staff obtained a urine specimen from the resident's suprapubic catheter. 11/22/24 at 5:30 PM the resident was started on Cipro (antibiotic used to treat bacterial infections) 500 mg twice a day for 10 days to treat a urinary tract infection. Review of Resident 23's current Care Plan with a revision date of 2/11/25 revealed the resident had a suprapubic catheter (flexible tube inserted into the abdomen and directly into the bladder to remove urine) due to diagnosis of prostate catheter and obstructive uropathy. The care plan also identified the resident was taking Macrobid as a prophylactic (medication used to prevent disease). Review of Health Status Progress Notes dated 1/14/25 at 3:22 PM, 2/14/25 at 4:23 PM, 3/25/25 at 4:41 PM and 6/27/25 at 9:05 AM revealed the resident's Primary Care Provider (PCP) reviewed the resident's documentation in the medical record and medication use. Further review revealed no evidence the PCP addressed the continued use of the Macrobid 100 mg daily given as a prophylactic for potential urinary tract infections. Review of a Urology Visit Note dated 5/6/25 revealed the resident was seen by the urologist but the urologist failed to assess the continued use of the Macrobid. Review of the resident's Order Recap Report dated 8/12/25 revealed Resident 23 continued to receive the Macrobid 100 mg given once daily. Interview with the Infection Preventionist on 8/11/2025 at 12:02 PM verified the following regarding Resident 23:-had an order for Macrobid 100 mg daily for prevention of UTI which was ordered with the resident's admission on [DATE].-was treated for a urinary tract infection on 11/22/24 despite the ongoing use of the Macrobid as a prophylactic. -no evidence the resident's urologist and/or PCP had addressed the need for a stop date or an indication for continued use of the antibiotic.-there was no evidence that the facility had provided education to the providers regarding use of the Macrobid. -the resident continued to receive the Macrobid 100 mg once daily without a stop date or documentation related to clinical use based on symptoms or laboratory results.

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review, and interview; the facility failed to implement Enhanced Barrier Precautions (EBP-infection control strategy using gowns and gloves during high contact resident care to reduce the spread of Multi-Drug-Resistant Organisms (MRDO's-germ/s resistant to many antibiotics) during the provision of wound care for Resident 7. The sample size was 5 and the facility census was 34.Findings are: Review of the facility policy Enhanced Barrier Precautions with a revision date of August 2022 revealed the following: -Enhanced Barrier Precautions were utilized to prevent the spread of multi-drug-resistant organisms to residents. -EBP employed targeted gown and glove use during high contact resident care activities when contact precautions did not otherwise apply. -Gloves and gowns were applied prior to performing high contact resident care activity. -Examples of high contact care included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assistance with toileting, device care (central lines, catheters, feeding tubes, tracheostomy/ventilators, and wound care. -EBP were indicated for residents infected or colonized with resistant organisms, and for residents with wounds, and/or indwelling medical devices regardless of their drug-resistant status. -EBP remained in place for the duration of the resident's stay or until wound resolution or discontinuation of the indwelling medical device. On 8/6/25 at 9:30 AM a sign on the door of Resident 7's indicated the resident was on Enhanced Barrier precautions. During an observation of the provision of wound care for Resident 7 on 8/7/2025 at 9:10 AM Licensed Practical Nurse (LPN)-B entered the resident room, instructed the resident that the LPN-B was going to change the foot dressing. Without putting on a gown or gloves, LPN-B proceeded to remove the resident's left heel boot and then put on a pair of disposable gloves. LPN- B then removed and disposed of a foam dressing from the resident's left heel, exposing a golf ball sized area of blackened skin on the resident heel. The was not open or draining. LPN-B then cleaned the wound with a wound cleanser, changed gloves and painted the area with liquid betadine (anti-infective agent). LPN-B [NAME] then placed the heel boot back on the resident, removed the gloves and sanitized hands with Alcohol Based Hand Sanitizer (ABHR). LPN-B completed the entire wound care task while not wearing a gown. In addition, LPN-B confirmed the area being treated was a facility acquired pressure ulcer.During an interview on 8/7/25 at 9:20 AM LPN-B reported being unaware Resident 7 was on EBP and acknowledged that all residents on EBP require the use of a gown and gloves during the provision of wound care. She confirmed she did not follow proper procedure caring for Resident 7's heel wound.During an interview on 8/11/25 at 3:22 PM the Care plan Registered Nurse (RN-K) confirmed Resident 7's Care Plan was not updated to reflect the use of EBP during high contact care.During an interview on 8/11/25 at 3:30 PM the Director of Nursing confirmed that EBP including the use of gowns and gloves was required during wound care for Resident 7.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to have a diagnosis in place to support the use of an antipsychotic (medication that affects behavior, mood, thoughts, perception, and is used to manage psychotic disorders) medication for Resident 25. The sample size was 5 and the facility census was 34. Findings are: Review of the undated facility policy Restraints-Physical or Chemical revealed the following: - Residents had the right to be free from any chemical of physical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. -An example of a chemical restraints included but was not limited to, psychoactive (mind or consciousness altering) medications or any other medication class ordered for the purpose of discipline or convenience and not required to treat medical symptoms. Review of the undated facility policy Psychotropic Medication Review and Gradual Dose Reduction revealed the following: -All antipsychotic medications were reviewed upon admission and quarterly to reduce unnecessary drugs and adverse drug reactions. Review of Resident 25's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/10/24 revealed the following: -The resident had diagnoses of dementia -The resident had taken Antipsychotic medication daily, Review of Resident 25's Care Plan with a revision date of 6/10/24 revealed the following: -The resident had a diagnosis of dementia without behavioral, psychotic, or mood disturbance. -The resident had severe cognitive impairment and displayed inattention and disorganized thinking. -The resident was taking antipsychotic medication, and staff were to monitor for adverse reactions. Review of Resident 25's Medication Administration Record dated August 2024 revealed the resident was taking the antipsychotic medication Quetiapine Fumurate 25 milligrams daily at bedtime. During an interview on 8/7/24 at 3:35 PM the Director of Nursing confirmed the facility did not have a diagnosis in place for the use of the antipsychotic medication for Resident 25.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an incident related to elopement for Resident 15. The sample size was 2 and the facility census was 34. Findings are: Review of the facility policy Elopement Emergency, undated revealed the following: -once a resident leaves facility grounds it was considered an elopement, -upon return to the facility, the resident would be assessed for injuries, -the resident's provider would be notified, -the charge nurse would document all events that transpired prior to the elopement through the residents return assessment including how the elopement occurred, if the alarm sounded, and the time the Director of Nursing (DON), Administrator, and Provider were notified, -Adult Protective Services (APS) would be notified within 24 hours (unless injury and medical treatment needed must be within 2 hours), -the Administrator, DON, and Social Service Director (SSD) would complete an investigation within 5 working days, -if a resident was not wearing a wander guard one would be placed, -residents that were at risk of elopement or had a wander guard device would be left unattended outside of the facility, and -nursing would monitor and document the resident for 48 hours after the elopement. Review of Resident 15's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 7/25/23 revealed the following: -the resident was admitted on [DATE], -had severe cognitive impairment, -had diagnoses of high blood pressure, arthritis, and dementia, -behaviors included hallucinations, delusions, and daily wandering, -required moderate assistance with toileting and dressing and supervision with transfers and ambulation, and -a wander guard alarm was not in use. Review of the facility form Wandering Risk Scale dated 7/29/23 revealed the resident was found to be at high risk for wandering. Review of the facility form Morse Fall Scale dated 7/29/23 revealed the resident was found to be at high risk for falling. Review of the resident's Progress Notes an entry dated 8/15/23 at 3:58 PM revealed the resident was found outside of the building by themself, the resident went back inside easily with staff assistance, and a wander guard was placed. Further review revealed no documentation that the DON, Administrator, Provider or that APS had been notified. Review of the resident's Care Plan last revised on 10/24/23 revealed on 8/18/23 the resident wandered outside by themself, and a wander guard was placed on the resident's wrist was handwritten in. Interview on 8/7/24 at 3:30 PM with the Administrator confirmed the elopement was not reported to the State Agency.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].09 Based on record review and interview; the facility failed to ensure Transportation Personal maintained current Cardiopulmonary Resuscitation (CPR-emergency procedures performed if a person stops breathing or their heart stops) credentials. This had the potential to affect 2 Residents 34 and 25) of 23 total sampled residents. The facility census was 34. Findings are: A. Review of the facility policy Emergency Procedure-Cardiopulmonary Resuscitation with a revision date of ,d+[DATE] revealed a policy statement which indicated personnel were to have completed training on the initiation of CPR for victims of sudden cardiac arrest (the sudden loss of all heart activity due to an irregular heart rhythm). The policy further indicated if a resident was found unresponsive and was not breathing, a certified staff member should initiate CPR unless it was known that a Do Not Resuscitate (DNR- (physician order which instructs staff not to perform CPR if a resident would stop breathing or if their heart would stop beating) order was in place. If the resident's DNR status was unclear, CPR was to be initiated until the resident's status was determined. Training was to be provided/required biannually by a certified instructor and staff were to provide the facility with current CPR card with completion. B. Review of Resident 34's Nursing Progress Note dated [DATE] at 11:30 AM revealed the resident was transferred to the facility per the facility van with the Social Service Director (SSD)-M driving. Review of the resident's Advanced Medical Directives (a written document that tells your health care provider who should speak for you and what medical decisions they should make for you) dated [DATE] revealed the resident wanted CPR for a witnessed arrest of heart or respirations. C. Review of Resident 25's Nursing Progress Notes dated [DATE] at 11:00 AM revealed the resident was transported by SSD-M to the facility from the hospital in the facility van. Review of Resident 25's Advanced Medical Directives dated [DATE] revealed the resident had requested CPR for witnessed arrest of the heart or respirations. D. Review of a current roster of staff who were listed as course participants in the CPR training dated [DATE] revealed no evidence SSD-M was listed as having received CPR certification. E. Interview on [DATE] at 10:37 AM with the Director of Nursing (DON) indicated a CPR certified staff member should always be available for any residents who indicated they wanted to receive CPR with a witnessed cardiac arrest and/or who had stopped breathing. F. Interview with SSD-M on [DATE] at 11:12 AM confirmed SSD-M was not CPR certified when SSD-M transported Residents 34 and 25 in the facility van.

Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure residents were free from potential abuse regarding a failure to verify there were no negative findings in the state nurse aide registry for 2 (Dietary Aides F & K) of 5 employee records reviewed. The facility census was 34. Findings are: A. Review of the undated Resident Abuse & Neglect Policy revealed: 1) all employees would have license verifications completed via the state board of licensure/registry and 2) the facility would not employ anyone that had a history of documented resident abuse or subsequently found guilty of any abuse. Record review on 8/7/24 at 08:15 AM of Dietary Aide (DA)-F's employee record revealed DA-F was hired on 2/13/24. There was no evidence of documentation facility staff had checked the state nurse aide registry for adverse findings prior to DA-F working in the facility. Record review on 8/7/24 at 08:15 Am of DA-K's employee record revealed DA-K was hired on 2/15/24. There was no evidence of documentation facility staff had checked the state nurse aide registry for adverse findings prior to DA-K working in the facility. An interview with the Business Office Manager (BOM) on 8/7/24 at 08:35 AM confirmed there was no evidence of documentation the state nurse aide registry was checked for employees DA-F and DA-K prior to them working in the facility. In addition, the BOM confirmed both employees had been working since they were hired in February 2024.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure Resident 2's Pre-admission Screening and Resident Review (PASARR-federally mandate screen performed to identify Mental Disorders (MD), Intellectual Disability (ID), or Related Disorders (RD) and to ensure appropriate facility placement with appropriate services), accurately reflected a potential MD. The sample size was 1 and the facility census was 30. Findings are: Record review of the facility policy dated 6/12/23 revealed the facility performed PASARR screening for all new admissions and readmission to the facility to screen for MD, ID, or RD, and new PASARR screening would be completed to reflect antipsychotic (medication used to treat psychotic disorders) medication use. Record review of Resident 2's PASARR dated 1/19/18 revealed the resident has no MD including depression or delusional disorders. Record review of Resident 2's Psychoactive Medication Review dated 4/17/23 revealed the resident took the antipsychotic medication Seroquel for a delusional disorder and hallucinations and antidepressant (medication used to treat depression, anxiety, and chronic pain) medication Duloxetine for treatment of depression, and the antidepressant medication Trazadone for insomnia. Record review of Resident 2's Minimum Data Set (MDS-federally mandated comprehensive assessment used for the development of resident Care Plans) dated 4/25/23 indicated the resident had a diagnosis of depression, displayed verbal behaviors 1-3 days in the preceding week, and took antipsychotic and antidepressant medication 7 out of 7 of the preceding 7 days. Record review of Resident 2's Care Plan with a revision date of 5/1/23 revealed the resident was delusional, had a delusional disorder diagnosis, and took antipsychotic and antidepressant medication. Interview on 6/21/23 at 8:44 AM the facility Administrator confirmed the facility did not have a PASARR for Resident 2 that accurately reflected a potential Mental Disorder and the use of antipsychotic medication.

Licensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to protect Residents 1, 10, 19, and 23 after allegations of potential abuse and neglect. The sample size was 5 and the facility census was 30. Findings are: A. Review of the facility Resident Abuse and Neglect policy dated 1/2/2020 revealed the following; -all employees of the facility are responsible to protect and prevent resident abuse from occurring. This included resident to resident, resident to staff and staff to resident abuse; -resident abuse included an intentional or negligent act or omission which resulted in mistreatment, neglect, misappropriation of resident's property, physical, mental, verbal or sexual abuse, or involuntary seclusion of a resident; -the facility would not employ or continue to employ anyone that had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -staff would report their knowledge or allegation without fear of reprisal; -if abuse or suspected abuse occurred the Charge Nurse, Director of Nursing (DON), Social Services, and the Administrator would be immediately notified: -an immediate investigation would be conducted; and -the appropriate state and local agencies would be called immediately, whether the facility felt the allegation was substantiated or unsubstantiated. B. An interview on 3/30/22 at 10:38 AM with Resident 23 revealed a staff member had told the resident to wet the bed rather than call for assistance to get up during the night. The resident reported this concern to the facility. Review of Resident 23's Care Plan dated 3/10/22 revealed the following; -recent right arm and right hip fractures and surgery; -bladder problems that required staff monitoring; -required extensive assistance of 1 or 2 staff for toileting, dressing, and personal hygiene; and -staff were to assist with toileting. Review of Resident 23's Grievance, Concern, and Suggestion Form dated 3/14/22 revealed the following; -when the resident called for assistance to the bathroom staff reported not having time to assist the resident to the bathroom; and -when the resident called again 45 minutes later, the same staff member offered the bed pan and instructed the resident to wet self the remainder of the night. Interview on 4/4/22 at 2:13 PM with the DON confirmed no staff were restricted from direct care or educated on abuse despite Resident 23's allegation of potential abuse, and the facility did not have a system in place to protect the residents during the course of the investigation, of the resident allegation on 3/14/22. C. An interview on 3/30/22 at 9:04 AM with Resident 19 revealed one staff member had hurt the resident. Resident 19 chose not to share the staff members name at the time of the interview but referred to the staff member as a Nurse Aide (NA). Review of the facility Vocalized Complaints form dated 12/1/21 revealed Resident 19 reported a NA picked up the resident and threw them against the wall. Further review revealed this occurred during rolling the resident in bed for bed pan use. Review of Resident 19's Care Plan dated 12/9/21 revealed the following; -the resident required total assistance with bed mobility and transfers; -was unable to stand, bear weight, transfer, or walk; and -required a mechanical lift for all transfers. Interview on 4/4/22 at 2:13 PM with the DON confirmed that no staff were restricted from direct care or educated on abuse despite Resident's 19's allegation of potential abuse, and the facility did not have a system in place to protect residents during the course of investigation, of the resident allegation on 12/1/21. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/29/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding Resident 1: -was cognitively intact; -no behaviors; and -required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of a Nursing Progress Note dated 1/3/22 at 2:02 AM revealed a late entry for 1/2/22 which indicated Licensed Practical Nurse (LPN)-O was called to the resident's room by NA-N as the resident had complained of not being able to breath. Resident 1 was wearing oxygen and was trying to remove. The resident requested assistance to the bathroom. Staff assisted the resident into the bathroom and when cares were completed transferred the resident back into the recliner. Resident 1 reported at this time, the resident did not want NA-N back in the resident's room again. Review of a Grievance, Concern and Suggestion Form dated 1/3/22 revealed the resident had turned on the call light as the resident needed to use the bathroom. NA-N responded to the call light, but threw a fit about the resident's positioning in the recliner. Resident 1 repeatedly requested assistance to the bathroom. NA-N left the room to obtain the help of a second staff and returned with LPN-O. The resident told the staff the resident needed to use the bathroom but they continued to argue with the resident about positioning in the recliner. The staff did finally assist the resident, but the resident reported the staff were mean. E. Review of Resident 10's MDS dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's cognition was severely impaired and the resident had behaviors which included hallucinations, delusions, physical and verbal behaviors directed at others and rejection of cares. Resident 10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and had occasional urinary incontinence. Review of a Grievance, Concern and Suggestion Form dated 12/7/21 revealed Resident 10 had told NA-P the resident was glad (gender) wasn't here as (gender) had grabbed the resident's hands and hurt the resident. F. During an interview on 4/4/22 at 2:43 PM, the DON confirmed the following: -both Resident 1 and 10 had histories of delusions and hallucinations and after initial review of the resident's grievances, the DON did not feel the residents had been abused or that an abuse investigation was warranted and made no attempt to investigate the allegations further; -despite Resident 1's allegation LPN-O and NA-N had been mean to the resident and the resident did not want NA-N back in the resident's room, both staff continued to work and to provide direct care to the residents; -did not investigate Resident 10's allegation regarding someone grabbing the resident's hands and hurting the resident; and -failed to develop and/or implement interventions to assure Resident 1 and 10's safety after their allegations of potential staff to resident abuse.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report, complete a thorough investigation and then submit the results of the investigation to the State Agency within the required time frames for Residents 1, 10, 19, and 23 after allegations of potential abuse and neglect. The sample size was 5 and the facility census was 30. Findings are: A. Review of the facility Resident Abuse and Neglect policy dated 1/2/2020 revealed the following; -all employees of the facility are responsible to protect and prevent resident abuse from occurring. This included resident to resident, resident to staff and staff to resident abuse. - Resident abuse included an intentional or negligent act or omission which resulted in mistreatment, neglect, misappropriation of resident's property, physical, mental, verbal or sexual abuse, or involuntary seclusion of a resident -the facility would not employ or continue to employ anyone that had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -staff would report their knowledge or allegation without fear of reprisal, -if abuse or suspected abused occurred the Charge Nurse, the Director of Nursing (DON), Social Services, and A dministrator would be immediately notified, -an immediate investigation would be conducted, and -the appropriate state and local agencies would be called immediately, whether the facility felt the allegation was substantiated or unsubstantiated. B. An interview on 3/30/22 at 10:38 AM with Resident 23 revealed a staff member had told the resident to wet the bed rather than call for assistance to get up during the night. The resident reported this concern to the facility. Review of Resident 23's Care Plan dated 3/10/22 revealed the following; -the resident had recent right arm and right hip fractures and surgery, -the resident had bladder problems that required staff monitoring, -the resident required extensive assistance of 1 or 2 staff for toileting, dressing, and personal hygiene, and -staff were to assist with toileting. Review of Resident 23's Grievance, Concern, and Suggestion Form dated 3/14/22 revealed the following; -when the resident called for assistance to the bathroom staff reported not having time to assist the resident to the bathroom, -when the resident called again 45 minutes later the same staff member offered the bed pan and instructed the resident to wet self the remainder of the night. Interview on 4/4/22 at 2:13 PM with the DON confirmed that allegations of potential abuse by Resident 23 were not reported to the appropriate State Agency and a thorough investigation was not submitted in the required time frames. C. An interview on 3/30/22 at 9:04 AM with Resident 19 revealed that a staff member hurt the resident. Resident 19 chose not to share the staff members name at the time of the interview but referred to the staff member as a Nurse Aide (NA). Review of the facility Vocalized Complaints form dated 12/1/21 Resident 19 reported that a Nurse Aide picked up the resident and threw them against the wall. Further review revealed this occurred during rolling the resident in bed for bed pan use. Review of Resident 19's Care Plan dated 12/9/21 revealed the following; -the resident required total assistance with bed mobility and transfers, -was unable to stand, bear weight, transfer, or walk, and -required a mechanical lift for all transfers. Interview on 4/4/22 at 2:13 PM with the Director of Nursing (DON) confirmed that allegations of potential abuse by Resident 19 were not reported to the appropriate State Agency and a thorough investigation was not submitted in the required time frames. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/29/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding Resident 1: -was cognitively intact; -no behaviors; and -required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of a Nursing Progress Note dated 1/3/22 at 2:02 AM revealed a late entry for 1/2/22 which indicated Licensed Practical Nurse (LPN)-O was called to the resident's room by NA-N as the resident had complained of not being able to breath. Resident 1 was wearing oxygen and was trying to remove as the resident needed assistance to the bathroom. Staff assisted the resident into the bathroom and when cares were completed transferred the resident back into the recliner. Resident 1 reported at this time, the resident did not want NA-N back in the resident's room again. Review of a Grievance, Concern and Suggestion Form dated 1/3/22 revealed the resident had turned on the call light as the resident needed to use the bathroom. NA-N responded to the call light, but threw a fit about the resident's positioning in the recliner. Resident 1 repeatedly requested assistance to the bathroom. NA-N left the room to obtain the help of a second staff and returned with LPN-O. The resident told the staff the resident needed to use the bathroom but they continued to argue with the resident about positioning in the recliner. The staff did finally assist the resident, but the resident reported the staff were mean. During an interview on 4/4/22 at 2:43 PM, the DON confirmed the following: -Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON felt the resident was more concerned about having enough toilet paper as opposed to potential abuse and did not feel any further investigation was warranted; -the DON had not questioned Resident 1 regarding the resident's allegation staff were mean or about the resident not wanting NA-N back in the resident's room; and -despite the residents' allegation of potential staff to resident abuse, the allegation was not reported, a thorough investigation was not initiated and/or completed and the results of the investigations sent to the State Agency within the required time frame. E. Review of Resident 10's MDS dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's cognition was severely impaired and the resident had behaviors which included hallucinations, delusions, physical and verbal behaviors directed at others and rejection of cares. Resident 10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and had occasional urinary incontinence. Review of a Grievance, Concern and Suggestion Form dated 12/7/21 revealed Resident 10 had told NA-P the resident was glad that (gender) wasn't here as (gender) had grabbed the resident's hands and hurt the resident. During an interview on 4/4/22 at 2:43 AM, the DON confirmed the following: -Resident 10 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON made no attempt to investigate the allegation further even though the resident identified someone had grabbed the resident's hand and hurt the resident; and -despite the resident's allegations of potential staff to resident abuse, the allegations were not reported, a thorough investigation initiated and/or completed and the results of the investigation sent to the State Agency within the required time frame.

Licensure Reference Number 175 NAC 12-006.09C Based on record review and interview; the facility failed to address insulin use on the care plan for 1 (Resident 27) of 19 total sampled residents. The facility census was 30. Findings are: Record review of Resident 27's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's Medication Administration Records (MAR) for March 2022 and April 2022 revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Comprehensive Care Plan, initiated 9/27/21, revealed no documentation to address the use of insulin. Interview on 4/5/22 at 9:20 AM with Registered Nurse/Minimum Data Set (a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator (RN/MDS-L) confirmed that the use of insulin was not addressed on the plan of care.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to assess, monitor and notify the physician in a timely manner when a change in condition was identified for 1 (Resident 4) of 1 sampled residents related to ongoing loose stools. The facility census was 30. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with revision date of 5/2017 revealed the facility was to notify the physician promptly of significant changes in the resident's medical/mental condition and/or status. Further review of the policy revealed a significant change was classified as a decline in the resident's status that would not normally resolve itself without intervention or by implementing standard clinical interventions. B. Review of Resident 4's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/11/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding the resident; -severely impaired cognition; -behaviors which included delusions, physical and verbal behaviors directed at others; resistance with cares and wandering; -required extensive staff assistance with toilet use and personal hygiene; and -always incontinent of bowel and bladder. Review of a Nursing Progress Note dated 2/4/22 at 10:33 AM revealed the resident's bowel elimination patterns were regular. Review of a Nursing Progress Note dated 3/1/22 at 7:42 AM revealed the resident's bowel elimination remained regular with a bowel movement every day or every other day. Review of a Nursing Progress Note dated 3/14/22 at 3:42 PM revealed the resident continued to have loose stools. Review of a Nursing Progress Note dated 3/17/22 at 3:52 AM revealed the staff reported the resident had watery loose stools. Review of a Bowel Elimination report from 3/1/22 to 3/31/22 revealed the resident was having loose/diarrhea stools on the Day Shift on 3/4, 3/5, 3/7, 3/10, 3/11, 3/12, 3/13, 3/14 (x2), 3/18, 3/20, 3/21, 3/22, 3/24, 3/25, and 3/29/22 (15 out of 31 days). The resident had loose/diarrhea stools on the evening shift on 3/11, 3/14, 3/16, 3/19, 3/25, 3/27, 3/29 and 3/30/22 (8 out of 31 days) and on the night shift on 3/3 and 3/16/22. The resident had loose/diarrhea stools a total of 21 out of 31 days. Review of a Nursing Progress Note/Communication with the Physician dated 3/30/22 (27 days after staff started documenting the resident's loose/diarrhea stools) at 3:34 PM revealed the resident's physician was notified the resident was having continuous large, loose stools, multiple times a day. The note further indicated the resident did not have orders for a routine [MEDICATION(S)]. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on 4/4/22 at 2:49 PM confirmed there was no documentation to indicate staff provided further monitoring/assessment of Resident 4 or that interventions were put into place to address the loose stools. In addition, the DON verified staff should have notified the resident's physician in a timelier manner and in accordance with the facility policy.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure orders for as needed [CONDITION(S)] (medication taken to exert an effect on the brain and/or nervous system) medications for Residents 19 and 21 were limited to 14 days in duration, a specific duration time was identified and that ongoing evaluations were completed regarding continuation of the medications. The sample size was 5 and the facility census was 30. Findings are: A. Review of Resident 19's Minimum Data Set (MDS- a federally mandated assessment used in the development of the resident Care Plan) dated 3/1/22 revealed the following; -diagnoses of anxiety, depression, [CONDITION(S)], delusions, heart failure, kidney disease, hypertension, and chronic lung disease, -rejected care daily, and -received antianxiety medication 2 of the previous 7 days. Review of Resident 19's Medication Administration Record (MAR) dated 4/22 revealed the resident had an order initiated on 2/22/18 for [MEDICATION(S)] (medication taken for the treatment of anxiety) 0.25 miligrams (mg) as needed up to 3 times daily with no prescribed duration for use. Review of Resident 19's Psychoactive Medication Review dated 1/17/22 revealed no evidence of an ordered duration of use for the as needed [MEDICATION(S)]. B. Review of Resident 21's MDS dated [DATE] revealed diagnoses of delusional disorder, dementia, depression and anxiety. The resident had behaviors which included delusions, verbal behaviors directed at others, other behavioral symptoms not directed at others, rejection of cares and wandering. In addition, the resident received an antipsychotic medication 7 out of the last 7 days of the look back period and an antianxiety medication 2 out of the last 7 days. Review of the resident's MAR dated 4/22 revealed the resident had an order dated 1/19/21 for [MEDICATION(S)] (medication used to treat anxiety) 0.5 mg every 2 hours as needed for anxiety and comfort with no prescribed duration for use. Review of the resident's Psychoactive Medication Review dated 2/21/22 revealed no evidence the [MEDICATION(S)] was evaluated by the physician to determine need for continued use. C. Interview with the Director of Nursing (DON) on 4/4/22 at 2:49 PM revealed the facility failed to assure ongoing assessment and evaluation of Resident 19's [MEDICATION(S)] and Resident 21's [MEDICATION(S)] were completed to monitor for therapeutic benefits and potential adverse side effects to determine need for continued use of the medications and/or the medications had a specified duration date for use.

Licensure Reference Number 175 NAC 12-006.17C Based on observations, record reviews, and interviews; the facility failed to implement infection control practices to prevent potential cross contamination including the spread of COVID-19. The facility failed to 1)screen resident's for signs and symptoms of COVID-19, 2) place and maintain residents in transmission based precautions, 3) implement standard precautions, 4) protect resident's from staff members displaying symptoms of COVID-19, and 5) ensure reusable items were cleaned in an approved manner. This had the ability to affect all residents. The sample size was 20 and the facility census was 29. Findings are: A. The facility policy for Isolation-Categories of Transmission Based Precautions dated October 2018 stated: -Standard precautions were used when caring for residents at all times regardless of their suspected or confirmed infection status. -Transmission based precautions were additional measures that protect staff, visitors and other residents from becoming infected. These measures were determined by the specific pathogen and how it spreads from person to person. -The Center for Disease Control and Prevention (CDC) maintained a list of diseases, modes of transmission, and recommended precautions. -Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces. B. The Center for Medicare and Medicaid Services (CMS) Memorandum QSO-14-28-NH dated 3/9/20 revealed: -CMS was responsible for ensuring the health and safety of nursing home residents by enforcing the standards required to help each resident attain or maintain their highest level of well-being. In light of the recent spread of COVID-19 CMS took several steps to help prevent the spread of [MEDICAL CONDITION]. -Prompt detection, triage, and isolation of potentially infectious residents was essential to prevent unnecessary exposures among residents, healthcare personnel, and visitors at the facility. -Facilities should be vigilant in identifying any possible infected individuals and preform frequent monitoring for symptoms of respiratory infections throughout the day. C. The Department of Health and Human Services Long Term Care COVID-19 Phasing Guidance dated 6/15/20 revealed the following guidance for resident screening: -screening must be completed for residents at least daily, -screening must include body temperature and questions/observations for other signs and symptoms of COVID-19. D. Review of the Resident Screening Logs for all facility residents dated July 2020 and August 2020 revealed the facility was monitoring residents' body temperatures daily until 8/6/20 and then starting on 8/6/20 the facility began to check the residents' body temperatures 2 times daily and resident oxygen saturations daily. There was no evidence that the facility was questioning/observing the residents for other signs and symptoms of COVID-19. E. Review of Resident 15's MDS (minimum data set- a federally required comprehensive assessment of the resident's condition) dated 5/26/20 revealed; -a [DIAGNOSES REDACTED].>-the resident had disorganized thinking that came and went, and changed in severity, -the resident displayed physical and verbal behaviors directed toward others 1-3 days a week, and -the resident displayed no rejection of care, and no wandering. Observation of Resident 15 on 8/12/20 revealed; -at 8:30 AM the resident was in a wheelchair near the nurses station wheeling about with no mask, staff did not attempt to apply a mask, or redirect or assist the resident to their room. -at 11:00 AM the resident was wheeling about the nurse station area with a surgical mask in place. -at 1:15 PM the resident was sitting in a wheelchair by the nurse station with a surgical mask not covering the nose or mouth. Review of Resident 15's Progress Notes revealed; -A late entry on 8/13/20 at 9:54 AM which revealed the facility received notification on 8/12/20 that the resident was COVID-19 positive. -on 8/13/20 at 2:54 AM the resident was frequently trying to leave the resident room and hallway. Interview with the facility Administrator on 8/12/20 at 10:00 AM confirmed Resident 15 was not wearing a mask, did not routinely wear a mask, and was not being kept in the resident's room. F. Review of Resident 14's MDS dated [DATE] revealed; -a prognosis that could result in a life expectancy of less than 6 months, -the resident required moderate assistance with bed mobility, transfers, dressing and toileting, and was able to eat independently, and -special treatments and procedures included hospice care and oxygen. Review of Resident 14's Progress Notes revealed: -A late entry on 7/24/20 at 3:11 PM which revealed on 7/8/20 the resident, the resident's son, and the son's wife were out of the facility for an eye appointment. -On 7/23/20 at 11:47 AM the residents oxygen saturation level was 86 percent (% ) (normal is 90% or above). The resident reported feeling tired and diminished lung sounds were noted by the hospice nurse whom administered a nebulizer treatment for [REDACTED]. -On 7/23/20 at 4:28 PM the hospice provider informed the facility of new orders to start a medication by nebulizer (a medical device used to administer an inhaled mist of medication into the lungs) for diminished lungs sounds and a change in oxygen orders. There was no indication that the facility implemented transmission based precautions for a potential respiratory illness. -On 7/24/20 at 9:21 AM the Respiratory Therapist reported the resident was short of breath when riding the stationary bike and the resident's oxygen saturation level was 86%. The resident's oxygen saturation after a nebulizer treatment improved to 88-89% and then to 92% after oxygen was administered. -On 7/24/20 at 11:34 AM the resident was out to church. -On 8/4/20 at 10:13 PM the resident had crackles in the base of the left lung and complained of chest feeling kinda tight. -On 8/7/20 at 11:26 AM the resident was tested for COVID-19. -On 8/8/20 at 10:35 AM the resident complained of right inner calf soreness. -On 8/11/20 at 6:30 PM the resident complained of not feeling well, arthritis pain, chest pain, stomach distress, and anxiety. -On 8/12/20 at 1:18 AM the resident continued to complain of not feeling well, being weak and tired, and was reported to be weak and unsteady requiring the use a mechanical lift for toileting. Review of Resident 14's Physician order [REDACTED].>-On 7/23/20 orders were received to apply oxygen while the resident was resting in bed and to start nebulizer treatment 2 times a day for 7 days for diminished lung sounds -On 8/1/20 an order for [REDACTED]. Resident 14's Care Plan dated 7/1/20 had no evidence that the resident received treatment for [REDACTED]. G. Interviews with the facility Administrator on 8/12/20 between 1:00 PM and 3:00 PM confirmed Resident 14 and Resident 15 were now COVID-19 positive. Interview with Licensed Practical Nurse (LPN)-C on 8/12/20 at 10:10 AM revealed all residents were having their temperature and oxygen saturation taken twice a day, and that lung sounds and additional assessments were only completed on residents whom were identified as ill. Interview with LPN-B on 8/12/20 at 10:00 AM revealed this nurse normally went throughout the facility taking temperature and oxygen saturations at the beginning of the shift or with the morning medication pass if unable to complete them prior to the medication pass. Residents who had identified illness received additional assessments. No routine screening assessments were completed on all the residents. H. Observations of Resident 19 on 8/9/20 at 9:25 AM, at 10:00 AM, and at 10:55 AM revealed the resident was seated in a wheelchair moving through the hallways without a face mask on. There were 2 other residents (Resident 15 and Resident 20) roaming through the hallways without face masks on. Staff members had not approached Resident 19 to encourage the use of a face mask and did not redirect the resident to a separate area away from others. This had the potential to expose Resident 19 and others to COVID-19. I. Review of the CDC COVID-19; Strategies for Optimizing the Supply of Eye Protection (updated 7/15/20) revealed the following: -while wearing gloves, wipe the inside, followed by the outside of the face shield using a clean cloth saturated with neutral detergent solution or cleaner wipe; -wipe the outside of the face shield using a wipe or clean cloth saturated with an EPA-registered hospital disinfectant solution; -fully dry (air dry or use clean absorbent towels); and -remove gloves and perform hand hygiene. J. Review of the undated facility policy Cleaning and Disinfecting of Equipment and Supplies revealed all equipment would be sanitized after each use and sanitizer would be located at the nurse's station, dirty hopper room, and on mechanical lifts. K. During observations on 8/9/20 at 10:00 AM the following was revealed: -Nursing Assistant (NA)-G and NA-L exited room [ROOM NUMBER] (in which the resident was on transmission based precautions) after cares were provided and removed the isolation gowns and gloves outside of the room as opposed to removing them inside the room; -NA-G and NA-L then rolled the gowns into a ball and carried them (without putting them in a bag), down the hall to the laundry cart located outside another room potentially exposing others to cross contamination from the gowns; and -NA-G and NA-L used an alcohol wipe to clean (approximately 1 inch square) the inside and outside of the face shields while wearing them. An observation of Medication Aide (MA)-F, on 8/9/20 at 10:20 AM revealed the following: -MA-F exited room [ROOM NUMBER] (in which the resident was on transmission based precautions) after cares were provided and removed the isolation gown outside of the room as opposed to inside the room; -MA-F then rolled up the gown in a ball and carried it (without a bag) to the opposite end of the hall and placed the gown inside the laundry cart, potentially exposing others to cross contamination from the gown. During observations of LPN-B on 8/9/20 at 11:25 AM, the following was revealed: -LPN-B provided cares to a resident in room [ROOM NUMBER], who was on transmission based precautions; -LPN-B exited the room and removed the isolation gown outside of the room as opposed to inside the room; -LPN-B then rolled up the isolation gown in a ball and carried the gown (without a bag) to the end of the hallway and placed it inside the laundry cart, which potentially exposed others to cross contamination from the gown; and -LPN-B used an alcohol wipe (approximately 1 inch square) to clean the inside and outside of the face shield while wearing it. During observations of a Dietary Member (DM)-M on 8/9/20 from 11:30 AM to 11:40 AM the following was revealed: -DM-M was wearing an N95 mask, face shield, cloth isolation gown and gloves; -DM-M carried a meal tray into room [ROOM NUMBER] and touched the resident's items on the bedside table moving them to the side; -DM-M disinfected the resident's hands with a spray bottle of hand sanitizer, then placed the resident's meal on the bedside table and exited the room; -DM-M had not removed gloves or sanitized hands before exiting the room; -DM-M then picked up a different tray off the meal cart and delivered it to the resident in room [ROOM NUMBER]; -DM-M had not removed gloves or sanitized hands after leaving room [ROOM NUMBER]; -DM-M then assisted LPN-B with putting on and securing the ties on LPN-B's isolation gown; and -DM-M had not removed gloves or sanitized hands before resuming the delivery of meal trays to other residents, which potentially exposed residents to cross contamination. L. An interview with LPN-B on 8/9/20 at 11:25 AM verified staff used alcohol wipes (approximately 1 inch square) to disinfect the face shields. M. Review of an Advanced Screening Tool dated 8/11/20 revealed Nursing Assistant (NA)-A was nauseous and had had a headache, the NA requested to go home after rounds (process of checking on all residents and providing toileting and any other cares needed). The request was made at 4:11 AM and the staff member left the facility at 5:21 AM. Interviews with the Director of Nursing (DON) on 8/12/20 from 9:00 AM to 4:30 PM confirmed NA-A felt ill and wanted to go home but not until after rounds were completed. The DON confirmed NA-A was allowed to stay and complete rounds prior to going home ill. N. Review of an Advanced Screening Tool dated 8/3/20 revealed LPN- I had multiple symptoms of illness (with potential other causes) including cough, shortness of breath, fatigue, muscle or body aches, and a headache. LPN-I also indicated running a temperature after mid-night with a temperature of 101.2 degrees at 1:00 AM. Further review revealed the nurse continued to work the remainder of the shift and provided cares to residents that needed morning medications and one other resident. O. Review of the facility COVID-19 Return-To-Work Procedures updated 7/15/20 revealed a process to be implemented for staff members due to signs or symptoms of COVID-19 (fever, cough, shortness of breath) and/or a positive COVID-19 test. The following criteria was identified: -exclude from work until at least 2 consecutive negative COVID tests done over 24 hours apart, or -exclude from work until 10 days since symptoms first appears with improvement in respiratory symptoms with at least 3 days with a temperature less than 99 degrees without fever reducing medications. Review of Advanced Screening Tools and the facility Nursing Schedule dated 7/2020 and 8/2020 revealed: - NA-K's Advanced Screening Tool dated 7/20/20 revealed NA-K had a headache with either nausea, vomiting, and/or diarrhea. NA-K was sent home on 7/20/20. - NA-J's Advanced Screening Tool dated 8/6/20 revealed NA-J had been having an increase in coughing with chills, fatigue, muscle aches, headache, and nausea. NA-J was sent home. NA-J also stated a family member and child may have COVID-19. Interview with the Infection Preventionist on 8/12/20 at 1:05 PM revealed NA-K returned to work on 7/23/20 and NA-J returned to work on 8/8/20 (less than 10 days since the start of symptoms and there was also no indication that 2 negative COVID tests had been completed). P. Review of the Long-Term Care COVID-19 Phasing Guidance dated 6/15/20 revealed if a facility had any residents in red zone or yellow zone isolation they had to be in Phase 1. In Phase 1 communal dining must be limited to only COVID-19 negative or asymptomatic residents and the facility was to restrict group activities. Review of a Progress Note dated 8/5/20 at 11:01 AM revealed Resident 6 was hard to arouse and was having increased confusion. Review of a Progress Note dated 8/5/20 at 5:35 PM revealed the resident had gone out to the dining room for dinner as well as for afternoon snack and activity. Interview with the Administrator on 8/12/20 at 3:30 PM confirmed Resident 6 (among others) had now tested positive for COVID-19. The deficient practices placed all 29 residents at risk for contracting COVID-19 and resulted in Immediate Jeopardy (IJ). As a result of the identified non-compliance the Administrator was notified on 8/12/20 at 2:40 PM of the IJ. The facility submitted an acceptable plan and the IJ was abated on 8/12/20 at 4:40 PM.

Based on observation, interview, and document review, the facility failed to protect all residents in the facility by not following acceptable infection control practice recommendations for COVID-19 from the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid (CMS) Services. The facility failed to have a screening system in place to ensure all staff and visitors who entered the facility were screened for signs and symptoms of COVID-19 prior to having contact or providing care to the residents. Specifically, a staff screening station was set up at the nurse's station next to the time clock. Staff entered the facility from two separate entrances of the facility and both entrances required staff to either pass by resident rooms or resident common areas prior to being screened for signs and symptoms of COVID-19. The screening form used for staff did not collect all the required screening information to monitor for COVID-19 signs, symptoms, and/or exposure. Once at the nurses' station, staff were instructed to conduct a self-assessment of their temperature, use hand sanitizer, obtain a mask and clock in for their shift. The facility had a screening station set up at the front entrance of the facility for visitors to self-screen themselves by assessing their temperature prior to entering into resident care areas or having contact with any of the residents. Documentation showed the visitors temperatures were assessed upon entrance to the facility or at the nurses' station. This deficient practice placed all 36 residents at risk for contracting COVID-19 and resulted in Immediate Jeopardy (IJ). The IJ was determined to have started on 3/11/20 with the failure to adequately screen the staff and visitors for sign and symptoms of COVID-19. As a result of the identified non-compliance, the Administrator was notified on 7/16/20 at 11am of the Immediate Jeopardy (IJ). The facility submitted an acceptable plan and the IJ was removed on 7/17/20 after verification of implementation of the removal plan. The deficient practice remained at a level F. Findings include: Professional References Review of CMS, Center for Clinical Standards and Quality, Safety and Oversight (QSO) Memo 20-14-NH, dated 3/13/20, provided guidance to long term care facilities which included screening all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough and sore throat. If ill, have them self-isolate at home. Facilities should actively screen and restrict visitation by those who meet the following criteria: Signs and symptoms of respiratory infection, such as fever, cough shortness of breath, or sore throat. In the last 14 days, has had contact with someone with a confirmed [DIAGNOSES REDACTED]. International travel within the last 14 days to countries with sustained community transmission. Residing in a community where community-based spread of COVID-19 is occurring. Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 3/13/20, showed the following: -Screen all healthcare professionals (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. If they are ill, have them keep their facemask on and leave the workplace. -Fever is either measured temperature >100.0 degrees Fahrenheit or subjective fever. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath and sore throat. - Screen visitors for fever and symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Facility Policy Review of the facility's COVID Pandemic/Infection Control Emergency plan dated 6/18/20 showed the following: - All visitors would be screened upon entry of the facility (Screening: temperature taken and COVID questionnaire asked). -Staff will take their own temperature upon arrival for their shift at the nurse's station and log it into the time clock binder by the time clock. Staff were to also log temperature upon completion of their shift. Staff would also answer COVID questions of having a fever greater than 100.4 degrees Fahrenheit, a cough, shortness of breath or difficulty breathing, any travel in the past fourteen days to regions affected by COVID-19 or a hot spot, or been in close contact with anyone who has a confirmed COVID-19 diagnosis. Observations During a tour of the facility on 7/15/20 with the facility Administrator, she identified that all staff entered the facility through the front door and went to the nurses' station to screen themselves for signs and symptoms of COVID-19. She stated staff were responsible to screen themselves, with the charge nurse providing oversight. She stated that if they had any signs or symptoms of COVID-19, they were to report to the charge nurse. The Administrator identified that she was responsible to ensure all staff and visitors were screened for signs and symptoms of COVID-19. Observation on 7/15/20 showed when staff entered the front door of the facility, they proceeded approximately 25 feet to the nurses' station by the time clock. Observation on 7/15/20 showed when staff entered the facility from the back door they proceeded past a resident room before reaching the COVID-19 screening station located at the corner of the nurses' station by the time clock. Observation on 7/15/20 at 1:25pm showed a staff member standing at the corner of the nurses' station in the area identified as the screening station for staff to screen themselves for signs and symptoms of COVID-19, which was next to the time clock. The staff person was assessing her temperature and completing the assessment form for signs and symptoms of COVID-19. An unidentified resident was sitting in a wheelchair less than 2 feet from the staff person. The resident was not wearing a mask. Observations made on 7/15/20 between 10am and 3pm showed residents in hallways and common areas of the facility with no face coverings on. Interviews During an interview on 7/15/20 at 11:51am, Nurse Aide (NA) 1, stated she enters the facility through the front door, goes to the time clock at the nurses' station, takes her temperature, and puts a mask on and clocks in for her shift. During an interview on 7/15/20 at 12:02pm, NA2 stated she enters the facility through the front door, goes to the time clock at the nurses' station, checks and records her temperature. She stated the facility just started using a new form which now included a section for answering yes or no to signs to some symptoms of COVID-19. During an interview on 7/15/20 at 12:10pm, NA3 stated he enters the facility through the front door, puts a mask on, uses hand sanitizer and proceeds to the nurses' station to check and document his temperature and clock in for his shift. He stated a few weeks ago the facility initiated a new form to assess for signs and symptoms of COVID-19 which included sore throat and cough. During an interview on 7/15/20 at 12:18pm, NA4 stated she also worked in the Assisted Living facility located within the Skilled Nursing Facility. She stated she enters the facility through the front door, washes her hands, takes her temperature and clocks in at the time clock which is located at the nurses' station. She stated the facility recently updated the COVID-19 screening form to include if they have experienced any symptoms of COVID-19. During an interview on 7/15/20 at 12:45pm, Housekeeper (HK1), stated she works two additional jobs besides her job at the facility. She stated she works as a bartender in a bar in a neighboring town and as a waitress at a local restaurant. She stated she worked at the restaurant about a week ago but the restaurant had since changed to carry out only. She stated she was not going to work at the bar anymore due to hearing there were positive COVID-19 cases in that community. She stated she comes in the front door of the facility, goes to the time-clock, puts a mask on, checks and documents her temperature. She stated the facility updated the assessment form a couple of weeks ago to include a section which asked about some signs and symptoms of COVID-19. During an interview on 7/15/20 at 12:50pm, HK2 stated she enters the facility through the basement, and then went to the nurses' station to complete the assessment form for signs and symptoms of COVID-19 which included her name, the date, the time and what her temperature was. She said she completes this form at the beginning and the end of her shift. She stated a couple of weeks ago the facility added a section to the form which included some symptoms of COVID-19 that she had to check yes or no on. During an interview on 7/15/20 at 1:20pm, Dietary staff (DS1) stated she enters the facility through the front door but most of the other dietary staff enter the facility through the back door. She stated after she enters the facility she goes to the nurses' station to screen herself for COVID-19. She stated she would take her temperature and document it in the book, put a mask on and clock in for her shift. Document Review Review of the facility's COVID-19 screening assessment form for staff, initiated on 3/16/20, showed the form contained a section to identify the date, time, employee name and what their temperature reading was at the beginning and the end of their shift. There was no other information on the form showing staff were actively screened for signs and symptoms of COVID-19 prior to having contact and providing care to the residents. Review showed the form was utilized from March 16 until July 2, 2020. The facility failed to actively screen all staff for signs and symptoms of COVID-19 from March 16th until July 2, 2020. On July 2, 2020 the form was updated to include a section which staff were supposed to answer yes or no if they had had any shortness of breath, change in cough or sore throat (not related to allergies [REDACTED]. The facility failed to update the screening form to ensure that staff were actively screened for all signs and symptoms of COVID-19 which included: shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, diarrhea, if they had been in contact with someone with a confirmed [DIAGNOSES REDACTED]. Review of an employee document provided by the Administrator on 7/15/20 showed 3 employees who were also working at another long term care facility, had been tested for COVID-19 due to staff in the other facility testing positive for COVID-19. Review of the visitor sign in book showed 284 visitors entered the facility between March 11 and June 27, 2020. The book contained the date and time the visitor entered and exited the facility. Review showed 270 of the visitors during this time frame had a temperature documented, with some of those temperature assessments being obtained at the nurses' station and 14 visitors had no temperature assessment or active screening for signs and symptoms of COVID-19. There was no other information on the form showing visitors who entered the facility were actively screened for signs and symptoms of COVID-19 prior to entering resident care area and/or providing care to the residents. Interviews During an interview on 7/15/20 at 10:30am, the Administrator stated the facility had been shut down since March 11, 2020 and had only allowed Hospice nurses, aides, and Chaplin, contracted therapy staff and 2 family members of any Hospice resident who was considered to be at the end of life, and essential vendors into the facility. They were to enter through the front entrance and conduct an assessment on themselves prior to entering resident care areas. During an interview on 7/15/20 at 1:38pm, the Director of Nursing (DON) stated that staff were screened for COVID-19 at the nurses' station but the Infection Control Nurse could provide better answers regarding the facility's staff and visitor screening process. During an interview on 7/15/20 at 1:42pm, the Infection Control Nurse (ICN) stated screening for signs and symptoms of COVID-19 was conducted at the nurses' station. She stated the form that was utilized for the screening had been a work in progress. She stated between March 16th and July 2, 2020, the expectation was that the charge nurse would contact her if staff had any signs or symptoms of COVID-19 when reporting for work. She stated that she thought it was very important to assess staff and visitors for signs and symptoms of COVID-19.