Every finding on record at Prestige Care Center of Nebraska City

Licensure reference: 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to ensure an ordered x-ray was completed for 1 [Resident 1] of 4 sampled residents. The facility had a total census of 43 residents. Findings are: A review of Resident 1's admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease [a progressive brain disorder that damages dopamine-producing neurons] without dyskinesia [involuntary, erratic, or writhing movements]. A review of HUCU messages system notes [a secure message system that allows the facility to communicate with the provider] revealed a message was sent on 8/3/26 at 2:52 PM that Resident 1 was having complaints of diarrhea and back pain. HUCU message from 8/3/26 at 3:47 PM revealed an order for Zofran 4 mg orally 3 times per day as needed for 3 days and one-time extra acetaminophen 1000 mg [Tylenol pain reliever] orally now. Another message was sent to provider on 8/4/26 at 10:01 AM requesting something stronger as Resident 1 reported acetaminophen did not work. Provider response on 8/4/26 at 4:22 PM revealed the following orders: diclofenac 1% gel apply 4 gm 4 times per day to back for 2-week trial, physical therapy to evaluate and treat, and lumbar x-ray, 2 view routine. A review of Resident 1's Progress Note dated 8/5/26 at 12:44 AM revealed Resident 1 reported lower back pain that felt like crushing. A review of Resident 1's Physician's Telephone Order document from the electronic medical record revealed the following orders dated 8/4/26 from HUCU application:-Diclofenac 1% gel apply four times per day to back for 2-week trial, may refuse-Physical Therapy evaluation and treat for back pain, pain modalities-Lumbar x-ray 2-view review A review of Resident 1's Electronic Medical Record did not reveal any lumbar x-ray results for Resident 1. In an interview on 8/19/26 at 10:47 AM, the Director of Nursing confirmed that the order for the lumbar x-ray had not been transcribed and forwarded to the x-ray company.

License Reference Number 175 NAC 12-006.09(I) Based on record reviews, interviews and observations, the facility staff failed to: evaluate risks and hazards, identify causative factors, thoroughly investigate, implement interventions to reduce risks and hazards, implement new interventions to help reduce risks, monitor effectiveness and/or modify interventions all related to falls for 4 (Resident 3, 4, 5, and 6) of 5 sampled residents. The facility staff identified a census of 46. A record review of the facility's Fall Prevention Program with a revision date of 01/2026 revealed the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding schedule. c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. d. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to resident's room. iii. Place Fall Prevention Indicator on resident's wheelchair. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or resident education ix. Therapy services referral 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. A record review of the facility's undated What to do When a Resident has a Fall document revealed the following: 1. Assess the resident while they are still on the floor. (Vitals, ROM, check if legs are symmetrical, check neuros (neurological) 2. After assessed, lift resident with a Hoyer and 2 staff members unless they are able to do it on their own. 3. If there is an injury call the Director of Nursing (DON) immediately. If there is no injury, a text may be made instead. 4. IF the resident is on any anticoagulation medications and they hit their head, notify the medical director and DON. Start neuro checks. 5. Complete a risk assessment. Go to clinical, then to risk assessment, click new and search the residents name. Select the type of incident and save. Fill out all areas including immediate action taken. 6. In the action taken section ensure you document the intervention. This intervention is what will prevent them from falling in the same (or a similar) way again. If there are no witnesses to the fall, neuro checks must be completed. This is not optional unless the medical director has ordered to stop neuro checks. 7. Update the Care Plan. A. A record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 5/21/2026 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE] -Brief Interview of Mental Status (BIMS) was 13 out of 15. A BIMS score of 13 indicates the resident was cognitively intact. -Resident 3 was setup/clean up assistance from facility staff with eating. - Resident 3 was supervision or touching assistance from facility staff with oral hygiene and wheel 50 feet. - Resident 3 was partial/moderate assistance from facility staff with rolling, sit to lying and lying to sitting on the side of the bed. - Resident 3 was substantial/maximal assistance from facility staff with toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, sit to stand and chair to bed transfer. - Resident 3 was dependent on staff with all other self-care and mobility needs. - Resident 3 had diagnosis of stroke, cerebrovascular accident, non-Alzheimer's dementia, and hemiplegia following a cerebral infarction affecting the right dominant side. A record review of the facility's Un-witnessed fall report for Resident 3 dated 7/2/2026 revealed that the resident did not give an answer or description of how the resident fell out of the wheelchair. There were no causative factors identified and no interventions noted. A record review of Resident 3's fall assessment risk dated 12/5/2025 revealed that Resident 3 scored a 12 indicating the resident was at a high risk for falls. A record review of Resident 3's fall assessment risk dated 7/2/2026 revealed that Resident 3 scored a 6 indicating the resident was at a low risk for falls. The resident fell on 7/2/2026. In an interview on 7/15/2026 at 8:35 AM, RDON confirmed that Resident 3's fall on 7/2/2026 was not a thorough investigation. In an interview on 7/15/2026 at 8:39 AM, RDON confirmed that there were no interventions put in place related to this resident fall on 7/2/2026. In an interview on 7/15/2026 at 8:40 AM, DON confirmed that no interventions were implemented for Resident 3's fall on 7/2/2026. In an interview on 7/15/2026 at 8:42 AM, DON and RDON confirmed that causative factor was not identified for Resident 3's fall on 7/2/2026. In an interview on 7/15/2026 at 2:34 PM, RDON confirmed that there should be a progress note in the incident report that would be the facility investigation. RDON confirmed that there was no facility investigation for Resident 3's fall on 7/2/2026. In an interview on 7/15/2026 at 2:40 PM, RDON confirmed that an incident report and facility investigation should be completed on all falls and there was not a facility investigation for Resident 3's fall on 7/2/2026. B. A record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 6/8/2026 revealed the facility staff assessed the following about the resident: - admitted to the facility on [DATE] - Brief Interview of Mental Status (BIMS) was 2 out of 15. A BIMS score of 2 indicates the resident had severe cognitive impairment. - Resident 5 was setup/clean up assistance from facility staff with rolling and lying to sitting on the side of the bed - Resident 5 was supervision/touching assistance from facility staff with eating, partial/moderate with sit to lying, chair to bed transfer. - Resident 5 was substantial/maximal assistance from facility staff with tub/shower transfer, toilet transfer, sit to stand, upper body dressing, lower body dressing, putting on and taking off footwear. - Resident 5 was dependent on facility staff for all other self-care and mobility needs - Resident 5 had diagnosis of stroke, cerebrovascular accident, non-Alzheimer's dementia, and difficulty walking. A record review of the facility's Un-witnessed fall report for Resident 5 dated 5/30/2026 revealed that the resident fell and was unable to give description to facility staff regarding what happened. There were no causative factors identified and no interventions noted. A record review of Resident 5's fall assessment risk dated 6/1/2026 revealed that Resident 5 scored a 19 indicating the resident was at a high risk for falls. A record review of Resident 5's fall assessment risk dated 5/8/2026 revealed that Resident 5 scored an 18 indicating the resident was at a high risk for falls. An observation on 7/16/2026 at 7:04 AM revealed Resident 5 was in bed and no interventions noted. In an interview on 7/14/2026 at 4:35 PM, RDON confirmed that there was no evidence that interventions were implemented for Resident 5's fall on 5/30/2026. In an interview on 7/15/2026 at 2:34 PM, RDON confirmed that there should be a progress note in the incident report that would be the facility investigation. RDON confirmed that there was no facility investigation for Resident 5's fall on 5/30/2026. In an interview on 7/15/2026 at 2:40 PM, RDON confirmed that an incident report and facility investigation should be completed on all falls and there was not a facility investigation for Resident 5's fall on 5/30/2026. C. A record review of Resident 4's admission Record revealed they were admitted to the facility 02/16/2026 with the following diagnoses: Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills) with late onset, Cognitive communication deficit ( a disorder that affects the ability to communicate effectively),dementia with other behavioral disturbance, Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), Chronic Heart Failure (a long-term condition where the heart muscle weakens or stiffens, preventing it from pumping blood efficiently), and Chronic Kidney (when the kidneys are damaged and cannot filter blood properly, causing waste to build up). A record review of Resident 4's Minimum Data Set (MDS – a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 05/14/2026, revealed Resident 4 had a Brief Interview for Mental Status (BIMS – a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) score of 3, indicating the resident had severe cognitive deficits. A record review of Resident 4's nursing progress notes (legal and clinical documents that track a patient's health status, the care provided and their response to interventions) by Licensed Practical Nurse (LPN) D revealed Resident 4 had an unwitnessed fall on 06/7/2026 at 1:55 PM. A record review of Resident 4's Care Plan (CP – a personalized, actionable document that outlines a patient's health needs, goals, and specific interventions to manage their care), revealed there were no new interventions put in place after Resident 4's fall on 06/17/2026. An interview on 07/15/2026 at 2:20 PM with the DON confirmed they did not do a fall investigation for Resident 4's fall on 06/17/2026 and therefore did not find any causative factors for Resident 4's fall. An interview on 07/15/2026 at 2:20 PM with the DON confirmed every fall requires new interventions to be placed on a residents care plan. The DON confirmed there were no new interventions placed on the care plan for Resident 4's Fall on 6/17/2026. D. A record review of Resident 6's admission Record revealed Resident 6 was admitted to the facility on [DATE] with the following diagnoses: History of falling, Hepatic failure (a condition caused when large parts of the liver become damaged), Alcoholic Cirrhosis of liver with ascites (an advanced stage of alcoholic-related liver disease where fluid leaks into the abdominal cavity), reduced mobility, Severe Protein-Calorie Malnutrition (a life threatening deficiency of macronutrients and energy), and traumatic subdural hemorrhage (bleeding caused by a head injury between your brain and your skull) without loss of consciousness. A record review of Resident 6's Minimum Data Set (MDS – a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 06/10/2026 revealed Resident 6 had a Brief Interview for Mental Status (BIMS – a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) score of 15, indicating Resident 6 was cognitively intact. A record review of Resident 6's nursing progress notes (legal and clinical documents that track a patient's health status, the care provided and their response to interventions) by the DON revealed Resident 6 had an unwitnessed fall on 07/01/2026. A record review of Resident 6's Care Plan (CP – a personalized, actionable document that outlines a patient's health needs, goals, and specific interventions to manage their care), revealed there were no new interventions put in place after Resident 6's fall on 07/01/2026. An interview on 07/15/2026 at 2:20 PM with the DON confirmed they did not do a fall investigation for Resident 6's fall on 07/01/2026 and therefore did not find any causative factors for Resident 6's fall. An interview on 07/15/2026 at 2:20 PM with the DON confirmed every fall requires new interventions to be placed on a residents care plan. The DON confirmed there were no new interventions placed on the care plan for Resident 6 Fall on 07/012026.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, interviews and record reviews, the facility staff failed to complete hand hygiene between glove changes for 2 (Residents 5 and 6) of 3 resident sample, complete glove changes when moving from a contaminated surface to a clean surface for 1 (Resident 5) of 1 sample resident, failed to put on personal protective equipment when administering tube feeding for 1 (Resident 7) of 1 sample resident, failed to secure a gown when providing catheter cares for 1 (Resident 5) of 1 sample resident and failed to have EBP signs on the doors for 1 (Resident 5) of 2 sample resident. The facility staff identified a census of 46. Record Review of the facility's policy Enhanced Barrier Precautions with a revision date of 1/2026 revealed the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC but may be considered epidemiologically important. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. c. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. f. Provide education to residents and visitors. g. Do not restrict room placement or out-of-room activities due to enhanced barrier precautions. h. See Table 1 for implementing contact versus enhanced barrier precautions for more information. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters h. Wound care: any skin opening requiring a dressing. Record Review of the facility's Hand Hygiene policy with a revision date of 2/1/2018 revealed the following: Policy: Staff involved in direct resident contact will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: b. The use of gloves does not replace hand washing. Wash hands after removing gloves. Record review of the facility's undated Hand Hygiene Table revealed the following: -When coming on duty -Between resident contacts -After handling contaminated objects -Before applying and after removing personal protective equipment (PPE), including gloves -Before preparing or handling medications -Before performing resident care procedures -Before and after providing care to resident in isolation -After handling items potentially contaminated with blood, body fluids, secretions, or excretions -When, during residents care, moving from a contaminated body site to a clean body site -After assistance with personal body functions (e.g., elimination, hair grooming. Smoking) -Before going off duty -When in doubt A. A record review of Resident 7's admission record revealed the resident was admitted on [DATE] with the following diagnoses: Paralysis of vocal cords and larynx ( a condition where nerve impulses to the voice box are disrupted, preventing the vocal cords from opening and closing properly),Hemiplegia ( total or severe paralysis affecting only one side of the body), protein-calorie malnutrition (a severe condition caused by inadequate intake or absorption of protein and calories), and Dysphagia (difficulty swallowing). A record review of Resident 7's Minimum Data Set (MDS – a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 7/2/2026 revealed Resident 7 had a Brief Interview for Mental Status (BIMS – a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 13, revealing Resident 7 has mild cognitive impairment. A record review of Resident 7's Care Plan (CP – a personalized, actionable document that outlines a patient's health needs, goals, and specific interventions to manage their care) revealed Resident 7 required tube feeding (a method of receiving liquid nutrition) due to dysphagia and vocal cord paralysis. A record review of Resident 7's Medication Administration Record (MAR) for July 2026 revealed the following order: TwoCal HN (a high nutrition tube feed formula) 240ml via Peg tube (percutaneous Endoscopic Gastrostomy – a flexible feeding tube placed directly into the stomach through the abdominal and used to deliver liquid nutrition) 5 times daily. Flush with 100ml (milliliters- a unit of measurement) water before and after each feeding. An observation on 7/14/2026 at 10:15 AM of Licensed Practical Nurse (LPN) B completing the administration of a tube feed formula bolus (a method of delivering liquid nutrition or formula, which is a specialized liquid food designed for people who cannot safely eat or swallow, into a feeding tube in single, relatively large doses at scheduled times, multiple times a day) to Resident 7. LPN B was observed pouring tube feed into a syringe attached to a g tube (gastric tube-a surgically inserted through the abdomen directly into the stomach, typically to deliver nutrition, hydration or medications) for Resident 7. LPN B was wearing gloves but was not wearing a gown. An interview on 07/14/2026 at 10:25 AM with LPN B confirmed they were not aware they were supposed to wear a gown for administering tube feedings and confirmed they had not worn a gown when they had administered the tube feed bolus. LPN B confirmed this was a breach of the Enhanced Barrier Precautions for infection control and was a potential source for cross contamination (the physical transfer of harmful bacteria, viruses, allergens or toxins from one surface, person or food to another). An interview on 07/15/2026 at 11:15 AM with the Regional Director of Nursing (RDON) confirmed staff members are required to wear a gown when providing tube feeding, in accordance with the EBP guidelines. The RDON confirmed not wearing a gown while administering tube feeding is a breach of infection control. B. A record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 6/8/2026 revealed the facility staff assessed the following about the resident: - admitted to the facility on [DATE] - Brief Interview of Mental Status (BIMS) was 2 out of 15. A BIMS score of 2 indicates the resident had severe cognitive impairment. - Resident 5 was setup/clean up assistance from facility staff with rolling and lying to sitting on the side of the bed - Resident 5 was supervision/touching assistance from facility staff with eating, partial/moderate with sit to lying, chair to bed transfer. - Resident 5 was substantial/maximal assistance from facility staff with tub/shower transfer, toilet transfer, sit to stand, upper body dressing, lower body dressing, putting on and taking off footwear. - Resident 5 was dependent on facility staff for all other self-care and mobility needs - Resident 5 had diagnosis of stroke, cerebrovascular accident, non-Alzheimer's dementia, and difficulty walking. An observation on 7/14/2026 at 3:50 PM of (LPN) B performing catheter care for Resident 5. LPN B gathered sterile packets of gauze 4 x 4's, a bottle of sterile water and gloves. LPN B knocked on Resident 5's, waited for acknowledgement and entered the room. LPN B placed the supplies on Resident 5's bedside table, opened the sterile gauze packets without touching their contents, and poured sterile water over the gauze. LPN B entered the bathroom and washed their hands. LPN B did not have a clean gown in the room, so they exited the room, obtained a gown from Resident 1's room and returned to Resident 5's room. LPN B had touched Resident 5's door on entering and exiting, touched Resident 1's door on entering and exiting, opened a set of plastic drawers in Resident 1's room and removed a gown before returning to Resident 5's room. LPN B did not use hand sanitizer or wash their hands when they returned to the room. LPN B put their arms in the gown but did not tie the gown ties behind them. LPN B donned gloves, used their gloved hands to close the door, pull the privacy curtain around the bed, pull the blankets off the resident, assist the resident to pull down their pants, unfasten their brief and move it out of the way. LPN B's gown slid down their arms and had to be shrugged back into place. LPN B changed gloves without using hand sanitizer. LPN B picked up a wet 4x4 in their right hand, grasped the base of Resident 5's penis with their left hand and then used their gloved right hand, which was still holding the wet 4x4, grabbed a trash can to place beside the bed. LPN B then used the contaminated 4x4 to wipe the head of Resident 5's penis in a circular motion. LPN B discarded the soiled gauze and repeated the cleaning with a clean gauze 4x4. LPN B discarded the soiled gauze, stabilized the catheter tube with their left hand, and used a clean gauze to wipe the catheter tube moving from the genitalia towards the bag. LPN B discarded the gauze, refastened the residents briefs and replaced (gender) pants. LPN B removed their gown and gloves, discarded the trash, and exited the room. LPN B used hand sanitizer after exiting the room. An interview on 7/14/2026 at 4:05pm with LPN B confirmed they did not use hand hygiene when they returned to Resident 5's room with a clean gown. LPN B confirmed they donned (put on) a gown and gloves without performing hand hygiene. LPN B confirmed they had closed the door, closed the privacy curtain, and touched the residents blankets and clothing before performing catheter care and had not used hand hygiene or changed gloves. LPN B confirmed they had used their gloved right hand, which was holding a wet 4x4, to relocate a trash can and they did not discard the 4x4, change gloves or use hand hygiene before cleaning Resident 5's penis. LPN B confirmed these actions could cause cross contamination for Resident 5 as LPN B moved from a dirty to clean area each time. LPN B confirmed they did not know there were supposed to use hand hygiene between glove changes. An observation on 7/16/2026 at 7:14 AM Licensed Practical Nurse (LPN)- A after entering Resident 5's room revealed LPN-A completed hand hygiene, closed the curtain, put on gloves, grabbed the trash can and placed it next to the residents bed, did not complete hand hygiene or change gloves and proceeded to open supplies. LPN-A removed Resident 5's sock, did not complete hand hygiene or change gloves and cleansed the wound area, painted the wound area with betadine, and removed gloves. LPN- A labeled and dated the dressing, did not complete hand hygiene. An observation on 7/16/2026 at 7:14 AM revealed that there was no EBP sign on Resident 5's door or in Resident 5's room. An observation on 7/16/2026 at 10:31 AM revealed that there was no EBP sign on Resident 5's door or in Resident 5's room. In an interview on 7/16/2026 at 7:26 AM LPN-A confirmed that hand hygiene and glove changes were not completed for Resident 5 while moving from a contaminated surface to a clean surface and should have been. LPN-A confirmed that hand hygiene was not completed between glove changes and should have been. In an interview on 7/16/2026 at 10:31 AM, Director of Nursing (DON) confirmed that there is no EBP sign on Resident 5's door or behind the door and there should be. C. A record review of Resident 6's admission Record revealed Resident 6 was admitted to the facility on [DATE] with the following diagnoses: History of falling, Hepatic failure (a condition caused when large parts of the liver become damaged), Alcoholic Cirrhosis of liver with ascites ( an advanced stage of alcoholic-related liver disease where fluid leaks into the abdominal cavity), reduced mobility, Severe Protein-Calorie Malnutrition (a life threatening deficiency of macronutrients and energy), and traumatic subdural hemorrhage (bleeding caused by a head injury between your brain and your skull) without loss of consciousness. A record review of Resident 6's Minimum Data Set (MDS – a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 06/10/2026 revealed Resident 6 had a Brief Interview for Mental Status (BIMS – a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) score of 15, indicating Resident 6 was cognitively intact. An observation on 7/14/26 at 12:20 PM of wound care provided by RN C for Resident 6. RN C gathered the supplies, which consisted of sterile 4 x 4 gauze packets, individual vials of normal saline and a bordered mepilex dressing, knocked and entered Resident 6's room. RN C placed the supplies on the bedside dresser and opened the dressing packets without touching the contents. RN C initialed and dated the exterior of the bordered mepilex. RN C donned (put on) a gown and gloves but did not use hand sanitizer or wash their hands. RN C assisted Resident 6 to pull down their brief and expose the open area. RN C removed their gloves and donned clean gloves without using hand sanitizer. RN C opened 4 vials of normal saline solution and soaked a pack of gauze pads with it. RN C used the gauze 4 x 4's to clean Resident 6's wound, located on the sacrum, and discarded each gauze pad after wiping the area. RN C changed gloves, without using hand sanitizer. RN C placed their gloved right hand on Resident 6's right hip and used their left hand to attempt to place the mepilex on the open area. The adhesive edge of the dressing flipped over and adhered to the dressing. RN C used both hands to separate the adhesive areas, touching the inside of the dressing with their soiled right glove and placed the dressing over the wound bed. RN C replaced Resident 6's briefs, discarded the trash and exited the room using hand sanitizer on the way out of the room. An interview on 7/14/2026 at 11:55 AM with RN C confirmed they had not used hand sanitizer or washed their hands between gloves changes when providing wound care to Resident 6. RN C reported they were not aware it was a requirement. RN C did not discard the residents dressing after touching the inside of the adhesive with a soiled glove. RN C confirmed touching the dressing and then placing it on Resident 6's open wound was a source of cross contamination and a breach of infection control. An interview on 7/15/2026 at 11:15 AM with the Regional Director of Nursing (RDON) and interim Infection Preventionist confirmed it is the facility expectation that hand sanitization is completed between glove changes and glove changes are required when going from a contaminated area to a clean area. The RDON confirmed touching the inside of a dressing with a contaminated glove is a breach of infection control. The RDON confirmed going from a dirty (contaminated) area to a clean area, for example, touching doors, curtains, blankets and then touching a resident without performing hand hygiene and changing gloves is a source of cross contamination. RDON confirmed touching a trash can and then performing catheter care without performing hand hygiene and changing gloves is a source of cross contamination and a breach in infection control.

License Reference Number 175 NAC 12-006.09(H) The facility failed to ensure a provider was contacted to provide pain management for Resident 4. The facility has a census of 46.A record review of the facility's Pain Management policy dated 04/2019 and reviewed 02/2025 revealed the following:Policy:The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences.Recognition:In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will:Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g., after a fall, change in behavior or mental status, new pain, or an exacerbation of pain)Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to:Change in gait (e.g., limping), skin color, vital signs (e.g., increased heart rate, respirations, and/or blood pressure), perspiration.Loss of function or inability to perform activities of daily living (ADLs) (e.g., rubbing a specific location of the body, or guarding a limb or other body partsFidgeting, increased or recurring restlessnessFacial expressions (e.g., grimacing, frowning, fright or clenching of the jaw)Behaviors such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities.Difficulty eating or loss of appetite.Weight lossDifficulty sleeping (insomnia)Negative vocalizations (e.g., groaning, crying, whimpering, or screaming)Decline in activity level.Skin ConditionsPain Assessment:The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain.Based on professional standards of practice, an assessment of evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident.Reviewing the residents current medical conditions (e.g., pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post CVA, venous and arterial ulcers, and multiple sclerosis)Identifying key characteristics of pain.Duration of painFrequencyLocationTimingPattern (e.g., constant, or intermittent)Radiation of painImpact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood)Pain management and treatment:Based on the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professions and the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. A record review of Resident 4's admission Record revealed they were admitted to the facility 02/16/2026 with the following diagnoses:Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills) with late onset, Cognitive communication deficit ( a disorder that affects the ability to communicate effectively),dementia with other behavioral disturbance, Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), Chronic Heart Failure (a long-term condition where the heart muscle weakens or stiffens, preventing it from pumping blood efficiently), and Chronic Kidney (when the kidneys are damaged and cannot filter blood properly, causing waste to build up). A record review of Resident 4's Minimum Data Set (MDS - a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 05/14/2026, revealed Resident 4 had a Brief Interview for Mental Status (BIMS - a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) score of 3, indicating the resident had severe cognitive deficits.A record review of a progress note dated 6/28/2026 by Registered Nurse (RN) C revealed the aide had reported to the nurse that the resident had not been eating for several days, has been moaning a lot and has on occasion said their back hurts. RN C placed a call to the provider but was unable to leave a message as the office is closed on weekends. RN C alerted the Director of Nursing (DON) for follow up with this on Monday (06/29/2026) when the office has the phone on. A record review of Resident 4's Order Summary revealed Resident 4 had an order for Acetaminophen 500mg tablets. Take 2 tablets (1,000mg) by mouth four times daily as needed.A record review of Resident 4's Medication Administration Record revealed Resident 4 did not receive any PRN pain medication on 06/28/2026.A record review of a fax from the DON to Resident 4's provider revealed the DON had informed the provider of the residents significant decline on 06/30/2026. An interview on 7/14/2026 at 1:25 PM with RN C confirmed a nurse assistant had reported Resident 4 was in pain. RN C reported they had tried to contact the Resident's provider, but it was Sunday and the phone was off. RN C confirmed they had passed the request to the DON to contact the Resident's Physician on Monday. In relation to the resident pain. RN C confirmed they did not give the resident any PRN pain medication and they did not attempt to contact the facility's attending provider.An interview on 7/15/2026 at 2:20 PM with the DON confirmed they had received notification of Resident 4's increased pain, and the request to contact Resident 4's provider on 06/28/2026. The DON confirmed they did not contact the provider until 06/30/2026. When asked why they waited to contact the provider, the DON replied, I was just so busy on the floor that I forgot to do it until the 30th. The DON confirmed they should have contacted the provider on the 29th as requested.

Based on interview and record review the facility staff failed to include the resident profile in the facility assessment and failed to update the facility assessment annually. The facility staff identified a census of 46. Findings are:A record review on 7/16/2026 11:04 AM of the facility assessment revealed the following:-Overview of the Assessment Tool: This is an optional template provided for nursing facilities, and if used, it may be modified. Each facility has flexibility to decide the best way to comply with this requirement.-The tool is organized into three parts: resident profile section that includes the numbers, disease/conditions, physical and cognitive disabilities, acuity, and ethnic/culture/religious factors that impact care. Further record review of the facility assessment revealed it did not contain the resident profile section that includes the numbers, disease/conditions, physical and cognitive disabilities, acuity, and ethnic/culture/religious factors that impact care. In an interview on 7/16/2026 11:49 AM, Director of Nursing (DON) confirmed that the resident profile is not in the facility assessment binder and should be. DON confirmed that the facility assessment binder is missing pages 3, 4, 5, and 6 and should not be. DON confirmed that the facility assessment has not been updated and should be.

Based on interviews and record reviews the facility staff failed to have patient transportation agreements with outside agencies and dialysis centers. The facility staff identified a census of 46. Findings are:A record review of the facility's provided document titled Dialysis Transportation Services with effective date of 01/2026 revealed that the facility had unsigned patient transfer agreement with zTrip [NAME]. A record review of the facility's provided document titled Dialysis Transportation Services with effective date of 01/2026 revealed that the facility had unsigned patient transfer agreement with Oceans Drive Transportation. In an email communication on 7/16/2026 at 1:37 PM, Regional Director of Operations (RDO) said that signed copies of the patient transportation agreements were in the facility survey binder, and staff was to get them and scan them to the RDO so the RDO can email them to the survey team. In an email communication on 7/16/2026 at 1:54 PM, RDO confirmed that the signed patient transportation agreements will be provided once the RDO has access to them. In an interview on 7/16/2026 at 3:11 PM, Director of Nursing confirmed that there was no evidence of patient transportation agreements. On 7/21/2026 at 1:00 PM the survey team had still not received the signed patient transportation agreements.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record review, observations and interviews, the facility failed to implement interventions to protect from potential elopement for 4 (Residents 1, 2, 4, and 5) of 5 sampled residents. The facility staff identified a census of 49.Findings are:Licensure Reference Number 175 NAC 12-006.09(I) Based on record review, observations and interviews, the facility failed to implement interventions to protect from potential elopement for 4 (Residents 1, 2, 4, and 5) of 5 sampled residents. The facility staff identified a census of 49. Findings are: A. Record review of facility policy entitled Elopement Prevention and Management dated revised 11/12/2019 revealed facility staff would complete the following: -2. Review evaluations and risk factor data. -3. Determine if the resident/patient is at risk for elopement. -4. Include resident/patient and family/responsible party in development of the Plan of Care. -5. Develop individualized interventions which may include, but are not limited to the following: electronic monitoring/alarm systems; environmental modifications; protected list of names and photographs of those at risk for elopement; psychosocial interventions; regular rounds; resident/patient and family education; staff interventions; and structured group activities. Record review of Resident 1's admission Record (AR) revealed the facility admitted the resident on 06/17/2025. Further review of the AR identified Resident 1 had diagnoses of Alzheimer's disease (a degenerative brain disease of unknown cause that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood) and psychosis (a serious mental illness characterized by defective or lost contact with reality often with hallucinations or delusions). Record review of Resident 1's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/30/2026 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 00. According to the MDS manual, a score of 00 indicated the resident had severe cognitive impairment. Further review of the MDS identified Resident 1 wandered daily. Record review of Resident 1's Progress Notes revealed Resident 1 eloped the facility on 06/17/2026. The local police department returned Resident 1 to the facility. Record review of Resident 1's Elopement Risk dated 06/17/2026 identified the resident was at risk for elopement. Record review of a sign displayed at the Memory Care Unit (MCU) medication on 06/22/2026 revealed all thirteen residents who resided in the MCU were on 15-minute checks until further notice. Further review of the sign instructed staff to document the 15-minute checks thoroughly. Record review of Resident 1's Every 15 Minute Check Sheet dated 06/19/2026, 06/21/2026, and 06/22/2026 revealed there was no documentation for each of the 15-minute checks from 12:15 AM through 5:45 AM. In interviews on 06/22/2026 at 7:41 AM, 8:01 AM and 8:34 AM, Medication Aide (MA)-A confirmed the sign that hung at the medication cart was hung up after Resident 1 eloped on 06/17/2026. MA-A further confirmed the 15-minute checks were not documented from 12:15 AM through 5:45 AM on 06/21/2026 and 06/22/2026. MA-A reported the 15-minute checks began after Resident 1 eloped the facility. In an interview on 06/22/2026 at 2:40 PM, the Regional Director of Nursing (RDON) confirmed missing documentation on the 06/19/2026 15-minute check sheet. During a follow-up interview on 06/23/2026 at 8:04 AM, the RDON confirmed it was expected that staff would fill out the 15-minute check sheet as the 15-minute checks were completed. B. Record review of Resident 2's AR revealed the facility admitted the resident on 06/03/2025. Further review of the AR identified Resident 2 had diagnosis of Alzheimer's Disease with early onset. Record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS score of 01. According to the MDS manual, a score of 01 indicated the resident had severe cognitive impairment. Further review of the MDS identified Resident 2 wandered for four to six days out of the seven-day review period. Record review of Resident 2's Elopement Risk dated 06/17/2026 identified the resident was at risk for elopement. Record review of Resident 2's Every 15 Minute Check Sheet dated 06/19/2026, 06/21/2026, and 06/22/2026 revealed there was no documentation for each of the 15-minute checks from 12:15 AM through 5:45 AM. In an interview on 06/22/2026 at 8:01 AM, Medication Aide (MA)-A confirmed the 15-minute checks were not documented from 12:15 AM through 5:45 AM on 06/21/2026 and 06/22/2026. In an interview on 06/22/2026 at 2:40 PM, the Regional Director of Nursing (RDON) confirmed missing documentation on the 06/19/2026 15-minute check sheet. During a follow-up interview on 06/23/2026 at 8:04 AM, the RDON confirmed it was expected that staff would fill out the 15-minute check sheet as the 15-minute checks were completed. C. Record review of Resident 5's AR revealed the facility admitted the resident on 02/27/2025. Further review of the AR identified Resident 5 had a diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]). Record review of Resident 5's MDS dated [DATE] revealed the resident had a BIMS score of 09. According to the MDS manual, a score of 09 indicated the resident had moderately impaired cognition. Record review of Resident 2's Every 15 Minute Check Sheet dated 06/19/2026, 06/21/2026, and 06/22/2026 revealed there was no documentation for each of the 15-minute checks from 12:15 AM through 5:45 AM. In an interview on 06/22/2026 at 8:01 AM, Medication Aide (MA)-A confirmed the 15-minute checks were not documented from 12:15 AM through 5:45 AM on 06/21/2026 and 06/22/2026. In an interview on 06/22/2026 at 2:40 PM, the Regional Director of Nursing (RDON) confirmed missing documentation on the 06/19/2026 15-minute check sheet. During a follow-up interview on 06/23/2026 at 8:04 AM, the RDON confirmed it was expected that staff would fill out the 15-minute check sheet as the 15-minute checks were completed. D. A record review of the facility's Elopement Prevention and Management policy dated 11/12/2019 revealed the facility would complete admission evaluations. The staff would review and risk factor data, determine if resident was at risk, develop a care plan, develop interventions which may include electronic monitoring, environmental modifications, protected list of names and photographs of those at risk, psychosocial interventions, regular rounds, resident and family education, staff interventions, and structured group activities. The current protected list of names and photographs of residents identified at risk would include the name, description, height, weight, age, and pertinent medical information. A record review of Resident 4's Clinical Census dated 06/09/2026 revealed the resident was admitted on [DATE]. A record review of Resident 4's Medical Diagnosis dated 06/23/2026 revealed the resident had diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side (partial loss of movement or complete paralysis of the right side after a stroke), Unspecified Symptoms And Signs Involving Cognitive Functions Following Cerebral Infarction (thinking and memory difficulties after a stroke), Primary Insomnia (difficulty falling and staying asleep), Anxiety, Depression, Nicotine Dependence. A record review of Resident 4's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/22/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 1 which indicated the resident was severely cognitively impaired (difficulty thinking and comprehending). The resident required partial/moderate assistance with eating and oral hygiene (cleaning) and substantial/maximal with bathing, toileting hygiene, dressing, footwear, and personal hygiene. The resident required partial/moderate assistance with all mobility and transfer needs except tub/shower transfer was substantial/maximal assistance. The resident used a wheelchair. It did not reveal the resident had behaviors including wandering. The resident was not on a wander/elopement (leaving the facility without staff knowledge) alarm. A record review of Resident 4's admission Assessment / readmission Bundle 6212024V1 – V2 dated 03/06/2026 revealed the resident was at risk for elopement based on the current assessment. A record review of Resident 4's Clinical – Assessment list dated 06/23/2026 revealed on 05/22/2026 an Elopement Risk assessment was completed, and the resident had a score of 19 which indicated the resident was at risk for elopement. On 06/17/2026 an Elopement Risk assessment was completed, and the resident had a score of 21 which indicated the resident was at risk for elopement. A record review of Resident 4's Quarterly / Comprehensive Bundle v3 * dated 06/05/2026 revealed the resident was at risk for elopement based on the current assessment. A record review of the facility's Updated Elopement risk 6-17-2026 dated 06/17/2026 revealed Resident 4 was on the list for being at risk for elopement. A record review of Resident 4's Progress Notes dated 06/23/2026 revealed on 05/22/2026 at 9:35 AM the resident was seen by staff trying to leave the facility out the front door. The facility contacted the resident's primary care physician (PCP) to get an order for a wander guard (a device placed on the resident or wheelchair that will set off an alarm if the resident attempts to exit a facility), but it did not reveal the PCP ordered a wander guard. The Progress Notes did not reveal that the resident refused a wander guard or that the resident and family had been educated on the risk versus benefits of a wander guard. A record review of RR of the facility's Fw: FM 5-22 email dated 06/23/2026 from the facility's Regional Director of Nursing (RDON) revealed the facility requested an order for a wander guard from the PCP as the resident continued to try to elope. The PCP requested additional documentation, but it did not reveal the PCP ordered a wander guard. A record review of Resident 4's Care Plan Report with a print date of 06/23/2026 revealed the resident had a Focus area of the resident was at risk for elopement with opportunity that had a created date of 05/22/2026 and revised date of 05/22/2026. Interventions included: Consider any pattern of exit seeking need or behavior to alter (change) resident schedule, treatment, medications or environment to manage behavior and ENSURE SAFETY. Date Initiated 05/22/2026, Revision on 06/10/2026 Explained wander guard placement to a specific resident's family member and Power of Attorney (POA)(person designated to make financial or healthcare decisions for a resident) and he/she verbalized understanding. Date Initiated 05/22/2026, Revision on 05/22/2026. Wander guard to wheelchair with resident's consent. Date Initiated 06/22/2026, Revision on 06/22/2026. The Care Plan Report did not reveal a focus area or interventions for the resident's elopement risk prior to 05/22/2026. A record review of Resident 4' s Clinical Physician Orders dated 06/23/2026 did not reveal that a wander guard was ordered until 06/22/2026. An observation on 06/22/2026 at 8:39 AM with the facility's Director of Nursing (DON) revealed Resident 4 did not have a wander guard on the resident or the wheelchair. An observation on 06/22/2026 at 3:50 PM revealed that Resident 4 was sitting in a wheelchair by the nurse's station and the resident did not have a wander guard on. In an interview on 06/22/2026 at 3:50 PM, Resident 4 confirmed the resident had tried to leave the facility and doesn't want to be there. In an interview on 06/22/2026 at 8:39 AM, the DON confirmed Resident 4 did not have a wander guard on because the resident refused it, the resident was the resident's own person and did not have a POA. In an interview on 06/22/2026 at 9:09 AM, the DON confirmed Resident 4 refused to have a wander guard on. In an interview on 06/22/2026 10:17 AM, the Social Services Director (SSD) confirmed Resident 4's BIMS were all 0 because the resident was hard to understand until the SSD redone the BIMS on 06/18/2026 and the SSD determined it was 15. The SSD confirmed the resident was not considered and elopement risk because the resident was of sound mind and the resident was the resident's own person. The SSD confirmed Resident 4 was exit seeking and refused a wander guard. In an interview on 06/22/2026 at 12:27 PM, Registered Nurse (RN)-B confirmed RN-B was not aware of anything the facility had that included a description and photographs of the residents at risk for elopement. In an interview on 06/22/2026 at 3:53 PM, RN-B confirmed Resident 4 did not have a wander guard on. RN-B confirmed there was nothing in place to stop the resident from getting out of the facility other than the resident's mobility limitations. In an interview on 06/22/2026 at 4:10 PM, Medication Aide (MA)-C confirmed Resident 4 was an elopement risk and the resident hangs out by the front door. MA-C confirmed staff have to keep an eye on the resident. In an interview on 06/22/2026 at 4:10 PM, Nursing Assistant (NA)-D confirmed NA-D thought Resident 4 had good safety awareness, the resident knew what not to do but still does it. NA-D confirmed the resident recently tried to leave the gray doors by the nurse's station and NA-D had to redirect the resident. NA-D had seen Resident 4 try to leave the building through the front doors. NA-D confirmed there were times the staff could not watch the resident, especially on nights and weekends. In an interview on 06/22/2026 at 4:20 PM, the DON confirmed staff rounded on the residents every 2 hours and staff always knew where Resident 4 was. Staff could always see the resident and could see the resident from the nurse's station. The DON confirmed that the fact the resident had attempted to leave twice made the resident high risk for elopement. The DON confirmed the resident's primary care physician (PCP) refused to sign the order for a wander guard because the resident was the resident's own responsible party. The DON confirmed the DON was not aware if the facility staff or PCP educated the resident or the resident's family on the risk versus benefits of not wearing a wander guard. In an interview on 06/23/2026 at 6:49 AM, NA-E confirmed Resident 4 was having issues with smoking about a month ago and tried to leave the building out of the front door. In an interview on 06/23/2026 at 10:01 AM, the DON confirmed the resident had tried to get out of the building to smoke a vape. The current elopement interventions in place for Resident 4 were monitoring and need-based checks. The DON confirmed the SSD was trying to get placed in Omaha. The DON confirmed the regular monitoring was not documented anywhere. The regular monitoring and need-based checks were not different than a resident that was not at risk of elopement received. In an interview on 06/23/2026 at 9:14 AM, Resident 4 confirmed by shaking the residents head no if the resident ever refused to allow the staff to put a bracelet or wander guard on. In an interview on 06/23/2026 at 9:19 AM, Resident 4's PCP confirmed the PCP did not order a wander guard for the resident because Resident 4 made the resident's own decision and does not attempt to go out the door. The PCP confirmed the PCP had been notified that the resident was at risk for elopement on 05/22/2026 and recently and that the resident attempted to exit the facility on 05/22/2026. The PCP confirmed that the PCP did not educate on the risk versus benefits of not wearing a wander guard. The PCP confirmed on 06/22/2026 the facility contacted PCP and said the resident agreed to a wander guard bracelet, so the PCP honored it and ordered a wander guard on 06/22/2026. In an interview on 06/22/2026 at 12:32 PM, the DON confirmed there was just a list of resident's at risk of elopement, but it did not contain photos or descriptions. In an interview on 06/23/2026 at 10:50 AM, the DON confirmed the facility did not have risk versus benefit education on Resident 4 for the wander guard. The DON confirmed the facility contacted the PCP on 05/22/2026 and requested a wander guard and the PCP did not order one. The DON confirmed the facility did not put any elopement interventions in place after the resident was initially assessed to be at risk for elopement on 03/06/2026 until the resident attempted to elope on 05/22/2026. The DON could not confirm that the resident did refuse the wander guard, but confirmed the PCP refused to sign a wander guard order.

Based on observation and interviews, the facility failed to ensure the posted nurse staffing sheet was updated daily. The facility census was 40. Findings are:An observation on 3/2/2025 at 7:11 AM revealed the facility staff posting is dated for 2/10/2026. An observation on 3/4/2025 at 8:17 AM revealed the facility staff posting had not been changed and was still dated for 2/10/2026. In an interview on 03/04/2026 at 8:17 AM Director of Nursing/Registered Nurse (DONRN) confirmed the staff posting was dated for 2/10/2026. DONRN confirmed that the staff posting should be changed and updated daily and has not been changed since 2/10/2026.

Licensure Reference Number 175 NAC 12-006.07(C) Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys maintained. The facility census was 40. Findings are:A record review of the facility's Quality Assurance and Performance Improvement (QAPI) policy with a revision date of 1/2026 revealed the following: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. During the recent survey with an exit date of 03/05/2026 the following deficiencies and repeat deficiencies were identified:F550 - The facility failed to honor the right for choices for Resident 36.F580 - The facility failed to notify the power of attorney of new orders and change of plan in care for Resident 36.F584 - (Repeat deficiency) - The facility failed to ensure resident rooms were clean and odor free.F628 - The facility failed to ensure that Resident 9 was given notification of transfer in a manner they could understand and the bed hold policy on discharge to the hospital.F684 - The facility failed to complete neurological checks after unwitnessed falls for Resident 23, and the facility failed to evaluate for and administer nausea medication for Resident 36.F692 - (Repeat deficiency) - The facility failed to provide ordered meals for Resident 36 to prevent potential weight loss.F695 - The facility failed to ensure Residents 1 and 3's oxygen concentrators were set at the ordered setting and ensure Resident 3's BiPAP was administered as ordered.F697 - The facility failed to provide effective pain management to Resident 6.F699 - (Repeat deficiency) - The facility failed to ensure staff provided trauma informed care for Resident 3.F732 - The facility failed to ensure the posted nurse staffing sheet was updated daily.F745 - The facility failed to provide medically related social services for Resident 3. F757 - The facility failed to document signs and symptoms of pain for the continued use of PRN opioid pain medications for Resident 45.F865 - The facility failed to ensure the QAPI program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. F880 - The facility failed to complete a risk assessment for the prevention of legionella, and failed to ensure Resident 21's IV tubing was disinfected prior to medication administration.F923 - The facility failed to ensure exhaust vents worked in 2 resident rooms. A record review of the facility's last standard survey results from the 11/13/2024 survey revealed the facility was cited for:F584 (Safe/Clean/Comfortable/Homelike Environment) - RepeatF699 (Trauma Informed Care) - RepeatF692 (Nutrition/Hydration Status Maintenance) - Repeat In an interview on 03/05/2026 at 12:59 PM Administrator confirmed that the Administrator was not aware of the concerns identified in the survey prior to the start of the survey. In an interview on 3/5/2026 at 1:26 PM Housekeeping Aide (HA)-G confirmed that HA-G did not know what QAPI was and did not know what quality assurance (QA) was or what the committee was working on. In an interview on 03/05/2026 at 1:27 PM Nursing Assistant (NA)-I confirmed that NA-I did not know what QAPI was and did not know what QA was. NA-I did confirm that the facility was working on the floor where tile is different and getting new lifts. In an interview on 3/5/2026 at 1:29 PM NA-H confirmed that NA-H did not know what QAPI was and did not know what QA was or what the committee was working on.

Licensure Reference Number 175 NAC 1.005.06Licensure Reference Number 175 NAC 12.006.18Based on observation, interview, and record review, the facility failed to complete a risk assessment for the prevention of legionella, and to ensure intravenous (IV) tubing was disinfected prior to medication administration for 1 (Resident 21) of 1 sampled resident. This had the potential to affect all residents in the facility. The facility census was 40. Findings are: A. A record review of the facility's undated Building Water Management Program revealed the plan did not include a risk assessment or a water flow diagram. A record review of the undated Evacuation Routes map revealed water inputs and sprinkler system locations but did not reveal water flow, mixing [NAME], or water heating system locations. In an interview on 03/05/2026 at 12:22 PM, the facility's Administrator confirmed the Building Water Management Program did not include a risk assessment or water flow diagrams on the facility maps. B. A record review of the facility's Intravenous Therapy policy with a revision date of 11/2025 revealed the following: 11. Attach male end of tubing to catheter hub directly or into the needleless connector or IV port, after disinfecting with an appropriate antiseptic (e.g., chlorhexidine, povidone iodine, an iodophor, or 70 percent alcohol). An observation on 03/03/2026 at 1:25 PM revealed Registered Nurse (RN)-A removed the sterile (clean) cap from the left upper arm intravenous (IV) connection site, flushed (rinsed) the IV connection site with 10 milliliters of 0.9% sodium chloride (normal saline), attached the IV tubing to the IV connection site and started the medication pump. In an interview on 03/03/2026 at 1:25 PM RN-A confirmed that the IV connection site was not disinfected with an alcohol swab prior to attaching the IV tubing and should have been.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interviews, the facility failed to ensure the Alzheimer's Care unit was free of odor. This had the potential to affect 12 residents living in the Alzheimer's Care unit and failed to ensure 1 (room [ROOM NUMBER]) of 11 rooms in the Alzheimer's Care unit was clean. The facility census was 40. Findings are:A.A record review of the facility's Midnight Census Report dated 03/02/2026 revealed the Alzheimer's Care unit had 12 occupied beds. A record review of facility's Deep Cleaning Schedule for January, February and March of 2026 revealed that Resident 31's room was deep cleaned once on the 4th Wednesday in January (2026). Resident 31 had no deep cleaning scheduled for the month of February, 2026. Resident 31's room was scheduled to be deep cleaned the second Wednesday in March, 2026. An observation on 03/02/2026 at 7:27 AM revealed the hallway in the Alzheimer's care unit had a strong urine odor. An observation on 03/04/2026 at 7:51 AM revealed the hallway in the Alzheimer's care unit had a strong urine odor. An observation on 03/05/2026 at 8:37 AM revealed the hallway in the Alzheimer's care unit had a strong urine odor. In an interview on 03/02/2026 at 8:40 AM Director of Nursing/Registered Nurse (DONRN) confirmed that there was a urine odor in the hallway of the Alzheimer's Care unit. In an interview on 03/04/2026 7:51 AM Medication Aide (MA)-D confirmed that there was a urine odor in the hallway of Alzheimer's Care unit. In an interview on 03/05/2026 at 8:37 AM Nursing assistant (NA)-D confirmed there was a urine odor in the hallway of Alzheimer's Care unit. B.A record review of the facility's Routine Cleaning and Disinfection policy with a revision date of 12/2025 revealed the following:12. Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care area should be cleaned: a. On a regular basis b. when soiling and spills occur c. when resident is discharged from facility. An observation on 03/02/2026 at 8:32 AM of room [ROOM NUMBER] revealed that there was black, brown and white particles on bedside table. There was a brown spot with white and brown particles on the floor. An observation on 3/3/2025 at 12:36 PM of room [ROOM NUMBER] revealed that there was black, brown and white particles on bedside table. There was a brown spot with white and brown particles on the floor. In an interview on 3/3/2025 at 12:36 PM Medication Aide (MA)-D confirmed that room [ROOM NUMBER] had black, brown and white particles on bedside table. There was a brown spot with white and brown particles on the floor.

Licensure Reference Number 175 NAC 12-006.05(E)Based on observations, interviews, and record review, the facility failed to honor the right to make choices for location of meal for 1 (Resident 36) of 1 sampled resident. The facility staff identified a census of 40.Findings are:Record review of facility policy entitled Resident Rights dated revised 08/2025 revealed: - 10. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. -11. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Training topics will be appropriate to the individual's role.Record review of Resident 36's admission Record revealed the facility admitted the resident on 02/28/2025. Further review of the admission record identified Resident 36 had diagnoses that included dysphagia (difficulty in swallowing), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies), and diabetes mellitus type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 36's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 02/05/2026 revealed Resident 36 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11. According to the MDS manual, a score of 11 indicates the resident had moderately impaired cognition. Further review of the MDS identified Resident 36 required partial assistance to eat and had significant weight loss without a prescribed weight-loss program. The MDS further identified the resident received mechanically altered foods.Record review of Resident 36's Order Summary Report identified the following orders: -Regular diet, mechanical soft texture, thin consistency dated 05/27/2025; -Comfort cares and do not hospitalize dated 06/05/2025; -Resident to be up in wheelchair for all meals. If resident refuses to get up, then chart as refusing meals for risk of aspiration pneumonia dated 01/01/2026.Record review of an undated Mealtimes document showed residents residing in the Skilled Nursing Facility unit received breakfast from 7:00 AM until 8:30 AM.Observation on 03/03/2026 at 8:35 AM revealed Resident 36 was in bed without a breakfast tray.Interview on 03/03/2026 at 8:35 AM with Resident 36 revealed the resident asked Registered Nurse (RN)-A for a breakfast tray in bed. Resident 36 reported RN-A reported that Resident 36 had to get out of bed to receive breakfast. Resident 36 reported [gender] did not feel that was right and wanted to receive breakfast in her room.Interview on 03/03/2026 at 8:37 AM with Food Service Employee (FSE)-J revealed breakfast trays had already been delivered for the morning. FSE-J reported no tray was made for Resident 36. FSE-J further reported nursing staff was to notify the kitchen when Resident 36 was ready to eat, and food service staff would fulfill the tray with the resident's desired foods.A follow-up interview on 03/03/2026 at 8:45 AM with FSE-J revealed nursing staff won't give Resident 36 a meal when she doesn't want to come to the dining room. FSE-J reported this happened all the time.Interview on 03/03/2026 at 8:48 AM with Nursing Assistant (NA)-K revealed Resident 36 did not want to get up. NA-K reported they believed NA-H had delivered Resident 36's room tray.Interview on 03/03/2026 at 8:52 AM with NA-H revealed NA-H did not deliver Resident 36's room tray. NA-H reported nursing staff was educated Resident 36 cannot receive food in bed.Interview on 03/03/2026 at 9:30 AM with RN-A revealed Resident 36 reported they did not want to get out of bed for breakfast. RN-A revealed Resident 36 was educated that there was an order that Resident 36 must get out of bed to eat. RN-A reported Resident 36 was unhappy with the response. RN-A reported [gender] informed the Director of Nursing Registered Nurse (DONRN) and DONRN responded to the room.Interview on 03/03/2026 at 9:36 AM with the DONRN revealed the DONRN was called to the room over Resident 36's request for breakfast. DONRN reported they explained to Resident 36 the need to get out of bed and Resident 36 agreed to get up in the wheelchair. The DONRN confirmed that the resident was still in bed at the time of interview.A follow up interview on 03/03/2026 at 9:50 AM with FSE-J confirmed a breakfast tray had not been made and delivered to Resident 36.During a follow-up interview on 03/04/2026 at 10:39 AM, Resident 36 reported being required to get out of bed for a meal has been happening for a few weeks, maybe longer.Interview on 03/04/2026 at 12:24 PM with FSE-M revealed if Resident 36 did not get up for meals, Resident 36 does not get a meal plate. FSE-M reported this practice had been going on for months.Interview on 03/05/2026 at 10:25 AM with the Interim Director of Nursing (IDON) confirmed it was a violation of Resident 36's rights to be required to get out of bed to receive a meal.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) The facility failed to notify the power of attorney of new orders and change of plan in care for 1 (Resident 36) of 1 sampled resident. The facility staff identified a census of 40. Findings are:Record review of a facility policy entitled Change of Condition dated Revised 09/2025 revealed: - If the resident is deemed incapacitated or given permission to release information regarding the change of condition, the resident's family or representative will be contacted. -1. The nurse will notify the resident's attending physician and family when there has been: - c. A change in medication/treatment or reaction to a medication. - f. A need for a significant alteration in the resident's medical treatment. - 3. The nurse will inform the resident, or resident representative if indicated, of any changes in his/her medical care or nursing treatments. -4. The nurse will document in the resident's medical record or SBAR (communication framework that is used to share critical information -Situation, Assessment, Background, Recommendation) in the resident's chart any changes in the resident's condition, who was notified (e.g., physician and family), and any new orders.Record review of Resident 36's admission Record revealed the facility admitted the resident on 02/28/2025. Further review of the admission record identified Resident 36 had diagnoses that included dysphagia (difficulty in swallowing), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies), and diabetes mellitus type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 36's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 02/05/2026 revealed Resident 36 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11. According to the MDS manual, a score of 11 indicates the resident had moderately impaired cognition. Further review of the MDS identified Resident 36 required partial assistance to eat and had significant weight loss without a prescribed weight-loss program. The MDS further identified the resident received mechanically altered foods.Record review of Resident 36's durable health care power of attorney (POA) dated 12/02/2025 identified Resident 36's Family Members to serve as healthcare agents. Further review of the POA document identified the document was effective immediately upon signing.Record review of Resident 36's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) identified Resident 36's Medical POA was invoked on 12/02/2025.Record review of Resident 36's Order Summary Report revealed an order dated 01/01/2026 that read Resident to be up in w/c for all meals. If resident refuses to get up then chart as refusing meals.Record review of Resident 36's progress notes dated 01/01/2026 to 03/02/2026 revealed no evidence of POA notification of the order for Resident 36 to be up in w/c for all meals.Interview on 03/04/2026 at 1:27 PM with Registered Nurse (RN)-A revealed RN-A attempted to notify Resident 36's POA to notify of the new order but there was no answer. RN-A reported [gender] probably did not put in progress notes that an attempt was made.Interview on 03/04/2026 at 2:01 PM with Resident 36's family member revealed they were the point of contact for order changes and communication from the facility. Resident 36's family member reported they were not contacted or notified of the new order regarding resident being out of bed for all meals, and if the resident refused it would be considered a meal refusal.Interview on 03/04/2026 at 2:30 PM with the Interim Director of Nursing (IDON) confirmed there was no evidence to support Resident 36's POA was notified of the new physician's order. The IDON confirmed Resident 36's POA should have been notified.

Based on interview and record review, the facility failed to ensure that 1 (Resident 9) of 3 sampled residents was given notification of transfer in a manner they could understand and the bed hold policy on discharge to the hospital. The facility census was 40. Findings are:A record review of Resident 9's Clinical Census dated 03/04/2026 revealed Resident 9 was admitted to the facility 10/20/2025, placed on hospital leave 01/19/2026, and returned to the facility 01/21/2026. A record review of Resident 9's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/27/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 13, which indicated the resident was cognitively aware (able to think and comprehend). The resident required supervision or touching assistance with oral hygiene (cleaning), toilet hygiene, dressing, and personal hygiene and the resident required setup or clean-up assistance with footwear and eating. A record review of Resident 9's Progress Notes dated 01/19/2026 revealed the nurse assessed the resident and the resident was confused, unable to follow directions, unable to stand or sit on the side of the bed, repeated sentences, and was unable to answer questions. The resident was unable to participate in a neurological assessment (examination to evaluate the brain and nervous system). The resident's provider was notified and ordered the resident be sent to the Emergency Department for evaluation of potential Cerebrovascular Accident (stroke) / Seizure (involuntary movement or behavior from the brain activity). A record review of the facility's Transfer/Discharge Form* 62024 dated 01/19/2026 revealed the reason for transfer was Stroke / TIA/ CVA. [TIA is Transient Ischemic Attack (temporary blockage of blood flow to the brain that causes stroke like symptoms]. A record review of the facility's Bed Hold Policy and Notification revealed the form was completed by Registered Nurse (RN)-A and was marked as verbal OK from the resident's Power of Attorney (POA)(person designated to make decisions for a resident) and dated 01/19/2026. In an interview on 03/02/2026 at 8:03 AM, Resident 9 confirmed the resident was sent to the hospital one and a half months ago. The resident confirmed the resident was not sure why the facility sent the resident to the hospital and the facility did not give the resident any paperwork on discharge. In an interview on 03/03/2026 at 1:12 PM, the facility's Interim Director of Nursing (IDON) confirmed the facility staff does not give transfer paperwork or a bed hold to the resident on a emergent transfer or send it to the resident's representative. The staff just gives the Transfer/Discharge Form, a copy of the Medication Administration Record and Treatment Administration Record (MAR & TAR), the orders and that kind of stuff to the Emergency Medical Services (EMS). The staff would call the family for the Bed Hold but not give it to the resident. In an interview on 03/04/2026 at 10:09 AM, Registered Nurse (RN)-A confirmed RN-A was the nurse that transferred the resident to the hospital on [DATE]. RN-A confirmed RN-A did not give any paperwork to the resident on discharge and did not send it to the resident's representative. RN-A confirmed they gave the packet to the Emergency Medical Technician (EMT). RN-A confirmed RN-A printed the bed hold but did not give the bed hold to the resident on discharge. In an interview on 03/05/2026 at 7:07 AM, the facility's Director of Nursing/Registered Nurse (DONRN) confirmed the Transfer/Discharge Form* 62024 dated 01/19/2026 reason for transfer of TIA/CVA was not in a manner a layperson could understand.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interviews, the facility failed to complete neurological checks after unwitnessed falls for 1 (Resident 23) of 3 residents sampled for falls; and the facility failed to evaluate for change in condition for 1 (Resident 36) of 2 sampled residents. The facility staff identified a census of 40.Findings are:A. Record review of Resident 23's admission Record showed the facility admitted the resident on 06/15/2017. Further review of the admission record showed the resident had diagnoses that included need for assistance with personal cares, degeneration of the nervous system due to alcohol, major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies), and dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]).Record review of Resident 23's significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) identified Resident 23 had a short-term and long-term memory problem and had severely impaired cognitive skills for daily decision making. Further review of the MDS showed Resident 23 had one non-injury fall and one fall with injury during the review period.Record review of an Un-witnessed Fall document dated 01/10/2026 showed Resident 23 was observed lying on the left side on the floor with the head up against the bed.Record review of Resident 23's Progress Notes dated 01/30/2026 showed Resident 23 was observed by nursing staff to be lying face down on the fall mat at bedside.Record review of Resident 23's electronic health record (EHR) which included progress notes, scanned documents, and assessments revealed no evidence neurological checks were performed for the fall dated 01/10/2026.Record review of Resident 23's Neurological Assessment dated 01/30/2026 showed the resident's neurological status was to be evaluated every 15 minutes for one hour, every 30 minutes for two hours, every hour for two hours, and every shift for 72 hours. The neurological assessment showed there was no assessment every shift for 72 hours.An interview on 03/05/2026 at 10:25 AM with Interim Director of Nursing confirmed there was no neurological assessment completed for the fall on 01/10/2026 and the neurological assessment was incomplete for the fall on 01/30/2026. The IDON further confirmed neurological checks should have been completed per the neurological assessment instructions for both falls.B. Record review of Resident 36's admission Record showed the facility admitted the resident on 02/28/2025. Further review of the admission record revealed Resident 36 had diagnoses that included gastro-esophageal reflux disease (GERD), constipation, anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 36's Order Summary Report revealed an order dated 08/25/2025 for ondansetron tab 4 mg one tablet every eight hours as needed (PRN) for nausea.Record review of a late entry Progress Note dated 03/03/2026 for Resident 36 revealed Patient complaining of nausea and vomiting. Charge nurse assessed patient in the morning. Patient then complained of vomiting in PM. This nurse assessed patient, abdomen soft and non-distended, bowel sounds present x 4. Patient denies pain and vomiting stating it is my esophagus. Charge nurse informed of this nurse's assessment and instructed charge nurse to note and notify MD.Further review of Resident 36's electronic health record (EHR) including progress notes and assessments revealed no assessment documented by the charge nurse.Record review of Resident 36's March 2026 Medication Administration Record revealed ondansetron was administered on 03/03/2026 at 4:04 PM.During an interview on 03/03/2026 at 8:35 AM, Resident 36 reported having episodes of nausea throughout the night and into the morning of 03/03/2026.Interview on 03/03/2026 at 9:30 AM with Registered Nurse (RN)-A revealed RN-A was unaware of Resident 36's complaints of nausea until the surveyor reported it.During an interview on 03/03/2026 at 9:36 AM, the Director of Nursing (DON) identified Resident 36 had reported complaints of nausea to the DON when the DON provided encouragement to get up for breakfast.During a follow-up interview on 03/04/2026 at 1:31 PM, RN-A revealed they did not complete an evaluation after being made aware of Resident 36's complaints of nausea on 03/03/2026. RN-A reported the DON completed an evaluation.During an interview on 03/04/2026 at 1:38 PM, the DON confirmed an assessment was completed in the afternoon of 03/03/2026. The DON reported instructions were provided to the charge nurse to complete an assessment, monitor the resident, notify the provider and document all tasks completed.Interview on 03/05/26 at 10:55 AM with the Interim Director of Nursing (IDON) confirmed there was no assessment completed until approximately 4:00 PM on 03/03/2026. The IDON further confirmed interventions could have been provided sooner had the evaluation been completed in the morning.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1)Based on observation, interview, and record review, the facility failed to provide ordered meals to prevent potential weight loss for 1 (Resident 36) of 3 sampled residents. The facility staff identified a census of 40.Findings are:Record review of facility policy entitled Nutritional Management dated revised 04/2025 revealed: - The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. - 1. A systematic approach is used to optimize each resident's nutritional status: -a. Identifying and assessing each resident's nutritional status and risk factors -b. Evaluating/analyzing the assessment information -c. Developing and consistently implementing pertinent approaches -d. Monitoring the effectiveness of interventions and revising them as necessary. - 4. Care plan implementation: -a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. -b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: -i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet -ii. Altered-consistency food/liquids are underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy) -iii. Weight-related interventions -iv. Environmental interventions -v. Disease-specific interventions -vi. Physical assistance or provision of assistive devices -vii. Interventions to address food-drug interactions or medication side effects -c. Real food will be offered first before adding supplements. - 6. Informed consent: -a. The resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. -b. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. -c. The comprehensive care plan should describe any interventions offered but declined by the resident or resident's representative.Record review of Resident 36's admission Record showed the facility admitted the resident on 02/28/2025. Further review of the admission record showed the resident had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), muscle weakness, dysphagia (difficulty in swallowing), and diabetes mellitus type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 36's Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed the following: -Resident 36 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11. According to the MDS manual, a score of 11 indicated the resident had moderate cognitive impairment. -Resident 36 had behavioral symptoms directed towards others and rejection of care during one to three days of the assessment period. -Resident 36 required partial assistance to eat. -Resident 36 had significant weight loss and was not on a physician-prescribed weight-loss regimen and had mechanically altered food. -Resident 36 received services from a Speech-Language Pathologist (SLP).Record review of Resident 36's Order Summary Report revealed the following orders: -May liberalize therapeutic dietary restrictions at resident's request. Consult speech for texture modifications dated 02/28/2025. -Regular diet mechanical soft texture, thin consistency dated 05/27/2025. -Comfort cares and do not hospitalize dated 06/05/2025. -Speech Therapy evaluate and treat as indicated dated 12/22/2025. -Resident to be up in wheelchair for all meals. If resident refuses to get up, then chart as refusing meals dated 01/01/2026. -Dietician evaluate and treat for adequate hydration and nutrition dated 01/26/2026.Record review of Resident 36's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed Resident 36 required set up assistance to eat dated revised 11/15/2025.Record review of Resident 36's Nutritional Assessment dated 02/08/2026 identified Resident 36 had a 5.2 percent (%) weight loss in the past month and 14.7% weight loss in the past six months.Observation on 03/03/2026 at 8:35 AM revealed Resident 36 in [gender] bed. Resident 36 did not have a breakfast tray in (gender) room.Observation on 03/03/2026 at 10:00 AM revealed the Business Office Manager went to the kitchen and requested a cup of broth for Resident 36.Observation on 03/03/2026 at 10:08 AM revealed Medication Aide (MA)-O went to the kitchen and requested dry toast for Resident 36.Interview on 03/03/2026 at 8:35 AM with Resident 36 revealed Resident 36 requested a room tray for breakfast from nursing staff. Resident 36 reported [gender] was told by the nurse Resident 36 could not eat in the room.Interview on 03/03/2026 at 8:37 AM with Food Service Employee (FSE)-J revealed a breakfast tray was not made for Resident 36. FSE-J further reported nursing staff were instructed to notify the kitchen when Resident 36 was ready to eat, and a tray would be made. FSE-J reported knowledge of Resident 36 being nauseated. FSE-J commented that nursing staff won't give Resident 36 a meal if Resident 36 did not want to come to the dining room.Interview on 03/03/2026 at 8:48 AM with Nursing Assistant (NA)-K revealed Resident 36 did not want to get out of bed because Resident 36 had been nauseated. NA-K revealed that when Resident 36 is nauseated, NA-K would offer Resident 36 choice between breakfast or a meal tray consisting of broth and toast. NA-K reported NA-H delivered room trays on the 100 hall.Interview on 03/03/2026 at 8:52 AM with NA-H revealed a breakfast tray was not delivered to Resident 36. NA-H reported Resident 36 cannot have food in the bed. NA-H further reported [gender] was educated that if Resident 36 did not want to get out of bed, the meal is documented as a refusal.During a follow up interview on 03/03/2026 at 9:13 AM, NA-K reported they were educated that if Resident 36 refused to get out of bed for the meal, the meal was documented as refused.Interview on 03/03/2026 at 9:30 AM with RN-A revealed Resident 36 did not want to get out of bed for breakfast. RN-A reported an explanation was provided to Resident 36 there was an order that the resident must get out of bed to eat. RN-A stated Resident 36 did not like my response and sent the Director of Nursing (DON) to the resident's room.Interview on 03/03/2026 at 9:36 AM with the DON revealed the DON informed Resident 36 needed to get up in the wheelchair to eat and Resident 36 agreed. The DON further reported when they walked down the hall a moment ago, Resident 36 was still in bed without a breakfast tray.Interview on 03/03/2026 at 9:50 AM with FSE-J revealed no breakfast tray had been made for Resident 36.During a follow up interview on 03/04/2026 at 10:39 AM, Resident 36 reported that [gender] does like breakfast. Resident 36 further reported not getting a meal if Resident 36 did not get out of bed had been happening for a few weeks, maybe longer.Interview on 03/04/2026 at 12:24 PM with FSE-M revealed if Resident 36 did not get up for meals, they didn't receive a meal. FSE-M reported that they did not feel like that is right and reported this practice had been going on for months.Interview on 03/04/2026 at 12:25 with FSE-J confirmed meal tray issues for Resident 36 had been going on for several months. FSE-J reported they felt the resident not receiving a room tray contributed to Resident 36's weight loss.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to ensure 2 (Resident 1 and 3) of 2 sampled resident's oxygen (o2) was set at the ordered settings and ensure 1 (Resident 3) of 1 sampled resident's Bilevel Positive Airway Pressure device (BiPAP) was administered as ordered. The facility census was 40. Findings are:A.A record review of the facility's Oxygen Administration policy with a date Reviewed/Revised of 04/2025 revealed Oxygen was to be administered under orders of a physician and the Care Plan would include settings for the prescribed flow rate. A record review of Resident 1's Order Summary Report dated 03/03/2026 did not reveal an order for oxygen. A record review of Resident 1's Clinical Physician's Orders dated 03/03/2026 did not reveal an order for oxygen. A record review of Resident 1's Care Plan with an admission Date of 12/28/2016 revealed the resident had oxygen therapy and the setting was for 3 liters per minute (l/m). A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated January - March 2026 revealed the facility was checking the resident's oxygen saturations (percent of oxygen in the blood) twice per day, but it did not include the setting the rest was completed on. A record review of Resident 1's Physician's Telephone Orders dated 11/29/2025 revealed an order for o2 at 3 l/m continuous, inform medical doctor if oxygen saturations less than 89%. It was signed by the provider 12/11/2025. An observation on 03/03/2026 at 8:01 AM revealed Resident 1 was seated in the recliner, the resident had a nasal cannula (tubing that goes in the nose to deliver oxygen) on, and the resident's oxygen concentrator (a machine used to purify oxygen) was set at 2 l/m. An observation on 03/03/2026 at 12:06 PM revealed Resident 1 was seated in the recliner, the resident had a nasal cannula on, and the resident's oxygen concentrator was set at 2 l/m. The resident got up and walked to the dining room without oxygen on, but did have a tank attached to the front of the walker. The resident was breathing heavy when the resident got seated in the dining room. An observation on 03/04/2026 at 7:31 AM with the Director of Nursing/Registered Nurse (DONRN) revealed Resident 1 was seated in the recliner, the resident had a nasal cannula on, and the resident's oxygen concentrator was set at 2 l/m. The DONRN confirmed there was a provider order in the Electronic Medical Record dated 12/11/2025 for o2 at 3 l/m continuously. The DONRN confirmed the resident's oxygen concentrator should have been set at 3 l/m. B.A record review of the facility's Oxygen Administration policy with a date Reviewed/Revised of 04/2025 revealed Oxygen was to be administered under orders of a physician and the Care Plan would include settings for the prescribed flow rate. A record review of Resident 3's Order Summary Report dated 03/04/2026 revealed an order for oxygen at 3 l/m via nasal cannula to keep the resident's oxygen level above 90 percent (%) and 2 l/m bled into the resident's BiPAP at hours of sleep (HS) and as needed (PRN). A record review of Resident 3's Clinical Physician's Orders dated 03/04/2026 revealed an order for oxygen at 3 l/m via nasal cannula to keep the resident's oxygen level above 90% and 2 l/m bled into the resident's BiPAP at HS and PRN. A record review of Resident 3's Care Plan with an admission Date of 10/27/2025 revealed the resident used supplemental oxygen at 3 l/m PRN, the resident used oxygen often in the evenings and staff was to document the PRN use, and staff was to document o2 prior to use and report it to the charge nurse. The resident also had oxygen and BiPAP at HS and the setting was for 2 l/m. A record review of Resident 3's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2026 - March 3rd, 2026 revealed that the staff marked the resident wore the BiPAP with oxygen bled-in every night except 02/04/2026 and the staff did not document the resident used o2 at 3 l/m via nasal cannula. An observation on 03/02/2026 at 9:01 AM revealed that Resident 3's oxygen concentrator was set at 2 l/m. An observation on 03/04/2026 at 1:59 PM with the DONRN revealed that Resident 3's oxygen concentrator was set at 2 l/m. In an interview on 03/02/2026 at 9:01 AM, Resident 3, with DONRN present, confirmed the resident did not use the BiPAP at night, but did use oxygen via nasal cannula and it was supposed to be set at 2 l/m. In an interview on 03/04/2026 at 1:59 PM, DONRN confirmed that Resident 3's oxygen concentrator was set at 2 l/m, the order was for 3 l/m when using the nasal cannula, and the resident's oxygen should have been set at 3 l/m. C.A record review of the facility's Noninvasive Ventilation (Continuous Positive Airway Pressure (CPAP), BiPAP, Trilogy (a ventilator) policy Date Reviewed/Revised of 02/2026 revealed it was the policy of the facility to provide noninvasive ventilation as per physician's orders and current standards of practice. The staff would document the use of the machine and the resident's tolerance. A record review of the facility's Oxygen Administration policy with a date Reviewed/Revised of 04/2025 revealed Oxygen was to be administered under orders of a physician. A record review of Resident 3's Order Summary Report dated 03/04/2026 revealed an order for BiPAP at HS and PRN with oxygen bled in at 2 l/m. A record review of Resident 3's Clinical Physician's Orders dated 03/04/2026 revealed an order BiPAP at HS and PRN with 2 l/m bled-in. A record review of Resident 3's Care Plan with an admission Date of 10/27/2025 revealed the resident used BiPAP related to sleep apnea and shortness of breath. The resident had a history of refusing the BiPAP and staff was to document all refusals and o2 status at the time of refusal, supplemental oxygen at 3 l/m PRN, the resident used oxygen often in the evenings and staff was to document the PRN use, and staff was to document o2 prior to use and report it to the charge nurse. The resident also had oxygen and BiPAP at HS and the setting was for 2 l/m. The Care Plan revealed be sure to document PRN oxygen use. A record review of Resident 3's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2026 - March 3rd, 2026, revealed that the staff marked the resident wore the BiPAP with oxygen bled-in every night except 02/04/2026 and the staff did not document the resident used o2 at 3 l/m via nasal cannula. An observation on 03/02/2026 at 9:01 AM revealed that Resident 3's BiPAP was unplugged and male end of the cord was laying on the floor in front of the bedside table and to the left of the bedside table. The oxygen concentrator had a nasal cannula hooked to it and it was set at 2 l/m. The mask was laying on top of the BiPAP facing toward the door. An observation on 03/03/2026 at 8:12 AM revealed that Resident 3's BiPAP was unplugged and the male end of the cord was laying on the floor in front of the bedside table and to the left of the bedside table. The oxygen concentrator had a nasal cannula hooked to it and it was set at 2 l/m. The mask was laying on top of the BiPAP facing toward the door, unchanged from 03/02/2026. An observation on 03/04/2026 at 7:34 AM revealed that Resident 3's BiPAP was unplugged and the male end of the cord was laying on the floor in front of the bedside table and to the left of the bedside table. The oxygen concentrator had a nasal cannula hooked to it and it was set at 2 l/m. The mask was laying on top of the BiPAP facing toward the door, unchanged from 03/03/2026. An observation on 03/04/2026 at 1:59 PM with the DONRN revealed that Resident 3's BiPAP was unplugged and the male end of the cord was laying on the floor in front of the bedside table and to the left of the bedside table. The oxygen concentrator had a nasal cannula hooked to it and it was set at 2 l/m. The mask was laying on top of the BiPAP facing toward the door, unchanged from 03/03/2026. In an interview on 03/02/2026 at 9:01 AM, Resident 3 confirmed the resident did not use the BiPAP at night, but did use oxygen via nasal cannula and it was supposed to be set at 2 l/m. The resident confirmed it had been weeks since the resident used the BiPAP. The mask wasn't working so the resident's company sent the resident a new one, the resident did not know how to put it together, and the new supplies were in the resident's closet because the staff did not know how to do it either. In an interview on 03/03/2026 at 8:25 AM Resident 3 with DONRN present, confirmed the staff did not ask or attempt to place the BiPAP on the resident. In an interview on 03/04/2026 at 1:59 PM, DONRN confirmed that Resident 3's BiPAP had not been used since the cord and mask were in the same spot since 03/02/2026 and the staff should have been applying Resident 3's BiPAP and oxygen at night.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to provide effective pain management to 1 (Resident 6) of 1 sampled resident. The facility census was 40. Findings are:A record review of the facility's Pain Management policy with a Reviewed/Revised date of 02/2026 revealed pharmacological interventions would follow a systematic approach for selecting medications and doses to treat pain. The staff would reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects A record review of Resident 6's Clinical Census dated 03/03/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 6's Medical Diagnosis dated 03/03/2026 revealed the resident had diagnoses of Unspecified Fracture of the Right Patella (broken right knee cap), Unspecified Fracture Of The Right Lower Leg, Difficulty Walking, Schizoaffective Disorder (severe mental illness), Mild Cognitive Impairment (trouble thinking and understanding), Anxiety, and Depression. A record review of Resident 6's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/08/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was independent with bathing and dressing and required setup or clean-up assistance with eating, oral and personal hygiene (cleaning), footwear, and toileting hygiene. The resident was independent for bed mobility and needed setup or clean-up assistance with transfers. The resident frequently experienced pain or hurting that frequently made it hard to sleep at night and limited the resident's day-to-day activities. The resident rated the pain at 8 out of 10. The resident was not on an Opioid (pain medicine). A record review of Resident 6's Care Plan Report with print date of 03/03/2026 revealed the resident had limited physical mobility related to fractures and an intervention of the resident may require staff encouragement to place equipment nearby to ensure safety with praising efforts. The resident had a focus area of the resident was admitted for short term rehab fracture and an intervention to administer medications per provider's order. The resident had a focus area of acute (sudden onset)/Chronic (long term) pain related to patellar/ankle fracture. The goals were pain level recognized by staff by facial expression if non-verbal and resident will have an acceptable level 1 hour after intervention initiated. Interventions were distracting activities, medication as ordered, and reposition. A record review of the Physical Therapy (PT) Evaluation and (&) Plan of Treatment dated 01/10/2026 - 03/10/2026 revealed the resident had a constant pain level of 5 out of 10. A record review of the facility's Pain Assessment (3.0)*342024V1 dated 01/06/2026 revealed Resident 6 had pain or hurting in the last 5 days. It did not indicate a location. The pain was frequent and frequently affected sleep. The pain frequently interfered with the resident's day-to-day activities. Indicators of pain were non-verbal sounds, vocal complaints, and protective bodily movements. The resident had daily indicators of pain. The resident received scheduled pain medicine, but not as needed (PRN) pain medications, and did not receive non-medication interventions for pain. A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated March 2026 revealed the resident had pain medication orders of take two 500 milligram (mg) tablets Acetaminophen (Tylenol) 3 times daily at 8:00 AM, 12:00 PM, and 8:00 PM. The resident had pain levels greater than 5 seven out of ten times the medication was administered. Every shift pain monitoring at 6:00 AM and 6:00 PM revealed pain levels greater than 5 and up to 9 six out of seven shifts. The MAR & TAR did not reveal any other pharmalogical or non-pharmalogical pain relief interventions. A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2026 revealed the resident had pain medication orders of take two 500 mg tablets Acetaminophen 3 times daily at 8:00 AM, 12:00 PM, and 8:00 PM. The resident had pain levels greater than 5 forty-two out of eighty-four times the medication was administered. Every shift pain monitoring at 6:00 AM and 6:00 PM revealed pain levels greater than 5 and up to 8 thirty-three out of fifty-six shifts. The MAR & TAR did reveal a muscle rub cream 4 times a day as needed 02/01/2026 - 02/09/2026, but it was not administered. A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated January 2026 revealed the resident had pain medication orders of take two 500 mg tablets Acetaminophen 3 times daily at 8:00 AM, 12:00 PM, and 8:00 PM. The resident had pain levels greater than 5 forty-four out of ninety-three times the medication was administered. Every shift pain monitoring at 6:00 AM and 6:00 PM revealed pain levels greater than 5 and up to 8 thirty-five out of sixty-two shifts. The MAR & TAR did reveal a muscle rub cream as needed 01/09/2026 - 01/31/2026, but it was not administered. A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated December 2025 revealed the resident had pain medication orders of take two 500 mg tablets Acetaminophen 3 times daily at 8:00 AM, 12:00 PM, and 8:00 PM. The resident had pain levels greater than 5 thirty-two out of ninety-three times the medication was administered. Every shift pain monitoring at 6:00 AM and 6:00 PM revealed pain levels greater than 5 and up to 9 twenty eight out of sixty-two shifts. The MAR & TAR did reveal an order for Oxycodone (a pain reliever medication) 2.5 mg three times daily as needed for pain 12/15/2026 - 12/27/2026, but it was not administered. A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated November 2025 revealed the resident had pain medication orders of take two 500 mg tablets Acetaminophen 3 times daily at 8:00 AM, 12:00 PM, and 8:00 PM. The resident had pain levels greater than 5 forty-four out of ninety times the medication was administered. Every shift pain monitoring at 6:00 AM and 6:00 PM revealed pain levels greater than 5 and up to 8 thirty-six out of sixty shifts. The MAR & TAR did reveal an order for Oxycodone 2.5 mg three times daily as needed for pain 11/06/2026 - 11/19/2026, but it was only administered once on 11/09/2025 for a pain level of 7. In an interview on 03/02/2026 at 10:51 AM, Resident 6 confirmed the resident had pain to the right lower leg related to a fall with fracture in September of 2025. Resident 6 confirmed the resident thought the resident was on hydrocodone (a pain-relieving medication). The resident confirmed the normal pain level for the resident was 7 to 9.5. In an interview on 03/03/2026 at 12:29 PM, Resident 6 confirmed the resident had spoken with the nurse several months ago about the resident's pain, the nurse was going to speak with the doctor, and the resident had not heard anything since. In an interview on 03/04/2026 at 7:59 AM, Medication Aide (MA)-O confirmed Resident 6 never complained of pain and has not asked for PRN pain medicine. MA-O looked up the resident's orders and confirmed the resident did not have PRN pain medication orders. In an interview on 03/04/2026 at 8:04 AM, Registered Nurse (RN)-A confirmed Resident 6 does complain of pain to the medication aides and the resident had a PRN Oxycodone order. In an interview on 03/04/2026 at 12:27 PM, RN-A confirmed if Resident 6 had a high pain level, staff should complete a pain assessment and see if the resident had a PRN acetaminophen order or PRN oxycodone order and ask what the resident wanted. RN-A confirmed Resident 6 complained of pain to the nurse that morning, so RN-A asked the resident if the resident wanted just the scheduled acetaminophen or PRN oxycodone, and the resident said no to the PRN oxycodone. RN-A looked up the resident's orders and confirmed the resident did not have a PRN oxycodone order anymore. In an interview on 03/04/2026 at 12:32 PM, Resident 6 confirmed RN-A did not ask Resident 6 if the resident wanted PRN oxycodone for pain that morning. Resident 6 confirmed that Resident 6 would not refuse PRN pain medications if offered. In an interview on 03/05/2026 at 11:30 AM, Resident 6 confirmed sometimes the scheduled Acetaminophen helps the pain and sometimes not. The resident confirmed that the pain does affect the residents daily functioning and sleep. Sometimes the resident can't get to sleep until 6:00 AM. The resident confirmed the staff has never offered muscle rub or creams. In a telephone interview on 03/05/2026, Physical Therapist (PT)-C confirmed that Resident 6 does complain of pain when PT-C is working with the resident. It was primarily when PT-C was working on weightbearing exercises with the resident. In an interview on 03/04/2026 at 12:57 PM, the facility's Director of Nursing/Registered Nurse (DONRN) confirmed the staff should have offered PRN Oxycodone or other interventions with Resident 6's high pain levels. DONRN confirmed it was DONRN's expectation that if a resident had high pain levels, the staff would contact the resident's provider for new pain management orders. In an interview on 03/05/2026 at 9:45 AM, DONRN confirmed the facility had not contacted the resident's provider to notify the provider of the high pain levels and should have. In an interview on 03/05/2026 at 11:54 AM, the interim Director of Nursing (IDON) confirmed the staff should have offered Resident 6 the PRN muscle rub creams when the resident had high pain levels and did not.

Licensure Reference Number 175 NAC 12-006.09(H)(vi) Based on observation, interview, and record review, the facility failed to identify and educate staff of 1 (Resident 3) of 1 sampled resident's Post Traumatic Stress Disorder (PTSD) and PTSD triggers (an event that caused immediate physical and emotion distress). The facility census was 40. Findings are:A record review of the facility's Behavioral Health Services policy with a Reviewed/Revised date 02/2026 all residents would receive necessary behavior health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning (ability to navigate daily life) and well-being. PTSD was defined as shocking, scary, or dangerous situations and symptoms that last more than a month and may be severe enough to interfere with a resident's daily life. All facility staff would receive education to ensure competencies and skill sets for meeting the resident's behavioral needs. Behavioral health training would include person centered care and services, meaningful activities, an environment conducive (making a certain situation possible) to mental and psychosocial well-being, non-pharmalogical (no medications) approaches to care, and care specific to an individual's needs. The facility would comprehensively (deal will all aspects) assess and identify a resident's mental and psychosocial status and provide person-centered care (specific to that resident). The facility would provide interventions that included individualized sleep routines, adjust the environment to be more preferred or homelike, support the resident through meaningful activities, and assist the resident with access to therapies, such as psychotherapy (treatment with a trained professional), behavior modification, cognitive behavioral therapy, and problem-solving therapy. The facility would assess and develop a person-centered care plan for the concerns identified in the assessment and document the changes, including the frequency of occurrence and potential triggers in the resident's record. A record review of Resident 3's Clinical Census dated 03/04/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 3's Medical Diagnoses dated 03/04/2026 revealed the resident had diagnoses of Dysthymic Disorder (chronic, long term, depression), Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Need For Assistance With Personal Cares, and PTSD. A record review of Resident 3's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/15/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was independent with oral hygiene (cleaning) and upper body dressing, required supervision or touching assistance with eating and bathing, the resident required setup or clean-up assistance with lower body dressing, and required partial/moderate assistance with upper body dressing, and personal hygiene. The resident did have mood symptoms, but no behaviors during the look-back period. The resident had serious mental illness and PTSD. A record review of the facility's Social Services Evaluation- Quarterly/ Sig (Significant) Chang* - V 2 dated 02/03/2026 did not revealed Resident 3 had a serious mental illness or intellectual disability but did not reveal the resident had a psychiatric diagnosis or social history and needs or concerns was blank. A record review of Resident 3's Trauma Informed Care Assessment12824 dated 11/13/2024 revealed the resident had experienced a frightening horrible or traumatic event. The resident tried hard not to think about or went out of the way to avoid situations that reminded the resident of the event. Been constantly on guard, watchful, or easily startled. Felt numb or detached from people, activities, or the resident's surroundings. The assessment did not reveal the resident's triggers from the event. A record review of the facility's Report of Consultation dated 03/04/2025 revealed the resident had PTSD and environmentally triggered anxiety. Recommendations were to continue to monitor and explore possible therapy, the resident could reach out if interested in starting. A record review of Resident 3's last Arbor Psychiatric and Wellness Center appointment dated 09/09/2025 revealed the resident had PTSD and the resident's chief complaint was daily headaches affecting concentration, chest pain, trouble breathing, anxiety related to living situation, irregular sleep pattern, and concerns about the resident's mood. The resident's stressors included severe stress due to housing concerns. The resident reported that the resident was struggling with negative thoughts and traumatic memories which may have been contributing to the resident's mood issues. The plan was to adjust the resident's medication, consider a change in living environment, and restarting therapy work to address past trauma and negative thought patterns. A record review of the facility's Communication re:BG email dated 03/04/2025 revealed Resident 3's psychiatric provider communicated to the facility that as a psychiatric medication provider, the primary role involved evaluation and management of psychiatric medications and that the provider did not routinely conduct detailed trauma therapy or formal triggers assessments. The resident had a history of PTSD, but specific triggers had not been identified. A record review of Resident 3's Care Plan Report with a print date of 03/04/2026 revealed a focus area of the resident had Major Depressive Disorder, Anxiety, PTSD, and Schizoaffective Disorder (chronic mental illness) with interventions of participation in activities. Ongoing dietary education, regular medication reviews, and social activities. The resident had a focus area of mood problems related to Bipolar Disorder, Depression, Anxiety, and PTSD. Interventions included medications, assisting the resident, family, and caregivers to identify strengths, positive coping skills and reinforce these, and encourage the resident to express the resident's feelings and provide the resident time to talk as needed. The Care Plan Report did not reveal triggers related to Resident 3's PTSD. A record review of Resident 3's Progress Notes 03/04/2026 revealed the only note that the staff had that may have been related to providing any services or interventions related to Resident 3's PTSD was on 04/17/2025 when the staff conducted a one on one with the resident and the resident was given a 48-hour notice of room change but it did not reveal what it was related to. A record review of Resident 3's Care Plan Report with a print date of 03/05/2026 revealed the staff added an intervention under the focus area mood problem related to Bipolar Disorder, Depression diagnosis, Anxiety diagnosis, and PTSD diagnosis of Avoid PTSD triggers such as sudden loud noises, dark rooms and not following through with tasks. The new intervention had a date initiated of 03/04/2026. An observation on 03/03/2026 at 8:12 AM revealed there was a shared bathroom with the room next door and that resident, Resident 26 also had a mental disorder. Resident 3 was using the restroom and Resident 26 needed to use the restroom and an unpleasant conversation occurred through the door. In an interview on 03/02/2026 at 8:47 AM, Resident 3 confirmed the resident had a history of PTSD related to the resident's mother and brother was abusive to the resident in the past. The resident confirmed that a couple of the resident's triggers were staff not listening to or dismissing the resident's concerns. The resident confirmed most of the time the resident could deal with it and sometimes it affected the resident. In an interview on 03/03/2026 at 8:25 AM, Resident 3 confirmed the resident had a bad night and had trouble sleeping due to the 2 residents in the next room were yelling at each other and playing loud music all night. In an interview on 03/04/2026 at 7:34 AM, Nursing Assistant (NA)-N confirmed that NA-N did not know if Resident 3 had PTSD. In an interview on 03/04/2026 at 7:52 AM, NA-H confirmed that NA-H did not know if Resident 3 had PTSD and had not seen any behaviors from the resident other than the resident gets bad headaches and gets medications for that. In an interview on 03/04/2026 at 7:59 AM Medication Aide (MA)-O confirmed MA-O did not know if Resident 3 had PTSD. In an interview on 03/04/2026 at 8:04 AM, Registered Nurse (RN)-A confirmed RN-A was not aware of Resident 3 having PTSD. In an interview on 03/04/2026 at 1:25 PM, the facility's Regional Director of Operations (RDO) confirmed interventions for the resident's PTSD were intermingled in the care plan interventions for depression and the staff should have looked there to know if the resident had PTSD and what the triggers were. In an interview on 03/04/2026 at 11:23 AM, the facility's SSD confirmed Resident 3 did have PTSD and the resident would get very anxious. The SSD confirmed the SSD did not know what Resident 3's PTSD triggers were. The SSD confirmed the only thing the facility was doing for Resident 3's PTSD was taking the resident to see the psychiatric provider to adjust the resident's medications. In an interview on 03/05/2026 at 11:23 AM, the facility's SSD confirmed Resident 3 the SSD had not had special education related to PTSD. The SSD confirmed the SSD had not discussed the possibility of starting therapy for the resident's PTSD. The SSD confirmed the resident sets the resident's own psychiatric appointments. The SSD confirmed the SSD was not doing anything specific to monitor or supplement the psychiatric provider's treatment plan. In an interview on 03/05/2026 at 10:24 AM, the facility's Interim Director of Nursing (IDON) confirmed they went and interviewed the resident on 03/04/2026 and added PTSD triggers to the care plan so the PTSD and triggers would show up on the staff's Kardex (electronic documents that sums up a resident's needs). The IDON confirmed Resident 3's PTSD triggers had not been identified and were not on the care plan before.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(1) Based on observation, interview, and record review, the facility failed to provide medically related social services for 1 (Resident 3) of 1 sampled resident's Post Traumatic Stress Disorder (PTSD). The facility census was 40. Findings are:A record review of the facility's Behavioral Health Services policy with a Reviewed/Revised date 02/2026 all residents would receive necessary behavior health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning (ability to navigate daily life) and well-being. PTSD was defined as shocking, scary, or dangerous situations and symptoms that last more than a month and may be severe enough to interfere with a resident's daily life. All facility staff would receive education to ensure competencies and skill sets for meeting the resident's behavioral needs. Behavioral health training would include person centered care and services, meaningful activities, an environment conducive (making a certain situation possible)to mental and psychosocial well-being, non-pharmalogical (no medications) approaches to care, and care specific to an individual's needs. The Social Services Director (SSD) would be the facility's contact person for questions regarding behavioral services provided. A record review of Resident 3's Clinical Census dated 03/04/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 3's Medical Diagnoses dated 03/04/2026 revealed the resident had diagnoses of Dysthymic Disorder (chronic, long term, depression), Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Need For Assistance With Personal Cares, and PTSD. A record review of Resident 3's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/15/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was independent with oral hygiene (cleaning) and upper body dressing, required supervision or touching assistance with eating and bathing, the resident required setup or clean-up assistance with lower body dressing, and required partial/moderate assistance with upper body dressing, and personal hygiene. The resident did have mood symptoms, but no behaviors. The resident had serious mental illness and PTSD. A record review of Resident 3's Care Plan Report with a print date of 03/04/2026 revealed a focus area of the resident had Major Depressive Disorder, Anxiety, PTSD, and Schizoaffective Disorder (chronic mental illness) with interventions of participation in activities. Ongoing dietary education, regular medication reviews, and social activities. The resident had a focus area of mood problems related to Bipolar Disorder, Depression, Anxiety, and PTSD. Interventions included medications, assisting the resident, family, and caregivers to identify strengths, positive coping skills and reinforce these, and encourage resident to express the resident's feelings and provide the resident time to talk as needed. A record review of the facility's Social Services Evaluation- Quarterly/ Sig (Significant) Chang* - V 2 dated 02/03/2026 did not revealed Resident 3 had a serious mental illness or intellectual disability but did not reveal the resident had a psychiatric diagnosis or social history and needs or concerns was blank. A record review of the facility's Report of Consultation dated 03/04/2025 revealed the resident had PTSD and environmentally triggered anxiety. Recommendations were to continue to monitor and explore possible therapy, the resident could reach out if interested in starting. A record review of Resident 3's last Arbor Psychiatric and Wellness Center appointment dated 09/09/2025 revealed the resident had PTSD and the resident's chief complaint was daily headaches affecting concentration, chest pain, trouble breathing, anxiety related to living situation, irregular sleep pattern, and concerns about the resident's mood. The resident's stressors included severe stress due to housing concerns. The resident reported that the resident was struggling with negative thoughts and traumatic memories which may have been contributing to the resident's mood issues. The plan was to adjust the resident's medication, consider a change in living environment, and restarting therapy work to address past trauma and negative thought patterns. A record review of Resident 3's Progress Notes 03/04/2026 revealed the only note that the SSD had that may have been related to providing any services or interventions related to Resident 3's PTSD was on 04/17/2025 when the staff conducted a one on one with the resident and the resident was given a 48-hour notice of room change but it did not reveal what it was related to. An observation on 03/03/2026 at 8:12 AM revealed there was a shared bathroom with the room next door and that resident, Resident 26 also had a mental disorder. Resident 3 was using the restroom and Resident 26 needed to use the restroom and an unpleasant conversation occurred through the door. In an interview on 03/02/2026 at 8:47 AM, Resident 3 confirmed the resident had a history of PTSD related to the resident's mother and brother was abusive to the resident in the past. The resident confirmed a couple of the resident's triggers were staff not listening to or dismissing the resident's concerns. The resident confirmed most of the time the resident could deal with it and sometimes it affected the resident. In an interview on 03/03/2026 at 8:25 AM, Resident 3 confirmed the resident had a bad night and had trouble sleeping due to the 2 residents in the next room were yelling at each other and playing loud music all night. In an interview on 03/04/2026 at 11:23 AM, the facility's SSD confirmed Resident 3 did have PTSD and the resident would get very anxious. The SSD confirmed the SSD did not know what Resident 3's PTSD triggers (an event that caused immediate physical and emotion distress) were. The SSD confirmed the SSD had not discussed the possibility of starting therapy for the resident's PTSD. The SSD confirmed the only thing the facility was doing for Resident 3's PTSD was taking the resident to see the psychiatric provider to adjust the resident's medications. In an interview on 03/05/2026 at 11:23 AM, the facility's SSD confirmed Resident 3 the SSD had not had special education related to PTSD. The SSD confirmed the SSD had not discussed the possibility of starting therapy for the resident's PTSD. The SSD confirmed the resident sets the resident's own psychiatric appointments. The SSD confirmed the SSD was not doing anything specific to monitor or supplement the psychiatric provider's treatment plan.

Licensure Reference Number 175 NAC 12-006.04(F)(i) Based on interview and record review, the facility staff failed to ensure practitioner's orders were implemented related to ordered medications, ordered laboratory (Labs) testing and obtaining weights for Residents 1 and failed to obtain weights as ordered for Resident 3 of 3 sampled residents. The facility census was 46 residents. Findings are: A. A review of Resident 3's Face Admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure [a chronic condition in which the heart is unable to pump blood efficiently enough to meet the body's needs]. A review of Resident 3's admission orders dated 7/31/24 revealed order for daily weights. A review of Resident 3's Care Plan revealed a focus area identifying Resident 3 had congestive heart failure dated 8/14/24 with the following interventions: -Encourage adequate nutrition and offer small frequent feedings -Give cardiac medications as ordered -Monitor lab work including potassium, sodium, blood urea nitrogen, and creatinine -Monitor/document/report as needed any signs/symptoms of congestive heart failure -Weight monitoring daily A review of Resident 3's 8/2024 MAR [Medication Administration Record] and TAR [Treatment Administration Record] revealed 3 separate orders for weights. A review of Resident 3's 8/2024 MAR revealed an order for daily weights one time a day starting 8/1/24. Resident 3's MAR was completed as follows: -A check was placed in the boxes for 8/1/24-8/16/24 indicating the order was completed -A code indicating Resident 3 was out on pass was documented in the box for 8/17/24 -A code indicating Resident 3 was hospitalized was documented in the box for 8/18/24-8/19/24 -A code indicating other/see nurses note was documented in the box for 8/21/24 A review of Resident 3's 8/2024 TAR revealed an order for weight at admission, weekly for 4 weeks then monthly starting on the first and ending on the third of every month with a start date of 8/1/24. The following weights for Resident 3 were recorded for this order: -8/1/24 295 lbs. -8/2/24 295 lbs. -8/3/24 295 lbs. A review of Resident 3's 8/2024 TAR revealed an order for weight at admission, weekly for 4 weeks then monthly. This order was to be completed every day shift every 7 days for 28 days. The following weights for Resident 3 were recorded for this order: -8/7/24 314.5 lbs. -8/15/24 318.4 lbs. A review of Resident 3's electronic medical record weight report revealed the following weights for Resident 3: -7/30/24 at 3:38 PM 295.02 lbs. -7/30/24 at 10:36 PM 295 lbs. -8/6/24 at 11:52 AM 316 lbs. -8/7/24 at 2:19 PM 314.5 lbs. -8/11/24 at 2:05 PM 320.5 lbs. -8/12/24 at 1:45 PM 318.5 lbs. -8/14/24 at 2:45 PM 318.4 lbs. A review of Resident 3's electronic medical record, 8/2024 MAR and 8/2024 TAR did not reveal any weights recorded for 8/4/24, 8/5/24, 8/8/24, 8/9/24, 8/10/24, and 8/13/24. A review of communication with Resident 3's practitioners on the HUCO application [an application used by the facility to communicate with Resident 3's providers] revealed the facility notified the practitioners on 8/4/24 Resident 3 had 2 plus edema in bilateral extremities, getting red/warm to touch, and hurts. An order was received to increase Resident 3's Torsemide [a diuretic] to 50 milligrams (mg) once per day, verify compression hose were worn correctly, and daily weights. A review of communication dated 8/6/24 with Resident 3's practitioners on the HUCO application revealed the practitioners were notified Resident 3's weight was 316 lbs. which was a 24 lb. weight gain with redness spreading to mid-calf. An order was received to cancel lymphedema wrap and to apply edema wraps on in am and off in pm. A review of communication dated 8/7/24 with Resident 3's practitioners on the HUCO application revealed Resident 3's left ankle had pitting edema and was warm to the touch. Resident 3's practitioners were also notified Resident 3 had lost 4 lbs. An order was received to increase Keflex (a antibiotic medication) to 500 mg four times per day for 5 days. A review of communication dated 8/9/24 with Resident 3's practitioners on the HUCO application revealed swelling had reached Resident 3's thighs alone with redness, warm, and weeping. Resident 3 rated pain level at a 9. The following orders were received from Resident 3's practitioner: -Add Zaroxlyn [a diuretic] 5 mg orally every morning for congestive heart failure. -Basic Metabolic Panel lab [a test that measures 8 different substances in your blood] to be completed on 8/12/24. -Decrease Keflex back to 500 mg twice per day. -Doxycycline (a antibiotic medication) 100 mg orally twice per day for 1 week. -Cipro (a antibiotic medication) 500 mg orally twice per day for 1 week. -Elevate and continue edema warps. -Update tomorrow and Sunday please. A review of Resident 3's electronic medical record, order summary, and 8/2024 MAR/ TAR did not reveal the order for Zaroxlyn or Basic Metabolic Panel lab had been implemented as ordered. A review of Resident 3's Progress Notes revealed a weight warning dated 8/11/24 that identified a weight of 314.5 lbs. which was a 6.6% weight gain since admission. A review of Resident 3's Progress Note dated 8/16/24 at 9 AM revealed the following: -Resident reports [gender] is unable to move [gender] legs, complaints of weakness, headache and dyspnea [shortness of breath]. BLE [bilateral lower extremities] redness has increased and spread up to groin. T [temperature] 98.9, BP [blood pressure] 83/60, P [pulse] 112, O2 [oxygen saturation] 92%. MD [Medical Doctor] notified and orders send to ER [emergency room ]. Resident transported per rescue squad. A review of Resident 3's Progress Notes revealed a weight warning date 8/17/24 that identified a weight of 318.4 lbs. which was a 7.9% weight gain since admit. Further review of Resident 3's Progress note revealed Resident 3 was sent to emergency room . A review of Resident 3's Progress Note dated 8/17/24 revealed Resident 3 was in the hospital. In interviews on 9/10/24 at 1:22 PM and 1:52 PM, the Administrator confirmed no additional documented weights could be found for Resident 3 and orders for Zaroxlyn and a Basic Metabolic Panel were never completed. The Administrator reported orders on the application are to be written on paper and faxed to the pharmacy. The pharmacy then puts the order in the electronic medical record and staff must verify the order before for it to be activated. B. A review of Resident 1's Admission Record revealed Resident 1 was admitted to the facility on [DATE] with a heart failure and chronic kidney disease [disease or condition impairs kidney function]. In an interview on 9/10/24 at 11:25 AM, Resident 1 reported getting weighed when going down for a shower and estimated that Resident 1 is weighed 2-3 times per week. Resident 1 confirmed that Resident 1 refused to be weighed at times. A review of Resident 1's order summary revealed an order for daily weight monitoring dated 6/20/24 first thing in the morning after voiding. A review of Resident 1's Care Plan revealed a focus area identifying Resident 1 had renal insufficiency related to chronic kidney disease stage 3 dated 6/3/24 with the following interventions: -Assist resident with activities of daily living and ambulation as needed. Watch for shortness of breath and match level of assistance to resident's current energy level. -Elevate feet when sitting up in chair to help prevent dependent edema. -Monitor/document/report to MD as needed the following signs/symptoms: weight gain of over 2 lbs. a day; neck vein distension; difficulty breathing; increased heart rate; elevated blood pressure; skin temperature; peripheral pulse; level of consciousness; monitor breath sounds for crackles. A review of Resident 1's 8/2024 MAR revealed an order dated 6/21/24 for daily weight first thing in the morning after voiding. Resident 1's MAR was completed as follows: - A check was placed in the boxes for the following dates to indicate the order had been completed 8/1/24-8/13/24, 8/15/24, 8/16/24, 8/18/24-8/23/24, 8/26/24, and 8/28/24-8/30/24 -A code indicating Resident 1 had refused was documented in the box on 8/9/24, 8/17/24, 8/24/24, and 8/25/24 -A code indicating Resident 1 was out on pass was documented in the box for 8/14/24 -A code indicating other/see nurses note was documented in the boxes for 8/27/24 and 8/31/24 A review of Resident 1's 8/2024 MAR revealed an order for weekly weights to be faxed to Resident 1's doctor and to notify of Resident 1's doctor of refusal on a weekly basis. A weight of 312.5 lbs. was documented on 8/28/24 for Resident 1. A review of Resident 1's 9/2024 MAR for dates between 9/1/24-9/9/24 revealed an order dated 6/21/24 for daily weight first thin in the morning after voiding. Resident 1's MAR was completed as follows: -A check was placed in the boxes for the following dates to indicate the order had been completed on 9/1/24 -A code indicating Resident 1 had refused was documented in the box on 9/2/24-9/4/24 and 9/6/24-9/9/24 -A code indicating other/see nurses note was documented in the boxes for 9/5/24 and 9/9/24 A review of Resident 1's electronic medical record weight report revealed the following weights for 8/2024 for Resident 1: -8/28/24 12:37 PM 312.5 lbs. -8/8/24 12;29 PM 309.5 lbs. A review of Resident 1's electronic medical record weight report did not reveal any weights recorded for 9/2024. A review of Resident 1's electronic medical record, 8/2024 MAR/TAR, and 9/2024 MAR/TAR did not reveal any additional weights recorded for Resident 1. In an interview on 9/10/24 at 11:29 AM, the Administrator confirmed no additional weights for Resident 1 had been located. The Administrator reported monitoring Resident 1's MAR/TAR and noted that the weighs had been checked off as being done. The Administrator reported discovering in the last couple of days that the Resident 1's daily weights had not been done. C. A review of undated facility policy titled How to use the Tele Doc: revealed the TeleDoc [HUCU] is the preferred way of contacting the provider group and identified the following procedure: -1. Log in information is located on the back of the Tele Doc tablet. -2. You use the Tele Doc like a smart phone. You can also send pictures if needed. -3. You MUST check the Tele Doc periodically throughout your shift. -4. All [Doctor] admissions you will take a picture of the discharge orders from the hospital. [Doctor] will then text back any changes to the orders. You will then write out the medication orders on a telephone order sheet and fax that to pharmacy. -5. Any orders received via the Tele Doc you must write out on to telephone order sheet. After processing the order put the telephone order into [Doctor] folder to be signed by [gender] on Thursday. -6. Notify [Doctor] of any of [gender] patient's behaviors, medications not given, falls and change of conditions. -7. [Doctor] wants to be notified via Tele Doc if a resident has a fall what caused the fall and what intervention will be placed to keep it from happening again.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to implement interventions, evaluate casual factors and evaluate the condition of the development of a pressure ulcer for 1 (Resident 40) of 4 sampled residents. The facility staff identified a census of 38. Findings are: Record review of Resident 40's Admission/Readmission Nursing Evaluation ([NAME]) dated 5-06-2022 revealed had [CONDITION(S)] and a [CONDITION(S)]. According to the [NAME] dated 5-06-2022 Resident 40 was evaluated as a low risk for the development of a pressure ulcer. Resident 40's [NAME] did not identify Resident 40 had a pressure ulcer. Record review of Resident 40's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 5-09-2022 revealed the facility staff assessed the following about the resident: - Brief Interview of Mental Status (BIMS) was a 3. According to the MDS Manuel a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. - Was not at risk and did not have a pressure ulcer. Record review of Resident 40's progress note dated 5-03-2022 revealed Resident 40 was sent to the hospital after a fall resulting in a left [CONDITION(S)]. Record review of Resident 40's Progress note dated 5-06-2022 revealed Resident 40 had readmitted to the facility. Record review of Resident 40's Order Summary Report printed on 6-01-2022 revealed Resident 40 had orders for a weekly skin assessment and to document results in the weekly skin assessment. Record review of Resident 40's medical record that included Progress notes, TAR (Treatment Administration Record), Practitioners orders and weekly skin assessments revealed on 5-06-2022 a weekly skin check had been completed. Further review of Resident 40's medical record revealed there was not weekly skin assessments completed with a documented result for May 2022 after Resident 40 returned from the hospital. Record review of Resident 40's Progress note dated 5-28-2022 revealed Resident 40 was identified with a pressure ulcer to the left heel. Record review of an unsigned Weekly Wound Evaluation dated 5-31-2022 revealed Resident 40 was assessed as having a stage 2 ( Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right heel that was acquired in the facility. Observation on 6-02-2022 at 10:00 AM of wound care by Licensed Practical Nurse (LPN) L revealed Resident 40 had a pressure ulcer to the left heel that measured approximately 4.5 centimeters (cm) roundish with necrotic whitish tissue in the center. Resident's right heel did not have skin breakdown during the observation. Review of Resident 40's medical record revealed there was not evidence the facility staff had evaluated the casual factors for the development of Resident 40's left heel pressure ulcer. In addition, Resident 40's medical record did not contain an assessment of the condition of the pressure that included measurement, description of the left heel pressure ulcer such as type of drainage, odor and wound bed. Further review of Resident 40's medical record that included care plans revealed there was no interventions implemented upon Resident 40's return to the facility to prevent the pressure ulcer to the left heel. Record review of a Wound Evaluation Sheet dated 6-02-2022 at 11:20 AM revealed Advanced Practice Registered Nurse (APRN) Q assessed Resident 40 with a unstageable (obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue) that measured 3.14 cm by 4.55 cm with a depth of 0.10 cm and had 30 percent eschar covering the pressure ulcer. APRN Q identified the left heel pressure was facility acquired. On 6-06-2022 at 11:17 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 40's weekly skin assessments had not been completed and further confirmed an assessment when the left heel pressure ulcer with casual factors had not been completed and should have been. Record review of the facility Policy and Procedure for Skin Assessment revised on 10/2022 revealed the following information: -Policy: -It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. The policy includes the following procedural guideline in performing the full body skin assessment. -Policy Explanation and Compliance Guidelines: -1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. -7. Documentation of skin assessment: -a. Include date and time of the assessment, your name and position title. -c. Document type of wound. -d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor or pain).

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to implement a pain management program for 1 sampled resident (Resident 40). The facility had a total census of 36 residents. The sample size was 12. The findings are: A review of a wound assessment for Resident 40 dated 7/28/22 and completed by DNP K (Doctor of Nursing Practice) revealed Resident 40 had an unstageable pressure ulcer to their left heel that measured 2.31 cm (centimeters) x 3.03 cm with a depth of 0.2 cm. DNP K documented that the wound had deteriorated since the last evaluation on 7/14/22. An observation on 8/18/22 at 8:45 AM revealed RN A (Registered Nurse) provided wound care to a pressure ulcer on Resident 40's left heel. Resident 40 was lying in bed with pressure-relieving boots noted to be in the recliner chair in the room and not on Resident 40. The pressure ulcer to Resident 40's left heel was open to air with no dressing in place. Resident 40's pressure ulcer was observed to be a little larger than quarter-sized with a blackened wound bed. The skin surrounding Resident 40's pressure ulcer was reddened. Resident 40 stated their heel was painful. RN A changed their gloves and cleansed the pressure ulcer using sterile gauze and Dakins 1/2 strength (a topical antiseptic used to clean wounds), then patted it dry with sterile gauze. As RN A cleansed Resident 40's wound, Resident 40 cried out, That hurts! That hurts! RN A opened a package of Xeroform (a sterile, non-adherent, gauze dressing) and squeezed Santyl ointment (a topical medication used to remove dead skin tissue to allow for wound healing) onto it. RN A placed the Xeroform with Santyl onto Resident 40's left heel pressure ulcer and then wrapped it with Kerlix (a white, gauze, bandage dressing) and taped to secure the dressing. Throughout the treatment, Resident 40 yelled things like, Oh my God, that's terrible! and, Boy, that really hurts! RN A changed their gloves and applied the pressure relieving boots to both of Resident 40's feet. RN A changed their gloves and cleaned up the room. As RN A left the room, Resident 40 stated again that their left foot really hurt. RN A exited the room without offering Resident 40 any interventions for pain management. A review of Resident 40's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Acetaminophen (Tylenol) 500mg - 2 tablets by mouth three times daily for pain- scheduled at 8:00 AM, 2:00 PM, and 8:00 PM. -[MEDICATION(S)] (a narcotic pain medication) 5mg - one tablet by mouth every 6 hours as need for severe pain Further review of Resident 40's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 8/18/22 at 11:58 AM, RN A confirmed Resident 40 complained of pain during the wound care that was provided earlier that morning. RN A stated they did not stop the treatment to attempt to treat Resident 40's pain because Resident 40 would refuse the pain medication, as Resident 40 often refused medications. RN A reported Resident 40 gets scheduled Tylenol in the morning and RN A figured it was okay to continue with the wound care because they were in and out. RN A confirmed the scheduled Tylenol Resident 40 received that morning did not seem effective controlling Resident 40's pain during wound care. A review of Resident 40's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 40's CCP (Comprehensive Care Plan), last revised 7/11/22, revealed the following interventions for pain management: -Administer analgesia (pain medication) as per orders. Give 1/2 hour before treatments or care. -Anticipate (Resident 40's) need for pain relief and respond immediately to any complaint of pain. -Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. -Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to implement a pain management program for 1 sampled resident (Resident 40). The facility had a total census of 36 residents. The sample size was 12. The findings are: A review of a wound assessment for Resident 40 dated 7/28/22 and completed by DNP K (Doctor of Nursing Practice) revealed Resident 40 had an unstageable pressure ulcer to their left heel that measured 2.31 cm (centimeters) x 3.03 cm with a depth of 0.2 cm. DNP K documented that the wound had deteriorated since the last evaluation on 7/14/22. An observation on 8/18/22 at 8:45 AM revealed RN A (Registered Nurse) provided wound care to a pressure ulcer on Resident 40's left heel. Resident 40 was lying in bed with pressure-relieving boots noted to be in the recliner chair in the room and not on Resident 40. The pressure ulcer to Resident 40's left heel was open to air with no dressing in place. Resident 40's pressure ulcer was observed to be a little larger than quarter-sized with a blackened wound bed. The skin surrounding Resident 40's pressure ulcer was reddened. Resident 40 stated their heel was painful. RN A changed their gloves and cleansed the pressure ulcer using sterile gauze and Dakins ½ strength (a topical antiseptic used to clean wounds), then patted it dry with sterile gauze. As RN A cleansed Resident 40's wound, Resident 40 cried out, That hurts! That hurts! RN A opened a package of Xeroform (a sterile, non-adherent, gauze dressing) and squeezed Santyl ointment (a topical medication used to remove dead skin tissue to allow for wound healing) onto it. RN A placed the Xeroform with Santyl onto Resident 40's left heel pressure ulcer and then wrapped it with Kerlix (a white, gauze, bandage dressing) and taped to secure the dressing. Throughout the treatment, Resident 40 yelled things like, Oh my God, that's terrible! and, Boy, that really hurts! RN A changed their gloves and applied the pressure relieving boots to both of Resident 40's feet. RN A changed their gloves and cleaned up the room. As RN A left the room, Resident 40 stated again that their left foot really hurt. RN A exited the room without offering Resident 40 any interventions for pain management. A review of Resident 40's August 2022 MAR revealed the following orders for pain management: -Acetaminophen (Tylenol) 500mg - 2 tablets by mouth three times daily for pain- scheduled at 8:00 AM, 2:00 PM, and 8:00 PM. -Oxycodone (a narcotic pain medication) 5mg - one tablet by mouth every 6 hours as need for severe pain Further review of Resident 40's August 2022 MAR revealed Resident 40 rated their pain at a 3 when given the Acetaminophen the morning of 8/18/22 and Resident 40 had not been given Oxycodone yet during the month of August 2022. In an interview on 8/18/22 at 11:58 AM, RN A confirmed Resident 40 complained of pain during the wound care that was provided earlier that morning. RN A stated they did not stop the treatment to attempt to treat Resident 40's pain because Resident 40 would refuse the pain medication, as Resident 40 often refused medications. RN A reported Resident 40 gets scheduled Tylenol in the morning and RN A figured it was okay to continue with the wound care because they were in and out. RN A confirmed the scheduled Tylenol Resident 40 received that morning did not seem effective controlling Resident 40's pain during wound care. A review of Resident 40's August 2022 MAR revealed Resident 40 refused their morning medications one time during the month of August, as of 8/18/22. A review of Resident 40's CCP (Comprehensive Care Plan), last revised 7/11/22, revealed the following interventions for pain management: -Administer analgesia (pain medication) as per orders. Give ½ hour before treatments or care. -Anticipate (Resident 40's) need for pain relief and respond immediately to any complaint of pain. -Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. -Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to clarify and implement a medication for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had a total census of 36 residents. The findings are: An observation on 8/18/22 at 11:40 AM revealed Resident 26 sat in a recliner in their room with their feet up in a reclined position. Resident 26 did not respond or open their eyes to voice or when NA H (Nurse Aide) repositioned the resident in their chair. In an interview on 8/18/22 at 11:40 AM, NA H reported Resident 26 had declined significantly since being diagnosed with COVID-19. NA H reported Resident 26 used to run in the hallways, but now wasn't even able to walk. A review of Resident 26's progress notes revealed the following: -7/31/22 - Resident 26 tested positive for COVID-19 with symptoms consisting of nasal drainage and congestion. -8/3/22 - Resident 26 was sent to the ED (Emergency Department) at 1:33 AM due to weakness and not eating or drinking. Resident 26 returned later that morning with orders from the hospital to continue to monitor oxygen saturation rates. -8/7/22 - Resident 26 was noted to be very weak and lethargic at times and was only able to eat soft foods. -8/8/22 - Nursing staff contacted Resident 26's physician at 12:42 PM due to concerns with Resident 26's condition. Resident 26 was not eating or drinking for staff; however, family had been able to get Resident 26 to eat small amounts. Resident 26's physician stated they would see Resident 26 the next day and instructed staff to send Resident 26 to the ED for evaluation and treatment if vital signs were unstable. -8/8/22 - At 5:44 PM, Resident 26's physician contacted the facility requesting Resident 26's vital signs. Resident 26's oxygen saturation was 90% and Resident 26's physician instructed family was to determine if they wanted Resident 26 sent to the ED. EMS (Emergency Medical Services) was called and when they arrived at the facility, Resident 26's oxygen saturation was 96%. At that time, Resident 26's family declined transfer to the ED. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -If symptoms less than 5 days, start nirmatrelvir 300mg/[MEDICATION(S)] 100mg (Paxlovid - an antiviral medication used to treat COVID-19 - dispensed as two 150mg tablets of nirmatrelvir and one 100mg tablet of [MEDICATION(S)]) take all 3 tablets together twice daily for 5 days. A review of Resident 26's August 2022 MAR (Medication Administration Record) did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a fax dated 8/2/22 from the facility's pharmacy regarding Resident 26's new order for Paxlovid revealed the following note: -(Resident 26) takes routine [MEDICATION(S)] (an anti-anxiety medication) - contraindicated with Paxlovid. In an interview on 8/18/22 at 3:08 PM, the DON (Director of Nursing) reported the facility did not implement the ordered Paxlovid for Resident 26 because of the fax from the pharmacist stating it was contraindicated with [MEDICATION(S)]. In an interview on 8/18/22 at 4:53 PM, the RDO (Regional Director of Operations) reported Resident 26's physician was notified about Resident 26 not receiving the Paxlovid by RN A (Registered Nurse) on 8/9/22 when Resident 26's physician was at the facility to see Resident 26. The RDO confirmed Resident 26's physician was not notified about the note from the pharmacy until a week after the Paxlovid was ordered and Resident 26 was outside the 5-day window to take the medication at that time. In an interview on 8/18/22 at 4:58 PM, the DON confirmed the Paxlovid order should have been clarified with Resident 26's physician immediately after the pharmacist identified the contraindication with the [MEDICATION(S)]. The DON further confirmed the error was significant and Resident 26 had declined since being diagnosed with COVID-19. A review of an article titled, 13 Things To Know About Paxlovid, the Latest COVID-19 Pill last updated 8/11/22 and retrieved from www.yalemedicine.org, revealed the following information: -(Paxlovid) .had an 89% reduction in the risk of hospitalization and death in the clincal trial . -Like all antivirals, Paxlovid works best early in the course of an illness - in this case, within the first five days of symptom onset . -Once you've been ill with the virus for more than a week, the damage done to the body in a severe case can't be undone by the antiviral.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to clarify and implement a medication for the treatment of COVID-19 for 1 (Resident 26) of 4 residents reviewed. The facility had a total census of 36 residents. The findings are: An observation on 8/18/22 at 11:40 AM revealed Resident 26 sat in a recliner in their room with their feet up in a reclined position. Resident 26 did not respond or open their eyes to voice or when NA H (Nurse Aide) repositioned the resident in their chair. In an interview on 8/18/22 at 11:40 AM, NA H reported Resident 26 had declined significantly since being diagnosed with COVID-19. NA H reported Resident 26 used to run in the hallways, but now wasn't even able to walk. A review of Resident 26's progress notes revealed the following: -7/31/22 - Resident 26 tested positive for COVID-19 with symptoms consisting of nasal drainage and congestion. -8/3/22 - Resident 26 was sent to the ED (Emergency Department) at 1:33 AM due to weakness and not eating or drinking. Resident 26 returned later that morning with orders from the hospital to continue to monitor oxygen saturation rates. -8/7/22 - Resident 26 was noted to be very weak and lethargic at times and was only able to eat soft foods. -8/8/22 - Nursing staff contacted Resident 26's physician at 12:42 PM due to concerns with Resident 26's condition. Resident 26 was not eating or drinking for staff; however, family had been able to get Resident 26 to eat small amounts. Resident 26's physician stated they would see Resident 26 the next day and instructed staff to send Resident 26 to the ED for evaluation and treatment if vital signs were unstable. -8/8/22 - At 5:44 PM, Resident 26's physician contacted the facility requesting Resident 26's vital signs. Resident 26's oxygen saturation was 90% and Resident 26's physician instructed family was to determine if they wanted Resident 26 sent to the ED. EMS (Emergency Medical Services) was called and when they arrived at the facility, Resident 26's oxygen saturation was 96%. At that time, Resident 26's family declined transfer to the ED. A review of a physician's order dated 8/1/22 for Resident 26 revealed the following: -If symptoms less than 5 days, start nirmatrelvir 300mg/ritonavir 100mg (Paxlovid - an antiviral medication used to treat COVID-19 - dispensed as two 150mg tablets of nirmatrelvir and one 100mg tablet of ritonavir) take all 3 tablets together twice daily for 5 days. A review of Resident 26's August 2022 MAR (Medication Administration Record) did not reveal an order for Paxlovid. A review of a fax dated 8/2/22 from the facility's pharmacy regarding Resident 26's new order for Paxlovid revealed the following note: -(Resident 26) takes routine clonazepam (an anti-anxiety medication) - contraindicated with Paxlovid. In an interview on 8/18/22 at 3:08 PM, the DON (Director of Nursing) reported the facility did not implement the ordered Paxlovid for Resident 26 because of the fax from the pharmacist stating it was contraindicated with clonazepam. In an interview on 8/18/22 at 4:53 PM, the RDO (Regional Director of Operations) reported Resident 26's physician was notified about Resident 26 not receiving the Paxlovid by RN A (Registered Nurse) on 8/9/22 when Resident 26's physician was at the facility to see Resident 26. The RDO confirmed Resident 26's physician was not notified about the note from the pharmacy until a week after the Paxlovid was ordered and Resident 26 was outside the 5-day window to take the medication at that time. In an interview on 8/18/22 at 4:58 PM, the DON confirmed the Paxlovid order should have been clarified with Resident 26's physician immediately after the pharmacist identified the contraindication with the clonazepam. The DON further confirmed the error was significant and Resident 26 had declined since being diagnosed with COVID-19. A review of an article titled, 13 Things To Know About Paxlovid, the Latest COVID-19 Pill last updated 8/11/22 and retrieved from www.yalemedicine.org, revealed the following information: -(Paxlovid) .had an 89% reduction in the risk of hospitalization and death in the clincal trial . -Like all antivirals, Paxlovid works best early in the course of an illness - in this case, within the first five days of symptom onset . -Once you've been ill with the virus for more than a week, the damage done to the body in a severe case can't be undone by the antiviral.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on interviews, record reviews, and review of policy and procedures, it was determined the facility failed to ensure 2 (Resident 7 and Resident 251) of 3 residents reviewed that were receiving wound treatments were provided care and services in accordance with professional standards of practice that met the resident's needs to promote healing by failing to: 1) implement skin and wound assessments 2) Implement dressing changes as ordered and 3) Notify the physician and/or family of a change of condition. Resident 7 did not receive ordered dressing changes for a left foot laceration. As a result, the resident was hospitalized with septic shock due to [MEDICAL CONDITION] of the left lower extremities resident returned to the facility for approximately one month admitted to a hospital again for bilateral amputations of both great toes due to osteo[DIAGNOSES REDACTED]. Resident 251 did not receive ordered dressing changes for a right foot wound, as a result, the wound deteriorated and became infected. These failures resulted in harm to these two residents. The Director of Nurses (DON) indicated 7 residents were receiving wound treatments. The DON indicated all residents received skin assessments. The facility census was 51. Findings are: 1. Resident 7 had [DIAGNOSES REDACTED]. Physician orders, dated 12/11/19, documented, Weekly skin assessment. Assess skin color, temperature, [MEDICAL CONDITION], turgor, moisture and integrity. Document any wounds, bruises, etc. every evening shift every Wed for Skin monitoring. A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had been admitted to the facility on [DATE] and was moderately impaired in cognitive skills for daily decision making. The resident had behaviors of rejecting care one to three days of the seven-day look-back period. The resident did not walk but used a wheelchair for locomotion with supervision. The resident had a history of [REDACTED]. A progress note, dated 02/17/20, documented after a fall on 02/15/20 the resident received a skin tear to the left toe. The note documented the resident was sent to a local emergency room and discharge instructions were received. emergency room (ER) notes dated, 02/15/20, indicated Resident 7 had an abrasion of the left great toe of approximately 7 mm (millimeters/approximately 1/4 inch) in diameter. The note indicated the resident was able to move the left great toe without any pain, and the wound was not deep enough to apply sutures or glue. Discharge instructions included, .Change dressing daily. Keep clean. Watch for signs of infection including redness, swelling, fever, or increased pain . Resident 7's Treatment Administration Record (TAR), dated February 2020, did not include the documentation of the treatment of [REDACTED]. Nursing progress notes were reviewed through the end of February 2020 and did not reveal documentation the resident's dressing had been changed or dressing changes had been attempted but refused by the resident. A review of Weekly Skin Check documentation for February 2020 indicated incomplete assessment information. A Weekly Skin Check, dated 02/16/20, documented, .open area to l (left) great toe - steri strips in place with non-stick and coban to secure . The next day the Weekly Skin Check, dated 02/17/20, documented, .No discoloration or open areas noted . There was no mention of the wound to the left great toe. A Weekly Skin Check, dated 02/26/20, documented, .Left great toe with discolored around the toe purplish brown bandage remains in place . A Weekly Skin Check, dated 02/27/20, documented, .No marks or injuries . There was no mention of the wound to the left great toe. A Weekly Skin Check, dated 02/28/20, documented, .Left great toe is light pink around area where the bandage is. A review of records indicated no documentation daily dressing changes had been implemented from the ER discharge orders of 02/15/20. A nurse's Progress Note, dated 03/03/20 at 8:44 PM, indicated Resident 7 experienced a change in level of consciousness and was sent to a local emergency room . A nurse's Progress Note, dated 03/04/20 at 1:07 AM, indicated ER staff called the facility and reported the resident was in septic shock (a life-threatening condition) and was being transferred to a larger hospital for admission. ER staff indicated the source of [MEDICAL CONDITION] (severe infection) was unknown. A physician's orders [REDACTED]. The order stated, .Cleanse area prior to [MEDICATION NAME] paint over wound cover with [MEDICATION NAME] or other nonadherent . The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A Summary of Skilled Services Note, dated 03/09/20 at 4:15 PM, indicated the resident returned to the facility, .Left lower leg with [MEDICAL CONDITION] wear mesh from just below the knee to the bottom of larger toes. (Gender) has a dressing on the left great toe . The MAR indicated [REDACTED]. Records indicated Resident 7 had received antibiotics [MEDICATION NAME] and [MEDICATION NAME] while in the hospital. A Summary of a Skilled Services Note, dated 03/10/20 at 1:33 AM, indicated Resident 7 returned to the facility and was receiving an antibiotic [MEDICAL CONDITION]. A Summary of a Skilled Services Note, dated 03/10/20 at 2:24 AM, indicated the resident was receiving an antibiotic for, .infection to wound to LLE (left lower extremity) at medial great toe .Wound is open with yellow drainage noted, [MEDICAL CONDITION] noted, peri (around) wound is red. Dressing changed, sterile border gauze used . A Summary of a Skilled Services Note, dated 03/13/20 at 3:13 PM, documented Resident 7 complained of pain to the left great toe, and redness around the wound. The TAR, dated 03/13/20, indicated the resident's dressing to the left toe had not been changed. The TAR did not indicate the resident had refused a dressing change. A nurse's Progress Note, dated 03/15/20 at 3:29 PM, indicated the resident had experienced some pain, but did not indicate where the pain was located. The note documented, .Legs elevated up between meals and activity. Dressing to toe. Has some slight pinkness and swelling no drainage. The TAR, dated 03/15/20, indicated Resident 7's dressing to the left toe had not been changed. The TAR did not indicate the resident had refused a dressing change. A review of Skilled Services Notes, Nurse's Progress Notes, and Nutrition Progress Notes, all dated 03/16/20, indicated the resident's skin was pink, warm, dry, and intact with trace [MEDICAL CONDITION]. There was no assessment documenting the wound on the left great toe. The TAR, dated 03/16/20, indicated the resident's dressing to the left toe had not been changed. The TAR did not indicate the resident had refused a dressing change. A Medication Administration Note, dated 03/18/20, documented the weekly skin assessment was not scheduled so it was not done. A review of Nursing and Skilled Progress, dated 03/18/20, indicated no assessment of the wound had been documented. While nursing notes documented the resident refused a blood draw on 03/18/20, there was no documentation the resident had refused the dressing change to his left toe. There was no documentation the resident's left toe wound had been assessed or the dressing changed on 03/18/20. There were no Skilled Service Notes or Nurse's Progress Notes documented on 03/21/20, 03/22/20, 03/23/20, or 03/25/20. A Summary of Skilled Services, dated 03/26/20 at 5:22 PM, documented the resident, continues to ask for pills from any staff member that comes by . There were no Skilled Service Notes or Nurse's Progress Notes documented on 03/27/20 or 03/28/20. A nurse's note, dated 03/29/20 at 4:54 PM, documented, .Upon treatment administration, resident was observed reclined in bed with legs elevated on bed. Left leg red, warm to touch and swollen, resident complains of pain from left leg. Nurse treats skin on ankle and foot according to TAR and discusses with resident nursing assessment. Resident agrees fot (sic. for) further interventions and wants a consult from PCP (Primary Care Provider) . There were no Skilled Service Notes or Nurse's Progress Notes documented on 03/30/20. A Communication Form to the physician, dated 03/30/20, documented Resident 7's left lower extremity was red, swollen, hot to touch and painful with the recommendation to rule out [MEDICAL CONDITION]. The physician ordered laboratory studies, starting an antibiotic, ordering staff to mark the borders of the [MEDICAL CONDITION], and orders to closely monitor the resident. A Weekly Skin Assessment, dated 04/01/20, documented the resident received treatment for [REDACTED]. A Summary of Skilled Services Note, dated 04/07/20 at 3:28 PM, documented, (Resident) has been weak today. concerns expressed to (Resident's) physician .plans are to send (gender) to the clinic for evaluation. A review of records indicated the resident was sent to the clinic on 04/07/20 and from the clinic was admitted to a hospital. A Progress Note, dated 04/09/20, by Advanced Practice Registered Nurse (APRN)-O documented, .(Named resident) was hospitalized . in March (3/4-3/9) for GAS bacteremia and LLE [MEDICAL CONDITION] (inflammation of subcutaneous tissue) in addition to concern for osteo[DIAGNOSES REDACTED] (infection in the bone) of the L (left) great toe .(Gender) apparently was doing well until 1-2 wks (weeks) ago when (gender) was diagnosed with [REDACTED]. The note indicated Resident 7 was admitted to the local hospital and an x-ray revealed destructive changes of the 1st right toe. The note indicated the resident was transferred to a regional hospital so imaging studies would be completed under sedation. A social service's note, dated 04/09/20 at 5:58 PM, documented Resident 7 had been admitted to the hospital with [REDACTED]. A social service note, dated 04/10/20 at 8:25 PM, documented the resident had been first taken to a local hospital and then transferred and admitted to a larger regional hospital. An After Visit (hospitalization ) Summary, dated 04/14/20, documented on 04/09/20 the resident had an ulcer on his/her left and right anterior (front) toes with a primary [DIAGNOSES REDACTED]. An admission summary note, dated 04/14/20 at 5:00 PM, documented Resident 7 arrived at the facility for readmission. A review of records indicated the resident was readmitted with bandages and therapeutic boots on both feet, an order for [REDACTED]. A Clinic Encounter Summary, dated 04/16/20, by APRN-I, indicated the resident underwent [REDACTED]. The note indicated the resident had been admitted to the hospital in March 2020 for septic shock and had been discharged to the facility on [MEDICATION NAME] after receiving antibiotics, [MEDICATION NAME] and [MEDICATION NAME]. The note indicated after Resident 7's readmission to the facility on [DATE], they were found to have recurrent [MEDICAL CONDITION] of (their) LLE (left lower extremity). On 09/22/20 at 11:38 AM, Medical Doctor-J (MD) was asked if they believed the resident received the care (gender) needed to avoid worsening. MD-J replied, I don't think so. MD-J stated they did not get updated about the resident's status, and they were concerned the updates they received were not accurate. MD-J stated they were not confident that their orders, will get done. MD-J further stated they were not confident the resident's assessments were accurate. MD-J stated lack of assessments could have impacted the resident for a worse outcome. MD-J stated, (the resident) came to the clinic, and we admitted (gender) because it was obvious, they (the facility) hadn't done anything. MD-J stated it was only when the resident came to the office visit that the ulceration on the other foot was found. MD-J said, I should have been informed when (gender)'s right foot became involved. I only found out when we brought (gender) into the clinic. I was not notified the right side was involved. MD-J stated the resident had a huge red swollen ankle, and I had not been notified. MD-J further stated they later reviewed the medical records, and there was no indication this had been going on. MD-J stated they took pictures of the resident's feet and sent the resident to the hospital. MD-J further explained the resident became septic due to [MEDICAL CONDITION] in the lower extremities. MD-J stated the resident had been hospitalized in the Intensive Care Unit (ICU) for septic shock prior to the hospitalization for the amputations. MD-J stated they were concerned the staff did not take Resident 7's complaints of ankle pain seriously but was concerned the staff thought the resident was only seeking drugs. On 09/22/20 at 2:00 PM, the Administrator and Director of Nurses (DON) were interviewed. They both stated they were not employed at the facility during the time these events occurred. The Administrator was asked should the orders related to the ER discharge, on 02/15/20, regarding daily dressing changes have been added to the resident's TAR and implemented. The Administrator said, Yes. The Administrator checked the medical record and confirmed the hospital discharge order to change the dressing daily had not been added to the resident's TAR. They were asked should Skin Assessments have been done weekly. They answered, Yes. The DON stated they had supplied the survey team with information on all the resident's Skin Assessments and were surprised to learn there were gaps in documentation for both skin assessments and dressing changes. The DON stated the facility also did separate wound assessments. The Administrator and DON searched the medical record but did not find any wound assessments for the resident in 2020. The Administrator stated the Skin Assessments should capture the information regarding any wound. The DON stated Registered Nurse (RN)-B had stated they had done the dressing changes. On 09/22/20 at 2:08 PM, RN-B was asked if they had done daily dressing changes when the resident returned from the emergency room in February. RN-B stated (gender) did not remember. RN-B was asked if the order was on the February 2020 TAR. RN-B referred to the TAR and stated it was not there. RN-B said, It should have been. RN-B stated (gender) was the only RN who worked days, and sometimes (gender) did not get to document as (gender) would like. RN-B stated there had been a problem with getting orders on the TARs, but that things were getting better. RN-B stated sometimes Resident 7 would pull off the dressing from their foot several times on (gender) shift. RN-B stated it was not documented when the resident pulled off (gender) dressing. (Gender) stated, If we didn't document it, we didn't do it. 2. Resident 251 had [DIAGNOSES REDACTED]. Physician orders, dated 12/03/19, documented the resident had been admitted to hospice care. A facility document titled, Abuse, Neglect or Misappropriation - Internal Investigation, dated 04/24/20, indicated on 04/01/20 a hospice nurse observed a wound to Resident 251's right ankle. The investigation documented the hospice nurse informed Licensed Practical Nurse (LPN)-K of the wound, told LPN-K they would get orders for the treatment, and gave LPN-K two dressings. The investigation indicated the hospice nurse documented wound measurements at that time, but LPN-K did not complete a wound assessment. The investigation included orders from hospice for the [MEDICATION NAME] dressing (a self-adhesive foam dressing) that were given the charge nurse, LPN-L, on 04/03/20. LPN-L did not complete the initial order entry and did not enter the order into the Treatment Administration Record (TAR). The investigation further indicated LPN-M completed a chart check on 04/03/20 but failed to see the treatment order and failed to enter the order onto the TAR. The investigation documented, on 04/08/20 the following week, the hospice nurse recognized the resident's dressings had not been changed since 04/01/20. The investigation indicated the hospice nurse informed the facility the dressing had not been changed since (gender) initially placed it a week ago. A new order was given for an antibiotic for an infection and [MEDICATION NAME] cream was ordered to be applied to the resident's right ankle because the foot looked worse. A facility document titled, Education/Corrective Action Notice, dated 04/14/20, indicated LPN-K should have started a weekly wound assessment the day the wound was noticed. The notice indicated the family was not notified of the wound until 04/08/20. The notice documented, .DON instructed nurse to obtain orders from PCP (primary care provider) if this ever happens again .Nurse advised to call all medication/treatment changes to the family . The notice also indicated that because LPN-L did not read and enter orders, .a wound deteriorated. No dressing or wound care was provided until 4/8/20 . A facility document titled, Education/Corrective Action Notice, dated 04/15/20, indicated LPN-M, . completed the chart audit 4/3/20 but didn't catch/enter a treatment order resulting in a deterioration of a wound .When completing chart audits, you need to verify that all orders are entered . On 09/23/20 at 9:36 AM, a hospice LPN was interviewed from the hospice company that provided care for Resident 251. The hospice LPN was asked if the resident worsened because the facility failed to implement the dressing order, and the hospice LPN replied, Yes. The hospice LPN added that, in addition to becoming infected, the resident's pain increased. (Gender) stated the hospice staff took over complete care of the resident's wound. On 09/23/20 at 10:37 AM, after reviewing the facility investigation, the Administrator stated the facility acknowledged responsibility. A facility policy titled, Notification of Changes, dated 08/2020, documented: .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification . A facility policy titled, Consulting Physician/Practitioner Orders, dated 08/2020, documented: .the nurse in a timely manner will .verify the order .follow facility procedures .noting the order, submitting to pharmacy, and transcribing to a medication or treatment administration record .

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility staff failed to implement interventions for fall prevention for 2 (Resident 14 and 204) resulting in falls with fractures for Resident 14 and Resident 204 of 4 sampled residents. The facility staff identified a census of 51. Findings are: A. Record review of Resident 14's Comprehensive Care Plan (CCP) printed on 9-21-2020 revealed Resident 14 was at risk for falls. The goal identified on the CCP was Resident 14 would not sustain serious injury. The interventions identified on the CCP included Resident 14 was provided with a walker, ensure the call light was within reach and Resident 14's room had been rearranged. Record review of a Fall Report Sheet (FRS) dated 4-24-2020 revealed Resident 14 was found laying on floor in the middle of Resident 14's room. According to the FRS dated 4-24-2020, the intervention was to have therapy evaluate for strengthen. The FRS dated 4-24-2020 did not identify an intervention staff were to use when Resident 14 was not working with Therapy. Record review of Resident 14's CCP printed on 9-21-2020 did not contain information on addition interventions staff were to utilize after being found on the floor on 4-24-2020. Record review of a FRS dated 5-14-2020 revealed Resident 14 was seen in the hallway without Resident 14's walker. According to the FRS dated 5-14-2020 Resident 14 became weak and slid to the floor. Further review of the FRS dated 5-14-2020 revealed there was no evidence the facility staff implement addition interventions to prevent further falls. Review of Resident 14's CCP printed on 9-21-2020 revealed there was not any additional interventions implemented to prevent additional falls. Record review of a Fall With Injury (FWI) sheet dated 6-22-2020 revealed Resident 14 stood up from a wheelchair lost balance and fell on to the floor on the right shoulder area on 6-20-2020. According to the FWI sheet dated 6-22-2020, Resident 14 was sent to the hospital and returned to the facility with a dislocated shoulder. On 9-22-2020 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed there were no new intervention implemented for fall prevention for nursing staff to follow for the falls on 4-24-2020 and on 5-14-2020. The DON further confirmed Resident 14 fell on [DATE] and sustained a dislocated shoulder. B. Record review of Resident 204's CCP printed on 9-23-2020 revealed Resident 204 was at risk for falls related to pain, weakness, poor safety awareness and wandering behaviors. The goal identified for Resident 204 was to have no episodes of fall related injuries. Interventions identified on Resident 204's CCP included a Bed alarm as Resident 204 is not steady with walking and does not use call light, keep Resident 204's call light within reach and provide a clutter free environment. Record review of a FWI dated 6-22-2020 revealed Resident 204 fell on [DATE] and was sent to the hospital. According to the information in the FWI dated 6-22-2020, the facility Director of Nursing (DON) received a report from the hospital informing the facility Resident 204 had sustained a left Humerus fracture. Further review of the FWI dated 6-22-2020 revealed there was no evidence the bed alarm was sounding or in use. On 9-23-2020 at 11:35 AM an interview was conducted with the facility Administrator. During the interview the facility Administrator reported the bed alarm was not on Resident 204.

licensure reference number 175 NAC 12-006.09D8b, 175 NAC 12-006.09d9 Based on record review and interview: the facility staff failed to implement interventions to prevent dehydration for 1(Resident 204), failed to comprehensively evaluate significant weight loss for 1 (Resident 14) and failed to obtain weights for 2 (Resident 14 and 204) for a total sample of 4. The facility staff identified a census of 51. Findings are: A. Record review of a History and Physical (H&P) dated 5-25-2020 revealed Resident 204 had been admitted to the hospital from home with the resulting [DIAGNOSES REDACTED]. Further review of Resident 204's H&P dated 5-25-2020 revealed Resident 204 had received IV fluids for hydration. Record review of an Admitting Standing Orders sheet dated and signed on 5-28-2020 by Resident 204's practitioner revealed the admitting [DIAGNOSES REDACTED]. Record review of a Nutritional Assessment sheet signed by the facility Registered Dietician (RD) dated 6-01-2020 revealed the facility RD had evaluated Resident 204's fluid needs per day as 1680 Milliliters (ml) per day. Record review of Resident 204's Admission Care Plan (ACP) revealed an admitted [DATE] with the first [DIAGNOSES REDACTED]. Record review of an Encounters and Procedure (EP) sheet dated 6-18-2020 revealed Resident 204's practitioner had evaluated Resident 204. According to the information EP sheet dated 6-18-2020, Resident 204 had been sent to the hospital the previous night with weakness. The assessment/plan section of the EP sheet dated 6-18-2020 was to obtain laboratory's testing and for staff to push fluids. Record review of Resident 204's Treatment Administration Record (TAR) for June 2020 revealed on 6-18-2020 directions for the facility staff to push fluids-offer 120 cubic centimeters (cc's) an hour if awake, every hour related to Dehydration. On 9-23-2020 at 9:10 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed interventions on Resident 204's ACP did not identify interventions to be used for management of Resident 204's hydration status. The DON confirmed during the interview Resident 204 continued to have dehydration issues. B. Record review of Order Summary Report (OSR) sheet dated as of 5-28-2020 revealed the facility staff were to obtain daily weights for 3 days, one time a day. Review of Resident 204's medical record revealed there was a weight obtained on 5-27-2020 and on 6-03-2020. On 9-23-2020 at 8:52 AM an interview was conducted with the facility Administrator. During the interview, the Administrator confirmed Resident 204's weights were not obtained as ordered. C. Review of Resident 14 weight revealed Resident 14's weight record on 6-13-2020 was 214.0 pound (lb). Review of Resident 14's weight record on 6-17-2020 revealed Resident 14 weight was 192. lbs, a loss of 22.0 pound or a loss of 10.28%. Further review of Resident 14's weight record revealed on 6-19-2020 Resident 14's weight was 194 lb's, a loss of 20 lb's 9.34 % within 30 days. Record review of a Nutrition Assessment (NA) sheet dated 9-14-2020 revealed the facility Registered Dietician (RD) evaluated resident 14's weight loss using the weight as of 6-19-2020. According to the information on the NA sheet dated 9-14-2020 Resident 14's weight would fluctuate related to fluid shift and diuretic usage and no recommendations were made. Review of Resident 14's medical record that included Resident 14's Progress notes, Care Plan and Practitioners orders revealed there was not any intervention at this time for the significant weight loss. Further review of Resident 14's medical record revealed there was not a weight obtained for August 2020. On 9-22-20 at 8:50 AM an interview was conducted with the facility RD via phone. During the interview the facility RD confirmed the NA dated 9-14-2020 was based on the 6-19-2020 weight. The RD reported Resident 14's weights were not available when completing the NA. The RD confirmed the NA would not be accurate and now knowing what Residents 14's weights were, would have consulted with Resident 14's practitioner for possible intervention. The facility RD confirmed there was not an August weight obtained for Resident 14. Record review of the facility Policy for Weight Monitoring revised 8-2020 revealed the following information: Policy: -Based on the resident's comprehensive assessment, the facility will ensure all residents maintain acceptable parameters of nutritional status. -Compliance Guidelines: -#5. Monitor weights monthly. -#7 a. The physician should be informed of a significant change in weight and may order nutritional interventions. -#7 e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutritional progress notes.

Licensure Reference Number: 175 NAC 12-006.05(9) Based on record review , observation and interview, the facility staff failed to evaluate and reevaluate placement into a secured unit (Alzheimer's Care Unit) and failed to reevaluate continued placement in the secured unit for 1 resident (Resident 34) of sampled resident. The facility census 42. Findings are: Record review of Alzheimer's Care Unit policy: reveals Admission Criteria includes Family/responsible party must agree on placement into the unit. Interdisciplinary team must complete pre-assessments and accept resident into the program. On 09/26/19 at 10:03 AM a telephone interview with Resident 34's, Power of Attorney (POA) revealed Resident 34 was admitted in February, 2019. According to Resident 34 POA, 5 months later the facility staff asked Resident 34's POA about placing Resident 34 on the locked unit, Alzheimer's Care Unit (ACU). According to Resident 34's POA both the Resident 34 and Resident 34 POA evaluated the unit and chose not to go back to the ACU According to Resident 34's POA about 1 month later the facility staff requested placement in the ACU as Resident 34 was having a lot of falls. Resident 34 's POA later requested repeatedly for facility staff to move Resident 34 from the ACU, due to, Resident 34 POA did not like Resident 34 being in the ACU. According to the Resident 34's POA the ACU was inconvenient for the POA and family members to visit and they refuse to move Resident 34. He does not try to leave or anything and (gender) does not understand why they are refusing to move Resident 34 back out of the locked unit. The Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/7/19 reveals a (Brief interview for Mental Status (BIMS) of 12. According to the MDS Manuel a score of 8-12 indicate moderately impaired cognition. On 9/15/19 after being placed in the ACU Resident 34 MDS reveals a BIMS of 9 with behavior Symptoms occurring 1 to 3 times a day towards others and wandering occurring 1-3 times a day. On 9-30-2019 at 7:31AM Resident 34 was observed in the dining area in the ACU. On 10-01-2019 7:15 AM Resident 34 was observed in the ACU dining room. Review of Resident 34's medical record revealed there was not evidence the facility staff had evaluated and re-revaluated Resident 34's placement into the ACU. An Interview was conducted on 9-26-2019 at 10:22 AM with (Licensed Practical Nurse) LPN F in the ACU. During the interview LPN F reported not being aware of why Resident 34 was in the ACU. LPN F reported thinking Resident 34 was admitted to the ACU due to multiple falls. On 10/02/19 an interview with Director of Nursing (DON) confirmed that Resident 34 was placed in ACU on 8/20/19 for safety related to frequent falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2B Based on observation, record review and interview; the facility staff failed to obtain treatment orders and failed to evaluate nutritional requirements for the development of a pressure ulcer for 1 resident (Resident 12). The facility staff identified a census of 45. Findings are: A. Record review of an Admission Record sheet printed on 1-06-2016 revealed Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 12's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-28-2015 revealed the facility assessed the following about the resident: -Resident 12 had a score of 15 on the Brief Interview of Mental Status (BIMS). According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Independent with transfers, dressing, eating and toilet use. -Required supervision with personal hygiene and bed mobility. -At risk for the development of pressure ulcers. -Had a Stage 2 pressure ulcer (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister). Record review of Resident 12's Comprehensive Care Plan (CCP) dated 7-09-2012 and revised on 12-10-2015 revealed Resident 12 was at risk for skin breakdown. The goal for Resident 12 was to have no skin breakdown. Interventions listed on the CCP included: -Monitor skin under braces, prosthetic, splints and cast for breakdown. -Observe skin weekly with bath and as needed. -Use boots to float heels at night as needed. Further review of Resident 12's CCP that was updated on 12-10-2015 revealed Resident 12 had a pressure ulcer to the right heel and left lateral foot. The goal for Resident 12 was that the pressure ulcers would heal without complications. Interventions to meet this goal included Heel boots, Nutritional and hydration support and pressure reliving devices. Record review of Resident 12's Progress Notes (PN) dated 11-27-2015 revealed the right heel pressure ulcer was healing. Record review of Resident 12's PN dated 12-10-2015 revealed Resident 12 had requested that Licensed Practical Nurse (LPN) B look at Resident 12's left foot. According to the PN, LPN B had noticed .bright,bloody drainage to the bottom of sock. According to the information in the PN dated 12-10-2015, LPN B documented that Resident 12 had a 5 centimeter (cm) by 5 cm open wound at the widest points and a wound bed at various stages of development. Record review of a Wound Evaluation Flow Sheet (WEFS) dated 12-14-2015 revealed Resident 12 was evaluated as having a blister to the left bottom of the foot that measured 7 cm by 7 cm with a depth of 0.2 cm. The ulcer was identified as a blister area. According to the information on the WEFS, the wound had white edges with a tan color towards the center with a yellow core. There was drainage from the wound and had multiple colors. According to the information on the WEFS, the facility was awaiting communications from the MD (Medical Doctor) for dressing. Record review of Resident 12's PN dated 12-15-2015 revealed Resident 12's Left plantar bottom wound worsened; center bed with brown area and strong odor, surrounding bed dark red with white yellow loose skin edges; surrounding skin reddened and warm to touch with 2+ [MEDICAL CONDITION] (swelling); large amounts of purulent (any product of inflammation that contains pus (e.g., leukocytes, bacteria, & liquefied necrotic debris)) drainage to old dressing. Record review of Resident 12's PN dated 12-16-2015 revealed the left foot wound had a .large amount of bloody drainage to the dressing. According to the PN dated 12-16-2015, Resident 12 would be seeing the wound provider on 12-17-2015. Record review of a Vascular Clinic (VC) report for Resident 12 dated 12-17-2015 revealed Resident 12 had new foot ulcers to the left foot. According to the VC report, Resident 12 had rubbing from a PRAFO (type of pressure reliving device) boot. The left foot ulcer measured 68 mm (millimeters) by 40 mm by 3 to 4 mm deep. The assessment section of the VC report identified Resident 12 had bilateral (both sides) foot ulcers with treatment of [REDACTED]. Record review of a WEFS dated 12-31-2015 revealed the left foot ulcer measured 8 cm by 8 cm and was unstageable ((full thickness tissue loss in which the base of the ulcer is covered by slough (Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy, at times)) with depth of ulcer unknown. Record review of a Fax sheet dated 12-11-2015 that was sent to Resident 12's physician revealed the facility was informing the physician of the left foot ulcer and had requested treatment orders. Further review of the Fax sheet revealed the practitioner responded on 12-22-2015 with orders for a antibiotic, have an appointment made with the wound practitioner and ordered a treatment to the left foot. B. Record review of Resident 12's record revealed there was not a evaluation of nutritional requirements for the pressure ulcer identified on 12-10-2015. C. Observation on 1-6-2016 at 10:16 AM revealed LPN B obtained required supplies for wound treatment to the left foot. LPN B removed the dressing from the left foot. The dressing contained grayish brown drainage and was placed into the garbage. Observations of the left bottom foot ulcer revealed an ulcer area that measured approximately 6 cm round, with black and gray looking tissue. LPN B cleansed the wound and applied the ointment as ordered. D. An interview on 1-06-2016 at 11:52 AM was conducted with the Director of Nursing (DON). During the interview the DON reported the left foot pressure ulcer was identified on 12-10-2015. The DON reported there was no order for the treatment to the left foot pressure ulcer until 12-17-2015 when Resident 12 had seen the wound practitioner. The DON further reported Resident 12's physician had not responded the fax sent on 12-11-2015. The DON confirmed Resident 12's pressure ulcer condition had declined prior to seeing the wound practitioner. According to the DON, the expectation to obtain treatment orders within 24 hours. A follow up interview was conducted with the DON on 1-7-2015 at 10:35 AM. Review of the WEFS dated 12-14-2015 was conducted with the DON. The DON reported the ulcer was caused from a plastic piece in the PRAFO boot that : .was rubbing and applying pressure. The DON stated it is a pressure ulcer. Review of the PN dated 12-15-2015 was conducted with the DON. The DON confirmed the pressure ulcer had worsened and that's when we call the wound doctor. The DON confirmed in the interview there was not a evaluation of Resident 12's nutritional requirements for pressure ulcer heeling. Record review of the facility undated Skin Integrity Guideline revealed the following information: -Nutritional Assessment determine need for nutritional interventions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09d7 Based on observation, record review and interview; the facility staff failed to implement interventions and re-evaluate interventions to prevent falls for 3 residents (Resident 28, 41 and 46) and failed to secure medications and chemicals on the secured unit. The facility staff identified a census of 50. Findings are: A. Record review of an Admission record sheet dated 3-10-2014 revealed Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 41's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-19-2014 revealed the facility staff assessed the following about the resident; -BIMs (Brief Interview for Mental status) revealed Resident 41 scored a 5. According to the MDS Manuel, a score of 0 to 7 indicated severe impairment. -Required extensive assistance with transfers, bed mobility, dressing, personal hygiene and toilet use. -Falls occasionally. Record review of Resident 41's Quarterly Interdisciplinary Resident Review (QIRR) sheet dated 10-19-2014 revealed Resident 41 scored a 13 on the section that was identified a Devices, Restraints and Falls. According to the information on the QIRR sheet revealed a total score of 10 or above deemed the resident at risk. Record review of a Balance Assessment Screen (BAS) dated 10-19-2014 revealed Resident 41 scored a 3. According to the information on the BAS form, a score of 3 indicated a standing balance test could not be completed without physical help. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair alarm. According to the CCP, this intervention was initiated on 6-09-2013 and reviewed on 9-09-2014. Further review of Resident 41's CCP revealed Resident 41 was incontinent with a goal to prevent Urinary Tract Infections (UTI) and a goal listed here dated 6-13-2013 was to use a chair alarm. Resident 41's CCP had a hand written entry dated 10-20-2014 that identified Resident 41 had a fall with a resulting laceration to the head that required staples. Record review of a Fax sheet dated 10-20-2014 revealed the facility had informed Resident 41's physician that Resident 41 had been sent to the hospital and received 3 staples. Record review of Resident 41's Verification of Investigation (VOI) dated 10-20-2014 revealed Resident 41 was found on the floor with a "laceration and contusion noted to the right side of (the) head". According to the VOI dated 10-20-2014, Resident 41 was not able to verbalize what had happened due to impaired cognition related to dementia. Further review of the VOI revealed a section that had an area for staff to "specify recommendations/interventions taken to prevent reoccurrence included a low bed, sensor alarms in the w/c (wheelchair) and bed. The VOI did not indicate if the alarm had been attached and sounding with the fall on 10-20-2014. On 12-09-2014 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 41's CCP and the VOI dated 10-20-2014 was reviewed with the DON. The DON confirmed that according to Resident 41's CCP, Resident 41 should have had an alarm on prior to the fall on 10-20-2014. According to the DON, the alarm was removed as Resident 41 had not recently fallen. When asked if an evaluation to remove the alarm had been completed, the DON stated "no". B. Record review of an Admission Record sheet dated 12-8-2014 revealed Resident 46 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 46's MDS dated [DATE] revealed Resident 46 was identified as independent with Activities of Daily living and required supervision with bathing. Record review of a VOI dated 10-17-2014 revealed Resident 46 had "attempted (to) crawl out of the bath tub over the side of the tub instead of opening the tub door and fell . Accord to to the information in the VOI, Resident 46 was sent to the hospital for an evaluation. Further review of the VOI dated 10-17-2014 did not contain information that Resident had been supervised prior to the fall. An interview was conducted with the DON on 12-09-2014 at 2:41 PM. During the interview the DON reported the Bath Aid had set the resident up for the bath and left the room and stepped outside the door. The DON confirmed an evaluation had not been completed for independently bathing for Resident 46. C. Record review of the care plan for Resident 28 revealed: Resident 28 was admitted on [DATE] with the following diagnoses-Dementia, unspecified, with behavioral disturbance; other and unspecified [DIAGNOSES REDACTED]; unspecified essential hypertension; Obstructive chronic bronchitis without exacerbation. Record review of the admission "Clinical Health Status" record dated 11/06/2014 revealed: Resident 28 scored a 6 on the fall scale. A score of 10 or above deems resident at risk. Record review of the care plan dated 12/01/2014 revealed: At risk for falls related to: Wandering, Use of Medications, New environment, History of falls. Goal-No fall related injuries requiring hospitalization . Interventions-Assess for pain, provide medication or non-pharmacologic pain relief methods and appropriate, assess effectiveness. Assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti-tippers. Call light or personal items available and in easy reach or provide reacher. Footwear to prevent slipping. Keep environment well lit and free of clutter. Observe for side effects of medications. Orientation to new room and roommate. Therapy services as ordered. Toilet schedule; assist resident to toilet in AM, before/after meals or activities, at HS (bedtime) and PRN (as needed). Provide incontinence cares as needed. A review of the VOI for Resident 28 revealed Resident 28 had fallen on 11/19/2014. Further review of Resident 28's VOI revealed there was no evidence of any new interventions implemented to prevent Resident 28 from further falls. Interview with the ACU (Alzheimer Care Unit) Director on 12/10/2014 at 7:35 AM revealed the following: confirmed that there were no new interventions identified nor were any new interventions care planned. D. During initial tour of the facility Alzheimer's Secured Unit on 12/01/2014 at 12:13 PM revealed the door to the bath house unlocked and the chemicals, Lemon-Eze and Neutral Disinfectant Cleaner, were located in an unlocked cabinet. Record review of the Safety Data Sheet dated 02/18/2014 from Ecolab for Lemon-Eze revealed: -Do not get in eyes, on skin, or on clothing. -Causes serious eye damage. -Keep out of reach. Record review of the Safety Data Sheet dated 02/18/2014 from Ecolab for Disinfectant Cleaner revealed: -Causes digestive tract, eye and skin burns. -Harmful if absorbed through skin or if swallowed. -Causes Respiratory tract irritation. -Corrosive to eyes and skin. -Causes burns to mouth, throat, and stomach. Interview with Alzheimer's Care Unit (ACU) Director on 12/01/2014 at 12:15 PM confirmed that the bath house door on the secured unit was left unlocked as well as the cabinet that contained the chemicals in it was also left unlocked. ACU Director also confirmed these chemical should be locked up and not accessible. E. During observation of meal service in the Alzheimer's Secured Unit on 12/04/2014 from 11:50 AM to 11:55 AM, in a small room connected to the main dining room, Resident 11 was sitting at the dining room table with a medication cup, containing 4 pills, sitting in front of the resident. No staff were in attendance in the small room. Resident 54 was sitting across the table from Resident 11. During this observation Resident 17 entered the room from the main dining room, walked around the table of Resident 11 and Resident 54, and exited the room going back into the main dining area. Observation on 12/04/14 at 11:55 AM revealed Resident 11 picked up the medication cup, dumped the pills in their hand and put the pills in Resident 11's mouth. Resident 11 picked up a glass of juice and took a drink. Observation on 12/04/2014 at 11:57 AM Licensed Practical Nurse (LPN) G walked into the small room adjoining to the dining room and revealed Resident 11 was given pills a few minutes ago and that Resident 11 was independent with medication administration but staff should stay with Resident 11 until Resident 11 took the pills. Interview with LPN G on 12/4/2014 at 11:57 AM, LPN G confirmed that Resident 11 should not be left alone with pills sitting in front of Resident 11 with wandering residents in the area. LPN G also revealed that staff should have stayed with Resident 11 until the pills were swallowed. Interview with the ACU Director on 12/04/2014 at 12:25 PM confirmed that medications were not to be left in front of a resident, unattended, at the dining room table with wandering residents in the area. The ACU director also confirmed that the expectation was to observe the resident swallow the medication

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews, observations and staff interviews; the facility administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot water temperatures in resident care areas, Maintanance of the resident environment related to the condition of the facility and failed to implement interventions to prevent accidents. The facility census was 50. A. Record review of an unused and undated Maintenance Director Orientation information check list revealed at the section titled: Water Temperature revealed the following: -Notify the Executive Director immediately of any water Temperature above 110 degrees Fahrenheit. -Water must be shut down so that residents can not utilize in the affected area, until the temperature is returned to 110 degrees Fahrenheit. Record review of a Preventative Maintenance (PM) rounds sheet dated 9-15-2014 revealed the following information: -Bathing water temperature on the skilled side of the facility was 117.8 degrees. There was no temperature of the bathing water on the secured unit of the facility. Record review of a PM rounds sheet dated 11-27-2014 revealed the following information: -Bathing water on the skilled side of the facility was 117.8 degrees. There were not any temperature of the bathing water in the secured unit of the facility. Record review of a PM rounds sheet dated 12-02-2014 revealed the following information: -Bathing water on the skilled side of the facility was 123.5 degrees. There were not any temperatures obtained of the bathing water on the secured unit of the facility. -room [ROOM NUMBER], the handwashing sink water temperature was 123.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 123.2 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.8 degrees. Observation of water temperatures in the residents' handwashing sinks revealed the following: - 12-02-2014 at 12:08 PM, room [ROOM NUMBER],handwashing sink water temperature was 124.9 degrees. -12-02-2014 at 2:03 PM, room [ROOM NUMBER],handwashing sink water temperature was 128.4 degrees. -12-02-2014 at 12:09 PM, room [ROOM NUMBER], handwashing sink water temperature was 124.1 degrees. -12-02-2014 at 2:08 AM, room [ROOM NUMBER], handwashing sink water temperature was 129.2 degrees. -12-02-2014 at 12:13 PM, room [ROOM NUMBER]. handwashing sink water temperature was 127.2 degrees. An interview with the facility Maintenance Director (MD) was conducted on 12-02-2014 at 12:35 PM. During the interview, the MD reported having been employed at the facility about a year. When asked if (gender) had an orientation to the position and what the water temperatures should be for both, handwashing skins and bathing, the MD stated "no". When asked what the water temperature should be for bathing and for resident handwashing sinks, the MD stated "I'm not sure". A follow up interview was conducted with the MD on 12-02-2014 at 1:18 PM. During the interview, when asked about the bathing water temperatures in the secured unit , the MD stated "I don't do that shower". On 12-03-2014 at 8:20 AM an interview was conducted with the facility Administrator. During the interview, the administrator reported the MD had been employed prior to the current Administrator. When asked about the MD orientation, the facility Administrator reported there was not any check list to indicate what the MD had been educated on in the facility. B. Observation the facility during an environmental tour on 12/09/2014 between 8:30 AM - 11:00 AM conducted with the facility Administrator and MD revealed the following areas: -Ventilation system not functioning in resident rooms were not functioning. -Urine odors noted in rooms: 115, 103, 113, 320, 324, and 325. -Caulking peeling or cracked behind the sink in the bathrooms and around toilet bases in resident rooms. -Kick guards of door chipped and or peeling away from the door of residents rooms. -Bolt sticking out of wall where old toilet paper hanger was located in residents rooms. -Rotting boards under heating/cooling unit in room [ROOM NUMBER]. -Behind the main nurses ' station, sink had coving and caulking coming away from the wall and caulking stained. Dark spots located on ceiling above the chart rack and red spots on wall above counter top to the left of the chart rack. -Alzheimer ' s unit kitchenette had sheet rock crumbling off the wall behind the sink and laminate bubbled and peeling off the back splash of counter behind the sink. Wall paper was peeling off the south wall by the window. An interview with Administrator and Maintenance Director on 12/09/2014 at 11:04 AM confirmed these findings during the environmental tour. C. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair alarm. According to the CCP, this intervention was initiated on 6-09-2013 and reviewed on 9-09-2014. Further review of Resident 41's CCP revealed Resident 41 was incontinent with a goal to prevent Urinary Tract Infections [MEDICAL CONDITION] and a goal listed here dated 6-13-2013 was to use a chair alarm. Resident 41's CCP had a hand written entry dated 10-20-2014 that identified Resident 41 had a fall with a resulting laceration to the head that required staples. Record review of a Fax sheet dated 10-20-2014 revealed the facility had informed Resident 41's physician that Resident 41 had been sent to the hospital and received 3 staples. On 12-09-2014 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 41's CCP and the VOI dated 10-20-2014 was reviewed with the DON. The DON confirmed that according to Resident 41's CCP, Resident 41 should have had an alarm on prior to the fall on 10-20-2014. According to the DON, the alarm was removed as Resident 41 had not recently fallen. When asked if an evaluation to remove the alarm had been completed, the DON stated "no".

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview; the facility Quality Assurance Plan failed to identify ongoing issues relevant to F166, F226, F242, F248, F250, F252, F272, F309, F323, F329, F353, F411, F431, F497, F499, 517 and implement effective plans of action to identify and correct the deficient practice. The Quality Assurance Plan failed to ensure the repeated deficiencies at F 253 and F371 were corrected and the correction maintained. The facility staff identified a census of 50. Findings are; A. An interview was conducted with the facility Administrator on 12-10-2014 at 7:13 AM. During the interview the facility Quality Assurance Program was reviewed with the Administrator. During the interview when asked if the facility staffing or hot water had been identified in the facility as a problem, the Administrator stated "no". B. An interview with Licensed Practical Nurse (LPN) E was conducted on 12-10-2014 at 8:12 AM. During the interview, when asked what the Quality Assurance committee was and what the committee was working on, LPN E stated " I don't know what they are working on. I don't know anything about it". C. An interview was conducted on 12-10-2014 at 8:16 AM with LPN F. When asked what the Quality Assurance committee was working on. LPN F stated "I don't know". D. On 12-10-2014 at 8:20 AM an interview was conducted with Nursing Assistant (NA) K. During the interview, when asked what the Quality Assurance Committee was working on, NA K stated "I don't know". E. On 12-10-2014 at 8:23 AM an interview was conducted with LPN L During the interview when asked what the Quality assurance committee was working on, NA L reported not being aware of what the committee was working on.