Every finding on record at Rock County Hospital Long Term Care

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l) Based on observations, record review, and interview; the facility failed to identify causal factors for the development and/or revision of fall prevention interventions and to implement fall interventions for 4 (Residents 1, 2, 3, and 4) of 4 sampled residents. The facility census was 20. Findings are: A. Review of the Fall Prevention and Treatment Long Term Care policy dated 6/25revealed the purpose of the policy was to prevent any unintended falls. Each resident was assessed for fall risk and was to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident was to be screened at admission, quarterly and with any significant change of status. The following procedure was identified:-upon admission, the nurse will complete the Morse Fall assessment along with the nurse assessment to determine the resident's level of fall risk. -the nurse would indicate on the resident's care plan what the residents fall risk was and then would initiate interventions on the baseline care plan in accordance with the resident's risk level.If the resident was at high risk for falls, the following protocols would be initiated:-the resident would be placed on the facility's Fall Prevention Program with a falling star on the resident's door and indicate fall risk on the care plan.-maintain a clear path to the bathroom.-keep the bed locked and lowered to the lowest position that allowed the resident's feet to touch the floor when sitting on the edge of the bed.-call light and frequently used items to be kept within reach.-adequate lighting.-monitor the resident's balance, cognition, gait, ability to rise, and/or sit.-ensure shoes or slippers with no slip soles.-increased frequency of rounds.-medication regimen review.-call pendants.-Physical Therapy or Occupational Therapy referrals. If the resident had a fall, the facility would: assess the resident with a full set of vitals; notify the physician and family; leave a message for the Director of Nursing (DON), do a risk management report; review and update the resident's care plan; document all actions and assessments; obtain witness statements in the case of injury; monitor the resident for 24 hours post fall and document any changes in the residents functional status, cognitive status and vitals; and communicate to all shifts that the resident had fallen and was at risk to fall again. B. Review of Resident 1's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of diabetes, high blood pressure, Non-Alzheimer's dementia and insomnia. The following was assessed regarding the resident: -severe cognitive impairment. -behaviors which included rejection of cares and wandering. -substantial to maximal assistance with toileting and dressing. -setup assist with transfers. -independence with bed mobility. -frequently incontinent of bowel and bladder. Review of an Incident Report dated 5/16/26 at 11:50 PM revealed the resident was found lying on the floor of the resident's room. The resident reported sliding out of bed. The resident was assisted per request to the bathroom and then to the recliner in the resident's room. New intervention developed for bed/chair alarms. Review of an Incident Report dated 5/21/26 at 3:00 AM revealed the resident was found on the floor in front of the recliner in the resident's room. A new intervention was identified to place fall alarms in areas the resident could not visualize. Further review of the report revealed no indication as to whether the bed/chair alarm was in place and functional or whether the alarm was sounding at the time the resident was found. There was no evidence causal factors for the fall were investigated/identified. During an interview on 6/8/26 at 11:05 AM, the DON indicated at the time of a fall, the Charge Nurse was responsible for completing an Incident Report and this should be completed by the end of their shift. The nurses are to look at causal factors and then implement an immediate intervention. The DON or designee would then do a follow up investigation and would review the Incident Report to determine if current interventions were appropriate or if a different intervention was needed. Confirmed with Resident 1's fall on 5/21/26 at 3:00 AM, the Incident Report does not clarify if the resident's alarm was in place or the causal factor for the resident's fall. The intervention to place the bed/chair alarms in areas the resident could not reach or visualize was developed because the resident had a history of dismantling electronics in the resident's room. C. Review of Resident 3's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 3/31/26 revealed the resident was admitted [DATE] with diagnoses of Non-Alzheimer's dementia, traumatic brain injury, and history of falling. The following was assessed regarding Resident 3: -cognition was moderately impaired. -behaviors which included wandering which occurred 1-3 days of assessment period. -required supervision/touching assistance with transfers and personal hygiene; partial to moderate assistance with toileting; and substantial to maximal assistance with dressing. -occasionally incontinent of urine. -frequent, moderate pain which affected ability to sleep and day to day activities. -no falls since the previous assessment. Review of an Incident Report dated 2/16/26 at 9:30 AM revealed the resident had an unwitnessed fall. The resident went to the bathroom by the Nurse's Station independently. The resident's shoe came off while toileting and caused the resident to fall. The report indicated an intervention to educate the staff that the resident might continue to require stand by assistance related to sitting, bathroom care, walking, turning, and sitting safely. The report further indicated the resident had impaired memory but failed to identify the resident's mental status, level of pain, or predisposing environmental factors. Review of an Incident Report dated 6/5/26 at 7:45 PM revealed the resident was found on the floor in front of a chair by the Nurse's Station. The resident identified reaching for something on the floor and falling out of the chair. The report indicated the resident had impaired memory and had attempted to transfer without assistance. An intervention was identified to check with the resident at 7:00 PM and to help the resident to bed early if desires. In addition, staff were to keep the area surrounding the resident neat and clean to prevent the resident from trying to pick items up off the floor. Review of an Incident Report dated 6/7/26 at 9:35 PM revealed the resident was heard calling out for assistance. The resident was found on the floor next to the resident's bed. The resident reported hearing a noise and got up to investigate. The report indicated the resident had impaired memory and was ambulating without assistance. An intervention was identified to keep the resident's walker in reach of the resident and to provide the resident with frequent reminders to keep the resident orientated to who, what, where and when. Further review of the report revealed no evidence as to where the walker was located at the time of the fall. During an interview on 6/8/26 at 12:00 PM, Nurse Aide (NA)-G verified the resident was at increased risk for falls. During the day shift, the staff would keep the resident in an area of constant supervision, normally next to the Nurses' Station. If the resident tried to get up or to reach down, the staff would redirect the resident and assist with cares. The resident was unable to remember cues or reminders and staff needed to provide the resident with close monitoring. An Interview with the DON on 6/8/26 at 12:30 PM confirmed the following regarding the residents' falls: -2/16/26 at 9:30 AM the resident was found on the floor of a public bathroom by the Nurses' Station. The resident recently had fall alarms discontinued and therapy had determined the resident could be independent with ambulation. The resident had indicated a shoe came off when in the bathroom as the cause of the fall. No interventions regarding assessment of the resident's footwear or need for different shoes. The staff were to provide the resident with reminders regarding safety when sitting, walking, transfers, and bathroom cares however, the resident had impaired cognition and memory loss so unable to determine if this was an effective/measurable intervention. -6/7/26 at 9:30 PM the resident had a fall next to the resident's bed. An intervention was identified to make sure the resident's walker was at beside and to provide frequent reminders to the resident as to who, what, when and where to help keep the resident orientated. Further review of the report revealed no documentation as to where the walker was at the time of the residents' fall. In addition, due to memory loss and impaired cognition, providing the resident with frequent verbal cues was not an effective and/or measurable intervention. C. Record review of Resident 2's fall report revealed that on 2/22/26 at 10:00 PM Resident 2 was noted to be lying on the floor on a blue mat next to the bed and the bed was in low position. The resident was oriented to person, no predisposing environmental or situational factors noted, the resident appeared to be more restless. New fall interventions put into place were: 1) residents' bed was moved against the wall, 2) bed bolsters to remind the resident not to get out of bed, 3) bed placed in the lowest position and 4) mats on floor in case the resident does roll out of bed. Review of Resident 2's care plan revised 3/11/26 revealed the following: -The resident was admitted to the facility on [DATE]. -had impaired thought process, diagnosis of dementia. -was a high fall risk for falls. -was dependent on staff for transfers. -dependent on staff, 2 assist for bed mobility. -bed bolsters to remind resident to stay in bed. -place bed in low position at all times, except during cares. -place bed against the wall to prevent the resident from falling out of the bed on the right side. -fall mat by the resident's bed. An observation on 6/8/26 at revealed that the resident was laying in bed with eyes closed, bed was in the lowest position, fall mat was on the right side of the bed and a bolster was on the left side of the bed. The bed was not against the wall. An interview with RN-B on 6/8/26 at 11:30 AM confirmed that Resident 2's fall interventions were: 1) keep the bed in the lowest position when staff were not in the room, 2) fall mat on the right side of the bed and 3) bolster to the left side of the resident in bed. RN-B was unsure when the current fall interventions were put into place. RN-B confirmed that the bed was not against the wall per the resident's care plan and the bolster was only on the left side of the bed (not both per care plan). D. Review of Resident 4's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 4/7/26 revealed a Brief Interview for Mental Status score of 9 (moderate cognitive impairment). Resident had 2 or more falls with no injuries, was occasionally incontinent of urine and always continent of bowel. Review of Resident 4's care plan with a revision date of 4/15/26 revealed the following: -had impaired cognitive function related to diagnosis of dementia. -had short- and long-term memory loss and made poor decisions at times. -required extensive one assist with repositioning, dressing and transfers. -does not ambulate. -used a wheelchair for locomotion with staff taking to meals and activities Record review of Resident 4's fall report revealed that on 3/26/26 at 7:10 AM the resident was on the floor on the mat. The resident was oriented to person, received no injuries, was confused, drowsy, incontinent of bowel movement and had impaired memory. New fall interventions put into place were: 1) do a visual check when staff walk by the room [ROOM NUMBER]) bolsters will be added to the bed to help from rolling out of bed. The facility did not identify the bowel incontinence as a causative factor. Record review of a fall reported dated 3/29/26 at 2:30 AM revealed Resident 4 was being assisted back to bed after being assisted to use the bathroom. The resident slid forward out of the wheelchair onto the floor. The resident was oriented to person and situation, no injuries were received, there were no predisposing environmental, physiological or situation factors. New fall intervention put into place where to change the resident in bed. Record review of a fall report dated 5/20/26 at 2:04 AM revealed Resident 4 was sitting on the floor off the fall mat, the call light was not on, and the bed was in low position. No injuries were received, the resident had gait imbalance and impaired memory, and the resident was attempting to get out of bed without assistance. Interventions were put into place to remind the resident to use call light for assistance. An interview completed with the DON on 6/8/26 at 1:15 PM confirmed that the facility did not identify bowel incontinence as a causative factor for the fall on 3/26/26. In review of the fall on 3/29/26 the resident used the bathroom for toileting cares, the resident would sit up on the edge of the bed when needing to use the bathroom and if staff were not in the room immediately the resident would attempt to get up. The intervention to change the resident in bed was not appropriate. In review of the fall on 5/20/26 the resident does not always use the call light and will request the roommate to turn the call light on. The intervention to remind the resident to use the call light for assistance was not appropriate.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review and interview; the facility failed to handle food in a manner that prevented potential food borne illness. This had the potential to affect all facility residents. The census was 18. Findings are: Review of the facility policy Proper use of Gloves with a revision date of 7/2013 revealed the purpose was to prevent disease and food borne illness. This included the following procedures: -Washing hands before gloving and when changing to a new pair of gloves. -Putting on new gloves before handling ready-to-eat foods such as sandwiches, and when handling fresh produce.-Prolonged use of a single pair of gloves could result in excess perspiration, which could be ideal for bacterial growth.-Disposable gloves were for one-time use.During observation of food service occurring from the portable steam table in the dining room on 9/9/25 from 11:55 AM through 12:15 PM the following was observed. -Dietary Aid B washed hands, put on gloves, took a food order from a resident while touching the back of the resident's chair and then returned to the food service cart with the same gloves, opened a drawer on the portable steam table, opened a bag of buns and then with the same gloves grabbed a bun, opened it, filled it with meat and served the meal to the resident. -Cook C exited the kitchen wearing gloves, took a resident's food order, touching both the table and the resident's back, then returned to the steam table, opened a drawer containing buns, opened the buns and with the same gloved hands retrieved a bun from the bag, opened the bun, placed meat on the bun and served it to the resident. After doing this [NAME] C returned to the kitchen wearing the gloves. The cook then returned to the dining room with gloves off holding a bag of chips. Without completing hand hygiene Cook-C put on a clean pair of gloves and returned to the food service steam table and again opened a drawer, retrieved a bun from the drawer and then with the same gloved hands opened the bun, put meat on the bun and then served the resident. During an interview on 9/9/25 at 2:58 PM the Dietary Manager confirmed staff should not have touched ready-to-eat food buns with the same gloved hands that are used while touching other surfaces such as the drawers on the food cart, chair backs, and table surfaces. In addition, any time staff change gloves they should wash their hands. During an interview on 9/10/25 at 3:38 PM the facility Administrator confirmed staff should not handle ready-to-eat food items with disposable gloves unless those gloves had not touched other potentially contaminated surfaces.

Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement infection control practices to prevent the potential spread of Covid-19 infection related to testing a symptomatic resident (Resident 4) for COVID-19. The sample size was 2 and the census was 18. Findings are: A. Review of the facility Infectious Patient, Communicable Disease, Pandemic Plan with a revised date of 1/2025 revealed the purpose of the policy was to include plans and actions to respond to the threat of Covid-19 and to prevent transmission. Staff and residents were to be tested for Covid-19 if onset of symptoms develop. B. Review of Resident 4's Nursing Progress Notes revealed the following:-5/21/25 at 7:52 PM the resident had a runny nose and a cough at times. There was no evidence the resident was tested for COVID-19. -5/22/25 at 4:57 AM the resident reported feels like crud with a temperature of 99.1 degrees Fahrenheit. -5/22/25 at 7:04 PM the Director of Nursing (DON) was called, and the resident was placed in isolation. -522/25 at 7:30 PM the resident's oxygen saturation (the measure of oxygen in the red blood cells, with normal levels ranging from 95 percent (%) to 100 %) level was 86%. -5/22/25 at 10:21 PM the resident had a cough and felt congested. Review of the resident's medical record revealed no indication the resident was tested for COVID-19. -5/25/25 at 8:04 AM the resident had a cough and congestion with complaint of not feeling well. -5/25/25 at 10:31 AM the resident had a cough and wheezing. -5/25/25 at 5:20 PM the resident's temperature was 100 degrees Fahrenheit. -5/25/25 at 6:28 PM the resident had wheezing and crackles to lungs with a temperature of 101.3 degrees Fahrenheit. The resident's Primary Care Practitioner (PCP) was notified, and the resident was started on Azithromycin (antibiotic that fights bacteria and treats various infections) 500 milligrams (mg) daily for 5 days and Prednisone (medication which can be used to treat upper respiratory tract infection symptoms) 40 mg daily for 3 days. Review of the resident's medical record revealed no evidence the resident had been tested for COVID-19 despite the resident's ongoing symptoms. During an interview on 9/10/25 at 10:13 AM, the DON confirmed the following regarding Resident 4:-5/22/25 the resident had a cough, elevated temperature, nasal drainage, and lowered oxygen saturation level.-the resident continued to have symptoms which included an elevated temperature, congestion, cough, nasal drainage, and wheezes to lungs through 5/25/25 when the resident was started on an antibiotic.-no evidence the resident was ever tested for COVID-19 from 5/22/25 to 5/25/25 despite the resident's ongoing symptoms. An interview with the Infection Preventionist on 9/10/25 at 2:08 PM confirmed Resident 4 had symptoms of an upper respiratory infection and should have been COVID tested on [DATE]. In addition, the resident continued to be symptomatic through 5/25/25 with no COVID-19 testing.

Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed related to a mental health diagnosis for Resident 3. The sample size was 1 and the facility census was 18. Findings are:Review of the facility policy Pre-admission Screening and Resident Review and admission dated 10/2024 revealed the following:-the review process was designed to identify individuals with Serious Mental Illness (SMI), Intellectual or Developmental Disabilities (IDD), or both, and to ensure they received the necessary specialized services and appropriate placement in accordance with federal and state guidelines,-the facility established a standard process that facilitated comprehensive screening, assessment, and decision-making to determine the eligibility and appropriate level of care for individuals seeking admission to a nursing home,-the discharging hospital or nursing home conducted an initial screening for all individuals seeking admission to determine reasonable suspicion of SMI, IDD, or both,-if the initial screening indicated a reasonable suspicion of SMI, IDD, or both, the evaluation was conducted by a qualified mental health professional or health care provider to determine if further evaluation would be required, and-if further screening confirmed the presence of SMI, IDD, or both determinations regarding the individual's condition, functional abilities, and support needs were considered to determine appropriate levels of care and specialized services and if admission to a Long-Term Care facility was appropriate. Review of Resident 3's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 8/19/25 revealed the resident was admitted on [DATE]. The resident was cognitively intact; didn't exhibit behaviors; required assistance with dressing and toileting; diagnoses included: Non-Alzheimer's Dementia, Parkinson's Disease, Depression, Chronic Lung Disease, and Post Traumatic Stress Disorder (PTSD- a mental health condition that is caused by an extremely stressful or terrifying event); was receiving Antianxiety and Antidepressant medications; and did not have a Level II PASARR evaluation. Review of the Resident 3's Care Plan last revised on 8/21/25 revealed the resident received a medication for Major Depressive Disorder, the facility was to arrange a psychological consult dated 7/31/25, and there was no documentation that the resident had a Level II PASARR evaluation completed. Review of the facility form PASARR for Resident 3 dated 10/3/22 revealed no mental health diagnosis was known or suspected and the results of the Level I screen revealed there were no signs of a serious mental illness, intellectual disability or related found during the Level I screen and no further clinical review or onsite evaluation was needed. Review of the facility form Diagnosis for Resident 3 revealed the resident had diagnoses of PTSD dated 11/6/24 and Major Depressive Disorder dated 9/27/24. Review of the facility form Order Summary Report dated 9/10/25 with Resident 3's active orders revealed an order for Venlafaxine (an antidepressant) with a diagnosis of Major Depressive Disorder. Interview on 9/10/25 at 2:45 PM with the Social Services Director confirmed Resident 3 had diagnoses of PTSD and Major Depressive Disorder. Further interview confirmed a new PASARR should have been completed.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review; the facility failed to ensure Resident 3 received trauma informed care related to a diagnosis of Post Traumatic Stress Disorder (PTSD) and to identify triggers and implement approaches to mitigate potential triggers. The sample size was 1 and the facility census was 18. Findings are:Review of the facility policy Trauma Informed Care dated 4/2025 revealed the following:-it was the policy of the facility to ensure residents who were trauma survivors received culturally competent, trauma informed care in accordance with professional standards of practice,-trauma was defined as an event or series of events or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, that had lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being,-trauma informed care was defined as organizational structure and treatment framework that involved understanding, recognizing, and responding to the effects of all types of trauma, -each resident was screened for a history of trauma upon admission and if that screening indicated the resident had a history of trauma or trauma-related symptoms, a physician's order would be obtained for the resident to be evaluated by a mental health professional, and-the facility accounted for resident experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that caused re-traumatization of the resident. Review of Resident 3's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 8/19/25 revealed the resident was admitted on [DATE], was cognitively intact; didn't exhibit behaviors; required assistance with dressing and toileting; and diagnoses included: Non-Alzheimer's Dementia, Parkinson's Disease, Depression, Chronic Lung Disease, and Post Traumatic Stress Disorder (PTSD-a mental condition that is caused by an extremely stressful or terrifying event). Review of Resident 3's Care Plan last revised 8/21/25 revealed no documentation that the residents diagnosis of PTSD was addressed. Review of the facility form Diagnosis Report revealed Resident 3 had a diagnosis of PTSD dated 11/6/24. Review of the facility forms Social Service Monthly Behavior Flow Sheet regarding Resident 3 for 12/2024 through 7/2025 revealed the PTSD diagnosis was not included. Interview on 9/11/25 at 10:00 AM with the Director of Nursing confirmed the PTSD diagnosis was not included on the behaviors sheets, a trauma informed care assessment had not been completed and PTSD was not identified with triggers and interventions on Resident 3's care plan.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview, and record review; the facility failed to implement measures to prevent the development of pressure ulcers (injury to skin and underlying tissue caused by prolonged pressure to skin) for Resident 10 prior to the development of pressure ulcers. The sample size was 3 and the facility census was 27. Findings are: Review of the facility policy Pressure Injury Prevention and Management with a review date of 7/2023 revealed the following: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers. -A Pressure Ulcer/Injury referred to localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Avoidable meant the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with the residents needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions or revise the interventions as appropriate. -The facility established and utilized a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervention to stabilize, reduce or remove underlying risk factors, monitored the impact of the interventions, and modified the interventions as appropriate. -Licensed nurses conducted pressure injury risk assessments for all residents upon admission/readmission, quarterly and/or with a significant change in the resident's condition and/or with an identified pressure injury. -The risk tool would be used in conjunction with other risk factors such as decreased mobility, co-morbid (simultaneously occurring and putting a person at increased risk for poor outcomes) conditions, drugs that could affect healing, impaired blood flow, skin exposure to incontinence, nutrition and/or hydration deficits, and the presence of a previously healed pressure ulcer. -After completing a thorough assessment, the interdisciplinary team developed a relevant plan of care that included measurable goals and appropriate interventions. -Evidenced based interventions for the prevention of pressure injury were implemented for all residents assessed at risk or who had present pressure injury/s, including but not limited to pressure redistribution such as positioning, protecting, and/or offloading (keeping the risk areas off of surfaces such as the bed) heels, minimizing moisture exposure, providing appropriate support surfaces (specialized devices/surfaces that help redistribute pressure to help prevent and treat pressure injury), and maintaining or improving nutrition/hydration. -Interventions were documented in the Care Plan and communicated to all relevant staff, and compliance with those interventions was documented. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 5/28/24 revealed the following: -The resident's cognitive assessment indicated severe cognitive impairment. -The resident received substantial assistance with transfers (moving from one surface to another), bed mobility, dressing, and toileting hygiene. -The resident had anemia, diabetes, heart failure, kidney disease, a thyroid disorder, high blood pressure, and dementia. -The resident had 2 Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. -The resident participated in Restorative Nursing (type of nursing care designed to assist residents of nursing homes maintain or improve their functional abilities) for ambulation (walking), transfers, and active range of motion. Review of Resident 10's Braden Scales for Predicting Pressure Sore Risk (assessment completed to identify risk of developing pressure sores) revealed the following: -On 2/26/24 the resident's score was 22 which did not indicate risk. -On 5/16/24 the resident's score was 18 which indicated the resident was at risk. Review of Resident 10's Nursing Admission Screening History dated 5/16/24 revealed the resident was readmitted from the hospital following a fall, was alert and oriented, had edema (fluid retention) in feet, was able to bear weight with both legs, required staff assistance with moving in bed, transferring, dressing, walking, toilet use,and personal hygiene. Review of Resident 10's Progress Notes revealed the following: -On 5/11/24 at 12:00 PM the resident was observed on the floor of the resident's room, complained of pain in the left hip, was found to have a skin tear to the left wrist, and hematoma's (collection of blood beneath the skin/tissues) on the left hip and head. The resident was taken to the emergency room (ER) later (3:50 PM) after passing out while being examined/assessed, and the hematoma had doubled in size. -On 5/15/24 at 9:58 AM the resident returned to the facility from the hospital and the left forearm had steri-strips (adhesive strips used to close open skin), the left hip had bruising with an intact wound dressing, and the resident had a bump to the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx (tail bone) or the left heel. -On 5/19/24 at 6:32 PM Resident 10 had a skin tear to the left forearm, bruising to the left thigh/hip, and a bump on the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx or left heel. -On 5/22/24 at 8:10 PM revealed the resident's left heel had a large blister with dark purple coloring beneath the skin. The blister area was 6 cm (centimeters) by 4.5 cm with a 2 cm reddened area surrounding the blister. A heel boot was applied to the left foot to keep pressure off the pressure area and a sheep skin pad was placed under the right heel to prevent pressure. The resident was scheduled to see the doctor the following day. -On 5/23/24 at 3:06 PM the heel blister remained and measured 6 cm by 4.5 cm and 3 cm by 2 cm of the blister was open. In addition, the resident had a 1 cm wound on the coccyx. On 8/19/24 at 4:00 PM during observation of the provision of care Resident 10 was transferred from bath chair to wheelchair using the stand-up mechanical lift (used to assist a resident into a standing position to facilitate movement from one surface to another) with 2 staff in attendance Nursing Assistant (NA)-G and RN-E. While standing in the stand-up lift resident treatment of coccyx pressure ulcer was completed. The wound was open to the air due to having just completed bathing. Registered nurse (RN)-E observed and measured the ulcer on the resident's coccyx. The coccyx ulcer presented as a red area with a layer of yellow slough (dead skin cells which are the byproduct of the inflammatory phase of wound healing) tissue in the center of the wound irregularly shaped. The resident's coccyx bone was prominent, and the resident's overall appearance was thin. After securing the resident in the wheelchair RN-E removed a dressing from Resident 10's heel revealing a golf ball sized open wound noted on the left heel. The area was moist in appearance with some pink tissue and yellow slough (dead tissue) was noted throughout the wound. The RN placed a clean dressing on the wound. During an interview on 8/19/24 at 4:58 PM the Director of Nursing (DON) revealed the following: -The resident fell on [DATE] and received a large hematoma to the left hip. The facility felt the hematoma was complicated as the resident was on a medication that could cause bleeding. The family had reported a similar situation in which the resident developed a hematoma after falling. Initially the facility observed the area for complications and when the area enlarged significantly the resident was sent to the ER (emergency room ) and subsequently admitted to the hospital. -The resident returned from the hospital to the facility on [DATE]. The hematoma remained and the resident's left leg was swollen. -On 5/22/24 the facility noted a blister to the resident's left heel and a heel boot was applied. -On 5/23/24 the facility noted a 1 cm open area to the resident's coccyx; this area had been previously opened and resolved with treatment in the past. The resident was seen by a Primary Care Physician (PCP). -On 5/25/24 a gel overlay/support surface was placed on the resident's bed due to the skin breakdown. -On 5/30/24 the facility initiated a dietary supplement Prostat to improve the resident's nutrition and the resident was also started on an antibiotic due to an odor from the heel wound. -On 6/3/24 the resident was seen by a wound care provider. -On 6/5/24 the resident was again seen by their PCP. -On 6/21/24 the resident was seen by Podiatry (foot doctor) and a wound vacuum (device used to seal and create a gentle suction to promote wound healing) was ordered for the heel ulcer. During further interview on 8/20/24 at 10:43 AM the Director of Nursing (DON) confirmed the facility identified a pressure sore for Resident 10 on 5/22/24 (4 days after readmission from the hospital) and a pressure ulcer on the resident's coccyx on 5/23/24 (5 days after returning from a hospitalization ). The facility believed the development of the heel ulcer and coccyx ulcer was a direct result of the resident's acute change which started while hospitalized . The resident was compromised in movement and had multiple co-morbid conditions which contributed to the resident's skin breakdown, including a history of skin breakdown and nutritional concerns. The resident was still walking at intervals at the time the breakdown was identified. The DON confirmed the facility reassessed the resident's risk for pressure sores at the time of readmission but did not document or care plan additional pressure sore prevention measures prior to identifying the skin breakdown on the resident's heel 4 days later.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview, and record review; the facility failed to implement measures to prevent the development of pressure ulcers (injury to skin and underlying tissue caused by prolonged pressure to skin) for Resident 10 prior to the development of pressure ulcers. The sample size was 3 and the facility census was 27. Findings are: Review of the facility policy Pressure Injury Prevention and Management with a review date of 7/2023 revealed the following: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers. -A Pressure Ulcer/Injury referred to localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Avoidable meant the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with the residents needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions or revise the interventions as appropriate. -The facility established and utilized a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervention to stabilize, reduce or remove underlying risk factors, monitored the impact of the interventions, and modified the interventions as appropriate. -Licensed nurses conducted pressure injury risk assessments for all residents upon admission/readmission, quarterly and/or with a significant change in the resident's condition and/or with an identified pressure injury. -The risk tool would be used in conjunction with other risk factors such as decreased mobility, co-morbid (simultaneously occurring and putting a person at increased risk for poor outcomes) conditions, drugs that could affect healing, impaired blood flow, skin exposure to incontinence, nutrition and/or hydration deficits, and the presence of a previously healed pressure ulcer. -After completing a thorough assessment, the interdisciplinary team developed a relevant plan of care that included measurable goals and appropriate interventions. -Evidenced based interventions for the prevention of pressure injury were implemented for all residents assessed at risk or who had present pressure injury/s, including but not limited to pressure redistribution such as positioning, protecting, and/or offloading (keeping the risk areas off of surfaces such as the bed) heels, minimizing moisture exposure, providing appropriate support surfaces (specialized devices/surfaces that help redistribute pressure to help prevent and treat pressure injury), and maintaining or improving nutrition/hydration. -Interventions were documented in the Care Plan and communicated to all relevant staff, and compliance with those interventions was documented. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 5/28/24 revealed the following: -The resident's cognitive assessment indicated severe cognitive impairment. -The resident received substantial assistance with transfers (moving from one surface to another), bed mobility, dressing, and toileting hygiene. -The resident had anemia, diabetes, heart failure, kidney disease, a thyroid disorder, high blood pressure, and dementia. -The resident had 2 Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. -The resident participated in Restorative Nursing (type of nursing care designed to assist residents of nursing homes maintain or improve their functional abilities) for ambulation (walking), transfers, and active range of motion. Review of Resident 10's Braden Scales for Predicting Pressure Sore Risk (assessment completed to identify risk of developing pressure sores) revealed the following: -On 2/26/24 the resident's score was 22 which did not indicate risk. -On 5/16/24 the resident's score was 18 which indicated the resident was at risk. Review of Resident 10's Nursing admission Screening History dated 5/16/24 revealed the resident was re-admitted from the hospital following a fall, was alert and oriented, had edema (fluid retention) in feet, was able to bear weight with both legs, required staff assistance with moving in bed, transferring, dressing, walking, toilet use,and personal hygiene. Review of Resident 10's Progress Notes revealed the following: -On 5/11/24 at 12:00 PM the resident was observed on the floor of the resident's room, complained of pain in the left hip, was found to have a skin tear to the left wrist, and hematoma's (collection of blood beneath the skin/tissues) on the left hip and head. The resident was taken to the emergency room (ER) later (3:50 PM) after passing out while being examined/assessed, and the hematoma had doubled in size. -On 5/15/24 at 9:58 AM the resident returned to the facility from the hospital and the left forearm had steri-strips (adhesive strips used to close open skin), the left hip had bruising with an intact wound dressing, and the resident had a bump to the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx (tail bone) or the left heel. -On 5/19/24 at 6:32 PM Resident 10 had a skin tear to the left forearm, bruising to the left thigh/hip, and a bump on the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx or left heel. -On 5/22/24 at 8:10 PM revealed the resident's left heel had a large blister with dark purple coloring beneath the skin. The blister area was 6 cm (centimeters) by 4.5 cm with a 2 cm reddened area surrounding the blister. A heel boot was applied to the left foot to keep pressure off the pressure area and a sheep skin pad was placed under the right heel to prevent pressure. The resident was scheduled to see the doctor the following day. -On 5/23/24 at 3:06 PM the heel blister remained and measured 6 cm by 4.5 cm and 3 cm by 2 cm of the blister was open. In addition, the resident had a 1 cm wound on the coccyx. On 8/19/24 at 4:00 PM during observation of the provision of care Resident 10 was transferred from bath chair to wheelchair using the stand-up mechanical lift (used to assist a resident into a standing position to facilitate movement from one surface to another) with 2 staff in attendance Nursing Assistant (NA)-G and RN-E. While standing in the stand-up lift resident treatment of coccyx pressure ulcer was completed. The wound was open to the air due to having just completed bathing. Registered nurse (RN)-E observed and measured the ulcer on the resident's coccyx. The coccyx ulcer presented as a red area with a layer of yellow slough (dead skin cells which are the byproduct of the inflammatory phase of wound healing) tissue in the center of the wound irregularly shaped. The resident's coccyx bone was prominent, and the resident's overall appearance was thin. After securing the resident in the wheelchair RN-E removed a dressing from Resident 10's heel revealing a golf ball sized open wound noted on the left heel. The area was moist in appearance with some pink tissue and yellow slough (dead tissue) was noted throughout the wound. The RN placed a clean dressing on the wound. During an interview on 8/19/24 at 4:58 PM the Director of Nursing (DON) revealed the following: -The resident fell on 5/11/24 and received a large hematoma to the left hip. The facility felt the hematoma was complicated as the resident was on a medication that could cause bleeding. The family had reported a similar situation in which the resident developed a hematoma after falling. Initially the facility observed the area for complications and when the area enlarged significantly the resident was sent to the ER (Emergency Room) and subsequently admitted to the hospital. -The resident returned from the hospital to the facility on 5/16/24. The hematoma remained and the resident's left leg was swollen. -On 5/22/24 the facility noted a blister to the resident's left heel and a heel boot was applied. -On 5/23/24 the facility noted a 1 cm open area to the resident's coccyx; this area had been previously opened and resolved with treatment in the past. The resident was seen by a Primary Care Physician (PCP). -On 5/25/24 a gel overlay/support surface was placed on the resident's bed due to the skin breakdown. -On 5/30/24 the facility initiated a dietary supplement Prostat to improve the resident's nutrition and the resident was also started on an antibiotic due to an odor from the heel wound. -On 6/3/24 the resident was seen by a wound care provider. -On 6/5/24 the resident was again seen by their PCP. -On 6/21/24 the resident was seen by Podiatry (foot doctor) and a wound vacuum (device used to seal and create a gentle suction to promote wound healing) was ordered for the heel ulcer. During further interview on 8/20/24 at 10:43 AM the Director of Nursing (DON) confirmed the facility identified a pressure sore for Resident 10 on 5/22/24 (4 days after readmission from the hospital) and a pressure ulcer on the resident's coccyx on 5/23/24 (5 days after returning from a hospitalization). The facility believed the development of the heel ulcer and coccyx ulcer was a direct result of the resident's acute change which started while hospitalized . The resident was compromised in movement and had multiple co-morbid conditions which contributed to the resident's skin breakdown, including a history of skin breakdown and nutritional concerns. The resident was still walking at intervals at the time the breakdown was identified. The DON confirmed the facility reassessed the resident's risk for pressure sores at the time of readmission but did not document or care plan additional pressure sore prevention measures prior to identifying the skin breakdown on the resident's heel 4 days later.

Licensure Reference Number 12-006.09(H) Based on record review and interview; the facility failed to ensure antibiotic medication orders for Resident 22 had the required duration of use or a documented rationale for continued daily use in accordance with facility policies and clinical standards. The sample size was 7 and the facility census was 27. Findings are: Review of the facility policy Antibiotic Stewardship-LTC with a revision date of 11/2018 revealed the following: -The facility followed an antibiotic stewardship policy -The purpose of the program was to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. -The facility tracked antibiotic use daily. -The facility communicated with physician with the use of a quarterly report card. Review of the facility policy Antibiotic Stewardship with a revision date of 3/2024 revealed the following: -The facility had a coordinated program that promoted the appropriate use of antimicrobial agents, improved outcomes, minimized adverse effects, reduced antimicrobial resistance, and decreased the spread of infections caused by Multi-Drug Resistant Organism (MRDO-organisms that are resistant to one or more classes of antimicrobial agents, such as antibiotics and antifungals). -The facility supported efforts to improve and monitor antibiotic use within the facility. -All antibiotics required a diagnosis and duration of therapy, were reviewed after initiation, and were reviewed by the stewardship team to determine recommended treatment guidelines, and to provide recommendations. Review of Resident 22's Care Plan with a revision date of 7/20/24 revealed the resident bladder incontinence, a history of urinary tract infections and had self-care deficits, activity intolerance and dementia. The resident was given antibiotics as ordered. The staff monitored for signs and symptoms of infection and were taught good hygiene practice. Review of Resident 22's Diagnosis Report dated 8/15/24 revealed diagnoses of Urinary Tract Infections with onset dates of 3/15/24, and 4/1/24. Review of Resident 22's Physicians Order Review Report date 8/15/24 revealed the resident had an order for Nitrofurantoin Monohyd Macro (antibiotic) oral capsule 100mg daily with an order date of 5/10/24. There was no evidence the order contained an end date. During an interview on 8/15/24 at 8:07 AM the Director of Nursing confirmed the Provider had been contacted about the long-term use of the antibiotic medication Macrodantin (Nitrofurantoin Monohyd Macro) for the treatment of chronic UTI's on 7/25/24, however the provider did not document a rationale for the continued use of this antibiotic, despite break through infections and lack of evidence that the prophylactic or preventative antibiotic was preventing the resident from getting infections.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)(4) Based on record review and interview; the facility failed to put interventions in place and/or revise interventions to prevent ongoing falls for Residents 8 and 24. The sample size was 4 and the facility census was 25. Findings are: A. Review of the facility policy Fall Prevention and Treatment last approved 1/2024 revealed the following: -upon admission a fall assessment would be completed to determine the resident's level of fall risk, -the nurse would indicate in the resident's care plan what the fall risk was then implement interventions in accordance with the fall risk level, -if the resident was at a high risk for falls, they would be placed on the facilities fall prevention program and additional interventions would be provided as directed by the resident assessment, and -when a resident experienced a fall the facility would assess the resident, notify the physician, family, and Director of Nursing (DON), review the resident's care plan and update as indicated, document all assessments and actions, obtain witness statements, neuro checks would be performed if there was suspicion of a head injury, Adult and Child Abuse and Neglect would be contacted if indicated, the facility would monitor the resident for 24 hours post fall and document any changes, and communication to all shifts that the resident had fallen and was at risk to fall again would be provided. B. Review of Resident 8's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 7/30/24 revealed the following: -diagnoses of high blood pressure, Alzheimer's Disease, and depression, -severe cognitive impaired with a memory problem, -required assistance with toileting, transfers, dressing and personal hygiene, -had one fall with no injury, -received antipsychotic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion), antianxiety, and opioid (a class of drugs that can be used to treat moderate to severe pain) medications, and -used bed and chair alarms daily. Review of Resident 8's Care Plan last revised 8/1/24 revealed the following: -the resident had short- and long-term memory loss and made poor decisions, -required extensive assistance with bed mobility and was dependent with dressing, toileting, and transfers, -the resident was high risk for falls, and -fall interventions included: toilet every 1-2 hours, make sure the resident's call light was within reach, make sure the room was free of clutter, make sure frequently used items were within reach, work with Hospice on falls, tab, and chair alarms, fall mat at bedside, make sure the bed is in the normal lowest natural position, when the resident is restless, try to figure out why-rule out pain or need to use the bathroom, offer to take the resident for a wheelchair ride outside (weather permitting), and offer diversional activities. Review of the facility form Fall Scale for Resident 8 dated 7/30/24 revealed the resident was at a high risk for falling. Review of the facility forms Un-witnessed Fall regarding Resident 8 revealed the following: -2/11/24 at 12:15 PM the resident rolled out of bed and was kneeling beside the bed in a praying position with no new intervention implemented, -2/23/24 at 10:25 PM the resident crawled out of bed, was on the floor on the resident's back with feet on the wheelchair with no new intervention implemented, -2/26/24 at 7:43 AM the resident was found crawling on the floor in the resident room with no new intervention implemented, -3/7/24 at 12:08 AM the resident was observed on laying on the floor in the resident room with wet pats and the bed alarm did not sound with no new intervention implemented, -3/11/24 at 8:15 AM the resident was found on the fall mat in the praying position at bedside with no new intervention implemented, and -4/10/24 at 6:50 AM the resident had crawled out of bed and was sitting on their buttock leaning on the bed and no new intervention implemented. C. Review of Resident 24's MDS dated [DATE] revealed the following: -diagnoses of hypertension and dementia, -severe cognitive impairment, -required substantial assistance with toileting, dressing, transfers and personal hygiene, -had 2 or more falls with no injury, -received antipsychotic medications routine and as needed, and -used bed and chair alarms daily. Review of Resident 24's Care Plan last revised 8/14/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required set up assistance or supervision with bed mobility, dressing, toileting, and transfers, -the resident was high risk for falls, and -fall interventions included: be sure the call light was within reach, check environment for safety issues, make sure the room is free of clutter, the bedspread is not touching the floor and the foot rest is down, encourage the resident to be at the nurse's station or activity when their spouse was taking a bath, ensure proper footwear, motivate the resident to make safe decisions, observe for changes in balance and gait, and make sure all items were in reach when the resident was in the resident room. Review of the facility form Fall Scale for Resident 24 dated 8/6/24 revealed the resident was at a high risk for falling. Review of the facility forms Un-witnessed Fall regarding Resident 24 revealed the following: -2/16/24 at 9:35 PM the resident was found on the floor next to their bed. The resident stated that they slid off the bed, no new intervention implemented, -4/3/24 at 11:25 AM the resident was in the recliner and the recliner tipped forward, no new intervention implemented, -6/5/24 at 4:00 PM the resident fell in the hallway, landed on their right side, no new intervention implemented, -6/13/24 at 8:50 PM the resident was found lying on the floor on their right side, no new intervention implemented, and -8/6/24 at 8:04 PM resident was found sitting on the floor in front of the recliner, no new intervention implemented. D. Interview with the DON on 8/20/24 at 1:35 PM confirmed new interventions were not implemented to prevent future falls for Residents 8 and 24.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview; the facility Pharmacist failed to identify medication irregularities related to a diagnosis for an antipsychotic medication for Resident 15, failed to ensure Resident 22's antibiotic medication had a clinical rationale to support ongoing daily use, failed to ensure a gradual dose reduction was attempted or there was a clinical rationale for continued use of Resident 11's antidepressant medication, and failed to ensure Resident's 8, 24, and 25's as needed antipsychotic medication orders did not exceed 14 days without a providers reassessment of the resident's conditions. The sample size was 7 and the facility census was 27. Findings are: A. Review of the facility policy Use of Psychotropic Drugs with a review date of 8/2023 revealed the following: -Resident were not given psychotropic (mind altering substance that changes brain function and can alter perception) drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -Psychotropic drug use included the use of antipsychotic, antidepressant, anti-anxiety, and hypnotic medication. -The indication for use of any psychotropic drug was documented in the medical record. -Residents who received psychotropic medications received gradual dose reductions, unless clinically contraindicated, and received non-pharmacological interventions to facilitate reduction and or discontinuation of the drugs. -PRN orders to psychotropic drugs were used only when the medication was necessary to treat a specific documented condition and limited in duration to 14 days. -PRN orders for antipsychotic drugs could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. B. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 7/16/24 revealed diagnoses of heart disease, depression, anxiety, and dementia. There was not evidence the resident had psychosis. In addition, the resident displayed no adverse behaviors, but took antipsychotic medication. Review of Resident 15's Care Plan with a revision date of 7/20/24 revealed the resident attended some facility activities but preferred to read books. The resident had trouble sleeping at night and took psychotropic medications for anxiety and depression. In addition, the resident was at risk for adverse medication reactions, adverse drug reaction symptoms were monitored, and the resident would receive the lowest possible doses for the shortest possible durations for treating clinical conditions. Review of Resident 15's Physician's Orders dated 8/15/24 revealed an order for the antipsychotic medication Risperidone 0.25mg (milligram) one tablet daily for anxiety/depression with an order date of 10/26/23. During an interview on 8/19/24 at 1:34 PM the Director of Nursing (DON) confirmed the facility did not have a diagnosis in place to support the use of the antipsychotic medication Risperidone for Resident 15. C. Review of Resident 11's MDS dated [DATE] revealed the resident was dependent on the staff for dressing, transfers, toileting hygiene, received substantial assistance with bed mobility, oral hygiene, and bed mobility, and eating. In addition, the resident had loss of physical functioning of extremities, had a history of stroke, depression, and dementia. The resident displayed physical and verbal behavior and rejected care. Medications taken included antipsychotic, and antidepressant medication. Review of Resident 11's Care Plan with a revision date of 6/5/25 revealed the following: -The resident displayed physical and threatening behaviors, and abusive language toward staff, resisted care, and displayed inappropriate sexual behavior. The resident was encouraged to express self in a calm manner. -The resident took psychotropic medications with a goal to be on the lowest possible doses to control signs and symptoms of depression and behaviors. -The Pharmacy Consultant reviewed medications monthly and made recommendations to the provider to reduce the dosage of psychotropic medication to ensure the lowest possible effective dose needed. Review of Resident 11's Physician's Orders dated 8/20/24 revealed the resident was taking the antidepressant medication Mirtazapine 15 mg daily for appetite. Review of Resident 11's Medication Administration Records revealed the Mirtazapine had remained at the 15mg dose since 12/30/22 when ordered for mood. Review of Resident 11's Pharmacy Review recommendations revealed no evidence the facility reviewed the resident's Mirtazapine for dose reduction and no evidence the provider documented a clinical contraindication. During an interview on 8/19/24 at 10:18 AM the Director of Nursing (DON) confirmed the facility pharmacist had not identified the need to review resident 11's antidepressant medication Mirtazapine for a gradual dose reduction or confirmed that Resident 11's provider had not documented a clinical rationale for continuing the medication at the current dose. 45739 D. Review of Resident 8's MDS dated [DATE] revealed the following: -diagnoses of high blood pressure, Alzheimer's Disease, and depression, -severe cognitive impaired with a memory problem, -the resident displayed physical and verbal behaviors directed towards others, other behaviors not towards others, rejection of care, and wandering, -required assistance with toileting, transfers, dressing and personal hygiene, and -received antipsychotic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion), antianxiety, and opioid (a class of drugs that can be used to treat moderate to severe pain) medications. Review of Resident 8's Care Plan last revised 8/1/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required extensive assistance with bed mobility and was dependent with dressing, toileting, and transfers, -the resident was high risk for falls, and -the resident received an antidepressant for depression and psychotropic medications for restlessness and anxiety, the Pharmacy Consultant reviewed psychotropic medications monthly, and would make recommendations to be sure the resident received the lowest effective dosage. Review of the facsimile (fax) dated 2/23/24 revealed the Resident 8 had an order for ABH (Ativan/Benadryl/Haloperidol [Haloperidol is an antipsychotic medication]) Cream-apply to skin every 6 hours as needed for restlessness or anxiety originally ordered 2/12/24 renewed for 364 days (stop date 2/21/25). Review of Resident 8's Order Summary with active orders as of 8/15/24 revealed an order for ABH Cream apply to skin topically every 6 hours as needed for restlessness or anxiety ordered 2/23/24 with a stop date of 2/21/25. An interview with the DON on 8/15/24 at 1:05 PM confirmed the as needed ABH Cream had an antipsychotic medication in it, and it did not have a 14-day limit. E. Review of Resident 24's MDS dated [DATE] revealed the following: -diagnoses of hypertension and dementia, -severe cognitive impairment, -displayed physical and verbal behaviors towards others, other behaviors not towards others, rejection of care, and wandering, -required substantial assistance with toileting, dressing, transfers, and personal hygiene, and -received antipsychotic medications routine and as needed. Review of Resident 24's Care Plan last revised 8/14/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required set up assistance or supervision with bed mobility, dressing, toileting, and transfers, -the resident was high risk for falls, and -the resident received an antipsychotic medication for agitation and dementia, the Pharmacy Consultant reviewed psychotropic medications monthly and would make recommendations to be sure the resident received the lowest effective dosage. Review of the fax dated 7/19/24 revealed the Resident 24 had an order for ABH gel topically to inner wrists every 6 hours as needed for agitation originally ordered 7/8/24 was continued for 90 days. Review of Resident 24's Order Summary with active orders as of 8/15/24 revealed an order for ABH Cream apply to inner wrists topically every 6 hours as needed for agitation ordered 7/19/24 until 10/17/24. An interview with the DON on 8/15/24 at 1:05 PM confirmed the as needed ABH Cream had an antipsychotic medication in it and it did not have a 14 days limit. F. Review of Resident 25's MDS dated [DATE] revealed the following: -diagnoses of dementia, hypertension, non-Alzheimer's dementia, -severe cognitive impairment with a memory problem, -the resident displayed physical and verbal behaviors directed towards others, other behaviors not directed towards others and rejection of care, -required assistance with toileting, transfers, dressing, and personal hygiene, and -received an antipsychotic and opioid (a class of drugs that can be used to treat moderate to severe pain). Review of Resident 25's Care Plan last revised 8/8/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required extensive assist with dressing, toileting, and transfers and supervision with bed mobility, -the resident was a high fall risk, and -the resident received psychotropic medications for agitation the Pharmacy Consultant reviewed psychotropic medications monthly and would make recommendations to be sure the resident received the lowest effective dosage. Review of the fax dated 6/17/24 revealed Resident 25 had an order for Haloperidol 2mg/milliliter (ml) give 0.5 ml (1mg) every 6 hours as needed, originally ordered 6/4/24 was continued for 180 days. Review of Resident 25's Order Summary with active orders as of 8/15/24 revealed an order for Haloperidol give 0.5 ml every 6 hours as needed ordered 6/18/24 until 12/4/24. An interview with the DON on 8/15/24 at 1:05 PM confirmed the Haloperidol was an antipsychotic and the stop date of the medication was longer than the 14-day limit.

Licensure Reference Number 12-006.09(H) Based on record review and interview; the facility failed to ensure antibiotic medication orders for Resident 22 had the required duration of use or a documented rationale for continued daily use in accordance with facility policies and clinical standards. The sample size was 7 and the facility census was 27. Findings are: Review of the facility policy Antibiotic Stewardship-LTC with a revision date of 11/2018 revealed the following: -The facility followed an antibiotic stewardship policy -The purpose of the program was to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. -The facility tracked antibiotic use daily. -The facility communicated with physician with the use of a quarterly report card. Review of the facility policy Antibiotic Stewardship with a revision date of 3/2024 revealed the following: -The facility had a coordinated program that promoted the appropriate use of antimicrobial agents, improved outcomes, minimized adverse effects, reduced antimicrobial resistance, and decreased the spread of infections caused by Multi-Drug Resistant Organism (MRDO-organisms that are resistant to one or more classes of antimicrobial agents, such as antibiotics and antifungals). -The facility supported efforts to improve and monitor antibiotic use within the facility. -All antibiotics required a diagnosis and duration of therapy, were reviewed after initiation, and were reviewed by the stewardship team to determine recommended treatment guidelines, and to provide recommendations. Review of Resident 22's Care Plan with a revision date of 7/20/24 revealed the resident bladder incontinence, a history of urinary tract infections and had self-care deficits, activity intolerance and dementia. The resident was given antibiotics as ordered. The staff monitored for signs and symptoms of infection and were taught good hygiene practice. Review of Resident 22's Diagnosis Report dated 8/15/24 revealed diagnoses of Urinary Tract Infections with onset dates of 3/15/24, and 4/1/24. Review of Resident 22's Physicians Order Review Report date 8/15/24 revealed the resident had an order for Nitrofurantoin Monohyd Macro (antibiotic) oral capsule 100mg daily with an order date of 5/10/24. There was no evidence the order contained an end date. During an interview on 8/15/24 at 8:07 AM the Director of Nursing confirmed the Provider had been contacted about the long-term use of the antibiotic medication Macrodantin (Nitrofurantoin Monohyd Macro) for the treatment of chronic UTI's on 7/25/24, however the provider did not document a rationale for the continued use of this antibiotic, despite break through infections and lack of evidence that the prophylactic or preventative antibiotic was preventing the resident from getting infections.

D. Review of Resident 8's MDS dated [DATE] revealed the following: -diagnoses of high blood pressure, Alzheimer's Disease, and depression, -severe cognitive impaired with a memory problem, -the resident displayed physical and verbal behaviors directed towards others, other behaviors not towards others, rejection of care, and wandering, -required assistance with toileting, transfers, dressing and personal hygiene, and -received antipsychotic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion), antianxiety, and opioid (a class of drugs that can be used to treat moderate to severe pain) medications. Review of Resident 8's Care Plan last revised 8/1/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required extensive assistance with bed mobility and was dependent with dressing, toileting, and transfers, -the resident was high risk for falls, and -the resident received an antidepressant for depression and psychotropic medications for restlessness and anxiety, the Pharmacy Consultant reviewed psychotropic medications monthly, and would make recommendations to be sure the resident received the lowest effective dosage. Review of the facsimile (fax) dated 2/23/24 revealed the Resident 8 had an order for ABH (Ativan/Benadryl/Haloperidol [Haloperidol is an antipsychotic medication]) Cream-apply to skin every 6 hours as needed for restlessness or anxiety originally ordered 2/12/24 renewed for 364 days (stop date 2/21/25). Review of Resident 8's Order Summary with active orders as of 8/15/24 revealed an order for ABH Cream apply to skin topically every 6 hours as needed for restlessness or anxiety ordered 2/23/24 with a stop date of 2/21/25. An interview with the DON on 8/15/24 at 1:05 PM confirmed the as needed ABH Cream had an antipsychotic medication in it, and it did not have a 14-day limit. E. Review of Resident 24's MDS dated [DATE] revealed the following: -diagnoses of hypertension and dementia, -severe cognitive impairment, -displayed physical and verbal behaviors towards others, other behaviors not towards others, rejection of care, and wandering, -required substantial assistance with toileting, dressing, transfers, and personal hygiene, and -received antipsychotic medications routine and as needed. Review of Resident 24's Care Plan last revised 8/14/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required set up assistance or supervision with bed mobility, dressing, toileting, and transfers, -the resident was high risk for falls, and -the resident received an antipsychotic medication for agitation and dementia, the Pharmacy Consultant reviewed psychotropic medications monthly and would make recommendations to be sure the resident received the lowest effective dosage. Review of the fax dated 7/19/24 revealed the Resident 24 had an order for ABH gel topically to inner wrists every 6 hours as needed for agitation originally ordered 7/8/24 was continued for 90 days. Review of Resident 24's Order Summary with active orders as of 8/15/24 revealed an order for ABH Cream apply to inner wrists topically every 6 hours as needed for agitation ordered 7/19/24 until 10/17/24. An interview with the DON on 8/15/24 at 1:05 PM confirmed the as needed ABH Cream had an antipsychotic medication in it and it did not have a 14 days limit. F. Review of Resident 25's MDS dated [DATE] revealed the following: -diagnoses of dementia, hypertension, non-Alzheimer's dementia, -severe cognitive impairment with a memory problem, -the resident displayed physical and verbal behaviors directed towards others, other behaviors not directed towards others and rejection of care, -required assistance with toileting, transfers, dressing, and personal hygiene, and -received an antipsychotic and opioid (a class of drugs that can be used to treat moderate to severe pain). Review of Resident 25's Care Plan last revised 8/8/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required extensive assist with dressing, toileting, and transfers and supervision with bed mobility, -the resident was a high fall risk, and -the resident received psychotropic medications for agitation the Pharmacy Consultant reviewed psychotropic medications monthly and would make recommendations to be sure the resident received the lowest effective dosage. Review of the fax dated 6/17/24 revealed Resident 25 had an order for Haloperidol 2mg/milliliter (ml) give 0.5 ml (1mg) every 6 hours as needed, originally ordered 6/4/24 was continued for 180 days. Review of Resident 25's Order Summary with active orders as of 8/15/24 revealed an order for Haloperidol give 0.5 ml every 6 hours as needed ordered 6/18/24 until 12/4/24. An interview with the DON on 8/15/24 at 1:05 PM confirmed the Haloperidol was an antipsychotic and the stop date of the medication was longer than the 14-day limit. Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview; the facility Pharmacist failed to identify medication irregularities related to a diagnosis for an antipsychotic medication for Resident 15, failed to ensure Resident 22's antibiotic medication had a clinical rationale to support ongoing daily use, failed to ensure a gradual dose reduction was attempted or there was a clinical rationale for continued use of Resident 11's antidepressant medication, and failed to ensure Resident's 8, 24, and 25's as needed antipsychotic medication orders did not exceed 14 days without a providers reassessment of the resident's conditions. The sample size was 7 and the facility census was 27. Findings are: A. Review of the facility policy Use of Psychotropic Drugs with a review date of 8/2023 revealed the following: -Resident were not given psychotropic (mind altering substance that changes brain function and can alter perception) drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -Psychotropic drug use included the use of antipsychotic, antidepressant, anti-anxiety, and hypnotic medication. -The indication for use of any psychotropic drug was documented in the medical record. -Residents who received psychotropic medications received gradual dose reductions, unless clinically contraindicated, and received non-pharmacological interventions to facilitate reduction and or discontinuation of the drugs. -PRN orders to psychotropic drugs were used only when the medication was necessary to treat a specific documented condition and limited in duration to 14 days. -PRN orders for antipsychotic drugs could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. B. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 7/16/24 revealed diagnoses of heart disease, depression, anxiety, and dementia. There was not evidence the resident had psychosis. In addition, the resident displayed no adverse behaviors, but took antipsychotic medication. Review of Resident 15's Care Plan with a revision date of 7/20/24 revealed the resident attended some facility activities but preferred to read books. The resident had trouble sleeping at night and took psychotropic medications for anxiety and depression. In addition, the resident was at risk for adverse medication reactions, adverse drug reaction symptoms were monitored, and the resident would receive the lowest possible doses for the shortest possible durations for treating clinical conditions. Review of Resident 15's Physician's Orders dated 8/15/24 revealed an order for the antipsychotic medication Risperidone 0.25mg (milligram) one tablet daily for anxiety/depression with an order date of 10/26/23. During an interview on 8/19/24 at 1:34 PM the Director of Nursing (DON) confirmed the facility did not have a diagnosis in place to support the use of the antipsychotic medication Risperidone for Resident 15. C. Review of Resident 11's MDS dated [DATE] revealed the resident was dependent on the staff for dressing, transfers, toileting hygiene, received substantial assistance with bed mobility, oral hygiene, and bed mobility, and eating. In addition, the resident had loss of physical functioning of extremities, had a history of stroke, depression, and dementia. The resident displayed physical and verbal behavior and rejected care. Medications taken included antipsychotic, and antidepressant medication. Review of Resident 11's Care Plan with a revision date of 6/5/25 revealed the following: -The resident displayed physical and threatening behaviors, and abusive language toward staff, resisted care, and displayed inappropriate sexual behavior. The resident was encouraged to express self in a calm manner. -The resident took psychotropic medications with a goal to be on the lowest possible doses to control signs and symptoms of depression and behaviors. -The Pharmacy Consultant reviewed medications monthly and made recommendations to the provider to reduce the dosage of psychotropic medication to ensure the lowest possible effective dose needed. Review of Resident 11's Physician's Orders dated 8/20/24 revealed the resident was taking the antidepressant medication Mirtazapine 15 mg daily for appetite. Review of Resident 11's Medication Administration Records revealed the Mirtazapine had remained at the 15mg dose since 12/30/22 when ordered for mood. Review of Resident 11's Pharmacy Review recommendations revealed no evidence the facility reviewed the resident's Mirtazapine for dose reduction and no evidence the provider documented a clinical contraindication. During an interview on 8/19/24 at 10:18 AM the Director of Nursing (DON) confirmed the facility pharmacist had not identified the need to review resident 11's antidepressant medication Mirtazapine for a gradual dose reduction or confirmed that Resident 11's provider had not documented a clinical rationale for continuing the medication at the current dose.

D. Review of Resident 8's MDS dated [DATE] revealed the following: -diagnoses of high blood pressure, Alzheimer's Disease, and depression, -severe cognitive impaired with a memory problem, -the resident displayed physical and verbal behaviors directed towards others, other behaviors not towards others, rejection of care, and wandering, -required assistance with toileting, transfers, dressing and personal hygiene, and -received antipsychotic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion), antianxiety, and opioid (a class of drugs that can be used to treat moderate to severe pain) medications. Review of Resident 8's Care Plan last revised 8/1/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required extensive assistance with bed mobility and was dependent with dressing, toileting, and transfers, -the resident was high risk for falls, and -the resident received an antidepressant for depression and psychotropic medications for restlessness and anxiety, the Pharmacy Consultant reviewed psychotropic medications monthly, and would make recommendations to be sure the resident received the lowest effective dosage. Review of the facsimile (fax) dated 2/23/24 revealed the Resident 8 had an order for ABH (Ativan/Benadryl/Haloperidol [Haloperidol is an antipsychotic medication]) Cream-apply to skin every 6 hours as needed for restlessness or anxiety originally ordered 2/12/24 renewed for 364 days (stop date 2/21/25). Review of Resident 8's Order Summary with active orders as of 8/15/24 revealed an order for ABH Cream apply to skin topically every 6 hours as needed for restlessness or anxiety ordered 2/23/24 with a stop date of 2/21/25. Review of Resident 8's Medication Administration records (MARs) for 2024 revealed in June the resident received the PRN ABH cream 14 doses, in July the resident received 15 doses and in August the resident received 15 doses. An interview with the DON on 8/15/24 at 1:05 PM confirmed the as needed ABH Cream had an antipsychotic medication in it, was not limited to 14 days and the resident had received the medication longer than the 14-day limit. E. Review of Resident 24's MDS dated [DATE] revealed the following: -diagnoses of hypertension and dementia, -severe cognitive impairment, -displayed physical and verbal behaviors towards others, other behaviors not towards others, rejection of care, and wandering, -required substantial assistance with toileting, dressing, transfers, and personal hygiene, and -received antipsychotic medications routine and as needed. Review of Resident 24's Care Plan last revised 8/14/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required set up assistance or supervision with bed mobility, dressing, toileting, and transfers, -the resident was high risk for falls, and -the resident received an antipsychotic medication for agitation and dementia, the Pharmacy Consultant reviewed psychotropic medications monthly and would make recommendations to be sure the resident received the lowest effective dosage. Review of the fax dated 7/19/24 revealed the Resident 24 had an order for ABH gel topically to inner wrists every 6 hours as needed for agitation originally ordered 7/8/24 was continued for 90 days. Review of Resident 24's Order Summary with active orders as of 8/15/24 revealed an order for ABH Cream apply to inner wrists topically every 6 hours as needed for agitation ordered 7/19/24 until 10/17/24. Review of Resident 24's August 2024 MAR revealed the resident received the PRN ABH Cream 5 times with the last time being 8/10/24 (8 days past the 14-day limit). An interview with the DON on 8/15/24 at 1:05 PM confirmed the as needed ABH Cream had an antipsychotic medication in it, was not limited to 14 days and the resident had received the medication longer than the 14-day limit. F. Review of Resident 25's MDS dated [DATE] revealed the following: -diagnoses of dementia, hypertension, non-Alzheimer's dementia, -severe cognitive impairment with a memory problem, -the resident displayed physical and verbal behaviors directed towards others, other behaviors not directed towards others and rejection of care, -required assistance with toileting, transfers, dressing, and personal hygiene, and -received an antipsychotic and opioid (a class of drugs that can be used to treat moderate to severe pain). Review of Resident 25's Care Plan last revised 8/8/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required extensive assist with dressing, toileting, and transfers and supervision with bed mobility, -the resident was a high fall risk, and -the resident received psychotropic medications for agitation the Pharmacy Consultant reviewed psychotropic medications monthly and would make recommendations to be sure the resident received the lowest effective dosage. Review of the fax dated 6/17/24 revealed Resident 25 had an order for Haloperidol 2mg/milliliter (ml) give 0.5 ml (1mg) every 6 hours as needed, originally ordered 6/4/24 was continued for 180 days. Review of Resident 25's Order Summary with active orders as of 8/15/24 revealed an order for Haloperidol give 0.5 ml every 6 hours as needed ordered 6/18/24 until 12/4/24. An interview with the DON on 8/15/24 at 1:05 PM confirmed the Haloperidol was an antipsychotic and the stop date of the medication was longer than the 14-day limit. Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review; the facility failed to have a diagnosis for the use of an antipsychotic (medication typically used to manage psychotic disorders) medication for Resident 15, failed to attempt a gradual dose reduction or have a documented contraindication for reducing an antidepressant (medication typically used to treat depression) medication for Resident 11, and failed to ensure PRN (as needed) antipsychotic medications orders were limited to 14 days for Residents 8, 24, and 25. The sample size was 7 and the facility census was 27. A. Review of the facility policy Use of Psychotropic Drugs with a review date of 8/2023 revealed the following: -Residents were not given psychotropic (mind altering substance that changes brain function and can alter perception) drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -Psychotropic drug use included the use of antipsychotic, antidepressant, anti-anxiety, and hypnotic (sleep inducing) medication. -The indication for use of any psychotropic drug was documented in the medical record. -Residents who received psychotropic medications received gradual dose reductions, unless clinically contraindicated, and received non-pharmacological interventions to facilitate reduction and or discontinuation of the drugs. -PRN orders to psychotropic drugs were used only when the medication was necessary to treat a specific documented condition and limited in duration to 14 days. -PRN orders for antipsychotic drugs could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. B. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 7/16/24 revealed diagnoses of heart disease, depression, anxiety, and dementia. There was no evidence the resident had psychosis. In addition, the resident displayed no adverse behaviors, but took antipsychotic medication. Review of Resident 15's Care Plan with a revision date of 7/20/24 revealed the resident attended some facility activities but preferred to read books. The resident had trouble sleeping at night and took psychotropic medications for anxiety and depression. In addition, the resident was at risk for adverse medication reactions, adverse drug reaction symptoms were monitored, and the resident would receive the lowest possible doses for the shortest possible durations for treating clinical conditions. Review of Resident 15's Physician's Orders dated 8/15/24 revealed an order for the antipsychotic medication Risperidone 0.25mg one tablet daily for anxiety/depression with an order date of 10/26/23. During an interview on 8/19/24 at 1:34 PM the Director of Nursing (DON) confirmed the facility did not have a diagnosis in place to support the use of the antipsychotic medication Risperidone for Resident 15. C. Review of Resident 11's MDS dated [DATE] revealed the resident was dependent on the staff for dressing, transfers, toileting hygiene, received substantial assistance with bed mobility, oral hygiene, and bed mobility, and eating. In addition, the resident had loss of physical functioning of extremities, had a history of stroke, depression, and dementia. The resident displayed physical and verbal behavior and rejected care. Medications taken included antipsychotic, and antidepressant medication. Review of Resident 11's Care Plan with a revision date of 6/5/25 revealed the following: -The resident displayed physical and threatening behaviors, and abusive language toward staff, resisted care, and displayed inappropriate sexual behavior. The resident was encouraged to express self in a calm manner. -The resident took psychotropic medications with a goal to be on the lowest possible doses to control signs and symptoms of depression and behaviors. -The Pharmacy Consultant reviewed medications monthly and made recommendations to the provider to reduce the dosage of psychotropic medication to ensure the lowest possible effective dose needed. Review of Resident 11's Physician's Orders dated 8/20/24 revealed the resident was taking the antidepressant medication Mirtazapine 15 mg daily for appetite. Review of Resident 11's Medication Administration Records revealed the Mirtazapine had remained at the 15mg dose since 12/30/22 when ordered for mood. Review of Resident 11's Pharmacy Review recommendations revealed no evidence the facility reviewed the resident's Mirtazapine for dose reduction and no evidence the provider documented a clinical contraindication. During an interview on 8/19/24 at 10:18 AM the DON confirmed the facility Pharmacist had not identified the need to review resident 11's antidepressant medication Mirtazapine for a gradual dose reduction or confirmed that Resident 11's provider had not documented a clinical rationale for continuing the medication at the current dose.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)(4) Based on record review and interview; the facility failed to put interventions in place and/or revise interventions to prevent ongoing falls for Residents 8 and 24. The sample size was 4 and the facility census was 25. Findings are: A. Review of the facility policy Fall Prevention and Treatment last approved 1/2024 revealed the following: -upon admission a fall assessment would be completed to determine the resident's level of fall risk, -the nurse would indicate in the resident's care plan what the fall risk was then implement interventions in accordance with the fall risk level, -if the resident was at a high risk for falls, they would be placed on the facilities fall prevention program and additional interventions would be provided as directed by the resident assessment, and -when a resident experienced a fall the facility would assess the resident, notify the physician, family, and Director of Nursing (DON), review the resident's care plan and update as indicated, document all assessments and actions, obtain witness statements, neuro checks would be performed if there was suspicion of a head injury, Adult and Child Abuse and Neglect would be contacted if indicated, the facility would monitor the resident for 24 hours post fall and document any changes, and communication to all shifts that the resident had fallen and was at risk to fall again would be provided. B. Review of Resident 8's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 7/30/24 revealed the following: -diagnoses of high blood pressure, Alzheimer's Disease, and depression, -severe cognitive impaired with a memory problem, -required assistance with toileting, transfers, dressing and personal hygiene, -had one fall with no injury, -received antipsychotic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion), antianxiety, and opioid (a class of drugs that can be used to treat moderate to severe pain) medications, and -used bed and chair alarms daily. Review of Resident 8's Care Plan last revised 8/1/24 revealed the following: -the resident had short- and long-term memory loss and made poor decisions, -required extensive assistance with bed mobility and was dependent with dressing, toileting, and transfers, -the resident was high risk for falls, and -fall interventions included: toilet every 1-2 hours, make sure the resident's call light was within reach, make sure the room was free of clutter, make sure frequently used items were within reach, work with Hospice on falls, tab, and chair alarms, fall mat at bedside, make sure the bed is in the normal lowest natural position, when the resident is restless, try to figure out why-rule out pain or need to use the bathroom, offer to take the resident for a wheelchair ride outside (weather permitting), and offer diversional activities. Review of the facility form Fall Scale for Resident 8 dated 7/30/24 revealed the resident was at a high risk for falling. Review of the facility forms Un-witnessed Fall regarding Resident 8 revealed the following: -2/11/24 at 12:15 PM the resident rolled out of bed and was kneeling beside the bed in a praying position with no new intervention implemented, -2/23/24 at 10:25 PM the resident crawled out of bed, was on the floor on the resident's back with feet on the wheelchair with no new intervention implemented, -2/26/24 at 7:43 AM the resident was found crawling on the floor in the resident room with no new intervention implemented, -3/7/24 at 12:08 AM the resident was observed on laying on the floor in the resident room with wet pats and the bed alarm did not sound with no new intervention implemented, -3/11/24 at 8:15 AM the resident was found on the fall mat in the praying position at bedside with no new intervention implemented, and -4/10/24 at 6:50 AM the resident had crawled out of bed and was sitting on their buttock leaning on the bed and no new intervention implemented. C. Review of Resident 24's MDS dated [DATE] revealed the following: -diagnoses of hypertension and dementia, -severe cognitive impairment, -required substantial assistance with toileting, dressing, transfers and personal hygiene, -had 2 or more falls with no injury, -received antipsychotic medications routine and as needed, and -used bed and chair alarms daily. Review of Resident 24's Care Plan last revised 8/14/24 revealed the following: -the resident had short and long-term memory loss and made poor decisions, -required set up assistance or supervision with bed mobility, dressing, toileting, and transfers, -the resident was high risk for falls, and -fall interventions included: be sure the call light was within reach, check environment for safety issues, make sure the room is free of clutter, the bedspread is not touching the floor and the foot rest is down, encourage the resident to be at the nurse's station or activity when their spouse was taking a bath, ensure proper footwear, motivate the resident to make safe decisions, observe for changes in balance and gait, and make sure all items were in reach when the resident was in the resident room. Review of the facility form Fall Scale for Resident 24 dated 8/6/24 revealed the resident was at a high risk for falling. Review of the facility forms Un-witnessed Fall regarding Resident 24 revealed the following: -2/16/24 at 9:35 PM the resident was found on the floor next to their bed. The resident stated that they slid off the bed, no new intervention implemented, -4/3/24 at 11:25 AM the resident was in the recliner and the recliner tipped forward, no new intervention implemented, -6/5/24 at 4:00 PM the resident fell in the hallway, landed on their right side, no new intervention implemented, -6/13/24 at 8:50 PM the resident was found lying on the floor on their right side, no new intervention implemented, and -8/6/24 at 8:04 PM resident was found sitting on the floor in front of the recliner, no new intervention implemented. D. Interview with the DON on 8/20/24 at 1:35 PM confirmed new interventions were not implemented to prevent future falls for Residents 8 and 24.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit a completed investigation report to the State Agency for a fall for Resident 8. The sample size was 3 and the facility census was 25. Findings are: Review of the facility policy Abuse Neglect and Exploitation last approved 9/23 revealed the following: -when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred, an investigation would immediately be warranted, -when abuse, neglect, or exploitation was suspected the nurse would respond to the resident needs and protect them from further incidents; notify the Director of Nursing (DON) and the Administrator; initiate an investigation immediately; notify the physician, the resident's representative and contact the State Agency to report the alleged abuse, -in response to alleged allegations the facility must ensure all alleged violations were reported immediately to the Abuse and Neglect Hotline no later than 2 hours after the allegation was made or no later than 24 hours if the events do not involve abuse or serious bodily injury, and have evidence that all alleged violations were investigated, -the facility must prevent further potential abuse, and -report the results of all investigations to the Administrator and to the State Agency within 5 working days of the incident. Review of Resident 8's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 10/10/23 revealed the following: -the resident had severe cognitive impairment, -diagnoses of Alzheimer's Disease, hypertension, and depression, -had impairments in range of motion of the upper extremities on one side, and impairments on both sides of the lower extremities, -required substantial assistance with toileting, dressing, transfers, and personal hygiene, and -had two or more falls with no injuries since the prior assessment. Review of Resident 8's Progress Notes for 10/6/23 timed at at 4:51 PM revealed the resident was up and walking unattended in the resident room and fell in the doorway of the room. According to Residents 8's Progress Note dated 10-06-2023 with w timed entry at 6:28 PM revealed staff palced a call to report the fall to the State Agency. An interview on 8/20/24 at 8:20 AM with the DON confirmed no report was sent into the State Agency.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit a completed investigation report to the State Agency for a fall for Resident 8. The sample size was 3 and the facility census was 25. Findings are: Review of the facility policy Abuse Neglect and Exploitation last approved 9/23 revealed the following: -when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred, an investigation would immediately be warranted, -when abuse, neglect, or exploitation was suspected the nurse would respond to the resident needs and protect them from further incidents; notify the Director of Nursing (DON) and the Administrator; initiate an investigation immediately; notify the physician, the resident's representative and contact the State Agency to report the alleged abuse, -in response to alleged allegations the facility must ensure all alleged violations were reported immediately to the Abuse and Neglect Hotline no later than 2 hours after the allegation was made or no later than 24 hours if the events do not involve abuse or serious bodily injury, and have evidence that all alleged violations were investigated, -the facility must prevent further potential abuse, and -report the results of all investigations to the Administrator and to the State Agency within 5 working days of the incident. Review of Resident 8's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 10/10/23 revealed the following: -the resident had severe cognitive impairment, -diagnoses of Alzheimer's Disease, hypertension, and depression, -had impairments in range of motion of the upper extremities on one side, and impairments on both sides of the lower extremities, -required substantial assistance with toileting, dressing, transfers, and personal hygiene, and -had two or more falls with no injuries since the prior assessment. Review of Resident 8's Progress Notes for 10/6/23 timed at at 4:51 PM revealed the resident was up and walking unattended in the resident room and fell in the doorway of the room. According to Residents 8's Progress Note dated 10-06-2023 with w timed entry at 6:28 PM revealed staff palced a call to report the fall to the State Agency. An interview on 8/20/24 at 8:20 AM with the DON confirmed no report was sent into the State Agency.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review and interview; the facility failed to review and revise Resident 10's Care Plan addressing pressure ulcer risk prior to the resident developing a pressure injury/s (injury to skin and or underlying tissue caused by prolonged pressure to skin). The sample size was 18 and the facility census was 27. Findings are: Review of the facility policy Pressure Injury Prevention and Management with a review date of 7/2023 revealed the following: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers. -A Pressure Ulcer/Injury referred to localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Avoidable meant the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with the resident's needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions or revise the interventions as appropriate. -The facility established and utilized a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervention to stabilize, reduce or remove underlying risk factors, monitored the impact of the interventions, and modified the interventions as appropriate. -Licensed nurses conducted pressure injury risk assessments for all residents upon admission/readmission, quarterly and/or with a significant change in the resident's condition and/or with an identified pressure injury. -The risk tool would be used in conjunction with other risk factors such as decreased mobility, co-morbid (simultaneously occurring and putting a person at increased risk for poor outcomes) conditions, drugs that could affect healing, impaired blood flow, skin exposure to incontinence, nutrition and/or hydration deficits, and the presence of a previously healed pressure ulcer. -After completing a thorough assessment, the interdisciplinary team developed a relevant plan of care that included measurable goals and appropriate interventions. -Evidenced based interventions for the prevention of pressure injury were implemented for all residents assessed at risk or who had present pressure injury/s, including but not limited to pressure redistribution such as positioning, protecting, and/or offloading (keeping the risk areas off of surfaces such as the bed) heels, minimizing moisture exposure, providing appropriate support surfaces (specialized devices/surfaces that help redistribute pressure to help prevent and treat pressure injury), and maintaining or improving nutrition/hydration. -Interventions were documented in the Care Plan and communicated to all relevant staff, and compliance with those interventions was documented. B. Review of the facility policy Comprehensive Care Plans dated 11/2023 revealed the following: -The purpose was to develop comprehensive care plans for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, dietary, activity, and psychological needs. -The interdisciplinary team in coordination with the resident, family or representative, developed and maintained a comprehensive care plan for each resident. -The care plan was designed to incorporate identified problems, incorporate risk factors associated with identified problems, build on resident strengths, reflect treatment goals and outcomes, prevent decline, and enhance optimal functioning. -Care plans were revised as changes in the resident's condition dictated. C. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 5/28/24 revealed the following: -The resident's cognitive assessment indicated severe cognitive impairment. -The resident received substantial assistance with transfers (moving from one surface to another), bed mobility, dressing, and toileting hygiene. -The resident had anemia, diabetes, heart failure, kidney disease, a thyroid disorder, high blood pressure, and dementia. -The resident had 2 Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. -The resident participated in Restorative Nursing (type of nursing care designed to assist residents of nursing homes maintain or improve their functional abilities) for ambulation (walking), transfers, and active range of motion. Review of Resident 10's Nursing Admission Screening History dated 5/16/24 revealed the resident was readmitted from the hospital following a fall, was alert and oriented, had edema (fluid retention) in feet, was able to bear weight with both legs, required staff assistance with moving in bed, transferring, dressing, walking, toilet use, and personal hygiene. In addition, the assessment indicated the Nurses Notes/Progress Notes contained information about the resident's skin condition. Review of Resident 10's Braden Scales for Predicting Pressure Sore Risk (assessment completed to identify risk of developing pressure sores) revealed the following: -On 2/26/24 the resident's score was 22 which did not indicate risk. -On 5/16/24 the resident's score was 18 which indicated the resident was at risk. Review of Resident 10's Progress Notes revealed the following: -On 5/11/24 at 12:00 PM the resident was observed on the floor of the resident's room, complained of pain in the left hip, was found to have a skin tear to the left wrist, and hematoma's (collection of blood beneath the skin/tissues) on the left hip and head. The resident was taken to the emergency room (ER) later (3:50 PM) after passing out while being examined/assessed, and the hematoma had doubled in size. -On 5/15/24 at 9:58 AM the resident returned to the facility from the hospital and the left forearm had steri-strips (adhesive strips used to close open skin), the left hip had bruising and an intact dressing, and the resident had a bump to the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx (tail bone) or the left heel. -On 5/19/24 at 6:32 PM the resident had a skin tear to the left forearm, bruising to the left thigh/hip, and a bump on the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx or left heel. -On 5/22/24 at 8:10 PM the resident's left heel had a large blister with dark purple coloring beneath the skin. The blister area was 6cm (centimeters) by 4.5cm with a 2cm reddened area surrounding the blister. A heel boot was applied to keep pressure off the area and a sheep skin pad was placed under the right heel to prevent pressure. The resident was scheduled to see the doctor the following day. -On 5/23/24 at 3:06 PM the heel blister remained and measured 6cm by 4.5 cm and 3cm by 2cm of the blister was open. In addition, the resident had a 1cm wound on the coccyx. -On 5/25/24 a gel overlay (pad that lays over a mattress to reduce pressure) was placed on the resident's bed due to the concern of skin breakdown. Review of Resident 10's Care Plan with a revision date of 5/30/24 (8 days after the heel blister had been identified and 7 days after the coccyx wound was identified) revealed the care plan was revised to include the resident having a pressure ulcer on the heel. Interventions included educating the resident/family/and caregivers, treating infection and pain, observing and documenting healing of the wound, obtaining blood work as order, using a wound vacuum (device used to seal and create an environment to promote wound healing) to the heel, and completing weekly documentation of the skin/wound. There was no evidence the interventions included pressure reductions interventions such as the use of the gel overlay mattress, the heel boot, or the sheep skin padding which had been implemented. There was also no evidence the Care Plan address the open coccyx wound. On 8/19/24 at 4:00 PM during observation of the provision of care Resident 10 was transferred from bath chair to wheelchair using the stand-up mechanical lift (used to assist a resident into a standing position to facilitate movement from one surface to another) with 2 staff in attendance NA-G and RN-E. While standing in the stand-up lift resident treatment of coccyx pressure ulcer was completed. The wound was open to the air due to having just completed bathing. RN-E observed and measured the ulcer on the resident's coccyx. The coccyx ulcer presented as a red area with a layer of yellow slough (dead skin cells which are the byproduct of the inflammatory phase of wound healing) tissue in the center of the wound irregularly shaped. The resident's coccyx bone was very prominent, and the resident's overall appearance was thin. After securing the resident in the wheelchair RN-E removed a dressing from Resident 10's heel revealing a golf ball sized open wound noted on the left heel. The area was moist in appearance with some pink tissue and yellow slough was noted throughout the wound. The RN placed a clean dressing on the wound. During an interview on 8/20/24 at 11:22 AM the Director of Nursing (DON) confirmed the facility assessed the resident's pressure ulcer risk on the day of re-admission from the hospital, and the assessment indicated the resident was at risk for pressure sores which was an increased risk from the previous assessment on 2/26/24, however there was no evidence the resident's Care Plan reflected the increase risk for pressure sores at the time of readmission, and no evidence the facility implemented additional measures to prevent pressure sores until after pressure injury/s were identified.

F. Observation on 8/19/24 at 9:10 AM RN-E obtained Resident 20's medications from the medication cart. RN-E placed the oral medications into a medication cup and obtained a topical medication in a tube and went to the resident room. RN-E donned a gown, gloves, and mask and entered the resident room. Resident 20 was still in bed and RN-E placed the medication cup and the topical medication on the resident's bedside table without a barrier. RN-E administered the resident's oral medications and gave the resident a sip of water. The resident started to spit out the medications and RN-E caught the medications in RN-E's gloved hand. RN-E removed their gloves and discarded, then put on a new pair without performing hand hygiene. RN-E obtained the topical medication from the resident's bedside table and applied the medication. RN-E placed the medication tube back onto the resident's bedside table and removed their gloves and did not perform hand hygiene. RN-E picked up the medication and removed their gown before exiting the resident room. RN-E went back to the medication cart and placed the topical medication on the top of the cart without cleaning the tube or placing a barrier, opened the medication cart, and placed the medication back into the cart and locked the cart. No observation was made of RN-E cleansing the top of the medication cart. Interview on 8/19/24 at 5:20 PM with the Director of Nursing confirmed hand hygiene was not completed at appropriate intervals and RN-E should have placed a barrier to lay the medication tube on instead of placing the tube directly on the resident's bedside table, should have cleansed the medication tube, and the cleaned top of the medication cart after the potentially contaminated medication tube was removed. Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview, and record review; the facility failed to complete gloving and hand sanitation at intervals during the provision of wound care for Resident's 10 and 20, failed to dispose of potentially infected dressings in a manner to prevent potential contamination for Resident 10, and failed to prevent potential cross contamination from improper handling of Resident 20's topical medication. A. Review of the facility policy Infection Control Isolation Precautions with a revision date of 4/2024 revealed the following: -A variety of infection control measures were used to decrease the risk of transmission of microorganisms (tiny living organisms that can only be seen under a microscope and referred to as pathogens when they have the potential to cause disease). -Precautions designed for the care of all residents Standard Precautions (measures implemented during all medical care provision to prevent contact with body fluids- for example the use of gloves, good hygiene habits, and clean technique), were the primary strategy for successful infection control. -Transmission Based Precautions-(TBP-a second level of infection control used in addition to Standard Precautions for those who were or may have been infected with infectious agents) were used for the care of specific patients for known or suspected infection with epidemiologically important pathogens (infectious agents with one or more of the following characteristics (readily transmissible, proclivity toward causing outbreaks, possibly associated with severe outcomes, and/or difficult to treat)). -All direct care staff were aware of the facility policy and responsible for the procedures contained within the policy. -Staff received initial and annual orientation to the policy. -Hand Washing was frequently called the single most important measure for preventing the spread of infection. -Wearing gloves did not replace the need for handwashing. -Gowns and protective apparel were worn to provide protection and to reduce contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. -Enhanced Barrier Precautions (EBP-precautions implemented in addition to Standard Precautions during high contact resident care activities when caring for residents with increased risk for acquiring a Multi-Drug Resistant Organism (MRDO-organisms that are resistant to one or more classes of antimicrobial agents, such as antibiotics and antifungals) were implemented for resident's with certain wounds, indwelling medical devices, or residents infected or colonized-(person is carrying but is not experiencing illness or symptoms) with an MRDO. B. Review of the facility policy Hand Washing with a revision date of 4/2023 revealed the following: -Staff were required to wash their hands after each direct resident contact for which handwashing was indicated by practice standards. -Alcohol-bases hand rubs were used. -Staff were required to wash hands before putting on gloves, after removing gloves, and after handling dirty items. C. Review of Resident 10's Care Plan with a revision date of 5/1/24 revealed the resident was on EBP due to having a urinary catheter (device that dwells in the bladder to promote urine drainage into a receptacle outside of the body). In addition, the resident had a pressure ulcer (injury to skin and underlying tissue caused by prolonged pressure to the skin), and a colostomy (opening in the large intestine that is surgically created and opens to the outside of the body for elimination of bowel contents). Observation of the provision of care for Resident 10 on 8/19/24 at 4:00 PM revealed the following: -The resident transferred from a bath chair to a wheelchair using the stand-up mechanical lift (used to assist resident to stand to move safely from one surface to another) with 2 staff in attendance (NA-G and RN-E). Both staff were wearing gowns, and gloves and NA-G was also wearing a mask. While the resident was standing in the stand-up lift, treatment of the coccyx (bone located in the triangular area at the base of the spine also known as the tail bone) pressure ulcer was completed. The wound was open to the air due to having just completed bathing. RN-E observed and measured the ulcer on the resident's coccyx. The coccyx ulcer presented as a red area with a layer of yellow irregularly shaped slough (dead skin cells which are the byproduct of the inflammatory phase of wound healing) tissue in the center of the wound. The resident's coccyx area was very prominent, and the resident's overall appearance was thin. RN-E then noticed BM (Bowel Movement) on the resident's buttocks, and using a disposable wipe cleaned the BM and disposed of the wipe. While using the same gloves used to clean up the BM, RN-E then applied a clean dressing to the resident's ulcer. RN-E then removed and disposed of the gloves, washed hands, and put on clean gloves. After securing the resident in a wheelchair RN-E sat down on the floor, removed a soiled dressing from the resident's left heel, laid the soiled dressing directly on the floor, and removed the gloves and set them on top of the soiled dressing that was on the floor. There was a golf ball sized open wound noted on the resident's left heel. The area was moist in appearance with some pink tissue and yellow slough noted throughout the wound. RN-E then put on clean gloves without performing hand hygiene and placed a clean dressing on the wound. D. Review of Resident 20's Care Plan with a revision date of 5/1/24 revealed the following: -The resident had a sacral (below the lower spine and above the tail bone) wound. -The resident had an indwelling urinary catheter. -The resident had a colostomy -The resident was on EBP due to the presence of a chronic wound and a urinary catheter. During an observation of care on 8/15/24 at 11:40 AM, RN-E donned (put on) a gown, gloves and a mask and entered the room. RN-E first changed the residents colostomy bag. There was liquid BM in bag and the bag did have some leakage. RN-E then changed gloves (did not perform hand hygiene) and retrieved a clean dressing for the resident's sacral pressure sore from a dresser drawer and reapplied the dressing. After completing the dressing change RN-E changed gloves but did not perform hand hygiene and cleaned the resident's genital area and catheter insertion site with disposable wipes. E. During an interview on 8/20/24 at 10:43 AM the Director of Nursing confirmed that RN-E failed to complete gloving changes and/or hand sanitation at proper intervals during the provision of wound care for Resident's 10 and 20 and failed to properly dispose of potentially infected dressings for Resident 10.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview, and record review; the facility failed to complete gloving and hand sanitation at intervals during the provision of wound care for Resident's 10 and 20, failed to dispose of potentially infected dressings in a manner to prevent potential contamination for Resident 10, and failed to prevent potential cross contamination from improper handling of Resident 20's topical medication. A. Review of the facility policy Infection Control Isolation Precautions with a revision date of 4/2024 revealed the following: -A variety of infection control measures were used to decrease the risk of transmission of microorganisms (tiny living organisms that can only be seen under a microscope and referred to as pathogens when they have the potential to cause disease). -Precautions designed for the care of all residents Standard Precautions (measures implemented during all medical care provision to prevent contact with body fluids- for example the use of gloves, good hygiene habits, and clean technique), were the primary strategy for successful infection control. -Transmission Based Precautions-(TBP-a second level of infection control used in addition to Standard Precautions for those who were or may have been infected with infectious agents) were used for the care of specific patients for known or suspected infection with epidemiologically important pathogens (infectious agents with one or more of the following characteristics (readily transmissible, proclivity toward causing outbreaks, possibly associated with severe outcomes, and/or difficult to treat)). -All direct care staff were aware of the facility policy and responsible for the procedures contained within the policy. -Staff received initial and annual orientation to the policy. -Hand Washing was frequently called the single most important measure for preventing the spread of infection. -Wearing gloves did not replace the need for handwashing. -Gowns and protective apparel were worn to provide protection and to reduce contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. -Enhanced Barrier Precautions (EBP-precautions implemented in addition to Standard Precautions during high contact resident care activities when caring for residents with increased risk for acquiring a Multi-Drug Resistant Organism (MRDO-organisms that are resistant to one or more classes of antimicrobial agents, such as antibiotics and antifungals) were implemented for resident's with certain wounds, indwelling medical devices, or residents infected or colonized-(person is carrying but is not experiencing illness or symptoms) with an MRDO. B. Review of the facility policy Hand Washing with a revision date of 4/2023 revealed the following: -Staff were required to wash their hands after each direct resident contact for which handwashing was indicated by practice standards. -Alcohol-bases hand rubs were used. -Staff were required to wash hands before putting on gloves, after removing gloves, and after handling dirty items. C. Review of Resident 10's Care Plan with a revision date of 5/1/24 revealed the resident was on EBP due to having a urinary catheter (device that dwells in the bladder to promote urine drainage into a receptacle outside of the body). In addition, the resident had a pressure ulcer (injury to skin and underlying tissue caused by prolonged pressure to the skin), and a colostomy (opening in the large intestine that is surgically created and opens to the outside of the body for elimination of bowel contents). Observation of the provision of care for Resident 10 on 8/19/24 at 4:00 PM revealed the following: -The resident transferred from a bath chair to a wheelchair using the stand-up mechanical lift (used to assist resident to stand to move safely from one surface to another) with 2 staff in attendance (NA-G and RN-E). Both staff were wearing gowns, and gloves and NA-G was also wearing a mask. While the resident was standing in the stand-up lift, treatment of the coccyx (bone located in the triangular area at the base of the spine also known as the tail bone) pressure ulcer was completed. The wound was open to the air due to having just completed bathing. RN-E observed and measured the ulcer on the resident's coccyx. The coccyx ulcer presented as a red area with a layer of yellow irregularly shaped slough (dead skin cells which are the byproduct of the inflammatory phase of wound healing) tissue in the center of the wound. The resident's coccyx area was very prominent, and the resident's overall appearance was thin. RN-E then noticed BM (Bowel Movement) on the resident's buttocks, and using a disposable wipe cleaned the BM and disposed of the wipe. While using the same gloves used to clean up the BM, RN-E then applied a clean dressing to the resident's ulcer. RN-E then removed and disposed of the gloves, washed hands, and put on clean gloves. After securing the resident in a wheelchair RN-E sat down on the floor, removed a soiled dressing from the resident's left heel, laid the soiled dressing directly on the floor, and removed the gloves and set them on top of the soiled dressing that was on the floor. There was a golf ball sized open wound noted on the resident's left heel. The area was moist in appearance with some pink tissue and yellow slough noted throughout the wound. RN-E then put on clean gloves without performing hand hygiene and placed a clean dressing on the wound. D. Review of Resident 20's Care Plan with a revision date of 5/1/24 revealed the following: -The resident had a sacral (below the lower spine and above the tail bone) wound. -The resident had an indwelling urinary catheter. -The resident had a colostomy -The resident was on EBP due to the presence of a chronic wound and a urinary catheter. During an observation of care on 8/15/24 at 11:40 AM, RN-E donned (put on) a gown, gloves and a mask and entered the room. RN-E first changed the residents colostomy bag. There was liquid BM in bag and the bag did have some leakage. RN-E then changed gloves (did not perform hand hygiene) and retrieved a clean dressing for the resident's sacral pressure sore from a dresser drawer and reapplied the dressing. After completing the dressing change RN-E changed gloves but did not perform hand hygiene and cleaned the resident's genital area and catheter insertion site with disposable wipes. E. During an interview on 8/20/24 at 10:43 AM the Director of Nursing confirmed that RN-E failed to complete gloving changes and/or hand sanitation at proper intervals during the provision of wound care for Resident's 10 and 20 and failed to properly dispose of potentially infected dressings for Resident 10. 45739 F. Observation on 8/19/24 at 9:10 AM RN-E obtained Resident 20's medications from the medication cart. RN-E placed the oral medications into a medication cup and obtained a topical medication in a tube and went to the resident room. RN-E donned a gown, gloves, and mask and entered the resident room. Resident 20 was still in bed and RN-E placed the medication cup and the topical medication on the resident's bedside table without a barrier. RN-E administered the resident's oral medications and gave the resident a sip of water. The resident started to spit out the medications and RN-E caught the medications in RN-E's gloved hand. RN-E removed their gloves and discarded, then put on a new pair without performing hand hygiene. RN-E obtained the topical medication from the resident's bedside table and applied the medication. RN-E placed the medication tube back onto the resident's bedside table and removed their gloves and did not perform hand hygiene. RN-E picked up the medication and removed their gown before exiting the resident room. RN-E went back to the medication cart and placed the topical medication on the top of the cart without cleaning the tube or placing a barrier, opened the medication cart, and placed the medication back into the cart and locked the cart. No observation was made of RN-E cleansing the top of the medication cart. Interview on 8/19/24 at 5:20 PM with the Director of Nursing confirmed hand hygiene was not completed at appropriate intervals and RN-E should have placed a barrier to lay the medication tube on instead of placing the tube directly on the resident's bedside table, should have cleansed the medication tube, and the cleaned top of the medication cart after the potentially contaminated medication tube was removed.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review and interview; the facility failed to review and revise Resident 10's Care Plan addressing pressure ulcer risk prior to the resident developing a pressure injury/s (injury to skin and or underlying tissue caused by prolonged pressure to skin). The sample size was 18 and the facility census was 27. Findings are: Review of the facility policy Pressure Injury Prevention and Management with a review date of 7/2023 revealed the following: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers. -A Pressure Ulcer/Injury referred to localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Avoidable meant the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with the resident's needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions or revise the interventions as appropriate. -The facility established and utilized a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervention to stabilize, reduce or remove underlying risk factors, monitored the impact of the interventions, and modified the interventions as appropriate. -Licensed nurses conducted pressure injury risk assessments for all residents upon admission/readmission, quarterly and/or with a significant change in the resident's condition and/or with an identified pressure injury. -The risk tool would be used in conjunction with other risk factors such as decreased mobility, co-morbid (simultaneously occurring and putting a person at increased risk for poor outcomes) conditions, drugs that could affect healing, impaired blood flow, skin exposure to incontinence, nutrition and/or hydration deficits, and the presence of a previously healed pressure ulcer. -After completing a thorough assessment, the interdisciplinary team developed a relevant plan of care that included measurable goals and appropriate interventions. -Evidenced based interventions for the prevention of pressure injury were implemented for all residents assessed at risk or who had present pressure injury/s, including but not limited to pressure redistribution such as positioning, protecting, and/or offloading (keeping the risk areas off of surfaces such as the bed) heels, minimizing moisture exposure, providing appropriate support surfaces (specialized devices/surfaces that help redistribute pressure to help prevent and treat pressure injury), and maintaining or improving nutrition/hydration. -Interventions were documented in the Care Plan and communicated to all relevant staff, and compliance with those interventions was documented. B. Review of the facility policy Comprehensive Care Plans dated 11/2023 revealed the following: -The purpose was to develop comprehensive care plans for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, dietary, activity, and psychological needs. -The interdisciplinary team in coordination with the resident, family or representative, developed and maintained a comprehensive care plan for each resident. -The care plan was designed to incorporate identified problems, incorporate risk factors associated with identified problems, build on resident strengths, reflect treatment goals and outcomes, prevent decline, and enhance optimal functioning. -Care plans were revised as changes in the resident's condition dictated. C. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 5/28/24 revealed the following: -The resident's cognitive assessment indicated severe cognitive impairment. -The resident received substantial assistance with transfers (moving from one surface to another), bed mobility, dressing, and toileting hygiene. -The resident had anemia, diabetes, heart failure, kidney disease, a thyroid disorder, high blood pressure, and dementia. -The resident had 2 Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. -The resident participated in Restorative Nursing (type of nursing care designed to assist residents of nursing homes maintain or improve their functional abilities) for ambulation (walking), transfers, and active range of motion. Review of Resident 10's Nursing admission Screening History dated 5/16/24 revealed the resident was re-admitted from the hospital following a fall, was alert and oriented, had edema (fluid retention) in feet, was able to bear weight with both legs, required staff assistance with moving in bed, transferring, dressing, walking, toilet use, and personal hygiene. In addition, the assessment indicated the Nurses Notes/Progress Notes contained information about the resident's skin condition. Review of Resident 10's Braden Scales for Predicting Pressure Sore Risk (assessment completed to identify risk of developing pressure sores) revealed the following: -On 2/26/24 the resident's score was 22 which did not indicate risk. -On 5/16/24 the resident's score was 18 which indicated the resident was at risk. Review of Resident 10's Progress Notes revealed the following: -On 5/11/24 at 12:00 PM the resident was observed on the floor of the resident's room, complained of pain in the left hip, was found to have a skin tear to the left wrist, and hematoma's (collection of blood beneath the skin/tissues) on the left hip and head. The resident was taken to the emergency room (ER) later (3:50 PM) after passing out while being examined/assessed, and the hematoma had doubled in size. -On 5/15/24 at 9:58 AM the resident returned to the facility from the hospital and the left forearm had steri-strips (adhesive strips used to close open skin), the left hip had bruising and an intact dressing, and the resident had a bump to the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx (tail bone) or the left heel. -On 5/19/24 at 6:32 PM the resident had a skin tear to the left forearm, bruising to the left thigh/hip, and a bump on the back of the head. There was no documentation that the resident had any indication of pressure injury to the coccyx or left heel. -On 5/22/24 at 8:10 PM the resident's left heel had a large blister with dark purple coloring beneath the skin. The blister area was 6cm (centimeters) by 4.5cm with a 2cm reddened area surrounding the blister. A heel boot was applied to keep pressure off the area and a sheep skin pad was placed under the right heel to prevent pressure. The resident was scheduled to see the doctor the following day. -On 5/23/24 at 3:06 PM the heel blister remained and measured 6cm by 4.5 cm and 3cm by 2cm of the blister was open. In addition, the resident had a 1cm wound on the coccyx. -On 5/25/24 a gel overlay (pad that lays over a mattress to reduce pressure) was placed on the resident's bed due to the concern of skin breakdown. Review of Resident 10's Care Plan with a revision date of 5/30/24 (8 days after the heel blister had been identified and 7 days after the coccyx wound was identified) revealed the care plan was revised to include the resident having a pressure ulcer on the heel. Interventions included educating the resident/family/and caregivers, treating infection and pain, observing and documenting healing of the wound, obtaining blood work as order, using a wound vacuum (device used to seal and create an environment to promote wound healing) to the heel, and completing weekly documentation of the skin/wound. There was no evidence the interventions included pressure reductions interventions such as the use of the gel overlay mattress, the heel boot, or the sheep skin padding which had been implemented. There was also no evidence the Care Plan address the open coccyx wound. On 8/19/24 at 4:00 PM during observation of the provision of care Resident 10 was transferred from bath chair to wheelchair using the stand-up mechanical lift (used to assist a resident into a standing position to facilitate movement from one surface to another) with 2 staff in attendance NA-G and RN-E. While standing in the stand-up lift resident treatment of coccyx pressure ulcer was completed. The wound was open to the air due to having just completed bathing. RN-E observed and measured the ulcer on the resident's coccyx. The coccyx ulcer presented as a red area with a layer of yellow slough (dead skin cells which are the byproduct of the inflammatory phase of wound healing) tissue in the center of the wound irregularly shaped. The resident's coccyx bone was very prominent, and the resident's overall appearance was thin. After securing the resident in the wheelchair RN-E removed a dressing from Resident 10's heel revealing a golf ball sized open wound noted on the left heel. The area was moist in appearance with some pink tissue and yellow slough was noted throughout the wound. The RN placed a clean dressing on the wound. During an interview on 8/20/24 at 11:22 AM the Director of Nursing (DON) confirmed the facility assessed the resident's pressure ulcer risk on the day of re-admission from the hospital, and the assessment indicated the resident was at risk for pressure sores which was an increased risk from the previous assessment on 2/26/24, however there was no evidence the resident's Care Plan reflected the increase risk for pressure sores at the time of readmission, and no evidence the facility implemented additional measures to prevent pressure sores until after pressure injury/s were identified.