Every finding on record at Sandhills Care Center

Licensure Reference Number 175 NAC 12-006.11EBased on observation, record review and interview; the facility staff failed to store, prepare and serve food in a manner to prevent the potential for cross contamination and/or food borne illness as: 1) items stored in refrigerators and on shelves were not labeled and undated or outdated; 2) failed to utilize handwashing and gloving techniques; 3) to ensure dietary staff wore beard restraints that fully enclosed all hair on the face during food preparation; and 4) failed to ensure scoops were stored separate from the rice and bread crumbs storage bins. These practices had the potential to affect all residents who were served meals from the kitchen. The facility identified a census of 35.Findings are:A.Review of the facility policy Date Marking for Food Safety (undated) revealed the facility adhered to the date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. The following guidelines were identified:-the food should be clearly marked to indicate the date or day by which the food shall be consumed or discarded.-the individual opening the food shall be responsible for datemarking the food at the time the food is opened or prepared.-the discard date or day may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening counts as day one. -the head cook or designee was to be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. B.Review of the facility policy Food Receiving and Storage (undated) revealed foods were to be stored in a manner that complied with safe food handling practices. The following guidelines were identified for dry food storage:-opened containers were to be labeled and dated then sealed or covered for storage.-dry foods that were stored in bins were to be removed from the original packaging, labeled and dated and no scoops to be stored with food items. C.Review of the Handwashing Guidelines for Dietary Employees (undated) revealed the dietary staff were to clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles. Staff were to wash hands with the following situations:-every time the employee enters the kitchen.-after hands had touched anything unsanitary.-while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.-when switching from working with raw food and working with ready to eat food.-before putting on gloves for working with food. D.Review of the facility policy Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices (undated) revealed gloves were considered a single-use item and were to be discarded after completing the task for which they were used. Gloves were to be removed, hands washed, and gloves replaced:-between handling raw meals and ready to eat foods.-between handling soiled and clean dishes.In addition, the policy indicated hair nets or caps and/or beard restraints were to be worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. E.Observations during the initial kitchen tour on 8/24/26 from 9:30 AM to 10:15 AM, with the Dietary Manager [DM] in the facility kitchen, revealed the following storage and sanitation concerns:-1/2 of a fresh peach was stored in a clear plastic bag which was not labeled or dated.-1/2 of a pie still in the pie tin was not labeled or dated.-a container of sloppy joes which was not labeled or dated.-container with applesauce which was dated 8/14.-a container of Jello which was not labeled or dated.-diced fruit in a small jelly jar which was not labeled or dated.-a container with baked beans which was not labeled or dated.-1/2 of a peach stored in a clear plastic bag which was dated 8/16.-3 opened containers of whipped cream which did not have opened dates.-container with chocolate pudding which was dated 8/19.-container with cauliflower which was dated 8/18. -plastic bag with carrots that had no date as to when it was opened.-container with cooked eggs dated 8/19. -large/uncovered container with whole kiwis which had a red colored liquid which had dripped into the container. -small white paper bag with a tomato which was unlabeled and undated. - container with Jello which was dated 8/5. Observations of the meal service and follow up kitchen sanitation tour on 8/25/26 from 11:15 AM to 11:50 AM revealed the following concerns:-the following unlabeled and undated items were stored in clear plastic bags on a shelf above a food prep counter; soup crackers, Oreo cookie crumbs, and 2 bags with marshmallows.-large storage bin which contained rice with scoop left inside with the food item.-large storage bin with breadcrumbs with the scoop stored inside with the food item. An observation of meal preparation/service with Dietary [NAME] (DC)-P on 8/25/26 revealed the following from 11:50 AM to 12:15 PM: -beard below the mouth but wore no beard restraint and facial hair was uncovered.-failed to wash hands, placed on a clean pair of disposable gloves then used gloved hands to open a recipe book and to locate a recipe for chicken salad.-dipped gloved hands into a sanitation bucket stored inside of a dishwashing sink and retrieved a dishcloth, removed excess water from the cloth and then used the cloth to clean/sanitize the surface of a food prep area.-used the same gloved hands to retrieve a cutting board and to place onto the newly cleaned surface.-exited the kitchen and opened the door to the pantry and obtained an onion which was carried back into the kitchen with gloved hands and placed on a countertop next to a food prep sink.-retrieved a knife and knife sharpening tool and proceeded to sharpen the knife.- once the knife was sharpened, staff obtained a paper towel and folded into several squares, then used the freshly sharpened knife to make several cuts into the edge of the paper towel.-discarded the paper towel in the trash and rinsed the knife under running water and placed on the cutting board.-picked the onion up with gloved hands and removed outer layers then placed on the cutting board and chopped the onion into smaller pieces.- removed gloves, washed hands and placed on new gloves to assist with cutting/serving corn bread for the noon meal. -removed gloves but did not perform hand hygiene, placed on new gloves.-performed the following tasks with the same gloved hands: retrieved a container with celery stalks from the pantry refrigerator, opened and used gloved hands to obtain several stalks of the celery and placed them in a bowl and rinsed the celery underneath of running water; picked up a small bowl of peas and placed inside of the microwave, and heated; retrieved a container of mayonnaise from the refrigerator; still wearing the same gloves, placed celery on the cutting board and chopped mixing the onions and the celery together; used the edge of the knife and gloved hands to pick up and transfer the chopped celery and onion from the cutting board to a mixing bowl, added mayonnaise and blended before removing gloves and cleansing hands. During an interview with the DM on 8/25/26 at 2:12 PM the following was confirmed:-leftovers are to be labeled and dated with the open date and the use by date.-the facility policy was to maintain leftovers for 3 days then to discard.-there were several items in the refrigerator which were outdated or had not been labeled and/or dated. -DC-P should wear a beard restraint when working in the kitchen. -large storage bins should not have scoops stored in them.-opened dry good items should have been dated when opened and with a use by date.-DC-P should not have worn disposable gloves and used for multiple tasks including touching ready to eat food items.-DC-P should have washed hands before placing on clean gloves and whenever removing soiled gloves.

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview; the facility failed to obtain comprehensive informed consent including current dosages being administered and alternate non-pharmacological treatment options for the use of psychotropic (mind altering) medication for Residents for Residents 1, 3, 4,18, 32, and 35. The sample size was 6 and the facility census was 35. Findings are: A. Review of the facility policy Psychotropic Medication Use with a revision date of [DATE] revealed the facility residents did not receive psychotropic medications that were not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental process and behavior. Psychotropic medication management was an interdisciplinary process that involved the resident, family, and/or the representative and included the following: -adequate indication for use,-established appropriate dose and duration,-adequate monitoring for efficacy and adverse consequences, -determining appropriateness of gradual dose reductions, and -preventing, identifying and responding to adverse consequences. Review of Resident 1's Minimum Data Set (MDS-federally required comprehensive assessment used to develop resident care plans) dated 7/30/26 revealed the resident received substantial assistance with activities of daily living (ADL's) including bathing, dressing, and toileting. The resident had diagnoses of anxiety and depression. In addition, the resident had taken antianxiety and antidepressant medications. Review of Resident 1's Care Plan with a revision date of 7/29/26 revealed the resident took the antidepressant medication lorazepam for anxiety, and the antidepressant medication duloxetine for depression. The facility was to monitor side effects and effectiveness. Review of Resident 1's Medication Administration Record (MAR) for August 2026 revealed the resident received the following psychotropic medication:-lorazepam 1 mg (milligram) every 8 hours PRN (as needed) for anxiety with a start date of 7/24/26.-duloxetine 60 mg daily with a start date of 8/21/26 for treatment of depression. Review of Resident 1's Psychotropic Medication Informed Consents revealed the following:-on 7/24/26 the resident consented to the use of duloxetine for treatment of depression. -on 7/24/26 the resident consented to the use of lorazepam for treatment of an anxiety disorder. -There were no listed doses of the medication to be given and no non-pharmacological treatment alternatives presented in the consent for the resident to make a comprehensive informed decision. During an interview on 8/26/26 at 7:08 AM the Director of Nursing (DON) confirmed Resident 1's consents for the antidepressant medication duloxetine and the antianxiety medication lorazepam did not include current doses of the medications being taken and /or any alternative non-pharmacological treatment alternative. B. Review of Resident 18's MDS dated [DATE] revealed the resident had delusions and behaviors including physical, verbal, rejection or care, wandering, and other behavior symptoms affecting others 1-3 days in the prior week. The resident received substantial assistance with ADL's including bathing, dressing, hygiene, and transfers. Further review of the MDS revealed Resident 18 had diagnoses of dementia, depression and bipolar disorder. Medications received included antipsychotic and antidepressant drugs. Review of Resident 18's Care Plan with a revision date of 7/13/26 revealed the resident took the antipsychotic medication Seroquel related to the potential for injury to self or others, aggression and agitation. The resident had impaired cognitive function related to dementia. Review of Resident 18's MAR dated August 2026 revealed the resident received the following psychotropic medication:-Seroquel (antipsychotic) 50 mg twice daily for treatment of psychosis related to obsessive-compulsive disorder (OCD). -sertraline (antidepressant) 100 mg daily for treatment of OCD. Review of Resident 18's Psychotropic Medication Informed Consents revealed the following;-On 7/2/26 the resident's responsible party gave verbal consent to increase the resident's antidepressant sertraline dose to treat confusion, agitation, and behaviors. -On 7/10/26 the resident's responsible party gave verbal consent for the antipsychotic medication, Seroquel to treat increased behaviors, and violent outbursts. -There were no listed doses for the Seroquel and no non-pharmacological treatment alternatives for either medication presented in the consent for the resident's representative to make a comprehensive informed decision. During an interview on 8/25/26 at 4:10 PM the DON confirmed Resident 18's consent for the use of the psychotropic medications Sertraline did not include alternate non-pharmacological treatment options, and the Seroquel (antipsychotic) did not include the current dosage or alternate non-pharmacological treatment options. C. Review of Resident 35's MDS dated [DATE] revealed the resident indications of moderate depression including thoughts of being better off dead. The resident had taken antipsychotic, antidepressant and antianxiety medication in the prior week. Further review of the MDS revealed Resident 35 had diagnoses of anxiety and depression. Review of Resident 35's Care Plan initiated on 7/29/26 revealed the resident had a terminal diagnosis related to congestive heart failure (CHF), was receiving hospice (end of life) services and had a depressed mood, lack of interest in doing things, and thoughts of being better off dead with no intent of self-harm. The facility was to administer medication as ordered and monitor for side effects and effectiveness. Review of Resident 35's MAR dated August 2026 revealed the resident received the following psychotropic medication. -sertraline (antidepressant) 25 mg daily for treatment of depression.-ABH (Ativan (antianxiety)/Benadryl(antihistamine)/Haldol(antipsychotic)) gel apply to inner wrist every 4 hours PRN. Review of Resident 35's Psychotropic Medication Informed Consents revealed the following;-on 7/21/26 the resident representative signed consents for the use of ABH gel and sertraline, however there were no listed doses and no non-pharmacological treatment alternatives for either medication presented in the consent for the resident's representative to make a comprehensive informed decision. During an interview on 8/25/26 at 4:10 PM the DON confirmed Resident 35's consent for the use of the psychotropic medications sertraline and ABH did not include the current doses ordered and/or alternate non-pharmacological treatment options. D. Review of Resident 3's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of renal insufficiency, non-Alzheimer's dementia, depression, and psychotic disorder. The resident had short and long-term memory loss with severely impaired decision making skills and required total staff assistance with cares. In addition, the resident had taken antipsychotic and antidepressant medications. Review of Resident 3's Care Plan with a revision date of 2/9/26 revealed the resident took the antidepressant medication sertraline and the antipsychotic medication Seroquel for diagnosis of dementia with psychotic disturbance and delusional disorder. The facility was to monitor side effects and the effectiveness of the medications. Review of Resident 3's MAR for August 2026 revealed the resident received the following psychotropic medications: -sertraline 100 mg daily for depression with a start date of 3/18/26. -Seroquel 25 mg twice a day for dementia/delusions and psychotic disturbances dated 3/6/26. Review of Resident 3's Psychotropic Medication Informed Consents revealed the following: -2/16/26 and 3/6/26 the resident's representative agreed to a dose increase of the Seroquel due to the resident's aggressive, violent behaviors. -3/16/26 the representative agreed to a dose increase of the sertraline to improve the resident's mood state. -there were no listed doses of the medications to be given and no non-pharmacological treatment alternatives presented in the consent for the resident/representative to make a comprehensive informed decision. During an interview on 8/25/26 at 2:14 PM, the DON confirmed the consents for the antidepressant Sertraline and the antipsychotic medication Seroquel did not include current doses of the medications being taken and /or any alternative non-pharmacological treatment alternative. E. Review of Resident 32's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of non-Alzheimer's dementia and depression. The resident had verbal/physical behaviors directed toward others which placed the resident at significant risk for physical illness or injury and interfered with the resident's care and participation in activities or social interactions. The resident was taking medications which included an antipsychotic and an antidepressant. Review of Resident 32's Care Plan with a revision date of 6/15/26 revealed the resident took the antipsychotic medication Zyprexa related to the potential for injury to self or others and behavior management. The resident was also taking sertraline for diagnosis of depression. Review of Resident 32's MAR dated August 2026 revealed the resident received the following psychotropic medication: -sertraline 150 mg daily for major depression with psychotic symptoms dated 4/10/26. -Zyprexa 5 mg twice a day for major depression with psychotic symptoms dated 5/22/26. Review of Resident 32's Psychotropic Medication Informed Consents revealed the following;-2/20/26 and 5/22/26 the resident's responsible party gave verbal consent to increase the resident's antipsychotic medication Zyprexa to treat increased aggression and behaviors. -1/8/26 and 4/10/26 the resident's responsible party gave verbal consent for the antidepressant medication, sertraline to be increased due to suicidal ideations. -there were no listed doses of the medications and no non-pharmacological treatment alternatives for either medication presented in the consent for the resident's representative to make a comprehensive informed decision. During an interview on 8/25/26 at 2:10 PM the DON confirmed Resident 32's consent for the use of the psychotropic medications sertraline and Zyprexa did not include the current dosages of the medications or alternate non-pharmacological treatment options. F. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnosis of depression, anemia, heart failure, and diabetes. The resident had taken antidepressant medication in the prior week. Review of Resident 4's MAR dated August 2026 revealed the resident received the following psychotropic medication. -fluoxetine 10 mg daily for major depressive disorder dated 2/19/26. Review of Resident 4's Psychotropic Medication Informed Consents revealed on 2/18/26 the resident representative signed a consent for the use of fluoxetine for anxiety. However, there was no listed dose and no non-pharmacological treatment alternatives for the medication presented in the consent for the resident's representative to make a comprehensive informed decision. During an interview on 8/25/26 at 1:43 PM the DON confirmed Resident 4's consent for the use of the psychotropic medication fluoxetine did not include the current dose ordered and/or alternate non-pharmacological treatment options.

Licensure Reference Number 175 NAC 12-006.18 (B) (D)Based on observation, record review and interview; the facility failed to follow established procedures for infection prevention to prevent the potential for cross contamination during the administration of insulin, eye drops, nasal spray, blood glucose monitoring and failed to complete hand hygiene during the provision of cares for Resident 7. The sample size was 15, the facility census was 35. Findings are: A. Review of the facility policy Hand Hygiene with a revision date of 1/20/26 revealed the following:-All staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. -Hand hygiene was a term for cleaning hands by handwashing with soap and water or the use of antiseptic hand rub.-Hand hygiene was indicated and would be performed under the following conditions: a. before performing resident care procedures. b. between resident contact. c. after handling items potentially contaminated with blood, body fluids, secretions or excretions. d. during resident care, moving from a contaminated body site to a clean body site. Review of the facility policy Standard Precautions Infection Control revised 1/20/26 revealed the following: -All staff were to assume that all residents were potentially infected with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff should adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. -Standard Precautions referred to the infection prevention practices that applied to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This included hand hygiene and selection and use of gloves. -Use of gloves refers to a protective item worn to protect the body from hazards that could cause injury and to protect residents from cross contamination. -Hand hygiene should be completed after touching body fluids, secretions, excretions, contaminated items; before and after removing gloves and between resident contacts. -Gloves should be worn when touching body fluids, secretions, excretions, contaminated items; for touching mucous membranes, non-intact and intact resident skin. B. Review of Resident 7's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 5/15/26 revealed the resident was dependent on staff for toileting hygiene, dressing, personal hygiene cares (combing hair, washing face and hands), transfers and wheelchair mobility. The resident had non-traumatic brain dysfunction, dementia, anxiety and depression. Resident 7's level of cognition was severely impaired. Review of Resident 7's Care Plan with a revision date of 8/25/26 revealed the resident had a self-care performance deficit related to a diagnosis of Dementia. Resident 7 required extensive assistance with dressing, oral care, personal hygiene, toileting care and transfers. During a provision of cares for Resident 7 on 8/25/26 at 9:00 AM Nursing Assistant (NA-D) and NA-E entered Resident 7's room (did not complete hand hygiene or apply gloves to hands). Resident 7 was laying down in the recliner, NA-E put a pull-up (an incontinent product) and pants to residents' lower extremities, then put shoes on the resident's feet. NA-D and NA-E then sat the resident up in the recliner, NA-E applied deodorant to resident's armpits and NA-D and NA-E changed resident's shirt. NA-D and NA-E transferred the resident from the recliner to the toilet with the use of a mechanical lift. While the resident was sitting on the toilet NA-E washed the resident's face, around eyes and hands with the use of a washcloth (no gloves on and no hand hygiene completed). After the resident was positioned in the wheelchair NA-E applied lotion to the resident's hands and lower arms, then wiped the excess lotion on own arms. (NA-E did not complete hand hygiene). NA-E assisted the resident to the dining room per wheelchair and positioned the resident up to the table, (no hand hygiene completed). NA-E then ambulated Resident 10 out of the dining room with one assist and walker. An interview with the Director of Nursing (DON) on 8/25/26 at 4:10 PM confirmed that staff should be completing hand hygiene before starting cares, when changing gloves with resident cares and at the completion of cares. Staff should wear gloves if touching the resident's skin or any soiled clothing or resident items. C. Review of facility policy for Medication Administration dated 2001 revealed the facility administered medications in a safe and timely manner, and as prescribed. In addition, staff followed established facility infection control procedures (hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During the observation of insulin on 8/25/26 at 07:40 AM Licensed Practical Nurse (LPN)-A entered the resident room, placed an insulin pen on the resident's bedside table which was cluttered with multiple personal items. LPN-A then washed hands, put on gloves, and administered the insulin. LPN-A removed the gloves and sanitized their hands, however the insulin which had been placed on an unclean surface was returned to the medication cart without being cleaned and placed directly into the medication cart which contained medication for multiple other residents residing in the facility. During the observation of the administration of eye drops and nasal spray at 9:20 AM LPN-A entered the resident's room and placed the eye drop bottle and nasal spray bottle directly on a personal blanket covering the receiving resident, sanitized their hands, put on gloves and administered the medications as ordered. LPN-A removed the gloves, sanitized their hands and then without cleaning the bottles returned the eye drops and nasal spray directly into the medication cart. During an interview on 8/25/26 at 3:55 PM the Director of Nursing (DON) confirmed medication containers taken into residents' rooms for administration need to be kept on a clean barrier to prevent potential contamination and/or cleaned prior to being placed back into the medication cart that contains medication for multiple residents to prevent potential cross-contamination. D. Review of the facility policy Cleaning and Disinfecting of Resident-Care Equipment with a revision date of 5/16/26 revealed resident-care equipment was a source of indirect transmission of pathogens and was to be cleaned and disinfected in accordance with current standards. Most equipment was to be cleaned/disinfected in the areas in which the equipment was used. Gloves were to be worn and manufacturer recommendations followed. E. Review of the undated Assure Platinum Glucometer manufacturer's recommendations for cleaning and disinfecting the glucometer revealed the device was to be cleansed after every single use with an EPA-registered germicidal wipe. The exterior plastic surface was to be wiped down to remove dirt/debris and blood. A second wipe was to be used to thoroughly coat the exterior housing and then allow the machine to air dry completely. F. Observations of a blood glucose monitoring test for Resident 4 on 8/25/26 at 7:08 AM revealed the following: -Resident 4 was in the resident's room and was seated in a recliner. -LPN-A entered the resident's room wearing a pair of disposable gloves. In the LPN's gloved hands were testing supplies which consisted of a glucometer, alcohol wipes, a lancet, cotton balls and testing strips. -without cleansing/disinfecting the surface of a bedside dresser and without placing a barrier, the LPN positioned testing supplies directly on the dresser surface. -LPN-A placed a test strip into the glucometer, obtained a drop of blood and applied to the test strip. -after completion of the test, LPN-A removed the left hand glove and carried the glucometer out of the room with the right hand which remained gloved. -LPN-A placed the glucometer directly on top of the medication cart without cleansing the cart or placing a barrier. -LPN-A removed right glove and without performing hand hygiene placed on a clean pair of gloves and proceeded to cleanse the glucometer with a Super Sani pre-moistened cleansing wipe and placed the machine back onto the top of the medication cart which the staff still failed to cleanse/sanitize. -LPN-A removed gloves but failed to complete hand hygiene before continuing with the medication pass. G. During an observation of toileting/incontinence cares for Resident 32 on 8/25/26 at 8:20 AM the following was observed: -NA-B and NA-C entered the resident's room with the mechanical lift and both staff were wearing gloves. -the resident was assisted from the bed and was transferred into the bathroom with the mechanical lift. -NA-C removed the resident's incontinence brief which was soiled with urine and disposed of gloves. NA-C failed to complete hand hygiene before wetting a washcloth and giving it to the resident to wash the resident's face. NA-C placed on a clean pair of gloves, rinsed the resident's dentures and assisted to position in the resident's mouth. NA-C then provided the resident with toileting hygiene and applied a barrier cream to the resident's coccyx. NA-C removed gloves but failed to complete hand hygiene before adjusting the resident's clean incontinence brief and slacks and positioning the resident in the wheelchair. H. During an interview with the DON on 8/25/26 at 4:00 PM, the DON confirmed the following: -LPN-A should have placed a barrier on the bedside table and the top of the medication cart before placing the glucometer and testing supplies. -LPN-A and NA-C should have performed hand hygiene before putting on clean gloves and when removing soiled gloves.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview; the facility failed to ensure that Resident 35's PRN (as needed) antipsychotic medication was not ordered and/or not in use for more than 14 days, without an in-person review of the medication and a documented clinical rationale or determination of the need for continued use. The sample size was 6 and the facility census was 35. Findings are: Review of the facility policy Psychotropic Medication Use with a revision date of [DATE] revealed the facility residents did not receive psychotropic medications that were not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental process and behavior. Psychotropic medication management was an interdisciplinary process that involved the resident, family, and/or the representative and included the following: -adequate indication for use-established appropriate dose and duration;-adequate monitoring for efficacy and adverse consequences, -determining appropriateness of gradual dose reductions, and -preventing, identifying and responding to adverse consequences. -PRN psychotropic medications were not prescribed or administered unless the medication was necessary to treat a specific condition that was documented in the clinical record. -PRN Psychotropic medications could be used in certain situations such as dose adjustment, intermittent symptom management, and/or in an emergency situation. -PRN orders for psychotropic medications were limited to 14 days. For psychotropic medications that were not antipsychotics the prescriber could extend the order beyond 14 days, with documented clinical rationale. For antipsychotic medications PRN could not be renewed unless the attending physician or prescriber evaluated the resident and documented the appropriateness of the medication.Review of Resident 35's Care Plan dated 7/29/26 revealed the resident was admitted to the facility receiving hospice (end of life) services for a terminal diagnosis of congestive heart failure and had a mood problem related to being a new admission to the facility, depressed mood, lack of interest in doing things and thoughts of being better off dead. The goal of the plan of care was to have an improved mood, calmer appearance, no signs and symptoms of depression, anxiety or sadness. The facility was to administer medications as ordered and monitor for side effects and effectiveness. Review of Resident 35's Medication Administration Record (MAR) dated July 2026 revealed the medication ABH (Ativan (antianxiety, Benadryl (antihistamine), and Haldol (antipsychotic) with a start date of 7/24/26 was to be applied to the resident's wrist every 4 hours PRN for restlessness and agitation until 8/6/26 (14 days). The medication was administered on 7/26/26 at 9:00 PM, on 7/28/26 at 7:23 PM, on 7/29/26 at 8:16 PM, on 7/30/26 at 6:51 PM, and on 7/31/26 at 8:19 PM. Review of Resident 35's MAR dated August 2026 revealed the medication ABH with a start date of 7/24/26 was to be applied to the resident's wrist every 4 hours PRN for restlessness and agitation until 8/6/26 (14 days). The medication was administered on 8/2/26 at 7:24 PM. Further review revealed the ABH gel was re-ordered with a start date of 8/7/26 at the same dose and frequency however, the order was for 364 days. The medication was given again on 8/13/26 at 7:28 AM. During an interview on 8/25/26 at 4:08 PM the Director of Nursing (DON) confirmed Resident 35's order for ABH cream on 8/7/26 was not limited to 14 days as required for PRN antipsychotic medications. In addition, there was no evidence the provider completed an in-person review or documented a clinical rationale for the need to continue the order beyond the original 14 days.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on interview and record review; the facility failed to report, investigate and submit the investigation to the State Agency within the required time frame, an incident which resulted in a significant injury for Resident 4. The sample size was 1 and the facility census was 35.Findings are:Review of the facility Abuse Prevention Policy (undated) revealed allegations of abuse were to be immediately reported to the Administrator.Any employee or other interested person, who has knowledge or reason to believe that a resident has been abused was under duty to immediately report such incident or suspicion to the Administrator, the Social Service Director (SSD) and/or the Director of Nursing (DON) immediately. An immediate investigation was to be initiated and the results of the findings were to be reported to the required agencies. The State Abuse hotline was to be notified immediately and a written report provided to the State within 5 days of the Administrator receiving the report. Review of Resident 4's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 8/11/26 revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure, diabetes, peripheral vascular disease, arthritis and renal insufficiency. The following was assessed regarding the resident:-cognition was intact.-no behaviors.-partial/moderate assistance with toileting and personal hygiene and substantial/maximal assistance with showering/bathing, and dressing.-no unhealed pressure ulcers or venous ulcers. Review of Resident 4's Nursing Progress Notes revealed the following:-5/19/26 at 2:38 PM the resident sustained a skin tear to the left foot in between the third and the fourth toe and the bottom of the fourth toe. Staff reported that when getting the resident into the bath, the side of the bathmat had sliced the resident's toe. The area was cleansed and a dressing was applied.-5/19/26 at 6:16 PM the resident's toe on the left foot kept bleeding throughout the shift and pressure dressing was applied. -5/20/26 at 3:45 AM pressure dressing remained to the fourth toe of the left foot. It was reported that the resident bled most of the morning shift. -5/20/26 at 2:56 PM the skin tear to left toe between the third and fourth toes and under the fourth toe remained. Area was cleansed with antibacterial soap, steri-strips applied, and gauze and pressure dressing applied due to continued bleeding. The resident's physician was updated on wound status and treatment.-5/21/26 at 11:40 AM the resident's physician was notified when the pressure dressing was removed, the area under the fourth toe began to bleed again. Due to the residents' comorbidities of diabetes and neuropathy with history of an amputated fifth toe to make an appointment for the resident to be seen by the provider.-5/22/26 at 5:58 PM seen by the podiatrist and decision was made to amputate the resident's fourth toe on the left foot.Review of facility investigations from 6/17/25 through 5/25/26 revealed no evidence the facility reported the resident's injury which resulted in an amputation which had occurred during a transfer in the bathhouse or that an investigation was completed with new interventions to prevent recurrence. During an interview on 8/25/26 at 6:32 AM, the facility Administrator confirmed the incident which involved the injury which led to the amputation of Resident 4's left foot fourth toe was not identified as a possible abuse/neglect allegation. The incident was not reported and/or investigated and no investigation was then sent to the State Agency.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(i)(1) Based on observations, record review and interview; the facility failed to provide timely toileting assistance/incontinence management and repositioning for Resident 3 who required assistance with all activities of daily living. The sample size was 1 and the facility census was 35. Findings are:Review of Resident 3's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 8/5/26 revealed the resident was admitted [DATE] with diagnoses of non-Alzheimer's dementia, depression, psychotic disorder, arthritis and renal insufficiency. The assessment further indicated the resident had short and long term memory loss with severely impaired decision making skills, had behaviors which included physical and verbal behaviors directed toward others, resistance with cares and wandering, was dependent on staff for assist with all activities of daily living and was frequently incontinent of bowel and bladder. Review of Resident 3's current Care Plan with a revision date of 2/9/26 revealed the resident had a self-care deficit related to diagnosis of dementia and history of a previous stroke, was frequently incontinent of bladder, and had the potential to be verbally/physical aggressive due to anger, anxiety, dementia, and depression. The resident's triggers for physical aggression were related to care times and male employees. The following interventions were identified:-substantial/maximal assistance of 2 staff with the sit-to-stand lift (mobile/mechanical lift that allows for resident transfers from a seated position to a standing position and was designed to support only the upper body of the resident and required the resident to have some weight-bearing capability) to safely complete toileting hygiene.-substantial/maximal assistance with personal hygiene cares.-when becomes agitated staff to walk away and reapproach with only one person to de-escalate. During observations on 8/24/26, the following was observed for Resident 3:-9:15 AM the resident remained lying in bed on the resident's left side. The bed was in the lowest position and 5 bolsters were observed between the mattress and the frame of the resident's bed on the right side which caused the mattress to be slanted toward the left and maintained the resident's positioning on the left side. The left side of the bed was against the wall. -11:15 AM the resident's position and the position of the bed/mattress remained unchanged. No staff had been in the resident's room to offer assistance with repositioning or to assist with toileting/incontinence cares. -12:15 PM the resident's position and the position of the bed/mattress remained unchanged. -1:15 PM the resident remained in bed with position unchanged. The resident still had not been repositioned or offered assistance with toileting/incontinence management. -1:30 PM Nurse Aide (NA)-B and NA-C entered the resident's room to assist the resident up and out of bed. The resident had remained in bed on the left side with no position change or incontinence/toileting cares for 4 hours and 17 minutes. Observations of Resident 3 on 8/25/26 revealed the following:-6:15 AM the resident was lying in bed on the resident's left side with eyes closed. Five bolsters were again observed between the resident's mattress and bed frame.-8:15 AM the resident remained in bed and positioned on the left side. No staff had assisted the resident with repositioning and/or incontinence cares. -9:15 AM there was no change in the resident's positioning and no staff had entered the resident's room to assist with cares.-11:15 AM the resident remained in bed with positioning unchanged and no toileting/incontinence cares.-11:45 AM NA-B and NA-C entered the resident's room to get the resident up for the day. The resident had been observed lying in bed on the left side with no toileting/incontinence cares for 5 hours and 15 minutes. During an interview on 8/25/26 at 12:45 PM, NA-C confirmed the following:-Resident 3 required total assistance with cares and was unable to reposition self independently. -because of the resident's behaviors, the direct care staff were instructed not to wake the resident in the morning, but to allow the resident to awaken independently as this resulted in fewer behaviors. Staff did not reposition the resident or provide toileting/incontinence cares until the resident woke up independently. -the resident was usually repositioned and provided cares around 5:30 AM before the night shift left for the day. -the bolsters between the resident's mattress and bed frame were a fall prevention intervention to keep the resident from rolling out of bed. During an interview on 8/25/2026 at 2:00 PM, the MDS Coordinator confirmed the current MDS assessment identified Resident 3 required total assistance with bed mobility and toileting cares/personal hygiene. In addition, the resident's care plan did not identify a behavior management intervention to let the resident remain in bed until the resident awakened in the mornings and to delay cares until that time.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1)Based on observations, record review and interview; the facility failed to assess current nutritional interventions and revise and/or develop new interventions for the prevention of weight loss for 2 (Residents 27 and 32) of 5 sampled residents. The facility census was 35.Findings are:A.Review of the facility Weight Assessment and Intervention Policy with a reviewed date of 2/16/26 revealed residents' weights were to be monitored to identify undesirable or unintended weight loss or weight gain. Early identification allows timely clinical intervention to prevent adverse outcomes and ensure regulatory compliance. All residents were to be weighed upon admission and at weekly intervals thereafter. All weights were to be documented in the resident's medical record. Any weight change of 3 lbs. (pounds) from the previous weight was to be re-obtained the following day for confirmation. If the weight change was verified; nursing was to notify the Primary Care Provider (PCP) and family/responsible party of the loss or gain unless otherwise care planned. The policy identified the following interventions for unplanned weight changes: Interventions for unplanned weight loss included the following:-nursing was to assess for contributing factors.-the PCP was to be notified.-the Registered Dietician (RD) was to be consulted.-appropriate interventions were to be implemented and care planned.-ongoing monitoring was to continue per the facility protocol.-review and revise interventions as needed.Review of Resident 32's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/13/26 revealed the resident was admitted on [DATE] with diagnoses of high blood pressure, non-Alzheimer's dementia and depression. The MDS indicated the resident had severe cognitive impairment, required assistance with eating/drinking and had a weight of 158 lbs.Review of Resident 32's current Care Plan dated 7/17/26 revealed the resident was at risk for malnutrition due to weight loss. The following nutritional interventions were identified:-ensure the resident was in the proper position for eating.-monitor the resident's ability to feed self.-provide supervision during meals.-spouted sippy cups (type of drinking cup designed with a spout opening that allows liquid to flow out without the need for the user to hold the cup at a certain angle. Used as a spill-proof feeding aid). -scoop plate (sides of the plate have a high, curved rim that acts like a ramp, allowing food to be pushed up and onto a spoon or fork without spilling) provided at meals. Review of the Weights and Vitals Summary form (a document used to record the residents' weights) revealed Resident 32 weighed 163 lbs. on 6/15/26 and on 7/14/26 the resident's weight was 155 lbs. (down 8 lbs. or a 5% weight loss in 1 month).Review of a Nutrition/Dietary Progress Note dated 7/14/26 at 12:32 PM revealed the resident was evaluated by the RD with a recommendation for Ensure (nutritional supplement with added calories) 4 ounces three times a day. Review of a Weight Change Progress Note by the Director of Nursing (DON) dated 7/23/26 at 3:05 PM revealed the resident's weight on 7/14/26 was 155 lbs. and on 7/22/26 the resident's weight was 152 lbs. The note indicated that the resident's weight was trending down since the beginning of July, the resident frequently refused assistance at meals and was drowsy at times. The note further indicated the resident was not receiving any nutritional supplements at the time.Review of a Weight Change Progress Note dated 7/24/26 at 10:41 AM revealed the PCP had ordered Ensure 8 ounces three times a day.Review of the resident's medical record from 7/14/26 when the RD made a recommendation for Ensure 4 ounces three times a day until 7/24/26 when the PCP ordered Ensure 8 ounces three times a day, there was no evidence the resident had received the 4 ounces of the nutritional supplement which had been recommended by the RD.Review of a Nutrition/Dietary Progress Note by the RD dated 8/8/2026 at 10:34 AM revealed the resident's weight was 150 lbs. and the residents' meal intakes averaged 23 percent. No additional recommendations were identified. Observations of Resident 32 in the dining room on 8/25/26 revealed the following:-9:00 AM served breakfast meal which consisted of a waffle with butter and syrup which had been cut into large pieces. No staff were in the dining room to cue/assist the resident to eat and the resident made no attempt to eat independently.-9:11 AM the Activity Director (AD) sat next to the resident and attempted to assist/cue the resident to eat/drink. -9:18 AM the AD walked away from the resident's table. -9:23 AM Nurse Aide (NA)-C sat next to the resident and provided cues to eat another bite and when resident took a bite independently, left the table. -9:36 AM remained seated at the table with eyes closed and no staff available to assist-9:49 AM the resident was assisted out of the dining room after consuming only bites of the breakfast meal. -12:12 PM the resident was seated in the dining room for the noon meal. The resident was served ground honey garlic chicken, rice with gravy, yellow squash, and a piece of cornbread. In addition, the resident had 8 ounces of Ensure supplement and a glass of water. The resident made no attempt to eat/drink independently. -12:20 PM NA-C sat next to the resident and provided cues and assist to eat/drink. -12:56 PM the resident had consumed only bites and refused to eat any more of the meal. -1:17 PM the resident was assisted out of the dining room after consuming only 25 percent of the noon meal. During an interview on 8/25/26 at 2:00 PM the Dietary Manager (DM) confirmed the resident continued with gradual weight loss and did not always accept the Ensure and had poor intakes at meals. The recommendation made by the RD on 7/14/26 for Ensure 4 ounces three times a day for unintentional weight loss was not initiated until 7/24/26 after the resident had continued weight loss. No additional interventions were developed to address the resident's ongoing weight loss. B.Review of Resident 27's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of cancer, heart failure, renal insufficiency, stroke, hemiparesis (weakness or partial loss of movement on one side of the body), and depression. The MDS indicated the resident had severe cognitive impairment, required assistance with eating/drinking and had a weight of 221 lbs.Review of a Nutrition/Dietary Progress Note dated 12/6/25 at 2:14 PM revealed a recommendation from the RD for Ensure 8 ounces twice a day due to low intakes and unintentional weight loss.Review of the resident's current Care Plan (undated) revealed the resident was at risk for malnutrition and the following nutritional interventions were identified:-if malnourished, consult RD.-provide supervision with meals.-scoop plate at meals.-adaptive silverware at meals.-8 ounces of Ensure twice a day at breakfast and the dinner meal. Review of the Weights and Vitals Summary form revealed Resident 27 weighed 230 lbs. on 6/2/26 and on 7/7/26 the resident's weight was 221 lbs. (down 9 lbs. in 1 month).Review of a Nutrition Review by the RD dated 7/14/26 at 5:41 PM revealed the resident's weight was 222 lbs. No new recommendations were identified. Review of the Weights and Vitals Summary form revealed Resident 27 weighed 218 lbs. on 8/25/26. During an interview on 8/25/26 at 1:38 PM, the DON confirmed the following:-12/16/25 the Registered Dietician recommended Ensure 8 ounces twice a day. -7/7/26 the resident's weight was 222 lbs. down 9 lbs. in one month. The resident's meal intakes had declined due to frequent recurrent urinary tract infections. -evaluated by the RD 7/14/26, current interventions were not reviewed/revised and no additional interventions were developed.

Record review of the facility policy Hand Hygiene with a revised date of 4/1/24 revealed the following: -all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and to visitors. -hand hygiene was a general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). -hand hygiene using soap and water was to be performed when hands were visibly soiled, before and after eating, after using the restroom, and any exposure to diarrhea type illnesses. -hand hygiene was indicated using ABHR when; reporting for duty and before going off duty, between resident contacts, after handling contaminated objects, before applying and after removing PPE, before preparing or handling medications, before and after handling clean or soiled dressings or linens, when during the care of a resident going from a contaminated body site to a clean site, after assistance with personal body functions, and whenever in doubt. Record review of Resident 19's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of heart failure, end stage renal disease, Parkinson's disease, and a multi drug-resistant organism. The resident was identified with coughing or choking with meals or when taking medications and with having a feeding tube. The resident's tube feeding supplied the resident with 51% or more of total calories and 501 cubic centimeters (cm) or more of fluids. Observation on 6/16/25 at 11:35 AM revealed an EBP sign was posted on the door of Resident 19's room. Licensed Practical Nurse (LPN)-C entered the resident's room and placed on an isolation gown and a pair of disposable gloves without performing hand hygiene. LPN-C removed the dressing from the resident's feeding tube insertion site, cleansed the area with hydrogen peroxide, and removed gloves. LPN-C failed to perform hand hygiene before putting on a clean pair of gloves and applying a clean dressing. LPN-C completed the resident's ordered tube feeding and removed the gown and gloves the staff were wearing. LPN-C exited the resident's room but failed to complete hand hygiene until the LPN reached the end of the corridor when ABHR was utilized from a container hanging on the wall. An observation of morning cares for Resident 19 on 6/17/25 at 7:20 AM revealed the following: -NA-M entered the resident's room, performed hand hygiene, and placed on a pair of disposable gloves. NA-M failed to put on an isolation gown despite the residents' current enhanced barrier precautions status. -NA-M assisted the resident with dressing and then ambulated the resident into the bathroom and transferred the resident onto the toilet. -NA-M discarded gloves and proceeded to remove the linens from the resident's bed and cleaned the mattress with a disinfectant wipe. NA-M failed to wear gloves or an isolation gown. -NA-M performed hand hygiene and placed on clean gloves before assisting the resident with toileting hygiene and transferring the resident out of the bathroom and into a recliner. During an interview on 6/17/25 at 8:20 AM, NA-M confirmed Resident 19 was on enhanced barrier precautions. NA-M indicated an understanding that the staff only needed to wear gloves and a gown if the staff were working with the resident's feeding tube. An interview on 6/17/25 at 9:25 AM with the DON and the Infection Preventionist confirmed LPN-C should have performed hand hygiene when entering the resident's room, before putting on clean gloves and gowns and after removing gloves and gowns. In addition, hand hygiene should have been performed before exiting the resident's room. NA-M should have worn both gloves and a gown when providing direct care and when handling bed linens for a resident who was on EBP. Licensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews, and interviews; the facility failed to implement the required use of Personal Protective Equipment (PPE) during the provision of care for Residents 19 and 27 who were on Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices)); prevent the potential spread of infection or cross contamination during the provision of care for Resident 19 related to hand hygiene; and to ensure laundry was stored in a clean environment. The total sample size was 18 and the facility census was 28. Findings are: A. Record review of the facility policy Enhanced Barrier Precautions, last reviewed 2/19/25 revealed the following: -the facility implemented EBP for the prevention of transmission of multi-drug resistant organisms (a germ that is resistant to many antibiotics); -EBP referred to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high-contact resident care activities; -all staff received training on EBP and were expected to comply with all designated precautions; -all staff received training on high-risk activities and common organisms that required EBP; -implementation of EBP included making gowns and gloves available immediately near or outside of the resident room, ensure access to Alcohol Based Hand Rub (ABHR) in every resident room; -high-contact care included bathing, dressing, transferring, hygiene provision, linen changes, toileting assistance and/or changing of briefs, device care (catheters, feeding tubes, intravenous lines, tracheostomy/ventilator tube care), and wound care; -EBP was used for the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the medical device occurred. Record review of Resident 27's Minimum Data Set (MDS, a federally mandated assessment tool used in care planning) dated 4/27/25 revealed the resident was admitted on [DATE] with a stroke affecting the left non-dominant side. The resident was cognitively intact; was dependent with toileting, dressing, and hygiene; eating was marked as not applicable, the resident had a feeding tube and received 51% or more of calories by feeding tube. Record review of Resident 27's Care Plan last revised 6/17/25 revealed the resident was at risk for infection related to feeding tube placement; was dependent on staff for bed mobility, dressing, transfers, and hygiene; and the resident had a swallowing problem. An observation on 6/16/25 at 9:30 AM revealed a sign on Resident 27's door that the resident had EBP in place. There was a caddy on the back of the door that housed gowns and gloves. The resident was in bed and a continuous tube feeding was running. An observation on 6/16/25 at 5:35 PM revealed an EBP sign on the door to Resident 27's room. Nursing Aid (NA)-I and NA-D entered Resident 27's room, performed hand hygiene and put gloves on but did not put on gowns. A caddy holding PPE was on the back of the resident's door. Both NA-I and NA-D went to Resident 27 and were leaning against the bed (clothes touching the linens) while talking to the resident and explaining what they were going to do. NA-D removed the resident's blankets and pillows (the linens were touching NA-D's clothes) and placed them on the dresser. NA-D, still not wearing a gown, gathered supplies to change the resident's brief and placed them on the bed. NA-D performed perineal care on the resident while still not wearing a gown, and changed gloves with hand hygiene when finished. NA-D and NA-I, continued to not wear gowns and repositioned the resident onto the resident's right side to perform rear perineal care. Both NA-D and NA-I were leaning against the resident's bed and the bed linens were touching NA-D and NA-I's clothing. NA-I performed rear perineal care and removed their gloves then performed hand hygiene. NA-D and NA-I repositioned the resident when they were done completing perineal care. NA-D obtained the residents linens from the dresser and placed the top blanket over NA-D's shoulder while continuing to not wear a gown. NA-D placed the resident's blankets on the resident and positioned Resident 27 with the pillows. Hand hygiene was performed when the NA's left the resident room. An interview on 6/16/25 at 5:45 PM with NA-D revealed staff only needed to wear PPE if they were doing something involving the feeding tube. Further interview confirmed NA-D and NA-I did not wear PPE during the provision of cares for Resident 27. An interview on 6/17/25 at 9:25 AM with the Director of Nursing (DON) and the Infection Preventionist confirmed that PPE should be worn during the provision of cares for residents on EBP. B. Record review of the facility policy Routine Cleaning and Disinfection with a revised date of 2020 revealed the following: -it was the policy of Sandhills Facility to ensure routine cleaning was completed in order to provide a safe, sanitary environment to prevent the development and spread of infections, and -cleaning referred to the removal of visible soil from objects and surfaces. An observation on 6/17/25 at 10:20 AM revealed the vent above the clean linens had a heavy layer of dust that covered the vent, and cold air was blowing out of the vent onto the clean linens and table. The clean side of the laundry room had a black fan that blew air on the clean linens. The fan had a thick layer of dust on the fan blades and the fan cover. The fan blew out dust particles on the clean linens. An interview with the head of laundry on 6/17/25 at 10:20 AM confirmed the vent above the clean linens had a heavy layer of dust and was blowing onto the clean linens and the black fan was blowing dust on the clean linens. The cleaning schedule for the laundry room was reviewed with the head of laundry, cleaning the vents was on the cleaning list to be done weekly, cleaning the fan was not on the cleaning list. Record review of the cleaning check list for the months of May and June 2025 revealed that the vent was not being cleaned weekly.

Licensure Reference Number 175 NAC 12-006.12(D)(i) Based on observation, record review and interview; the facility failed to ensure medications were securely stored to prevent potential unauthorized access. This had the potential to affect any resident who were mobile within the facility. The facility census was 28. Findings are: Record review of the facility Medication Labeling and Storage policy dated 2001 revealed the facility stored all medications and biological in locked compartments under proper temperature, humidity and light controls. Only authorized personnel had access to keys. During an observation on 6/17/25 at 9:00 AM the treatment cart containing topical medications was left unlocked in the hallway adjacent to the nurses' station and no staff were present to ensure the residents or unauthorized personnel did not have access to the medications in the cart. During an interview on 06/17/25 at 9:02 AM the Director of Nursing confirmed the cart containing medication was not locked and should be locked at all times when not directly attended by approved staff.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review; the facility failed to maintain the cleaning of food storage surfaces and prepare and serve food in a manner to prevent potential food borne illness. This had the ability to affect all residents that ate from the facility kitchen. The total sample size was 18 and the facility census was 28. Findings are: A record review of the facility policy Food Preparation and Service with a revised date of 11/22 revealed: Appropriate measures used to prevent cross contamination included: -cleaning the food contact equipment between uses, -bare hand contact with food was prohibited, and -gloves were to be worn when food was directly handled. A record review of the facility policy Sanitization with a revised date of 11/22, revealed: -the food service area was maintained in a clean and sanitary manner. -all counters, shelves and equipment were kept clean. A record review of the facility's cleaning schedule revealed the following task was completed on a weekly basis: -clean all shelving. Observation during the initial kitchen tour on 6/16/25 at 9:40 AM revealed the following: -a black plastic shelf used to store spices, oils and pans had a heavy layer of grease with dried on brown and white spots in areas of the shelves. Observations during the follow-up kitchen tour on 6/16/25 from 11:25 AM to 1:10 PM revealed the following: -dietary staff member-G, was cutting cucumbers with bare hands, scraped the knife and scooped up the cucumbers with bare hands and then washed their hands. Dietary staff member-G, then cut tomatoes with bare hands, scraped the knife and scooped up tomatoes with bare hands. -at 11:53 AM dietary staff member-H, pureed 6 meat balls, after puree meat balls were put on the steam table, staff member-H, set the container used to prepare the puree meatballs on the prep table. At 12:30 PM staff member-H, picked up the dirty puree container and put 2 meatballs in the container and stated that more puree meatballs were needed. Dietary Manager (DM)-F, stopped staff member-H and asked if it was safe to use an unclean container, staff member-H shook head yes. DM-F stopped staff member-H from using the dirty container. -dietary staff member-H, put a plate of spaghetti noodles on the serving cart, the spaghetti noodles fell off of the plate onto the serving cart, staff member H picked up the noodles off of the serving cart with bare hands and put them on the plate, DM-F, stopped the staff member, questioned staff member if picking up the noodles off of the cart and putting back on the plate was safe, and staff member shook head yes. DM-F had dietary staff member-H, wash their hands and serve a new plate for this resident. An interview with the DM-F on 6/16/25 at 1:10 PM confirmed: -the shelf with spices and pans was not being cleaned weekly per the cleaning schedule. The last date the shelf was cleaned was 5/31/25. -a clean container is to be used each time pureeing a food item. -staff members were to wear gloves when touching ready-to-eat food items.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews, the facility failed to notify the Primary Care Practitioner (PCP) of a change in condition for 1 (Resident 19) of 1 sampled resident. The facility staff identified a census of 28. Findings are: Record review of the facility policy Notification of Changes with a revised date of 6/12/24 revealed the purpose of the policy was to ensure the facility promptly informed the resident, the physician and the resident's representative when there was a change requiring notification. Circumstances which might require notification include: -accidents resulting in an injury or have the potential to require physician intervention. -a significant change in the resident's physical, mental, or psychosocial condition. -circumstances which might require a need to alter treatment. -a transfer or discharge from the facility. -a change of room or roommate assignment. -a change in resident's rights. -death of a resident. Record review of Resident 19's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 4/10/25 revealed the resident was admitted [DATE] with diagnoses of heart failure, Parkinson's disease, end stage renal disease, cancer, anxiety, depression, pneumonia, and chronic obstructive pulmonary disease (COPD). The following was assessed for Resident 19: -cognitively intact. -required staff assistance with toileting, dressing, transfers, personal hygiene, and bed mobility. -shortness of breath or trouble breathing with exertion or when lying flat. -antidepressant, antibiotic, diuretic (drug which causes the kidneys to make more urine), and antiplatelet (drugs that prevent platelets, a type of blood cell, from clumping together to form a blood clot) medications used daily. -the resident was identified with coughing or choking with meals or when taking medications and with having a feeding tube. The resident's tube feeding supplied the resident with 51% or more of total calories and 501 cubic centimeters (cm) or more of fluids. Record review of Resident 19's Nursing Progress Note dated 1/24/25 at 10:25 AM revealed the resident was seen in the facility by the PCP. The resident had a cough, and a new order was received for the staff to monitor the resident and if the resident worsens or develops a fever, to notify the physician. Record review of Resident 19's Medication Administration Record (MAR) dated January 2025 revealed the staff were monitoring the resident's vital signs and lung sounds every shift for potential pneumonia. From 1/24/25 to 1/31/25 the following was identified: -1/24/25 for the day shift the resident's oxygen saturation (measurement of the amount of oxygen carried in the blood stream. Normal oxygen saturation levels range from 95 to 100%) was 90%. -1/25/25 for the day shift the resident's oxygen saturation was 90%. -1/26/25 for the day shift the resident's temperature was 99 degrees. -1/27/25 for the day shift the resident's temperature was 100 degrees. -1/28/25 for the day shift the resident's temperature was 99.5 degrees. -1/29/25 on the evening shift the resident's temperature was 99 degrees. -1/30/25 on the evening shift the resident's temperature was 99.9 degrees. -1/31/25 for the day shift the resident's temperature was 99.3 degrees and on the evening shift, the temperature was 99.8 degrees. Record review of Resident 19's electronic medical record from 1/24/25 to 1/31/25 revealed no evidence the facility staff had notified the resident's physician of the resident's elevated temperature or lowered oxygen saturation levels. Record review of Resident 19's Nursing Progress Note dated 2/1/25 at 11:20 PM revealed the resident's temperature was 101.6 degrees and the resident had been complaining the resident's stomach hurt and was upset. Record review of Resident 19's MAR dated February 2025 revealed the following regarding the resident's vital signs and lung sounds: -2/1/25 for the evening shift the resident's temperature was 100.8 degrees. -2/2/25 for the evening shift the resident's temperature was 101.7 degrees. Record review of Resident 19's Nursing Progress Notes dated 2/3/25 revealed the following: -7:10 AM it was reported that the resident's temperature had spiked over the weekend, and the current temperature was 99.1 degrees, the resident's oxygen saturation was 89% and the resident had a cough. -11:17 AM the resident's PCP was updated (10 days after the physician order to keep the PCP notified if the resident's condition worsened) regarding the resident's condition. Record review of Resident 19's MAR dated February 2025 revealed the following regarding the resident's vital signs and lung sounds: -2/4/25 for the evening shift the resident's temperature was 99.9 degrees. -2/5/25 on the day shift the resident's oxygen saturation level was 90% and for the evening shift the resident's temperature was 100.6 degrees. Record review of Resident 19's Nursing Progress Note dated 2/5/25 at 9:11 PM revealed the resident's lower left lung sounds were diminished, the resident felt congested, and the resident had a productive cough. Record review of Resident 19's Nursing Progress Notes dated 2/6/25 revealed the following: -12:03 AM the resident's temperature remained 100 degrees, and the oxygen saturation level was 90%. The physician had not responded to the notification sent on 2/3/25 and the facility sent the physician another update. -3:59 PM the resident had been running a fever for multiple days, was more fatigued and was difficult to awaken. A new order was received for Levaquin (antibiotic) 500 milligrams daily for 10 days. An interview on 6/16/25 at 4:44 PM with the Director of Nursing (DON) confirmed the following regarding Resident 19: -had a history of COPD and of pneumonia. -seen by the PCP on 1/24/25 and was identified as having a cough. New orders were received to monitor the resident and to notify the PCP if condition worsened. -from 1/24/25 to 2/3/25 the resident had coughing, elevated temperatures, and lowered oxygen saturations. -the facility did not notify the physician about these changes until 2/3/25 (10 days later). -the PCP did not respond on 2/3/25 and the resident's condition continued to decline. -the staff should have contacted the PCP again within 24 hours if a response was not received regarding a change in condition. -the facility did not contact the PCP again until 2/6/25 and the resident was then started on an antibiotic.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5%. The number of opportunities for administration observed was 28 with 2 errors (involving Residents 6 and 16) revealing an error rate of 7.14%. The sample size was 7 and the facility census was 28. Findings are: Record review of the facility policy Administering Medications with a revision date of April 2019 revealed the following: -Medications were administered in a safe and timely manner, and as prescribed. -Medications were administered in accordance with prescriber orders. -The individual administering the medication checks to ensure the medication was given to the right resident, the right medication, the right dose, the right time, and the right administration method/route. Record review of the facility policy Adverse Consequences and Medication Errors with a revision date of February 2023 revealed the following: -The interdisciplinary team monitored medication usage to prevent and detect medication-related problems such as adverse drug reactions and/or side effects. -A medication error was defined as the preparation or administration of drugs or biologicals which was not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles. -Examples of medication errors included, not administering a drug that was ordered, administering an unauthorized drug, providing the wrong dose, routine of administration, at the wrong time, or failure to follow manufacturer's instructions. During observations of the morning medication administration pass performed by Licensed Practical Nurse (LPN)-C on 6/17/25 between 7:39 AM and 8:00 AM the following was observed: -LPN-C prepared 1 tablespoon of Psyllium Fiber Oral Powder and mixed the powder into a glass of orange juice. The label on the medication read, give 3.4 Grams mixed in liquid. Resident 6 was given and consumed approximately 2/3 of the mixture and then LPN walked away without ensuring the resident consumed the entire dose. -LPN-C prepared 1 capful of ClearLax Oral powder and mixed it into a glass of water. LPN-C then assisted the Resident 16 to drink approximately ½ of the prepared liquid and then discarded the remaining medication in the trash bin on the medication cart. Record review of Resident 6's Medication Administration Record (MAR) dated June 2025 revealed the resident's scheduled medications included Psyllium Fiber Oral Powder 51.7%-give 3.4 grams daily by mouth. During an interview on 6/17/25 at 7:40 AM LPN-C confirmed the label for Resident 6's Psyllium Fiber powder did not contain instructions of how much medication was to be measured; and confirmed giving one tablespoon as having been trained to do. LPN-C was unable to confirm the measured dose was equivalent to 3.4 Grams. Record review of Resident 16's Medication Administration Record dated June 2025 revealed the resident's scheduled medications included ClearLax Oral Powder 17 Grams-give one scoop by mouth one time every other day. During an interview on 6/17/25 at 8:00 AM with LPN-C, the LPN reported I don't know when asked why the LPN discarded 1/2 the dosed glass of ClearLax Oral medication for Resident 16 without administering it. During an interview on 6/17/25 at 8:45 AM the Director of Nursing (DON) confirmed that all medication orders that required measurement should contain the proper measurements of each medication to ensure proper dosing. In addition, all medications need to be fully consumed under observation of the staff providing the medication, to ensure the resident received the full dose as ordered and if the full dose was not administered that would constitute a medication error.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to implement and maintain hand hygiene practices, ensure the dishwasher temps were monitored, and failed to implement and maintaining the cleaning or food preparation equipment and surfaces to prevent the potential for food borne illness. This had the potential to affect all facility residents. The facility census was 28. Findings are: Review of the facility policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated November 2022 revealed the following: -The food and nutrition employees followed appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness, -All employees who handled food were free of communicable diseases, -Employee washed their hands whenever entering or re-entering the kitchen, before coming in contact with any food surfaces, after handling raw meat, poultry, or fish and when switching between working with raw and ready to eat food, after handling soiled equipment or utensils, as often as necessary to prevent cross contamination and to prevent cross contamination when changing tasks, and after engaging in activities that contaminated the hands. -contact between food and ungloved hands was prohibited and gloves were considered single use items and were discarded after completing tasks in which they were used. After gloves were removed hands were washed and the gloves replaced. -The use of disposable gloves was not a substitute for proper hand washing. -Food service employees were trained in the proper use of utensils, gloves, deli paper and spatulas to prevent food borne illness. Review of the facility policy Food Safety Requirements dated 4/1/24 revealed the following: -the facility policy was to procure food items from sources approved or considered satisfactory by Federal, State and Local authorities, -food was stored, prepared, distributed and service in accordance with professional standard for food service safety, -food safety practices followed throughout the food handling process including procurement, storage, preparation, distribution, equipment uses and handling, and employee hygienic practices, -all equipment used in the handling of food was kept clean and sanitized in a manner to prevent contamination, -staff adhered to safe hygienic practices to prevent food contaminations including the appropriate use of gloves during food handling, and -staff would follow procedures for dishwashing and cleaning fixed cooking equipment. During the initial kitchen tour on 5/20/24 at 6:40 PM the following concerns were identified: -There was no dishwasher temp log to for the staff to record dishwasher temps to ensure the water temps were at the desired levels. -The cupboard door below the steamer was soiled with water stains and swollen and distorted from being wet; this was not a cleanable surface. All the wooden cupboards in the facility were stained and had darkened areas around all the access handles and knobs. -The Ninja cooker which staff reported was used to cook baked potatoes was heavily soiled with grease and food debris. -The Certified Dietary Manager (CDM) was unable to produce evidence the facility had cleaning schedules for food service equipment. During an interview on 5/20/24 at 6:52 PM Dietary Aide (DA)-A confirmed the staff had no awareness of a log for recording dishwasher temperatures, no idea at which temperature the wash or rinse water for the dishwasher should be, or even where to look to check the dishwasher temps. In addition, DA-A reported using the dishwasher every shift worked. During an interview on 5/20/24 at 6:54 PM DA-B confirmed the staff had no awareness of a log for recording dishwasher temperatures, no idea at which temperature the wash or rinse water for the dishwasher should be, or even where to look to check the dishwasher temps. In addition, DA-B reported using the dishwasher every shift worked. During an interview on 5/20/24 6:59 PM the CDM confirmed being unaware staff were not checking the dishwasher wash and rinse temperatures to ensure the required temperatures of 120 degrees were being achieved for proper sanitation and food safety. The CDM also confirmed being unable to produce a log of dishwasher temp checks. During the subsequent kitchen tour on 5/21/24 at 11:30 PM and 12:30 PM the following concerns were identified: -DA-W washed hands, dried them and then turned off the water with the same towels used to dry hands with then donned disposable gloves, and reported to the serving area. -DA-W removed all the lids from the food items on the steam table wearing disposable gloves and began serving the meal. -DA-W left the serving area to retrieve serving bowls from a cupboard and a serving spoon from a drawer and then returned to the serving area wearing the same gloves and continued to serve food. -With the same gloved hands DA-W reached into a bag of bread and retrieved slices of bread which were topped with meat using a tong and then using the same gloved hands held the bread and cut it in half and reached for the serving ladle and covered the bread and meat with gravy. -With the same gloved hands DA-W used a tong to put beef into a chopper to cut the meat up, touching the meat in the process using the same gloved hands, then put the lid on to chop it, and then returned to serving the meal with the same gloves still in use. -DA-W then retrieved a chicken breast with tongs from the serving area, and while holding the chicken onto a plate with the same gloved hands cut it into smaller pieces and then continued to serve food touching multiple serving spoons with the same gloves. -Again, using the same gloves which had touched both beef and chicken and numerous kitchen surfaces and serving utensils DA-W reached into a bread bag and grabbed 2 slices of bread; topped it with meat using a serving tong and then with the same gloved hands held the bread on a plate and cut the bread and meat in half and topped it with gravy and continued to serve the meal. During an interview on 5/22/24 at 2:00 PM the CDM confirmed staff must perform hand hygiene prior to all food handling, before and after changing gloves. In addition, if gloves are used to touch potentially unclean surfaces such as drawers and or cabinet door pulls the gloves must be changed including hand hygiene prior to touching ready to eat food. Further interview confirmed that not all staff were recording dishwasher temps to ensure the dishwasher was reaching temperatures to ensure the proper sanitation of dishes, and the facility had no evidence or log to show that kitchen equipment and surfaces were being cleaned regularly to prevent potential food borne illness.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to prevent potential spread of infection when staff 1) had not worn the required Personal Protective Equipment (PPE) during care of Resident 20's feeding tube (a flexible plastic tube placed into the stomach or bowel used to provide nutritional needs), 2) failed to implement hand hygiene measures during incontinence care of Resident 15 and while residents were assisted with eating during the meal service, and 3) failed to implement a legionella water management plan to prevent the potential for water-borne illness. The sample size was 17 and the facility census was 28. Findings are: A. Review of the facility policy Enhanced Barrier Precautions (EBP) dated 4/1/24 revealed the following: -EBP referred to an infection control intervention used to reduce transmission of drug-resistant organisms by implementing use of gown and gloves during high contact resident care activities. -Initiation of EBP included obtaining a physician's order for residents with wounds (ie. chronic pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (ie. Central lines, urinary catheters, feeding tubes, and tracheostomy/ventilator tubes.) -Implementation of EBP included isolation gowns and gloves made available immediately near or outside of the resident's room. -Personal Protective Equipment (PPE- gloves, gown, masks, face shield and/or eye protection) for EBP was necessary when high-contact care activities were performed. -High contact resident care activities include dressing, bathing, transferring, hygiene care, changing linens and/or briefs or assisting with toileting, device care use (feeding tubes) and wound care. -Ensured access to hand sanitizer and positioned a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exiting the room. Review of Resident 20's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/15/24 revealed the resident was admitted [DATE] with diagnoses of cancer, heart failure, high blood pressure, pneumonia, stroke, Parkinson's, anxiety, depression, and lung disease. The resident was assessed with a feeding tube and received nutritional calories and fluids via feeding tube on a daily basis. During an observation of Resident 20's feeding tube cares on 5/20/24 at 6:40 PM the following was revealed: -The resident was seated on a chair and had a feeding tube device located on [gender] stomach. -Registered Nurse (RN)-D prepared to administer the resident's feeding tube solution and wore a pair of disposable gloves. There were no isolation gowns available in the room and RN-D did not have a gown on throughout the procedure. -RN-D opened the cap on the end of the feeding tube and using a 60 Cubic Centimeter (CC) needleless syringe, inserted air into the tube to check for correct placement in the resident's stomach. -RN-D then removed the syringe from the feeding tube and removed the plunger from the inside the syringe. -RN-D re-inserted the 60cc needless syringe into the feeding tube and poured the feeding solution into the tube. RN-D then flushed the feeding tube with water and replaced the cap back on the feeding tube. -RN-D then removed gloves and washed hands prior to exiting the room. During an interview with RN-D on 5/20/24 at 6:40 PM, RN-D confirmed [gender] had no knowledge EBP should have been implemented when providing tube feeding cares for Resident 20. During an interview with the Director of Nurses (DON) on 5/20/24 at 7:45 PM, the DON confirmed the facility had not yet implemented Enhanced Barrier Precautions for Resident 20 or other residents as of this date. During an interview with the administrator on 5/20/24 at 7:50 PM, the administrator confirmed Enhanced Barrier Precautions should have been implemented for Resident 20 and those who residents who met the criteria for EBP. B. Review of the facility policy Hand Hygiene dated 4/1/24 revealed all staff performed proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. Hand hygiene was indicated and would be performed under the conditions listed in, but not limited to the following: -When hands were visibly soiled, before and after eating, after using the restroom, known exposure to bacteria/pathogens, when reporting to duty, between resident contacts, after handling contaminated objects, before and after performing procedures, before putting on and after taking off Personal Protective Equipment (PPE), before preparing and handling medications, before and after resident care procedures, before and after handling soiled dressings or linens, and when in doubt. -Alcohol based hand rub was the preferred method for cleaning hands in most clinical situations. Washing with soap and water was indicated whenever hands were visibly dirty, before eating, and after using the restroom. C. Review of Resident 15's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of cancer, dementia, Parkinson's disease and vision problems. The resident was assessed with severe cognitive impairment, was incontinent of bowel and bladder and was totally dependent upon staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene. During observation of cares provided to Resident 15 on 5/21/24 at 3:25 PM the following was revealed: -Nurse Aide (NA)-K and NA-J washed hands and put disposable gloves on upon entering the resident's room. -The resident was lying in the bed and NA-J opened the disposable brief and noted the resident was incontinent of Bowel Movement (BM). The resident was positioned onto [gender] left side and NA-J cleaned the BM from the resident's buttocks using several cleansing wipes. -NA-J then removed the soiled gloves and did not wash or sanitize hands before putting on clean gloves. NA-J then proceeded to clean the resident's front genital area. An interview with NA-J on 5/21/24 at 3:35 PM confirmed [gender] should have washed or sanitized hands after cleaning the BM from the resident's buttocks and between changing gloves. 42360 D. The facility policy Infection Prevention and Control Program dated 4/1/24 revealed the following: -The facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable disease and infections as per acceptable standards and guidelines. E. Review of the Legionella Surveillance policy dated 4/1/24 revealed the facility established primary and secondary strategies for the prevention and control of legionella infections (pneumonia type bacterial illness). Primary prevention strategies included diagnostic testing, source investigation, physical controls, and temperature controls. Secondary prevention strategies included full scale environment investigation, decontamination and heightened surveillance and environmental sampling. F. Review of the facility Water Management Program dated 4/1/24 revealed the facility established water management plans to reduce the risk of legionella or other opportunistic pathogens in the facilities water system based on nationally accepted standards. This included staff education, access to water treatment professionals, environmental specialists, and State and Local health officials. A risk assessment considered water system components, medical devices utilized that could spread Legionella bacteria, and identification of their at-risk population. Data would be used to complete a risk assessment including but not limited to water system schematics, Legionella environmental assessment, resident infection surveillance, environmental culture results, observation data, water temperature logs, water quality reports, and community infection surveillance through health department reporting. The facility would conduct an annual review of the water management program, document activities related to water management, and report relevant information to the QAPI (Quality Assurance and Performance Improvement) Committee. G. During an interview on 5/22/24 at 12:41 PM the facility Administrator confirmed they had not identified potential sources for water borne illness or implemented a water management plan to prevent potential water borne illness. H. Review of the facility policy Hand Hygiene dated 4/1/24 revealed the following: -all staff performed proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. -Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to a hand hygiene schedule indicating that hand hygiene should be performed when hands were visibly soiled, before and after eating, after using the restroom, known exposure to bacteria/pathogens, when reporting to duty, between resident contacts, after handling contaminated objects, before and after performing procedures, before putting on and after taking off Personal Protective Equipment (PPE), before preparing and handling medications, before and after resident care procedures, before and after handling soiled dressings or linens, and when in doubt. -Alcohol based hand rub was the preferred method for cleaning hands in most clinical situations. Washing with soap and water was indicated whenever hands were visibly dirty, before eating, and after using the restroom. I. During observation of the breakfast meal on 5/21/24 at 7:30 AM the following concerns were identified: -Staff members H and I while assisting residents at the assisted tables in the dining room were moving from resident to resident; handling the residents' cup/glasses and silverware before and after the resident handled them and then would move between residents without utilizing hand hygiene. J. During an interview on 05/22/24 at 11:10 AM the Infection Preventionist (IP) confirmed that staff were to complete hand hygiene between resident contacts in the dining room to prevent potential transmission of disease.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to protect Residents 1, 9, 15, 18 and 24's right to be free from staff-to-resident verbal abuse. The sample size was 5 and the facility census was 28. Findings are: A. Review of the facility Abuse Prevention Policy (undated) revealed the policy was a mechanism for the prompt identification, investigation and reporting of any allegation or complaint of abuse, neglect, or exploitation. The policy indicated allegations of potential abuse were to be immediately reported to a supervisor, the facility Administrator or designee and in accordance with the state and federal laws. If there was reasonable suspicion of a crime or if serious bodily injury occurred, then the report was to be made immediately but no later than 2 hours. Allegations were to be promptly investigated and documented. After completion of the in-depth investigation, the facility was to submit a report of all investigation results to the State Agency within 5 working days. B. Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/27/24 revealed the resident was admitted [DATE] with diagnoses of non-traumatic brain dysfunction, heart failure, dementia, anxiety, depression, and psychotic disorder. The assessment further revealed the resident's cognition and decision-making skills were severely impaired and the resident was dependent or required substantial to maximal staff assistance with toileting, transfers, dressing, hygiene, and bed mobility. Review of a facility investigation dated 1/5/24 revealed an allegation of staff to resident abuse. Nurse Aide (NA)-O reported on 1/2/24, staff had assisted NA-N with placing Resident 24 in bed. Resident 24 was positioned in the sit-to-stand lift (a mechanical lift that allows for transfers from a seated position to a standing position. The lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) and refused to keep feet on the footplate of the lift. NA-N pushed Resident 24's feet down on the footplate 3 times. NA-O further reported NA-N was rough when pushing down the resident's feet. C. Review of Resident 18's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of dementia, Parkinson's disease, anxiety, and depression. The resident's cognition was severely impaired, and the resident was dependent or required substantial to maximal staff assistance with hygiene, toileting, dressing, bed mobility, and transfers. Review of a facility investigation dated 1/5/24 revealed an allegation of staff-to-resident abuse involving Resident 18 and NA-N. NA-O identified on 1/2/24, NA-O and NA-N had assisted Resident 18 with morning cares. Staff were attempting to transfer the resident out of bed. Resident 18 refused to lean forward and to hold onto the hand grips of the sit-to-stand mechanical lift, so NA-N proceeded to roughly pull the resident's arm forward and the resident then voiced ouch. D. Review of Resident 15's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of a progressive neurological condition, Parkinson's disease, cancer, and non-Alzheimer's dementia. The resident had short- and long-term memory loss with severely impaired decision-making skills and the resident was dependent on staff to assist with all activities of daily living. Review of a facility investigation dated 1/5/24 revealed an allegation of staff-to-resident abuse involving Resident 15 and NA-N. NA-O identified on 1/2/24, NA-O and NA-N had assisted Resident 15 with evening cares. Resident 15 was not leaning forward properly, and staff were having a difficult time positioning the sling for the sit-to-stand lift behind the resident. NA-N pulled the resident forward and NA-N then placed an elbow in the resident's back to keep the resident forward so the sling could be placed behind the resident's back. E. Further review of the investigation involving NA-N and Residents 15, 18 and 24 revealed NA-N was suspended pending the outcome of the investigation. In addition, NA-O was reminded any allegations of potential abuse/neglect should have been reported immediately and not days after the incident. After completion of the investigation, the facility determined the allegations of abuse were not substantiated as NA-N had meant no ill will or harm and NA-N was not aware of own strength. NA-N was to complete online training related to abuse and dealing with residents with dementia and behaviors before NA-N was allowed to return to work. Review of NA-N's training transcript revealed on 1/12/24 NA-N completed the following training modules: -A day in the life of [NAME], a dementia experience, -Advanced Care Skills in late-stage dementia, and -Alzheimer's disease and related disorders; the environment. Review of the nursing staff schedule for January/2024 revealed NA-N worked on 1/13/24 and on 1/14/24 from 6:00 AM to 6:00 PM Further review of NA-N's training record revealed no evidence NA-N had completed any training related to abuse from 1/5/24 to 1/13/24, despite the staff returning to work and providing direct cares for the facility residents. F. Review of Resident 1's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of non-traumatic brain dysfunction, Alzheimer's, dementia, and depression. The resident's cognition was assessed as severely impaired and the resident required partial to moderate staff assistance with toileting, dressing and personal hygiene. Review of a facility investigation dated 1/16/24 revealed an allegation of staff to resident abuse on 1/14/24 with NA-N and Resident 9. NA-X reported NA-N had grabbed Resident 9 by the waist and made the resident sit back down in a wheelchair. NA-N propelled the resident into the dining room and pushed the resident's wheelchair up against a table. NA-N then used their knee to hold the resident and the wheelchair against the table. In addition, Resident 9 had attempted to enter the public restroom and NA-N took the resident's shoulders and then slammed the resident down and into the wheelchair. Further review of the facility investigation revealed on 1/14/24 NA-N submitted their resignation. G. Review of a facility investigation dated 5/6/24 revealed on 5/5/24 at 11:30 AM, Licensed Practical Nurse (LPN)-P documented in Resident 1's Nursing Progress Notes the resident had slapped NA-Y who had attempted to assist the resident to get dressed as the resident had been incontinent. LPN-P went down to the resident's room and asked the resident how old are you? LPN-P told the resident the resident was acting like a 2-year-old who did not want to mind and told the resident they could get up on their own or LPN-P and NA-Y would help the resident. The resident did not move and so LPN-P and NA-Y got under the resident's arms and assisted to a seated position. Resident 1 was resisteive but then got up from the bed, ambulated into the bathroom with a walker and came out to the dining room for the breakfast meal. Further review of the investigation revealed a skin assessment completed on 5/6/24 revealed the resident had bruising on their wrists. LPN-P indicated staff had not touched the resident's wrists, but the resident had been combative during the incident. The Director of Nursing (DON) did not substantiate the abuse allegation against LPN-P as the LPN was often loud and had a matter of fact personality. LPN-P was educated regarding resident rights and was assigned to complete training related to Resident Rights, Dementia and Abuse. Review of the Nursing schedule for 5/2024 revealed LPN-P worked on 5/18/24 from 6:00 AM to 6:00 PM. Review of LPN-P's training transcript revealed from 5/5/24 to 5/18/24 there was no evidence the LPN had completed the required training related to abuse, dementia and resident rights before returning to work. H. Interview with the DON and the Administrator on 5/21/24 at 5:38 PM confirmed the following: -staff to resident allegation of potential abuse dated 1/2/24 with NA-N and Residents 24, 18 and 15. The allegations were not substantiated but NA-N was assigned retraining related to abuse, residents with behaviors and residents with dementia. NA-N was to complete the re-training prior to returning to work. -NA-N failed to complete the Abuse training prior to returning to work and providing direct resident cares on 1/13/24. -1/14/24 staff to resident allegation of potential abuse with Resident 9 and NA-N. -1/14/24 NA-N submitted their resignation. -staff to resident abuse allegation dated 5/5/24 with LPN-P and Resident 1. The allegation was not substantiated but the staff member was assigned retraining related to abuse, dementia and resident's rights. LPN- P was to complete these training's prior to returning to work. LPN-P worked on 5/18/24 as a Charge Nurse and failed to complete the required training prior to working.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review; the facility failed to administer medication with an error rate of less than 5 percent (%). This included crushing medications that should not be crushed for residents 20 and 28, giving medications outside of the recommended/schedules times for Residents 1 and 26, and not observing the consumption of the entire dose of a medication for Resident 1. The sample size was 8 and the facility census was 28. Findings are: A. Review of the facility policy Medication Administration with a revision date of 4/1/24 revealed the following: -Medications were administered by licensed nurses or other staff who are legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice, -Medications were administered in accordance with manufacturer specifications including not crushing medications with do not crush orders. B. Review of the facility policy Medication Errors dated 4/1/23 revealed the following: -The facility provided protections for the health, welfare, and rights of each resident by ensuring residents received care and services safely in an environment free of significant medication errors. -A Medication Error meant the observed of identified preparation or administration of medications or biologicals which was not in accordance with the prescribers' orders, manufacturers specifications regarding the preparation and administration of medications or biologicals, or accepted standards and principles which applied to professionals providing services. -The facility ensured a medication error rate of less than 5%. C. Review of Resident 20's Care Plan with a revision date of 1/31/24 revealed the resident had a tube feeding due to nutritional problems and risk for aspiration (when food accidently goes to the lungs during eating/swallowing) and could only have ice chips orally. Staff were to administer medications as order and monitor for effectiveness and potential side effects. Review of Resident 20's Medication Administration Record (MAR) dated May 2024 revealed a scheduled daily medication of Tamsulosin HCL (Medication used to relax muscle and allow urine to flow more easily from the body- this medication should not be crushed or chewed to avoid all of the medication from being absorbed at once causing a potential drop in blood pressure) 0.4mg capsule at bedtime given by Peg-tube (feeding tube). During an observation of Medication Administration on 5/20/23 at 8:31 PM Registered Nurse (RN)-D prepared a dose of Tamsulosin for administration for Resident 20. RN-D opened the capsule of tamsulosin, emptied it into a bag used for crushing medications and crushed the beads of medication, emptied the crushed beads into a medication cup of warm water and administered the medication through Resident 20's feeding tube. D. Review of Resident 28's Care Plan with a revision date of 3/27/24 revealed the resident had a heart disease, atrial fibrillation (irregular heartbeat that increases a resident's chance for having a stroke), potential for nutritional problems, was diabetic, and staff were to administer medications as ordered and monitor for effectiveness and potential side effects. Review of Resident 28's MAR dated May 2024 revealed the resident received Isosorbide Mononitrate ER(Extended Release -medication used to prevent chest pain in patients with certain heart conditions that should be administered whole and should not be crushed as it could release all the drug at once increasing the potential for adverse side effects) daily for treatment of heart failure. During an observation of the provision of medication for Resident 28 on 5/21/24 during the breakfast meal Licensed Practical Nurse (LPN)-E prepared a dose of Isosorbide Mononitrate ER by placing the tablet in a bag used for crushing medication, crushed the pill, mixed it in apple sauce and administered it to Resident 28. E. Review of Resident 1's Care Plan with a revision date of 1/11/24 revealed the resident was confused and forgetful and was not able to make informed decisions. The resident was at risk for nutritional decline and had GERD (gastro-esophageal reflux disease - condition in which food or gastric content can reflux into the esophagus causing heartburn and or esophageal irritation or erosion and should be taken 30 minutes before breakfast on an empty stomach) In addition, staff were to administer the resident's medication and observe for effectiveness. Review of Resident 1's MAR dated May 2024 revealed the resident received Omeprazole (medication used to treat GERD) one tablet daily at 7:30 AM and Wheat Dextrin powder 2 teaspoons dissolved in liquid 3 times daily for fiber supplementation (promotes good bowel health). During an observation of the provision of medications to Resident 1 during the breakfast meal on 5/21/23 LPN-E administered Omeprazole 1 tablet after the resident had consumed 75% of breakfast (should have been given 1/2 hour prior to the meal). In addition, LPN-E then gave the resident Wheat Dextrin 2 tsp mixed in a glass of fluid and walked away not ensuring the resident consumed the entire dose of Wheat Dextrin. F. Review of Resident 26's Care Plan with a revision date of 1/20/24 revealed the resident had physical and cognitive limitations. The resident was at risk for nutritional problems secondary to obesity. Staff were to administer medications as ordered and monitor effectiveness and for side effects. Review of Resident 26's MAR date May 2024 revealed the resident received Pantoprazole 40mg daily for GERD. During an observation of the provision of medication to Resident 26 during the breakfast meal on 5/21/24 LPN-E administered Pantoprazole 1 tablet after the resident had consumed 100% of the meal. Pantoprazole should be given 30-60 minutes before a meal. G. During the observed medication administration, the surveyor observed 26 opportunities of medications administration from 5/20/23 through 5/21/23 with 5 errors, revealing an error rate of 19.23%. H. During an interview on 5/22/24 at 2:00 PM the Director of Nursing (DON) confirmed Omeprazole and or Pantoprazole should be administered 30-60 minutes prior to meals, and Isosorbide Mononitrate ER and Tamsulosin should not be crushed. In addition, the DON confirmed that during medication administration, the nurse is responsible to ensure residents consume the entire dose of a medication under direct supervision.

Licensure Reference Number 175 NAC 12-006.05(21) Based on record review and interviews, the facility failed to treat Resident 1 with dignity and respect when assisting the resident with cares. The sample size was 1 and the facility census was 28. Findings are: A. Review of the facility list of Resident's Rights given to each resident and/or the resident's responsible party at admission, revealed all residents had the right to be treated with respect and dignity. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/27/24 revealed the resident was admitted [DATE] with diagnoses of non-traumatic brain dysfunction, Alzheimer's, dementia, and depression. The resident's cognition was assessed as severely impaired and the resident required partial to moderate assistance with toileting, dressing and personal hygiene. Review of a facility investigation dated 5/6/24 revealed on 5/5/24 at 11:30 AM, Licensed Practical Nurse (LPN)-P documented in Resident 1's Nursing Progress Notes the resident had slapped Nurse Aide (NA)-Y when staff had attempted to assist the resident to get dressed when the resident was incontinent. LPN-P went down to the resident's room and asked the resident how old are you? LPN-P then told the resident they were acting like a 2-year-old who did not want to mind and the resident could get up on their own or LPN-P and NA-Y would help the resident. The resident did not move and so LPN-P and NA-Y got under the resident's arms and assisted the resident into a seated position on the resident's bed. The resident was resistive but then got up from the bed, ambulated into the bathroom with a walker and later went out to the dining room for the breakfast meal. Interview with the Director of Nursing and the Administrator on 5/21/24 at 5:38 PM confirmed Resident 1 was not treated with respect and dignity by LPN-P on 5/5/24.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 11's physician of a weight loss and Resident 24's representative of increased edema, shortness of breath, persistent cough, difficulty ambulating, and new physician orders related to the resident's change in condition. The sample size was 2 and the facility census was 28. Findings are: A. Review of the facility policy Nutrition (Impaired)/Unplanned Weight Loss with a revision date of 9/21, revealed the facility staff were to report to the physician significant weight losses or persistent change from baseline appetite or dietary intakes. B. Review of Resident 11's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/9/24 revealed the following: -severe cognitive impairment and decision-making skills, -diagnoses of dementia, depression, and cancer, -required partial to moderate assistance with eating and drinking, -loss of liquids/solids from mouth when eating, with coughing and choking when eating meals or taking medications, -mechanically altered diet, -weight of 187 lbs. (pounds), and -weight loss of 5 % (percent) or more in 1 month or a loss of 10% or more in the last 6 months and not on a physician prescribed weight loss regimen. Review of the resident's current Care Plan dated 8/22/20 revealed the resident was at risk for a nutritional decline related to diagnoses of dementia and gastroesophageal reflux disease (GERD-a condition in which acidic gastric fluid flows backward into the esophagus). In addition, the resident had a history of a stroke and had difficulty with swallowing and with feeding self. The following interventions were identified: -extensive staff assistance with eating, and -mechanical soft (any food which can be blended, mashed, pureed, or chopped to make food soft and easy to eat) diet with pureed meat and honey-thick (honey or a milkshake consistency) liquids. Review of Resident 11's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature, and pulse) revealed the following regarding the resident's weights: -11/24/23 the resident's weight was 199 lbs. -12/19/23 weight was 196 lbs. (down 3 lbs. in 1 month). -1/30/24 weight was 194 lbs. (down 2 lbs. in 1 month). -2/27/24 weight was 188 lbs. (down 6 lbs. in 1 month). -5/17/24 weight was 177 lbs. (the resident was down 22 lbs. or had a loss of 11% in the last 6 months). C. Review of Resident 24's MDS dated [DATE] revealed the resident had severe cognitive impairment with diagnoses of non-traumatic brain dysfunction, dementia, heart failure, depression, anxiety, and psychotic disorder. Review of Resident 24's current Care Plan with a date of 1/11/24 revealed the resident had a diagnosis of congestive heart failure and was at risk for fluid overload and edema. An intervention was identified to monitor/document/report any signs and symptoms which included edema to the legs and feet, shortness of breath upon exertion, dry cough, weakness and/or fatigue. Review of Nursing Progress Notes for Resident 24 revealed the following: -5/7/24 at 12:12 PM the resident had increased edema and swelling to bilateral lower extremities with increased difficulty walking, -5/8/24 at 3:15 PM the resident was having shortness of breath with walking and a persistent cough with continued increase in swelling to lower extremities. The resident's physician was notified with new orders for laboratory testing and a urinalysis, and -5/10/24 at 1:00 PM new orders received to increase the resident's protein intake with shakes and to update the physician on swelling in 1 week. Review of the resident's electronic medical record revealed no evidence the resident's representative was notified of the residents' change in condition and new physician orders. D. Interview on 5/23/24 at 7:21 AM with the Director of Nursing confirmed the following: -the facility does not have a policy related to notification of change for a physician and/or responsible party, -the DON expected the Charge Nurses to notify the resident's physicians and the resident's representatives within 24 hours of a change of condition which would include a fall, skin tears/bruises/open areas/pressure ulcers, a change in physician orders, incidents of potential abuse/neglect, and of a weight loss or gain, -the facility failed to notify Resident 11's physician of the resident's 22 lb. weight loss from 11/24/23 to 5/17/24, and -the facility failed to notify Resident 24's representative of the resident's increased edema to lower extremities, shortness of breath with exertion, and persistent cough. In addition, the facility failed to notify the representative of new orders from the resident's physician regarding the resident's change in condition.

Licensure Reference Number 175 NAC 12-006.09C3 Based on interview and record review; the facility failed to complete a Discharge Recapitulation Summary for Resident 29. The sample size was 1 and the facility census was 28. Findings are: Review of the facility policy Discharge Summary and Plan with a revision date of October 2022 revealed the following: -When a resident's discharge was anticipated, a discharge summary and post discharge plan was developed to assist the resident with discharge. -The discharge summary included a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary included diagnoses, medical history, course of illness/treatment/therapy, laboratory information, physical/mental functional status, ability to perform activities of daily living, sensory impairments, nutritional status, special treatments and procedures, psychosocial status, discharge potential, activity potential, rehab potential, cognitive status, and medication therapy. -As part of the discharge summary, the nurse reconciled all pre-discharge medications with the resident's post discharge medication and documents. Review of Resident 29's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 4/17/24. Review of Resident 29's Medical Record revealed no evidence the facility had completed a Discharge Summary. During an interview on 5/22/24 at 8:34 AM the Director of Nursing (DON) confirmed the facility had not completed a comprehensive Discharge Recapitulation Summary of Resident 29's stay in the facility.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to identify causal factors and to develop and/or revise interventions to prevent ongoing falls for Resident 24. The sample size was 5 and the facility census was 33. Findings are: A. Review of the facility Fall Prevention Program Policy (undated) revealed each resident was to be 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. At the time of admission, each resident's risk for falls was to be evaluated. If the resident's score was 45 or higher, they were considered high risk for falls. The following procedure was indicated after a resident fall: -assess the resident, -complete an Incident Report, -complete a post-fall assessment and determine causal factors, -notify the physician and family, -develop or revise interventions as needed and monitor for effectiveness, -review the resident's care plan and update as indicated, and -document all assessments actions. B. Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/27/24 revealed diagnoses of osteoarthritis, atrial fibrillation, heart failure, non-Alzheimer's dementia, anxiety, and depression. The following was assessed for Resident 24: -short- and long-term memory loss with impaired decision-making skills, -incontinent of bowel and bladder, -required substantial to moderate staff assistance with transfers, bed mobility, toilet use, dressing and personal hygiene, and -2 falls without injury since the previous assessment. Review of the resident's Morse Fall Scale dated 1/1/24 at 8:50 AM revealed the resident's score was 65 indicating Resident 24 was at high risk for falls. Review of an Incident Report dated 1/19/24 revealed at 10:30 AM, the resident was in the dining room, dropped something on the floor, leaned over to retrieve and fell forward out of the chair. Further review revealed a fall alarm had been in place. A new intervention was developed to place the resident at the Nurse's Station so staff could provide with increased monitoring. Review of an Incident Report dated 2/3/24 at 3:00 PM revealed staff heard the resident's fall alarm sounding and observed the resident fall out of a chair. The report confirmed the resident's fall alarm was in place at the time of the fall and documented there was nothing which could be done to avoid future/further falls. In addition, no causal factors were identified. Review of an Incident Report dated 3/10/24 revealed at 5:25 AM the resident was observed lying on the floor by the resident's wheelchair at the Nurse's Station. Current fall interventions were not revised, and no new interventions were indicated. Staff were to continue to monitor the resident. Review of an Incident Report dated 3/19/24 revealed at 8:35 PM the resident was found lying on the floor near the Nurse's Station. The resident had been very restless and had required 1 on 1 supervision throughout the shift. Further review of the report revealed the resident's fall alarm had not sounded and no staff had been in the area when the resident fell . Staff were to assure the resident was supervised when restless and the fall alarm was functioning to prevent further falls. Review of an Incident Report dated 3/20/24 at 2:25 PM, revealed the staff observed the resident stand up unassisted in the wheelchair, turn and try to sit in another chair and then fall to the floor. Review of the resident's electronic medical record revealed no evidence a new intervention was developed for fall prevention. Review of an Incident Report dated 4/17/24 revealed at 4:20 AM, the resident was found on the floor with a 1.5 centimeter (cm) by .1 cm laceration above the resident's left eye. Review of the post-fall assessment revealed staff failed to respond timely to the resident's fall alarm. Staff were provided education regarding timely fall alarm responses. Review of an Incident Report dated 4/26/24 at 8:00 PM revealed Resident 24 was observed on the floor by the Nurse's Station. The resident had attempted to self-transfer and ambulate without the walker. Current interventions were not revised, and no new interventions were listed. Review of an Incident Report dated 4/28/24 at 7:45 PM revealed the resident's fall alarm was sounding and staff found the resident on the floor next to the resident's wheelchair in the dining room. Staff documented the need for a psychiatric consult and use of gripper socks to prevent further falls for the resident. Review of an Incident Report dated 5/4/24 at 2:50 PM revealed the resident was lowered to the floor when staff were attempting to assist the resident to the bathroom. A new intervention indicated the facility should assure use of 2 staff when ambulating and/or transferring the resident. Review of an Incident Report dated 5/20/24 at 2:10 AM revealed the resident tipped the wheelchair over and fell . The resident's fall alarm did not sound when the resident fell . Staff were again educated to make sure the resident's fall alarm was functioning. No further interventions were identified. Interview with the Director of Nursing (DON) on 5/21/24 at 5:43 PM confirmed the resident was at high risk and had a history of multiple falls. Due to the resident's restlessness (scooting up and down in the chair) the fall alarm was rendered dysfunctional at times, but the alarm had been instrumental in preventing falls so the facility continued use to maintain the resident's safety. The DON verified the following: -staff were to develop a new intervention or were to revise current interventions with each resident fall to prevent further falls and potential injuries. -with the resident's falls on 2/3/24, 3/10/24, 3/20/24 and 4/26/24 staff failed to determine causal factors, to develop new interventions or to revise current interventions. -5/20/24 the resident's fall alarm was not working, and staff received re-educated again to assure the alarm was functional. No interventions were put into place to guarantee the alarm continued to function.