Every finding on record at Saunders Medical Center

Licensure Reference Number 175 12-007.04 (D) The facility failed to ensure resident bathroom ventilation was functional in eight resident rooms (rooms 102, 105, 107, 114, 119, 121, 204, and 206 ) out of eight resident rooms sampled. The facility census was 53 at the time of the survey. Findings are: An observation on 4.13.2026 during the initial screening at 8:00 AM, the resident bathroom ventilation was not functioning in rooms 102, 105, 107, 114, 119, 121, 204, and 206 when checked with a one-ply tissue. An observation on 4.14.2026 at 8:10 AM, the resident bathroom ventilation was not functioning in rooms 102, 105, 107, 114, 119, 121, 204, and 206 when checked with a one-ply tissue. During the environmental tour on 4.14.2026 at 10:55 AM with the Facilities Manager (FM), the resident bathroom ventilation was not functioning in rooms 102, 105, 107, 114, 119, 121, 204, and 206 when checked with a one-ply tissue. In an interview on 4.14.2026 at 10:55 AM with the FM, it was confirmed the resident bathroom ventilation was not functioning in rooms 102, 105, 107, 114, 119, 121, 204, and 206 when checked with a one-ply tissue. In an interview on 4.14.2026 at 12:00 PM with the FM, it was confirmed the facility does not have a policy to check the resident bathroom ventilation for functionality or a preventative maintenance program for the Heating, Ventilation, and Air Conditioning (HVAC) system. In a record review of the facility's HVAC Service Checklist dated 2026 revealed the filters are checked with no mention of the resident bathroom ventilation system checks. In an interview on 4.14.2026 at 2:20 PM with the Director of Nursing (DON), it was confirmed the facility does not have an HVAC policy or preventative maintenance program.

License Reference Number 175 NAC 12.006.09(B)(iii)Based on record review and interviews, the facility failed to accurately code a Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected that antipsychotic (medication used to manage psychosis including hallucinations, delusions and agitation) was being given. This affected 1 (Resident 41) out of the five sampled residents. The facility census was 53 at the time of survey.Findings are:Record review of Resident 41's Quarterly MDS dated [DATE] revealed the following:-resident was admitted on [DATE]-Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scores from 0-15, the higher the score, the higher the cognitive function) score of 6 which indicated severe cognitive impairment-resident had delusions-no behaviors were indicated.-Antipsychotic medication use was not indicated in section N.Record review of Resident 41's admission physician visit dated 9/30/25 revealed a diagnosis of Dementia with psychosis.Record review of Resident 41's Comprehensive Care plan date initiated 10/15/2025 revealed the following:-Psychotropic Medication use-AIMS (Abnormal Involuntary Movement Scale) testing to be completed quarterly and as needed.-Behavior committee to review quarterly and as needed.-Pharmacy review every month and as needed.-Medications to be given as ordered.Record review of Resident 41's physician order revealed an order for Risperdone (antipsychotic medication) to be given every evening was dated 9/30/2025.Record review of Resident 41's Informed Consent for Antipsychotic medication was dated 10/10/2025.During an interview on 04/14/2026 at 10:52 AM Registered Nurse (RN) - A, the MDS nurse, confirmed the following:-MDS was coded wrong and that the antipsychotic medication was coded as an antianxiety because it was used for anxiety. -the RAI manual is used to ensure MDS accuracy. -no one audits the MDS's or care plans for accuracy.During an interview on 04/14/2026 11:08 AM RN - B, the Education Coordinator, confirmed that nursing is supposed to complete the AIMS assessment for those residents taking an antipsychotic medication. During an interview on 04/14/2026 11:10 AM RN - C, the Quality Control nurse, confirmed that the behavior committee did not notice the AIMS was not completed for Resident 41 and should have. Review of the Behavior Committee notes dated 1/7/26 and 3/26/26 revealed that risperidone was used by the resident. Target behaviors and nonpharmacological interventions identified. Recommendations did not include to complete an AIMS assessment. Review of Drug Regimen Reviews dated 10/23/25, 11/18/25, 12/11/25, 1/27/26, 2/18/26, and 3/17/26 did not reveal a recommendation to complete an AIMS assessment for the use of an antipsychotic medication. Review of pharmacy communication dated 3/26/26 revealed the resident was on an antipsychotic medication and was having hallucinations and delusions.During an interview on 04/14/2026 11:43 AM the Pharmacist confirmed that (gender) does not look for the AIMS assessments because nursing has always done that. Review of the facility policy titled Psychotropic Drug Use last reviewed 10/2025 revealed the following:- residents on antipsychotic medications will have an AIMS assessment completed quarterly- the Behavior Committee will evaluate changes in the residents function - Medication Management Review will be performed monthly and will include medication monitoring During an interview on 04/15/2026 at 9:40 AM Director of Nursing (DON) confirmed the following:-no job duty list, policy or expectations for the behavior committee.-there was not an AIMS assessment completed for Resident 41 and there should have been one because the resident is on an antipsychotic medication- it was coded wrong on the MDS.

License Reference number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to store Resident 29's nasal canula and oxygen tubing in a bag that would prevent cross contamination. This had the potential to effect 1 of 1 residents. The identified a census of 56. Findings are: An observation on 10/15/24 10:46 AM, revealed Resident 29's Oxygen tubing was laying across the top of the oxygen concentrator. Resident 29's nasal canula and oxygen tubing were found lying on the floor behind concentrator. Resident 29's nasal canula and oxygen tubing was not placed into the bag attached to the back of the concentrator. Resident 29 is sleeping in her recliner chair at this time. An observation on 10/16/24 at 9:26 AM, Resident 29's Oxygen tubing was laying across the concentrator, the nasal canula laying on the floor behind the concentrator. The nasal canula was not covered or placed into the bag that was attached to the back of the concentrator. The Oxygen tubing revealed a piece of tape placed onto the tubing, with a noted date 10/14/24 wrote on it. Resident is laying in her recliner chair with her call light across her lap. Resident is had their eyes closed. An interview on 10/16/24 at 9:29 AM with Resident 29, revealed they did not self-remove the nasal cannula independently. An interview on 10/16/24 at 10:19 AM with Medication Aide- A (MA-A) confirmed the nasal canula and the oxygen tubing was not placed into the attached bag on the back of the oxygen concentrator. MA-A confirmed the nasal canula and the oxygen tubing was laying on the floor. MA-A confirmed the nasal canula and the oxygen tubing should be placed into the protective bag that is attached to the back of the nasal canula. An interview on at on 10/16/24 at 1025 AM with the Director of nursing (DON) confirmed the nasal cannula and oxygen tubing was laying on the floor behind the concentrator. The DON confirmed the nasal cannula, and the oxygen tubing should be placed into the bag that is attached to the back of the concentrator when it is not in use by the resident.

Based on record review and interview, the facility failed to provide a written notice of bed hold upon transfer to the hospital for 1 (Resident 25) of 1 sampled resident. The facility census was 55. Findings are: Record review of the Bed Hold policy dated 11/2022 stated, 1. in the event a resident requires hospitalization , the Bed Hold Consent will be completed. 7. Upon transfer to another facility, the resident/responsible party will be informed of bed hold policy by nursing staff. This information may be given in person or per telephone conversation, two facility staff will witness the conversation and sign the Bed Hold Consent form. A copy of the Bed Hold Consent will be given to the family. Record review of Resident 25's Registration form last updated 7/7/2023, revealed that the resident admitted to the facility on [DATE] with diagnoses of: dementia (condition of progressive loss of intellectual functioning, with impairment of memory), osteoporosis (bones become fragile and brittle), decreased appetite, gastroesophageal reflux, (stomach acid irritates stomach lining), nausea, chronic pain, and chronic kidney disease. Record review of Resident 25's Progress Note dated 5/21/2023 revealed that Resident 25 had been transferred to the hospital with complaints of pain with an x-ray that revealed a left hip fracture following a fall during the night. Resident 25 returned to the facility on [DATE]. Record review of Resident 25's Electronic and Paper Health Record revealed no documentation that a written Bed Hold Consent was provided to the resident and/or resident representative upon transfer to the hospital on 5/21/2023. Interview on 11/1/2023 at 1:30 PM with Licensed Practice Nurse (LPN)-C revealed [gender] was unaware if nurses completed the Bed Hold Consents. LPN-C revealed [gender] believed Administration completed the Bed Hold Consents. Interview on 11/1/2023 at 1:45 PM with the Director of Nursing (DON) revealed no documentation was found regarding a Bed Hold Consent for Resident 25 prior to transfer to the hospital on 5/21/2023. The DON revealed nurses are responsible to complete the Bed Hold Consent and it should have been completed for Resident 25. Interview on 11/2/2023 at 9:15 AM with Registered Nurse (RN)-A revealed that if a Bed Hold Consent was completed it would be in the resident's electronic medical record. RN-A revealed the nurses complete the Bed Hold Consent.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to follow the provider's orders for medication paratmeters prior to medication administration for 2 (Resident 24 and 14) of 5 sampled residents. The facility census was 55. Findings are: Record review of the facility's Administering Medications policy dated 11/2016 revealed under Procedures 11. the following information must be checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary. 14. if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document an explanation by adding a comment to the administration note and progress note. A. Review of Resident 24's current clinical diagnoses, dated 11/1/23, revealed the following diagnoses: edema (swelling), essential (primary) hypertension (elevated blood pressure readings), and hypertensive heart disease with heart failure. Review of Resident 24's current physician orders dated 11/2/23 revealed the following medications with parameters: -Furosemide (Lasix) 40mg daily, hold if systolic blood pressure (SBP-top number in a blood pressure reading) is less than (<) or equal to (=) 110 -Losartan 100mg daily, hold if SBP </= 110 -Metoprolol tartrate 100mg twice daily (BID), hold if SBP </=100 and/or heart rate (HR) <60. Review of Resident 24's August thru October 2023 Medication Administration Record (MAR) revealed a box for staff to document the blood pressure and/or heart rate obtained with each ordered administration of Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's August thru October 2023 MAR revealed that Resident 24 was administered the Furosemide and Losartan 14 times with no blood pressure obtained and the Metoprolol tartrate 32 times with no blood pressure and heart rate obtained and 10 times with no heart rate obtained. Further review revealed that Resident 24 was administered the Losartan on 9/14/23 with a SBP of 99 and that the Metoprolol tartrate was administered 6 times when Resident 24's HR was <60. Review of Resident 24's EHR and paper chart revealed no other documentation of blood pressures or heart rates obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's Cardiovascular IPOC revealed the following intervention: -Vital signs per order and update the MD as needed Interview on 11/2/23 at 12:55 PM, Licensed Practical Nurse (LPN)-B revealed that it was the expectation for staff to obtain a blood pressure and/or heart rate and document the readings prior to administration of a medication with parameter and that if the blood pressure and/or heart rate was less than the parameter the medication is not to be administered. Interview on 11/2/23 at 1:49 PM, the Director of Nursing (DON) confirmed that there was no documentation that a blood pressure and/or heart rate had been obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate for Resident 24. The DON revealed Resident 24 was administered the Losartan and Metoprolol tartrate outside of the ordered parameters. B. Record review of Resident 14's Registration form last updated on 7/7/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses of: atherosclerotic heart disease (CAD) (damage or disease in the hearts blood vessels due to buildup of plaque), unspecified combined systolic and diastolic congestive heart failure (the heart is not strong enough to pump blood properly), and atrial fibrillation (an irregular and very rapid heart rhythm). Record Review of Resident 14's MAR dated October 2023 revealed an order for Metoprolol 100 mg orally daily for CAD with parameters to hold medication if pulse less than 60 or systolic blood pressure less than 120. Record review of Resident 14's Care Plan initiated on 2/10/2023 revealed an intervention of vital signs per order and update the MD (medical doctor) as needed under the Cardiovascular plan of care. Record review of the MAR dated October 2023 revealed metoprolol was given 5 times without a pulse or blood pressure taken. Record review of the MAR dated October 2023 revealed metoprolol was given 1 time without a pulse taken. Record review of the MAR dated October 2023 revealed metoprolol was held 13 times due to a low blood pressure and/or pulse, without notification to the physician. The MAR revealed 8 out of the 13 times the medication was held was conseutive days in a row. Interview on 11/1/2023 at 1:05 PM with Medication Aide (MA)-A revealed MA-A would follow provider orders related to parameters. MA-A revealed if the blood pressure was outside of the ordered parameters they would inform a nurse. MA-A revealed it was an issue if vital signs were not taken prior to giving metoprolol. Interview on 11/1/12023 at 1:00 PM with LPN-D revealed they would expect vital signs to be taken to evaluate the ordered parameters and then either administer the medication or hold it. LPN-D revealed that if the medication is held 2 or more days they would notify the provider. LPN-D revealed it was an issue if vitals were not taken prior to administering a blood pressure medication. Interview on 11/1/2023 at 3:20 PM with DON regarding expectations of medication administration with parameters for a blood pressure medication revealed DON expects the nurse or medication aide to take vital signs prior to giving the medication and then if the medication is held, a reason for holding needs documented and the nurse notified. DON confirmed it is a problem if medication is given without a set of vital signs and physician should have been notified with the metoprolol being held 13 times the month of October for Resident 14. 47312 Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to follow the provider's orders for medication parameters prior to medication administration for 2 (Resident 24 and 14) of 5 sampled residents. The facility census was 55. Findings are: Record review of the facility's Administering Medications policy dated 11/2016 revealed under Procedures 11. the following information must be checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary. 14. if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document an explanation by adding a comment to the administration note and progress note. A. Review of Resident 24's current clinical diagnoses, dated 11/1/23, revealed the following diagnoses: edema (swelling), essential (primary) hypertension (elevated blood pressure readings), and hypertensive heart disease with heart failure. Review of Resident 24's current physician orders dated 11/2/23 revealed the following medications with parameters: -Furosemide (Lasix) 40mg daily, hold if systolic blood pressure (SBP-top number in a blood pressure reading) is less than (<) or equal to (=) 110 -Losartan 100mg daily, hold if SBP </= 110 -Metoprolol tartrate 100mg twice daily (BID), hold if SBP </=100 and/or heart rate (HR) <60. Review of Resident 24's August thru October 2023 Medication Administration Record (MAR) revealed a box for staff to document the blood pressure and/or heart rate obtained with each ordered administration of Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's August thru October 2023 MAR revealed that Resident 24 was administered the Furosemide and Losartan 14 times with no blood pressure obtained and the Metoprolol tartrate 32 times with no blood pressure and heart rate obtained and 10 times with no heart rate obtained. Further review revealed that Resident 24 was administered the Losartan on 9/14/23 with a SBP of 99 and that the Metoprolol tartrate was administered 6 times when Resident 24's HR was <60. Review of Resident 24's EHR and paper chart revealed no other documentation of blood pressures or heart rates obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's Cardiovascular IPOC revealed the following intervention: -Vital signs per order and update the MD as needed Interview on 11/2/23 at 12:55 PM, Licensed Practical Nurse (LPN)-B revealed that it was the expectation for staff to obtain a blood pressure and/or heart rate and document the readings prior to administration of a medication with parameter and that if the blood pressure and/or heart rate was less than the parameter the medication is not to be administered. Interview on 11/2/23 at 1:49 PM, the Director of Nursing (DON) confirmed that there was no documentation that a blood pressure and/or heart rate had been obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate for Resident 24. The DON revealed Resident 24 was administered the Losartan and Metoprolol tartrate outside of the ordered parameters. Surveyor: [NAME], [NAME] B. Record review of Resident 14's Registration form last updated on 7/7/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses of: arteriosclerotic heart disease (CAD) (damage or disease in the hearts blood vessels due to buildup of plaque), unspecified combined systolic and diastolic congestive heart failure (the heart is not strong enough to pump blood properly), and atrial fibrillation (an irregular and very rapid heart rhythm). Record Review of Resident 14's MAR dated October 2023 revealed an order for Metoprolol 100 mg orally daily for CAD with parameters to hold medication if pulse less than 60 or systolic blood pressure less than 120. Record review of Resident 14's Care Plan initiated on 2/10/2023 revealed an intervention of vital signs per order and update the MD (medical doctor) as needed under the Cardiovascular plan of care. Record review of the MAR dated October 2023 revealed Metoprolol was given 5 times without a pulse or blood pressure taken. Record review of the MAR dated October 2023 revealed Metoprolol was given 1 time without a pulse taken. Record review of the MAR dated October 2023 revealed Metoprolol was held 13 times due to a low blood pressure and/or pulse, without notification to the physician. The MAR revealed 8 out of the 13 times the medication was held was consecutive days in a row. Interview on 11/1/2023 at 1:05 PM with Medication Aide (MA)-A revealed MA-A would follow provider orders related to parameters. MA-A revealed if the blood pressure was outside of the ordered parameters they would inform a nurse. MA-A revealed it was an issue if vital signs were not taken prior to giving Metoprolol. Interview on 11/1/12023 at 1:00 PM with LPN-D revealed they would expect vital signs to be taken to evaluate the ordered parameters and then either administer the medication or hold it. LPN-D revealed that if the medication is held 2 or more days they would notify the provider. LPN-D revealed it was an issue if vitals were not taken prior to administering a blood pressure medication. Interview on 11/1/2023 at 3:20 PM with DON regarding expectations of medication administration with parameters for a blood pressure medication revealed DON expects the nurse or medication aide to take vital signs prior to giving the medication and then if the medication is held, a reason for holding needs documented and the nurse notified. DON confirmed it is a problem if medication is given without a set of vital signs and physician should have been notified with the Metoprolol being held 13 times the month of October for Resident 14.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the resident's representative of a significant weight loss for Resident 9. The sample size was 1. The facility census was 57. FINDINGS ARE: A record review of the facility policy titled Weight Status and dated 05/2001, revealed the following; -Parameters for evaluating significance of unplanned and undesired weight loss are: -1 month/5% = significant loss, greater than 5% = severe loss -3 month/7% = significant loss, greater than 7.5% = severe loss -6 month/10% = significant loss, greater than 10% = severe loss A record review of weights recorded for Resident 9 revealed that on 08/29/2022, Resident 9 weighed 100.5 lbs. and on 09/29/2022, Resident 9 weighed 93.7 pounds which is a -6.77% Loss in one month. A record review of weights recorded for Resident 9 revealed that on 03/28/2022, Resident 9 weighed 101.2 lbs. and on 09/29/2022, Resident 9 weighed 93.7 pounds which is a -7.41 % Loss in 6 months. A record review of the facility policy titled Notification of Changes and dated 06/2021, revealed the following: Circumstances requiring notification include: B. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. 1. Life-threatening conditions, or 2. Clinical Complications A record review of the weight loss notification to Resident 9's representative revealed the resident representative had been notified on 10/5/22 at 11:37 AM which was after the request to review the documentation. An interview on 10/05/22 at 01:45 PM with the DON (Director of Nursing), after review of the significant weight loss notification to Resident 9's Representative documented on 10/5/22 at 11:37 AM, confirmed that the notification had not occurred until the information had been requested during the onsite survey.

Licensure Reference Number 174 NAC 12-006.09B Based on record review and interview, the facility failed to code the MDS (Minimum Data Set -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) to reflect wounds for 1 resident (Resident 51) out of 4 sampled residents. The facility identified with a census of 57 at the time of survey. Findings are: A record review of Resident 51's wound care notes dated 9/25/22 through 10/5/22 revealed a Stage 4 (skin tissue with extensive damage to muscle, bone or supporting structure such as a tendon or joint capsule) pressure ulcer to right lateral foot. An interview on 10/06/22 11:08 AM with Wound Care nurse RN-C (Registered Nurse) confirmed that Resident 51's wound was a Stage 4 pressure wound to the resident's right leg and had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 51's Wound History and Physical from Methodist Health System dated [DATE] stated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 51's Body Check Form completed with baths and signed by a nursing assistant and a nurse dated 9/2/22, 9/13/22, 9/16/22, and 9/20/22 revealed in question #6 Any open ulcers, all were answered no. A record review of Resident 51's MDS, dated [DATE] revealed in question M0210 Does the resident have one or more unhealed pressure ulcers/injuries was answered no. A record review revealed the Facility wound policy, Management of Pressure UIcers dated last revised 1/2021, stated #1. Document in nurses notes. # 2. Only a physician can stage a wound. #3. Notify Director of Nurses (DON). #4. weekly assessments to include measurements. #8. Update careplan. An interview on 10/06/22 01:02 PM with RN-B MDS nurse confirmed the pressure wound was not on the MDS or the careplan and there was not a significant change MDS done and there should have been. An interview on 10/06/22 02:06 PM with DON revealed the DON was not aware of the pressure wound diagnosis.

Based on interview and record review, the facility failed to ensure behavior monitoring was completed to support the use of [CONDITION(S)] medication for Resident 9. The sample size was 1. The facility identified a census of 57. FINDINGS ARE: A record review of the All Active Orders list with a print date of 10/6/22 revealed Resident 9 was taking [MEDICATION(S)] (an antipsychotic medication used to treat certain mental/mood conditions) 6.25mg in the AM and 37.5 mg every evening. A record review of the document titled Corp-Resident Behavior Chart Detail Report (w/impact) dated 4/8/22 through 10/5/22 and documented by the NA's (Nurse Aides) revealed the following negative behaviors had occurred for Resident 9; verbal behavior on 5 occasions, Physical Behavior on 21 occasions, Socially Inappropriate on 1 occasion, Rejects Care on 6 occasions. A record review of the facility policy titled Behavioral Health Services and dated 11/2020, revealed the following: The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The process includes: 4. ongoing monitoring of mood and behavior An Adverse Behavior is defined as but not limited to: verbally aggressive behavior directed at another resident, such as screaming, cursing, insulting, physically aggressive behavior toward another resident such as aggressive behaviors toward another resident. An interview on 10/05/22 at 03:37 PM with the DON (Director of Nursing) confirmed that the facility expectation and process is that if a negative behavior occurs, the NA should document it in the EMR (Electronic Medical Record) for NA charting and report behaviors to the nurse in charge, the nurse in charge is then expected to document behaviors and non-pharmacological interventions in the Progress Notes, and confirmed that documentation for NA's and Nurses should match regarding behaviors. During the interview on 10/05/22 at 03:37 PM with the DON, after review of the Corp-Resident Behavior Chart Detail Report (w/impact) dated 4/8/22 through 10/5/22 for Resident 9 and the Nursing Progress Notes, confirmed the two did not match.

Based on record reviews and interviews, the facility failed to ensure measures in place were followed to prevent the potential spread of Covid-19 (a mild to severe respiratory illness that is contagious and caused by a coronavirus) related to staff screening logs not being completed as outlined on the screening log and unvaccinated staff not meeting the requirement of testing twice weekly. FINDINGS ARE: An interview with the facility Administrator on 6/14/22 at 08:10 AM revealed the facility had no current positive Covid-19 cases amongst staff or residents. The interview revealed no Covid-19 positive cases in the last 4 weeks. A record review of the staff Covid-19 screening logs dated 4/13/22 through 6/14/22 revealed that the questions related to Covid-19 signs and symptoms had been left unanswered on 7 occasions. A record review of timecards revealed those staff that had not completed the screening by answering the questions related to signs and symptoms of Covid-19 had worked on those corresponding days. An interview with the DON (Director of Nursing) on 6/14/22 at 08:54 AM, after reviewing the staff Covid-19 screening logs dated 4/13/22 through 6/14/22, confirmed that all screenings should be answered completely and were not. An interview on 6/14/22 at 10:26 AM with MA (Medication Aide)-D revealed (gender) had received the Covid-19 vaccine but had not received the booster vaccine yet. The interview confirmed that MA-D had received education prior to receiving the Covid-19 vaccine. During the interview with MA-D it was confirmed that all staff completed their own screening logs with oversight from another staff member prior to beginning work. An interview on 6/14/22 at 10:29 AM with NA (Nursing Assistant)-E revealed (gender) had received the Covid-19 vaccine but had not received the booster vaccine yet. The interview confirmed that NA-E had received education prior to receiving the Covid-19 vaccine. An interview on 6/14/22 at 10:30 AM with WC (Ward Clerk)-F revealed (gender) had received the Covid-19 vaccine but had not received the booster vaccine yet. The interview confirmed that WC-F had received education prior to receiving the Covid-19 vaccine. An interview on 6/14/22 at 10:35 AM with M (Maintenance)-G revealed (gender) had received the Covid-19 vaccine and one booster vaccine. The interview confirmed that M-G had received education prior to receiving the Covid-19 vaccine. During the interview, M-G confirmed awareness that vaccinated staff required no routine testing for Covid-19. An interview on 6/14/22 at 10:40 AM with MA-H revealed (gender) had received the Covid-19 vaccine. The interview confirmed that MA-H had received education prior to receiving the Covid-19 vaccine. During the interview, MA-H confirmed awareness that vaccinated staff required no routine testing for Covid-19. A record review of the County Transmission Rates (COVID-19 Community Levels are a new tool to help communities decide what prevention steps to take based on the latest data. Levels can be low/green, medium/yellow, or high/red.) for the facility revealed the community to be in a High level of Covid-19 within the county which required un-vaccinated staff to be tested for Covid-19 twice weekly currently. A record review of 3 unvaccinated staff members revealed the following Covid-19 test dates which did not meet testing requirements of a high level/red county of twice weekly: MA-J tested on [DATE], 5/29/22, 5/24/22, 5/18/22, and 4/28/22 RN-K tested on [DATE], 6/7/22, 6/3/22, 5/24/22, 5/19/22, and 4/28/22 AA-L tested on [DATE], 6/3/22, 5/25/22, 5/18/22, and 4/28/22 An interview on 6/14/22 at 12:32 PM with IP-A revealed that at times twice weekly testing for Covid-19 was not completed due to staff members being off that day and confirmed that staff were not required to test prior to their next shift. An interview with the facility Administrator on 6/14/22 at 02:10 PM confirmed that the facility had stopped twice weekly testing of unvaccinated staff since the vaccination mandate for Health Care Professionals had gone into effect in February 2022. An interview with IP-A on 6/14/22 at 02:12 PM confirmed that the last resident positive for Covid-19 was September of 2021 and has had no Covid-19 outbreak since that time.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to ensure food was stored in a manner to prevent the potential for food borne illness related to food being undated and vegetables being wilted and brown in color in the walk-in cooler and walk-in freezer. This had the potential to affect all residents. The facility census was 50. FINDINGS ARE: An observation on 6/14/22 at 10:14 AM of the kitchen walk-in cooler/refrigerator and walk-in freezer revealed produce of lettuce, onions and a head of cauliflower which were in plastic bags, wilted and browning in color and not dated, a container of cherries which had been opened but not dated, and a box of frozen hamburgers in an opened bag which was not resealable and had no opened date. During the observation of the kitchen walk-in cooler and walk-in freezer/refrigerator, when accompanied by the DS (Dietary Supervisor)-C, interview confirmed that the produce in the walk-in freezer should have been removed prior to today since the produce was wilted and brown in color, confirmed that all items should have been dated when opened and some items were not dated. The interview with DS-C also confirmed that foods that were in a plastic bag and non-resealable should have been placed in a sealable container. A record review of the task assignment sheets for the dietary staff with a date of 6/1 at the top revealed that the AM Cook was responsible to check the walk-in cooler/refrigerator weekly on Sundays. The observation revealed this task had been completed on 6/1/22 (a Wednesday) but not been signed since 6/1/22.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to identify a change in condition and complete an assessment for a resident that had an air hunger episode that required hospitalization for 1 resident (Resident 18). The facility census was 48. Findings are: An interview on 06/07/21 at 04:36 PM with the Resident's representative reported Resident 18 had been admitted to the hospital and the hospital had removed 8 pounds of fluid. The reporter relayed the staff had been informed multiple times of the concern for Resident 18, related to a change in the resident's condition. The reporter revealed LPN-C (Licensed Practical Nurse) had reported the breathing problem was related to Resident 18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 06/09/21 at 11:08 AM with the Dietician related to the weight gain for Resident 18 revealed Resident 18 had a significant increase in weight. The resident takes meals sporadically- sometimes eats better than others. Resident 18 had taken a supplement well for a period of time. Record review of Resident 18's weights revealed the following weights: -On 3/20/21 was 84 pounds -On 3/24/21 was 85 pounds -On 3/27/21 was 88 pounds -On 3/31/21 was 90 pounds -On 4/3/21 was 89 pounds -On 4/7/21 was 91 pounds -On 4/17/21 was 101 pounds -10 pound weight gain in 10 days, -On 4/21/21 was 104 pounds, -On 4/24/21 was 104 pounds, -On 4/28/21 was 104 pounds, -On 5/1/21 was 104 pounds, -On 5/5/21 was 103 pounds, -On 5/11/21 was 94 pounds. Decreased 9 pounds Daily weights were started -On 5/11/21 was 94, -On 5/12/21 was 94, -On 5/12/21 was 93, -On 5/13/21 was 92, -On 5/14/21 was 94, -On 5/15/21 was 90, -On 5/15/21 was 90, -On 5/16/21 was 92, -On 5/17/21 was 88. Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Departmental Notes for Resident 18 on the following dates revealed; -4/16/21 Resident 18 had remained in bed for the shift, no meals were taken. Resident was nonverbal to staff but was observed talking to self when in bed. Resident 18 would not awaken for staff in the evening or for meals. Resident 18 had small urine output, fluids offered. -4/19/21 Resident 18 was seen by PA (Physician Assistant) New orders: CT (Computerized tomography scan used to create cross sectional images of the bones, vessels and soft tissues) abdomen, CT head, [MEDICATION(S)] 25mg PO every day, Volteran Gel TID (Three Times a Day) to hands. Podiatry appointment next available date. Labs CBC (Complete Blood Count), CMP (Complete Metabolic Profile) Amylase, Lipase. -4/21/21 Dietary note revealed; Resident 18 had 20 pounds weight gain in 30 days, 11 pounds in 90 days and 4 pounds in 180 days which is a significant change at 30 and 90 days. Diet order is regular, regular texture, thin liquids with meal intakes sporadic, nursing reports meal/snack intake have really increased recently. Resident did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 18 preferred chocolate. Resident 18 makes own food choices. Medications were reviewed. Resident 18 had severe malnutrition diagnosis. Registered dietician to update the physician on weight changes. No new recommendations at this time. Registered dietician will follow weight intakes and notify Provider with any changes or concerns. -4/22/21 received a fax related to resident weight gain. No new orders at this time. -4/22/21 Received orders from PA to discontinue [MEDICATION(S)] due to medication interactions. Start [MEDICATION(S)] 50 mg TID PRN (As needed) headache. -4/26/21 new orders regarding labs. Start Iron 325mg PO (by mouth) BID (twice a day). Start [MEDICATION(S)] sodium 100 mg (milligrams) BID. Recheck iron panel and CBC in 2 weeks. CT approval still pending. Record review of Departmental Notes for Resident 18 on 5/3/21 revealed the resident was wheezing this evening with exhalation, oxygen saturations 93 to 96 percent on RA (Room Air), Respirations are 22-24, shallow. Lungs clear to auscultation. Gulping for air with speech, has difficulty with deep breathing exercises and or shallow techniques (chin tuck). Noted to be gulping water when using straw and taking medications. Increased anxiety noted during medication administration and swallowing of medications. Resident calmed with about 10 minutes of nursing reassurance and education. Record review of Departmental Notes for Follow up documentation/assessments after air hunger episode dated 5/3/21 revealed; the facility was unable to provide assessments/documentation dated 5/3/21 and 5/4/21. Record review of Departmental Notes for Resident 18 on 5/5/21 revealed, received results of CBC with diff drawn this morning previously faxed to provider from unit clerk for physician review. WBC (White Blood Cell Count- Indicates infection if elevated) elevated at 12.86, RBC (Red Blood Cell) low at 2.88, HGb (Hemoglobin) low at 29.7, Platelet count elevated at 402, awaiting physician review. Record review of fax sent to provider dated 5/5/21 revealed CBC without differential results: Response from provider dated 5/6/21 revealed was waiting for CT - What was iron dose- staff response was 325mg BID. Record review of Departmental Notes for Resident 18 on 5/6/21 revealed. Received fax from iron panel awaiting PCP (Primary Care Provider) orders. Record review of Departmental Notes for Resident 18 on 5/7/21 revealed, received new orders after CT 1) Chest x-ray, 2) Increase in [MEDICATION(S)] to 40 mg daily, 3) [MEDICATION(S)] 500 mg BID x 10 days Pneumonia. PA (Physician Assistant) will see at LTC (Long Term Care) on Monday 5/10/21. Record review of Radiology report for Resident 18 dated 5/7/21 revealed; Small right greater than left pleural effusions with bibasilar opacities compatible with compressive atelectasis. Impression: 1. Evidence of Fluid overload with small bilateral pleural effusions. 2. Upper- mid lung interstitial and alveolar opacities may represent interstitial/alveolar pulmonary [CONDITION(S)]. Super imposed pneumonia is possible. Record review of Departmental Notes for Resident 18 on 5/8/21 revealed, at 0300 the nurse was called to Resident 18's room. Upon entry the nurse noted the bed was below 30 degree angle. Resident 18 was experiencing shortness of breath, and gurgling with every breath. The HOB (Head of Bed) was raised up and oxygen saturation was taken and between 68-70%, heart rate was 98-101. Resident 18 had attempted to speak to the nurse but the resident was not able to form words due to SOB (Shortness of Breath). The nurse pivot transferred Resident18 to the w/c (wheel Chair) and transported Resident 18 to the ER (emergency room ). The on call nurse and DON (Director of Nurses) were notified. The Staff attempted to call the POA (Power of Attorney) at 12:53 AM, 12:55 AM, and 12:56 AM the phone calls were unanswered and unable to leave a message related to the messages were full. ER was informed the staff were unable to contact the POA. At 4:05 AM the ER nurse returned the resident w/c and informed staff the resident would be transferred to Hospital in Lincoln. Bed hold policy was yet to be filled out awaiting POA to sign. Record review of a fax sent by Provider dated 5/7/21 with orders for 1) chest x-ray today, 2. Increase [MEDICATION(S)] to 40 mg daily for CHF, 3. [MEDICATION(S)] 500mg BID x 10 days for PNA (Pneumonia), Provider will see Resident 18 at LTC. Record review of Saunders Medical Center fax dated 5/8/21 revealed Resident 18 had experienced shortness of breath, wheezing, sweats, non-productive cough, 02 saturations 68-70 % heart rate 98-101 Resident transferred to ER- Provider response was ok. Record review of a Dietary Note dated on 5/12/21 for Resident 18 revealed; Resident 18 had been up to 104 pounds in the past month and the resident had been sent out to be diuresed. Resident 18 was now back down to previous weight. Physician updated on weight changes. Record review of Family Care Clinic Visit dated 5/24/21 revealed Resident had Diastolic CHF, continue [MEDICATION(S)] 40mg daily. Low sodium diet, IBS (Irritable Bowel Syndrome)-C continue current management for that increased fiber to BID [MEDICATION(S)] 625mg 1 PO BID. PNA resolved will check chest x-ray. A Record review of Resident 18's Hospital Document dated 5/8/21 revealed; Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Acute [CONDITION(S)] in the lungs Acute/chronic diastolic CHF (Congestive Heart Failure) AKI (Acute Kidney Injury) [CONDITION(S)] CKD (Chronic Kidney Disease) History of Dementia History of [CONDITION(S)] disease Hypertension. EF (Ejection Fraction- am measurement of the percentage of blood leaving the heart each time it squeezes) 50-55%- grade 1 mild left ventricular dysfunction (the inability of the ventricle to fill to a normal end diastolic volume, both during exercise and rest) Mitral valve shows mild regurgitation There was moderate aortic valve stenosis (hardening of the aortic valve). Severe pulmonary hypertension present' Moderate regurgitation is present in the aortic valve. Cardiac Attestation Statement: Resident 18 was seen and evaluated. Resident 18 was admitted with acute on chronic diastolic heart failure, agree with diuresis and follow renal function. Acute on chronic diastolic heart failure Acute hypoxemia respiratory failure - on room air baseline Acute pulmonary [CONDITION(S)] (Lung [CONDITION(S)]) AKI/CKD3 (Acute Kidney Injury/Chronic Kidney Injury stage 3) [CONDITION(S)] History of [CONDITION(S)] History of mild dementia Plan: Resident 18 was presented to the ER (emergency room ) from SNF (Skilled Nursing Facility) with dyspnea (shortness of breath) and hypoxemia (low level of oxygen in the blood). Chest X-ray showed CHF (Congestive Heart Failure-a chronic condition in which the heart doesn't pump blood as well as it should) exacerbation as well as Pulmonary [CONDITION(S)]. Resident 18 was given [MEDICATION(S)] in the ER. Admit Creatinine was 1.9. Resident 18 was hypertensive. Resident 18 had an allergy to [MEDICATION(S)] so was treated with IV pain medication. Resident 18 blood pressure had improved. Resident 18 had elevated WBC (White Blood Cell) Count was elevated and there was a transfer to another hospital for treatment. Resident 18 was on a rebreather at 4 L (Liters) of oxygen Resident 18 had been on 10 L. The plan to continue to diuresis and watch the creatinine. The hospital will continue full code. had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 6/9/21 at 12:13 PM with LPN-C reported that Resident 18 had not complained of SOB to staff. LPN-C reported that after the Admission to the hospital the resident had decrease in complaints of SOB and now is able to participate in ambulation more. The LPN reported Resident 18 is definitely doing better post hospital stay Resident 18 had more strength to complete transfers and walking. Prior to the hospital stay was walking one meal per day and post they are encouraging 3 meals per day. LPN- C reported the symptoms of SOB were due to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN-C reported the staff would talk the resident down. Staff would turn the air on because it was hot in the room. Resident 18 did not always complain to the nurses. Resident would complain to other people. Resident 18 usually had symptoms in the AM with the amount of medication that were given. LPN reported the family had not spoken to them related to the resident condition. An interview on 06/09/21 at 05:00 PM with the DON confirmed the air hunger episode dated 5/3/21 required physician notification. An interview on 06/10/21 03:38 PM with the DON confirmed staff had not completed follow up documentation related to the air hunger incident dated 5/3/21 and the provider had not seen the Resident until 5/7/21. The DON reported that the expectation would be the staff document on the resident for at least 24 hours post incident,

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the provider of a change in condition related to air hunger which required hospitalization for 1 resident (Resident 18). The facility census was 48. Findings are: An interview on 06/07/21 at 04:36 PM with the Resident's representative reported Resident 18 had been admitted to the hospital and the hospital had removed 8 pounds of fluid. The reporter relayed the staff had been informed multiple times of the concern for Resident 18, related to a change in the resident's condition. The reporter revealed LPN-C (Licensed Practical Nurse) had reported the breathing problem was related to Resident 18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of PN (Progress Note) dated 5/3/21 revealed Resident 18 had wheezing this evening with exhalation, oxygen saturation was 93-96 on room air, respirations were 22-24, shallow. Lungs were clear to auscultation. Gulping for air with speech, had difficulty with deep breathing exercises and or shallow techniques, chin tuck etc. Noted to be gulping water when using a straw and taking medications. Increased anxiety noted during medication administration and swallowing of medications. Resident calmed with about 10 min of nursing reassurance and education. A Record review of Resident 18's Hospital Document dated 5/8/21 revealed; Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Acute [CONDITION(S)] in the lungs Acute/chronic diastolic CHF (Congestive Heart Failure) AKI (Acute Kidney Injury) [CONDITION(S)] CKD (Chronic Kidney Disease) History of Dementia History of [CONDITION(S)] disease Hypertension. EF (Ejection Fraction- am measure ment of the percentage of blood leaving the heart each time it squeezes) 50-55%- grade 1 mild left ventricular dysfunction (the inability of the ventricle to fill to a normal end diastolic volume, both during exercise and rest) Mitral valve shows mild regurgitation There was moderate aortic valve stenosis (hardening of the aortic valve). Severe pulmonary hypertension present' Moderate regurgitation is present in the aortic valve. Cardiac Attestation Statement: Resident 18 was seen and evaluated. Resident 18 was admitted with acute on chronic diastolic heart failure, agree with diuresis and follow renal function. Acute on chronic diastolic heart failure Acute hypoxemia respiratory failure - on room air baseline Acute pulmonary [CONDITION(S)] (Lung [CONDITION(S)]) AKI/CKD3 (Acute Kidney Injury/Chronic Kidney Injury stage 3) [CONDITION(S)] History of [CONDITION(S)] History of mild dementia Plan: Resident 18 was presented to the ER (emergency room ) from SNF (Skilled Nursing Facility) with dyspnea (shortness of breath) and hypoxemia (low level of oxygen in the blood). Chest X-ray showed CHF (Congestive Heart Failure-a chronic condition in which the heart doesn't pump blood as well as it should) exacerbation as well as Pulmonary [CONDITION(S)]. Resident 18 was given [MEDICATION(S)] in the ER. Admit Creatinine was 1.9. Resident 18 was hypertensive. Resident 18 had an allergy to [MEDICATION(S)] so was treated with IV pain medication. Resident 18 blood pressure had improved. Resident 18 had elevated WBC (White Blood Cell) Count was elevated and there was a transfer to another hospital for treatment. Resident 18 was on a rebreather at 4 L (Liters) of oxygen Resident 18 had been on 10 L. The plan to continue to diuresis and watch the creatinine. The hospital will continue full code. had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 06/10/21 03:37 PM with the DON (Director of Nurses) confirmed, the facility had not reported Resident 18's signs and symptoms of air hunger on 5/3/21 to a provider.

Licensure Reference Number 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 24 hours and provided to the Resident Representative for 1 resident (Resident 101) who resides on memory care unit. Findings are: Record review of Resident 101's admission record revealed, Resident 101 admitted on [DATE]. The Admission Record revealed; Resident 101 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Baseline Care Plan for Resident 101 revealed, the facility was unable to provide a copy of the Care Plan with confirmation the Resident Representative had received the document. Record review of Care Plan for Resident 101 revealed the following care plan Categories with start dates: [CONDITION(S)] (Hypertension), HDL ([CONDITION(S)]-High cholesterol), [CONDITION(S)] (low potassium), and Allergies: start date 5/31/21 - Resident 101 was informed of care plan on 6/2/21 at 1:52 PM, Pain; Cognition: BIMS (Brief Interview Mental Status- an assessment used to monitor cognition in the elderly) Score was 9- start date 5/31/21 - Resident 101 was informed of care plan on 6/2/21 at 1:52 PM, Falls; Cognition: start date 5/31/21 - Resident 101 was informed of care plan on 6/2/21 at 1:52 PM, ADLs (Activities of Daily Living) ; Vision; Communication; Dental: start date 5/31/21 - Resident 101 was informed of care plan on 6/2/21 at 1:52 PM. New to the Facility start date 6/8/21, resident representative informed of care plan on 6/8/21 at 1:03 PM Discharge start date 6/8/21, resident representative informed of care plan on 6/8/21 at 1:20 PM, Nutrition -start date 6/2/21, resident was informed of care plan on 6/2/21 at 1:52 PM, Skin Integrity-start date 5/31/21, Resident 101 was informed of care plan on 6/2/21 at 1:52 PM, Activity Programming restriction related to COVID 19, start date was 6/4/21, Resident 101 was informed of care plan on 6/4/21 at 8:52 AM Advanced Directives start date 6/8/21, Resident Representative was informed of care plan on 6/8/21 at 12:58 AM, An interview on 6/8/21 at 5:05 PM with the Resident representative revealed; Resident 101 was unable to retain information and had short term memory loss. Resident 101's representative reported they had not received a copy of the Baseline Care Plan. The facility presented a Baseline Care Plan which revealed Resident 101 was admitted on [DATE], had confusion, required glasses, was at risk for weight loss, and had restrictions during COVID 19, Therapy to maintain current functional status. Require nonskid foot wear, ambulated with 1 assist and walker, no longer met criteria for an ALF (Assisted Living Facility). Behavioral interventions: crush meds place them in something good. Mobility: 1 assist for bed mobility, transfers, waking, toileting, locomotion, grooming and hygiene, bathing, required set up for eating. Resident 101 was incontinent of bladder require briefs, occasional rather than frequently, toilet every 2-3 hours 1-2 times at night, Skin Braden was 17, Special mattress Pressure relieving, [MEDICATION(S)] for sensitive skin, [MEDICATION(S)] to bottom, encourage to float heels when in recliner. Other conditions: [CONDITION(S)] scheduled [MEDICATION(S)], Risk - [CONDITION(S)], Goal: no s/s of [CONDITION(S)] Interventions: Encourage fluids throughout the day. These items below had check marks to reflect they were completed. Physician orders: see MAR and TAR Current medication list provided to resident/resident representative Pharmacological Pain regimen revealed Resident 101 had the presence of pain, location was back, and pain was occasional moderate - no scheduled medications. Other medications were ASA (Aspirin) [CONDITION(S)], KCL (Potassium) -[CONDITION(S)], [MEDICATION(S)]- GERD (Gastroesophageal Reflux Disorder), [MEDICATION(S)] and [MEDICATION(S)] for constipation, artificial tears for dry eyes. The back of the form revealed the form had not been completed with the admitted , the baseline care plan completion date, the date reviewed with resident representative, staff signatures, resident signature, representative signature. An interview on 06/09/21 at 03:36 PM with the MDS (Minimum Data Set- A federally mandated assessment used to develop a comprehensive care plan) coordinator confirmed the Base Line Care Plan was entered in the computer completed and printed on 6/9/21. Record review of Interdisciplinary Care Plan Policy dated 9/2020 revealed; 1. To assure that the resident's immediate care needs are met and maintained, an IDT (Interdisciplinary Team) Care Plan would be developed within 48 hours of the resident admission. 2. The IDT team would review the Attending Providers orders and implement an initial care plan to meet the resident immediate care needs. 3. The IDT Care Plan would be used until the staff could conduct the comprehensive assessment and develop a Comprehensive Care Plan.

Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to ensure a resident's care plan was revised following a hospitalization , change in condition, and new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 48. Findings are: Record review of Care Plan for Resident 18 revealed, the Care Plan had not reflected the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 18 had been hospitalized on [DATE], of 2021 with fluid overload. Record review of the Policy for Comprehensive Care Plan dated 9/2020 revealed; E. Evaluation I. Evaluation is done on a continual basis. II. If a goal is not being met, revision of the care plan will be done. III. Quarterly evaluations of goals and interventions will be done on all care plans. IV. Care planning process will be continuous. Plan of Care will be updated as residents condition change. V. When the care plan is evaluated, documentation will include goal met and date goal partially met with explanation why it was partially met and date or not met with an explanation and date. An interview on 6/9/21 at 4:03 PM with the DON (Director of Nurses) confirmed the current care plan had not addressed the current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview and record review; the facility failed to ensure hand hygiene was completed as required during the provision of wound care to prevent cross contamination. This had the ability to affect 1 resident (Resident 22). The facility census was 48. Findings are: An observation on 06/10/21 at 8:52 AM of wound care with RN (Registered Nurse)-F Educator completed by RN-G. Supplies were ready-hand sanitizer was used. The dressing was removed by cutting it off from the top and letting the dressing drop to the pad below. Gloves donned. Soap and water was used to cleanse the right heel. [MEDICATION(S)] swab was used to the heel site x 2 the third swab was dropped on the floor. RN-G picked the swab off the floor and placed in the trash can continued to place clean dressing to the heel. An interview on 06/10/21 at 8:30 AM with RN-F confirmed, after picking up items from the floor, gloves should be doffed and hand hygiene should be performed Record review of Hand Hygiene Policy dated 4/2021 revealed; Attachment A Hand Hygiene Table Condition for antimicrobial soap and water Hands are visibly dirty Hands are visibly soiled with blood or other body fluids Before and after eating After using the bathroom Exposure to Bacillus anthraces is suspected or proven Exposure to CDIFF is suspected or proven. Either Antimicrobial Soap and Water or Alcohol based Hand Rub When coming on duty Between resident contacts After handling contaminated objects Before performing invasive procedures Before applying and after removing personnel protective equipment including gloves Before preparing or handling medications Before and after handling clean or soiled dressings, linens Before performing resident care procedures Before and after providing care to residents in isolation After handling items potentially contaminated with blood, body fluids, secretions, or excretions When during resident care, moving from contaminated body site to a clean body site After assistance with personnel body functions After sneezing coughing and or blowing or wiping nose Before going off duty When in doubt.

LICENSURE REFERENCE NUMBER NAC 175 12-006.05(9) Based on record reviews and interviews the facility failed to protect 10 residents on the memory care unit from Resident 1 who had adverse behaviors toward others, failed to implement interventions to prevent adverse behaviors, and the facility failed to have a policy for the Behavior Committee with expectations related to observations and documentation frequency for a resident with adverse behaviors. The facility Census was 52. Findings are: Record review of Resident 1's Admission Record revealed; Resident 1 was admitted on [DATE]. Resident 1 had the following [DIAGNOSES REDACTED]. Record review of APS (Adult Protective Service) reports submitted to the State of Nebraska for Resident 1 striking other Residents revealed: Resident 1 had 13 resident to resident incidents from 4/24/20 until 6/24/20. The dates are as follows: 4/24/20, 4/26/20, 4/15/20, 5/16/20, 5/23/20, 5/30/20, 6/2/20, 6/6/20, 6/12/20, 6/14/20, 6/18/20, 6/22/20, and 6/24/20. Record review of Resident 1's discharge orders dated 2/5/20 revealed Resident 1 was to be admitted to Saunders Medical Center. Orders for the following Prescription for mental health: 1. 01/23/2020 - 06/23/2020 ABH Cream ([MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]) - cream; 0.5 mg (milligrams)/25 mg/0.25 mg per ML (Milliliter); amount: 1 Syringe= 1 ML Dose; topical Special Instructions; for Agitation & Anxiety. For 6 months due to intermittent symptoms. Every 6 Hours - As needed. 2. 01/07/20 - Open Ended [MEDICATION NAME] tablet; 7.5 mg; amount; 1 tab; oral for generalized anxiety disorder twice a day. Record review of an email dated 2/4/20 by SSC (Social Service Coordinator revealed Resident 1 would be admitting on 2/6/20. Resident 1 had a [DIAGNOSES REDACTED]. Resident 1 had some episodes of agitation by this could have been related to approach. Record review of the discharge facility PN (Progress Notes) dated 1/23 20 revealed Resident 1 had increased agitation, delusions and combativeness at night, ABH cream was ordered. A call to the POA (Power of Attorney) who was okay with the medication ordered. Record review of MAR (Medication Administration Record) dated 2/2020 revealed medication administration began on [DATE]th 2020 and orders for: 1. [MEDICATION NAME] 7.5 MG PO BID (Twice a day) DX Diagnosis): GENERALIZED ANXIETY DISORDER Order Date: 2/06/20 Start Date: 2/06/20 Discontinue Date: 3/27/20 2. [MEDICATION NAME]-10 MG PO BID Order Date: 2/21/20 Start Date: 2/28/20 Discontinue Date: 3/27/20 [MEDICATION NAME] HBR/[MEDICATION NAME] SULFATE PBA (PsuedoBulabar Affect a condition that caused uncontrollable crying or laughing that happened suddenly and frequently). Medication ABH Cream was not noted on the February MAR for Saunders Medical Center Long Term Care. Record review of MAR indicated [REDACTED] 1. [MEDICATION NAME] 25 MG Q (Every) HS (at night) TO START DX: [MEDICAL CONDITION] Order Date: 3/17/20 Start Date: 3/17/20 Discontinue Date: 3/19/20 Resident 1 was given 2 doses. Record review of MAR indicated [REDACTED] 1 .[MEDICATION NAME] 25 MG PO Q DAY AT 12 PM DX: ANXIEPT Order Date: 5/20/20 Start Date: 5/20/20 2. [MEDICATION NAME] 25 MG PO ONE TIME, THEN START Q DAY AT 12 PM DX: ANXIEPT Order Date: 5/20/20 Start Date: 5/20/20 Record review of MAR for 6/2020 revealed; 1. [MEDICATION NAME] 25 MG PO Q DAY AT 12 PM DX: ANXIEPT Order Date: 5/20/20 Start Date: 5/20/20 2. [MEDICATION NAME] 25 MG PO PRN 8 HOURS PRN (as Needed) DX ANXIETY/AGITATION Order Date: 6/11/20 Start Date: 6/11/20 QUETIAPINE [MEDICATION NAME]. 12 doses were given out of 39 opportunities. Record review of Behavior Committee documentation dated 04/23/20 revealed Behavior Committee Note dated 3/25/20 Resident 1 has had an increase in documented behaviors. 64 behaviors consist of: difficulty concentrating, easily annoyed, aggressive verbal/physical behavior, difficulty concentrating, and three instances of ability to sleep at night, and restlessness. Her medications consist of but not limited to: [MEDICATION NAME] 10 mg take 1.5 tabs per day, Indication: anxiety, target disruptive vocalizations [MEDICATION NAME] 0.5 mg two tabs every 6 hours PRN anxiety [MEDICATION NAME] 50 mg PO (Oral) BID PRN pain [MEDICATION NAME] 25 mg at 1600, and 50 mg at HS Indication [MEDICAL CONDITION] Tylenol 325 mg-650 mg PO every 4 hours PRN indication pain [MEDICATION NAME] 7.5 mg PO TID (Three Times a Day) for general anxiety disorder Resident 1 had an increase in agitation, anxiety, and aggressiveness towards staff. Resident 1 had been striking out, cussing, and hitting staff and pulling the fire alarm numerous times. Resident 1 had been unable to re direct. List of interventions to try for Resident 1 had been giving to charge nurse in memory lane. They included offer warm blanket, lotion to hands, massage, reminisce about Lincoln, and Havelock with (genders) photo books, offer (genders) favorite snacks (coffee & cookies) and go for a stroll around memory lane. Due to (genders) increase in behaviors [MEDICATION NAME] has been started, and [MEDICATION NAME] has been increased to TID, [MEDICATION NAME] dose has been also increased to 1 mg PRN anxiety. Resident 1 had enjoyed being in dining and living room areas. (Gender) liked to visit about living In Lincoln, Continue to monitor per Behavior committee. Resident 1's POA was aware of the medication changes, and behaviors. Record review of Behavior Committee documentation dated 6/19/20 revealed on 6/17/20 Resident 1 continued to have an increase in agitation, aggression and obsessive behaviors towards others. Resident 1 had an order from the Provider to consult with psychiatrist. An appointment was made for telehealth on 6/05/20 with MHP (Mental Health Provider). New orders from the MHP to decrease Resident 1's [MEDICATION NAME] to 0.5 mg TID scheduled, and add PRN [MEDICATION NAME] 25 mg every 8 hrs PRN and to report back in one week. Updates have been faxed to the MHP. Record review of Behavior Committee documentation dated 6/23/20 revealed Resident 1 continued to be restless and anxious at times. Resident 1 did better with 1:1 staff vs large group or crowd. Resident 1 continued to reside in memory lane. Resident 1 had poor eye sight, and very hard of hearing, Resident 1 would not wear hearing aids. Resident 1 enjoyed 1:1 short visit with staff, looking at pictures of Havelock, Resident 1's favorite snacks of coffee and cookies. Resident 1 preferred to self-propel independently in the hallways via the w/c. Resident 1's medications consist of but not limited to: -[MEDICATION NAME] 0.5 mg TID indication anxiety, dementia with agitation -[MEDICATION NAME] 20 mg PO daily, indication anxiety, target disruptive vocalizations -[MEDICATION NAME] 25 mg scheduled daily at noon, indication: anxiety -[MEDICATION NAME] 50 mg BID (0500 and 1800) for pain, history of Orbital fracture -[MEDICATION NAME] 50 mg at HS indication. [MEDICAL CONDITION] -[MEDICATION NAME] 5/325 mg BID x 2 weeks, ends 6/26/20 -[MEDICATION NAME] 7.5 mg PO TID: indication general anxiety disorder -[MEDICATION NAME] 10 mg at MS for [MEDICAL CONDITION] -[MEDICATION NAME] 25 mg PM order from the MHP every 8 hours PM agitation, started 6/14/20 Daily updates have been sent to MHP on 6/18, 6/19, and 6/22. No new orders or changes at this time. Record review of Physician Recommendations from Pharmacist dated 3/12/20 revealed The Behavior Committee recently met to review this resident's [MEDICAL CONDITION] medications. This Committee consists of the RN Quality Coordinator, Social Work, Assistant Director of Nursing and the consultant Pharmacist. Each hall's charge nurse is also asked to provide input. [MEDICAL CONDITION] target behaviors are assessed for each medication and the resident's [MEDICAL CONDITION] medications are discussed. This resident's medications include: [MEDICATION NAME] 7.5 mg PO BID (anxiety) Behavior Committee's Recommendation: Per three day sleep log Resident 1 had been averaging 5-6 hours most nights. Resident 1 was up during the night due to restlessness, agitation, and [MEDICAL CONDITION]. Resident 1 was not currently on any sleep aids. The reply from the Provider was: Already addressed was put on [MEDICATION NAME]- this was signed by the Provider on 4/13/20 Record review of Pharmacy Recommendations revealed: Record review of Physician Recommendations from Pharmacist for Resident 1 dated 3/19/20 revealed Given the FDA (Federal Drug Administration) findings related to increased mortality in dementia patients receiving antipsychotic drugs for related behaviors, (due [MEDICAL CONDITION], heart failure/ sudden death, infections and FALL risk increase) currently, no antipsychotic agent is approved by the FDA for dementia and related behaviors. Their use would be out of compliance with a CMS (Centers for Medicare and Medicaid Services) survey. medications: [REDACTED] [MEDICATION NAME] 25 mg PO Q HS ([MEDICAL CONDITION]) [MEDICATION NAME] l0 mg PO Q HS ([MEDICAL CONDITION]) [MEDICATION NAME] 0.5 mg Q 6 hour as needed [MEDICATION NAME] 7.5 mg PO BID (Generalized Anxiety) Neudexta 1 PO BID (PBA PsuedoBulbar Affect a condition that ) To facilitate CMS compliance please consider the following adjustments: (X)Stop [MEDICATION NAME]. Start [MEDICATION NAME] 25 mg PO Q 4:00PM and 50 mg PO Q HS ([MEDICAL CONDITION]) (X) [MEDICATION NAME] l0 mg PO QHS (Diagnosis) Circadian Rhythm Support (X) [MEDICATION NAME] 0.5 mg Q 6 hour as needed for 180 days ([DIAGNOSES REDACTED]. The Provider agreed and signed the document dated 3/19/20. Record review of Physician Recommendations from Pharmacist for Resident 1 dated 5/28/20 revealed The Behavior Committee recently met to review this resident's [MEDICAL CONDITION] medications. This Committee consists of the RN Quality Coordinator, Social Work, Assistant Director of Nursing and the consultant Pharmacist. This resident's [MEDICAL CONDITION] medications include: [MEDICATION NAME] 1 mg PO TID (Anxiety) Quetiapine 25 mg PO Q NOON (Anxiety) [MEDICATION NAME] 7,5mg PO TID (Anxiety) [MEDICATION NAME] l0 mg PO Q HS (Sleep) [MEDICATION NAME] 25 mg Q 4:00 PM and 50 mg QHS (sleep) [MEDICATION NAME] 20 mg PO QD Anxiety TB disruptive vocalizations APAP ([MEDICATION NAME]) 650 mg Po TID (Pain) Behavior Committee's Recommendation: Resident 1 has had a recent fracture the Behavioral Committee recommended to schedule (gender) PM (as needed_ [MEDICATION NAME] 5/325 mg (milligrams) pain medication, to schedule during this time period secondary to Increase In pain. Committee also recommended to continue (gender) titration of [MEDICATION NAME] to 20 mg PO Q day. Resident 1 has had challenging days post (gender) fracture. Physician's Response: (X) Change to [MEDICATION NAME] 5/325 PO TID (Pain) only for 7 days (X) [MEDICATION NAME] 20 mg PO QDAY (Anxiety TB disruptive vocalizations) The Provider signed agreed and dated on 5/29/20. Record review of Physician Recommendations from Pharmacist for Resident 1 dated 6/3/20 revealed The Behavior Committee recently met to review this resident's [MEDICAL CONDITION] medications. This Committee consists of the RN Quality Coordinator, Social Work, Assistant Director of Nursing and the consultant Pharmacist. Each hall's charge nurse is also asked to provide Input. [MEDICAL CONDITION] target behaviors are assessed for each medication and the resident's [MEDICAL CONDITION] medications are discussed. This resident's [MEDICAL CONDITION] medications Include: [MEDICATION NAME] 1 mg PO TID (Anxiety) Quetiapine 25 mg PO Q NOON (Anxiety) [MEDICATION NAME] 7.5 mg PO TID (Anxiety) [MEDICATION NAME] 10 mg PO Q HS (Sleep) [MEDICATION NAME] 25 mg Q 4 PM and 50 mg QHS (Sleep) [MEDICATION NAME] 20 mg PO Q Day Anxiety TB disruptive vocalizations APAP 650 mg PO TID (Pain) Behavior Committee's Recommendation: Asked to review medications due to documented increase in aggression to staff and resident peers in the late afternoon and evenings. Multiple non-pharmacological interventions have been implemented. Physician's Response: (X) Trazadone 50 mg PO Q 4 PM (suggested by the pharmacist) Signed and dated by the Provider on 6/4/20. Record review of documentation of observations of Resident 1's behaviors time period 4/24/20 through 6/24/20 by the SSC (Social Services Coordinator) revealed; 1. Documented on 05/13/20 11:01 AM A PHQ-9 (Patient Health Questionnaire an assessment used for depression scores) was attempted on 5-8-20 and Resident 1 was unable to answer the questions asked, A PHQ-9-OV was completed with a score of 4/30 which may indicate a minimal Depression. Symptom frequencies noted trouble concentrating and short tempered. If Resident 1 did not understand what is being asked of (gender), does become irritated and will yell and strike out at staff. Resident 1 had very poor hearing and this added to the frustration. Resident did not want hearing aids per (genders) family. Resident 1 was able to make simple decisions such as choosing between milk and juice. Resident 1 was able to propel the wheelchair and moved about Memory Lane continually. It was difficult for (gender) to attend to task for any length of time including meals. Resident 1 would close and open doors and push the buttons on the door pads. Resident 1 was not able to leave the area and (gender) had become less intent on doing so. Resident 1 would pull the plastic cover off the fire alarm but this had also decreased in intensity. Resident 1 often says 'help me and I don't know*. When asked what (gender) needed help with Resident 1 could not answer the question. Resident 1 would continue to reside In Memory Lane as this is appropriate for (gender). Long term care continues with no potential for discharge. 2. Documented on 05/20/20 at 4:30 PM SSC was in Memory Lane with Resident 1 form approximately one hour and two other staff as well. About afternoon Resident 1 had become very loud, repeating over and over, 'Help me, help me. I don't know, I don't know.' Resident 1 was pointing at other residents wanting them taken out because this was (genders) house. Resident 1 was mainly drawn to another resident (gender) may believe they were (genders) parent. Resident 1 was very loud. The charge nurse and SSC attempted multiple interventions and approaches. Other residents in the area were getting loud and responding in a negative way to Resident 1's voice. At approximately 4 PM Resident 1 calmed some but continued to repeat, 'help me and I don't know. The DON (Director of Nursing) and the Administrator came to the area as well as the RN (Registered Nurse) from the Behavior Committee. The physician was notified and [MEDICATION NAME] was ordered. See nurse's notes for dose and time. 3. Documented on 6/23/20 a Late Entry from 6-22-20 SSC visited with Resident 1 at approximately at 11:15 am in (genders) room. Resident 1 was repeating 'Help me, help me! Don't know, I don't know.' When asked what (gender) needed Resident 1 would respond with I don't know. SSC reminded Resident 1 of hitting another Resident this morning and Resident said, I did not.' (Gender) could not recall the incident. SSC reminded Resident 1 that (gender) could not hurt other people, (genders) response was, 'I don't know'. Resident 1 had not recalled the incident. Looking out (Genders) bedroom window Resident 1 asked if the town (gender) saw was Havelock. Resident 1 was not orientated to time or place. Record review of documentation of Observations for Resident 1 by the RN Quality Coordinator that participated on the Behavior Committee revealed the facility was unable to provide documentation of observations done by the Behavior Committee RN. Record review of Resident 1 Care Plan for Behaviors dated 2/10/20 revealed Resident 1 displayed agitated behaviors due to (genders) confusion Inappropriate and or disruptive behaviors will decrease in occurrence by specified time frame. Intervention dated 2/10/20 revealed: 1) Monitor and document target behaviors 2) Monitor closely for signs of increased frustration and/or anxiety. Resident 1 was hard of hearing and will become loud and yell if (gender) did not understand. 3) Ask simple yes or no questions 4) Report onset or increase in behaviors to Behavior Committee and/or physician 5) Behavior Committee every quarter and PM 6) Administer behavior medications as ordered 7) Assist in selection of appropriate coping mechanisms. Resident 1 enjoyed visiting, working her crossword puzzle, snacks. 8) If calling out, sit with Resident 1 and attempt to assess what is bothering (gender). Offer bathroom, fluids, warm blanket. If none of these interventions are effective. Offer to take (gender) to their room and sit with them. The quiet environment seems to sooth Resident 1. 9) With every approach explain what is expected of Resident 1 in regards to assistance with ADL's or activities. Interventions dated 2/13/20 revealed: 1) Identify causes for behavior and reduce factors that may provoke aggressive behaviors (4-24-20 ex: taking medications can cause anxiety and agitation swing arms). 2) If having aggressive behaviors (ex; hitting, biting) excuse yourself and explain you will come back later. Interventions dated 2/26/20 revealed: 1) if attempting to open exit door redirect to another area by visiting first and making eye contact Offer snack or fluids. Sit with Resident 1 and visit about past interests. (Worked in Lincoln, lived in Havelock and had one sibling) Interventions dated 4/24/20 revealed: If refusing medications- dismiss yourself and explain you will be Active back in 5 minutes with medications. (If LPN (Licensed Practical Nurse F was in the area they would administer medications.) Interventions dated 4/29/20 revealed; DON to reach out to agency nursing company to suggest additional training on dementia. Interventions dated 4/30/20 revealed; 4-30-20 Behaviors discussed in Behavior Committee. Will group medications to less times a day, walk to dine to increase activity and sit in a stationary chair. Interventions dated 5/18/20 revealed; Dr. (facility psychiatrist) would be contacted for a consultation and evaluation. Family contacted. Interventions dated 5/19/20 revealed; Staff to sit with Resident 1 in (genders) room while eating if (gender was irritable or if (gender) was irritating others. (EX: yelling, propelling quickly around area, striking out at staff). Interventions dated 5/26/20 revealed; 1) FYI (For Your Information): increased agitation in the 1 1/2 weeks. Fax to Provider with suggestion for possible lab and/or UA (Urinalysis). Awaited orders 2) Attempted directing Resident 1 to a less stimulated area at mealtime. Interventions dated 5/29/20 revealed; 5-28-20 Behavior Committee met and suggested scheduled [MEDICATION NAME] for pain. Primary care physician had been faxed. Interventions dated 6/3/20 revealed; if Resident 1 was asleep do not wake for meals or snacks. Check back in on (gender) periodically Resident 1 did not like to be woke up. Interventions dated 6/4/20 revealed; Behavior Committee review. Medication adjustment due to continued behaviors. Will see Provider via telehealth 6-4-20 Interventions dated 6/11/20 revealed; Offer Resident 1 the opportunity to lay down in (genders) bed after lunch. If (gender) refused wait 10-15 minutes and offer again. Re-enforce that this will make (gender) feel better. Interventions dated 6/22/20 revealed; 6-12-2020 1) Resident 1 was to be offered snack 10-15 minutes before to meals to distract (gender) from other residents. 2) 6-14-2020 Behavior Committee to meet weekly review medications and interventions. Interventions dated 6/19/20 revealed; 6-19-2020 if Resident 1 had got up early (before 5 am) ask (Gender) if they needs to lay down later to rest before breakfast Intervention dated 6/22/20 hand written on the care plan but not typed on the care plan revealed; during change of shift, charting, staff was to keep Resident 1 in eye shot. Interventions dated 6/24/20 revealed; 1) Incident with another resident 1-1 staffing will be utilized until calm. 2) FYI resident 1 was sent to inpatient psychiatric care for evaluation. An interview on 8/3/20 at 10:04 AM the with the DON who reported the facility had reported multiple different APS reports related to Resident 1 hitting other Residents. There had been multiple. The DON reported that Resident 1 was pretty much a 1:1 in memory lane - if you turned your back on Resident 1 for a minute (gender) was on it. The resident was fast. The DON confirmed Resident 1 was in an inpatient psychiatric facility. An interview on 8/3/20 at 1:09 PM with NA/MA (Nurse Aide/Medication Aide) G reported staff tried to do a 1:1 with Resident 1, but the resident would become agitated. An interview on 8/3/20 at 1:13 PM RN-H confirmed when they were scheduled to work back on the unit, Resident 1 was a 1:1. RN H reported that they did not usually work on the unit. An interview on 8/3/20 at 1:14 PM NA-I revealed; that Resident 1 was never 1:1 when they were worked on the unit. An interview on 8/3/20 at 1:35 PM with the DON confirmed; the incident dated 5/23/20 the facility was unable to locate the interventions. The incident on 6/6/20 the interventions were documented in the nurse's notes but not placed on the care plan. An interview on 08/03/20 at 3:22 PM with the DON revealed Interventions for Resident 1 helped for short periods of time. A Medication was ordered and had been changed related to a pharmacy recommendation. The DON reported they had visited Resident 1 at the previous facility. The DON reported during the visit the Resident had not had any behaviors. Resident 1 had been on ABH cream at the previous facility. An interview on 8/4/20 at 8:38 Am with NA-A revealed Resident 1 wandered into other resident rooms. An interview on 8/4/20 at 8:41 AM with NA-J revealed Resident 1 they kept a close eye on when Resident 1 roamed they tried to keep (gender) from others but the staff were not always present when Resident 1 struck other Residents. NA reported that usually 3 staff on duty in the unit. An interview on 8/4/20 at 8:46 AM with LPN-F revealed Resident 1 was normally up by 6 am and the nurse attempted to give medications in the early am hours. Resident 1 tried to hit people if they did not have their medications. LPN-F reported that resident 1 required 1-1 if they did not have 1-1 attention would hit others. Resident 1 did not like bathing. Resident 1 was more aggressive in the afternoons. The staff tried 1-1 most of the time. There was not a designated staff member for 1-1 with Resident 1. LPN-F reported there were several interventions attempted folding laundry, walking in the wheelchair, walking with the walker, picture book. When the staff was busy, was when Resident 1 would hit other Residents. LPN-F reported that Resident 1's Provider had started an antipsychotic medication and that had been discontinued after a few doses, the staff were able to get the medication back and felt it had been helpful. LPN-F reported the medication had been started on 3/27 and stopped on 3/31/20. LPN reported the medication [MEDICATION NAME] was not restarted again until 5/28/20, except for a 1 time dose on 5/20/20. An interview on 8/4/20 at 9:28 AM with the DON who confirmed the Nurses and Nurse Aides document behaviors. The Behavior Committee goes by what they see in the documentation and the observations on the unit. Then they make recommendations if something does not get documented this information is not accurate. An interview on 8/4/20 at 9:28 AM with the Administrator confirmed the expectation for the Behavior Committee is they make weekly observations, meet weekly and document those findings with a resident with increase in behaviors. The Administrator reported the Behavior Committee members consisted of the Pharmacist, the SSC, and the QA Nurse. The Administrator confirmed it would be beneficial to have additional members on the Behavioral Committee such as a member of the memory care unit, MDS Coordinator, Life Enrichment. An interview on 8/4/20 at 10:15 AM with the Administrator confirmed there was no current policy or procedure for the Behavioral committee and expectations, however there was mention of the Behavior Committee in the Antipsychotic Use Policy. The Administrator confirmed it was the expectation that the Behavior Committee document and observe residents that have adverse behaviors on a weekly basis. The Administrator reported the Behavior Committee consisted of the Quality Control Nurse, Social Service, and the Pharmacist and they are the only ones that attend this meeting. An interview on 08/04/20 at 11:03 AM with BC RN {Behavioral Committee RN (Registered Nurse)} confirmed When the Behavior Committee met related to behaviors there would be a documented note. The Behavior Committee met once a week on Wednesdays and at times on Thursday. The BC RN confirmed that the residents on the list to be seen would come from the MDS (Material Data Set- A required federally mandated comprehensive assessment used to develop a comprehensive care plan) according to the MDS schedule. The BC RN reported that the staff committee had done quite a few observations on the unit and had become familiar with Resident 1. BC RN reported that Resident 1 was impulsive, became agitated, and was hard of hearing. Interventions would be speak to Resident 1- 1:1, make sure needs were met and reproach. The BC RN reported that the facility had a PIP (Process Improvement Plan) for Antipsychotic use in the facility related to Quality Measures. The BC RN reported Resident 1 had admitted in February and there had not been behaviors for the first few months, no APS (Adult Protective Services) calls. The BC RN reported Resident 1 had not flagged to identify them for behaviors. An interview on 8/4/20 at 11:03 AM with the SSC confirmed Resident 1 had become 1:1 with staff on 6/24/20, and at times from April to June discharge date . An interview on 8/4/20 at 2:00 PM with LPN F confirmed Resident 1 had behaviors on admission to time of discharge. An interview on 8/4/20 at 2:16 PM with NA-K revealed; Resident 1 moved around in the w/c (wheelchair). Resident 1 was agitated some days and would not sit at the table. NA confirmed the staff always watched Resident 1 but the resident was not always a 1-1. An interview on 8/4/20 at 2:20 PM with NA-L confirmed Resident 1 required a lot of attention. Resident 1 would wander a lot and yell causing increased agitation to other residents. NA-L confirmed, if Resident 1 was not 1-1 it could create unsafe environment for other residents. An interview on 8/4/20 at 1:10 PM with the Administrator confirmed the DON's concerns related to behaviors would be relayed during the morning standup. The Administrator confirmed if the information was not documented by the team then this information could be missed. The Administrator reported they felt that it was not necessary to have the DON on the committee. An interview on 8/4/2020 at 2:41 PM with BC/QA (Quality Assurance) nurse revealed Resident 1 was on ABH cream prior to admission. The medications had not been continued. QA nurse reported the facility was below average for QM for Antipsychotic use and the facility had a previous Process Improvement Plan for the Antipsychotic use. The QA nurse was unaware of whether or not the facility had a current PIP for increase in behaviors for the Memory Care Unit. QA nurse reported the Behavior Committee would meet on residents according to the List given them by the MDS coordinator. An interview on 8/4/20 at 3:00 PM with the DON (Director of Nurses) confirmed Resident 1 had not been ordered the ABH cream at the facility related to the cream had [MEDICATION NAME] in it. The DON confirmed the facility did not have a Process Improvement Plan for Increase in Behaviors. The DON reported the facility did not have a current ADON (Assistant Director of Nurses).

Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews, observations, and staff interviews, the facility failed to secure the mechanical lift sling properly for 1 (Resident 2) of 3 sampled residents reviewed for accidents. As a result of not properly securing the sling while using the mechanical lift, the resident fell from the lift and was guided down to the floor by staff. The resident sustained [REDACTED]. This had the potential to affect all residents who require a mechanical lift for transfers. The facility Census was 52. Findings are: Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2's Minimum Data Set (MDS), dated [DATE], revealed the resident's cognition was severely impaired and required extensive assistance with two staff for bed mobility, transfer, dressing and bathing. A care plan, dated 04/21/20 and updated 05/07/20, documented the resident had an inability to stand, needed two person assist and the mechanical lift for transfers. The interventions indicated: the resident transfers with two persons assist and the mechanical lift. Assure correct sling used during transfers. On 04/21/20 at 7:30 PM, a nurse's note documented two NAs (Nurse Assistants) were transferring the resident to bed using a mechanical lift. One of the straps came off causing the resident to slide out of the sling. NA-A caught Resident 2 and broke her fall. The nurse was called to the room and the resident's head was lying on one of the legs of the mechanical lift and her legs were across the other leg of the mechanical lift. Resident 2 was lifted up off of the floor using the mechanical lift by the staff. Resident 2 had sustained a laceration on the right side of her head 3 cm (centimeters) X 0.2 cm, and an abrasion to the back of her leg, The nurse cleaned the laceration with saline and noted that it may need stitches. Review of the incident report, dated 04/21/20, revealed Resident 2 was being transferred from the chair to the bed and slipped out of the mechanical lift pad, falling to the floor. NA-A tried to break the resident's fall. The intervention put in place after the fall was the resident was sent to the emergency room (ER) for an evaluation due to laceration on the right side of her head. The Restorative Aide (RA) offered additional training to staff on the mechanical lift transfers and sling placement. A radiology report, dated 04/21/20, revealed the results from the head impression as right frontal scalp contusion. The emergency room (ER) report, dated 04/21/20, documented Resident 2 was in a mechanical lift and somehow one of the straps gave way. The resident was lowered down by staff. The resident did not hit (gender) head on the ground but instead hit the right temporal area on the lift somehow. Resident 2 sustained a small laceration. It was noted that it was difficult to assess the resident's mental status due to history of dementia and [MEDICAL CONDITION] (TBI). The report further stated the staff that took the resident over to the ER reported Resident 2 was at baseline for the resident's mental responsiveness. This was responsive to verbal commands but not appropriate response. The ER course of treatment was the wound on Resident 2's right temporal scalp was cleaned with iodine swabs and staples were applied to close the wound. NA-B's written statement, dated 04/22/20, and interview on 08/03/20 at 10:00 AM, revealed on 04/21/20 around 7:30 PM, NA-A and NA-B were in the process of putting Resident 2 in bed using a lift. NA-B said the sling was in place and crossed between Resident 2's legs. NA-A was operating the lift and NA-B was guiding Resident 2's legs. NA-A said suddenly NA-B yelled that Resident 2's legs were coming out of the sling and Resident 2's body was crooked in the sling. NA-A thought the sling came off the hook but was not sure. NA-A reported they lowered Resident 2 to the floor, and she ended up on the legs of the lift. Neither NA thought Resident 2 hit her head or was injured. NA-A then saw blood on the floor under the resident's head and called for the charge nurse. LPN-B brought in the blood pressure machine. A towel was put under Resident 2's head. LPN-B asked NA-A and NA B to get a sling under the resident and put her on the bed. During the interview on 08/03/20 at 10:30 AM, LPN-A stated at about 7:30 PM, NA-A came to get the nurse and said the resident had a fall to the floor when they were transferring Resident 2 to bed. When the nurse entered the room, the resident was on the floor with (gender) head across the bottom on the mechanical lift. LPN-B said Resident 2 was awake and did not appear to be in pain. There was blood on the floor. LPN-B attempted to initiate vital signs, but the resident began to pull away. With the assistance of the two NAs, they got the resident off the floor and placed the resident on the bed. During an interview on 08/03/20 at 2:45 PM, NA-B said Resident 2 was in the wheelchair when NA-A and NA-B hooked up the mechanical lift. NA-B felt like the straps of the lift were crossed and hooked up properly. NA-B said the resident was not crooked in the sling. NA-B was holding the resident's legs and NA-A was driving the lift. NA-B heard a noise and looked up at the top of the lift and suddenly the resident went down to the floor. The lift was positioned right next to the bed. NA-B did not let go of the resident's legs. When CNA-B looked up from the floor, the sling was out of one of the hooks. The charge nurse was contacted. During the interview on 08/04/20 at 10:26 AM, the Restorative Aide (RA) reported on 04/21/20 after the Resident 2 fell , the RA completed the evaluation of the mechanical lift and discovered there was no damage on the mechanical lift sling. RA concluded that NA-A and NA-B must not have hooked up the mechanical lift sling properly before transferring the resident from the wheelchair to bed. The RA reported the two NAs were in-serviced on the proper way of hooking up the slings on the mechanical lift and placing the resident in the center of the sling before transferring the resident. During the interview on 08/04/20 at 12:30 PM, the Director of Nursing (DON) stated it was reported to her that Resident 2 fell on the floor when NA-A and NA-B were using the mechanical lift to transfer Resident 2. She reported after Resident 2 was sent out to the hospital, the facility completed an investigation about the fall incident, and it was found that the mechanical lift sling was not secured properly. Two staff members were in-serviced on the proper use of a mechanical lift by securing the mechanical sling properly before transferring a resident. The DON stated the investigation revealed there was no mechanical problems with the lift and the two staff members used a correct lift pad. During the interview on 08/04/20 at 1:45 PM, the Administrator reported after the investigation of Resident 2's fall was completed, it was found that the mechanical lift sling was not secured properly. The two staff members were in-serviced, and his expectation was for staff to properly secure the mechanical lift sling properly before transferring a resident from the wheelchair to the bed.

Licensure reference number 175 NAC 12-006.09D2b Based on record reviews and interviews, the facility failed to consistently monitor pressure ulcers on 2 residents (Resident 7 and Resident 34) out of 2 residents sampled. The facility census was 58. Findings are: [NAME] Record review of Resident 7's Admission Record dated 8/5/2019 revealed a date of admission of 2/14/2011. The Admission Record revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5/3/2019 revealed the resident had an unhealed PU (pressure ulcer) staged as a stage 2 (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising). Record review Resident 7's Physician order [REDACTED]. Resident refuses to wear her boots at night. The assessment revealed a 3 cm x 4 cm blister on left heel and was able to get resident to wear boots on that night and off load heels. MD response was needs to keep wearing boots for treatment and prevention. [MEDICATION NAME] treatment to heel. Record review of Resident 7's Physician order [REDACTED]. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise) to the right heel. Area has ill- defined border and is light purple in color. The assessment revealed a 1.4 cm x 1.6cm (approximately as ill-defined). Tissue surrounding is pink in color skin is all intact with complaint of pain, to heel. Resident 7 reports heel protectors on all day causing pain to areas. Request for resident to wear prevalon boots to bilateral lower extremities related to pressure areas. MD response was yes. Record review of Resident 7's Physician order [REDACTED]. It's caused [MEDICAL CONDITION] also occur in pressure wounds. Eschar is typically tan, brown or black and may be crusty. Wounds are classified into stages based on how deep they are and how much skin tissue is affected. When a wound has eschar on top of it, the wound cannot be classified. This is because eschar is dead, dark tissue that makes it difficult to see the wound underneath. Because eschar is part of the body's natural healing process, a physician will not always recommend removing it.) MD response was change every 3 days and more often as needed). Record review of Resident 7's Physician order [REDACTED]. The current treatment is skin prep (is a no-sting skin protective that is fast-drying, sterile, liquid film-forming skin protectant that prepared damaged or intact skin) and cover with [MEDICATION NAME] ([MEDICATION NAME] is suitable for dressing many types of wounds). Skin is very dry related to the use of skin prep. Request to change treatment to [MEDICATION NAME] (a non-adhering, impregnated with [MEDICATION NAME] to be used as an antibacterial barrier). MD response was yes. Record review revealed the wound was not monitored and assessed on a routine basis which was supposed to completed weekly. Charting was found for the following days: 12/25/18 1/2/19 1/8/19 1/15/19 2/5/19 2/12/19 3/7/19 5/8/19 6/5/19 7/6/19 8/3/19 Interview with the DON (Director of Nursing) on 8/13/19 at 10:15 AM revealed there were 2 staff members that were assigned to wound cares, on worked at the facility on an on call basis but was there every Tuesday to do wound assessments, and there was another one that worked part-time. Neither are still with the facility so now, it is the responsibility of the nurse providing cares on the weekly shift that are to complete the assessments and cares. B. Record review of Resident 34's Admission Record dated 8/5/19 revealed a date of admission of 3/23/18. The Admission Record revealed [DIAGNOSES REDACTED]. A stage 4 (A Stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often included undermining and tunneling) pressure ulcer was added to Resident 34's [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had an unhealed PU Stage 2. Record review of Resident 34's wound cares revealed they were completed on: 3/27/19 4/3/19 4/15/19 4/17/19 5/13/19 5/24/19 6/5/19 6/10/19 6/13/19 6/19/19 6/21/19 6/28/19 7/10/19 7/17/19 Interview with the DON (Director of Nursing) on 8/13/19 at 10:15 AM revealed there were 2 staff members that were assigned to wound cares, on worked at the facility on an on call basis but was there every Tuesday to do wound assessments, and there was another one that worked part-time. Neither are still with the facility so now, it is the responsibility of the nurse providing cares on the weekly shift that are to complete the assessments and cares.

Licensure Reference Number 175 NAC 12-006.09D7b Based on record review and interview the facility failed to complete Fall Risk Assessments (an assessment of the individual resident to identify factors for risk of falls) quarterly as required to prevent resident falls with fractures for 6 residents (Residents 2, 8, 12, 26, 31, 52) of 6 residents reviewed. The facility failed to review causal factors and revise interventions to prevent falls with injury for 4 residents (Residents 2, 8, 12, 52) of 6 residents reviewed. The facility census was 58. Findings are: Record review of the facility policy and procedure titled Fall Prevention dated 2/2019 revealed that the facility must identify and implement standards of care and treatment to prevent resident falls. The policy revealed the procedure steps: 1. A Fall Risk Assessment will be completed on admission and at least quarterly by nursing staff. If resident is determined to be at risk for falls, the Fall Risk Assessment Supplement is completed, interventions will be care planned and implemented. All changes will be communicated to staff. A star will be placed on door if resident is a fall risk. 2. A Report of Occurrence is to be completed on each incident of a resident fall and the charge nurse for that shift must implement and communicate a new intervention to prevent the event from recurring. Interventions will be added to the resident care plan. 3. The Director of Nursing (or designee) will review Reports of Occurrences for appropriate interventions. [NAME] Record review of the last Fall Risk Assessment completed for Resident 26 revealed that it was completed on 12/10/18 and that the resident fall risk total score was 9. A total score of 11 or higher was identified as high risk for falls. Record review of the Report of Occurrence for Resident 26 revealed that the resident had a fall with major injury on 4/30/19 at 4:35 PM. Record review of the radiology Computed [NAME]ography (CT) scan report revealed that Resident 26 sustained a [MEDICAL CONDITION] inferior ramus (a [MEDICAL CONDITION]) from the fall. Interview on 8/7/19 at 4:14 PM with the Minimum Data Set assessment (MDS) Coordinator confirmed that the fall risk assessment is completed generally quarterly and was uncertain if the facility had a policy on the frequency of assessments. Interview on 8/13/19 8:08 AM with the MDS Coordinator confirmed that the last Fall Risk Assessment for Resident 26 was on 12/10/18. B. Record review of the last Fall Risk Assessment completed for Resident 31 revealed that it was completed on 12/17/18 and that the resident fall risk total score was 11. A total score of 11 or higher was identified as high risk for falls. Record review of the Report of Occurrence for Resident 31 revealed that the resident had a fall with major injury on 5/11/19 at 2:30 PM. Record review of the radiology X-ray report revealed that Resident 31 sustained a [MEDICAL CONDITION] femoral neck (a [MEDICAL CONDITION] leg at the hip) from the fall. Interview on 8/7/19 at 4:14 PM with the Minimum Data Set assessment (MDS) Coordinator confirmed that the fall risk assessment is completed generally quarterly and was uncertain if the facility had a policy on the frequency of assessments. Interview on 8/13/19 8:08 AM with the MDS Coordinator confirmed that the last Fall Risk Assessment for Resident 31 was on 12/17/18. C. Review of Resident 2's Face Sheet dated 8/5/19 revealed Resident 2 was legally blind, and noted diagnosed including: [DIAGNOSES REDACTED]. Review of Resident 2's quarterly MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning) dated 7/19/19 revealed the resident's BIMS (Brief Interview for Mental Status) score indicated moderately impaired cognition. The daily use of motion sensor alarms was also noted. The assessment of Resident 2's functional status revealed the resident required staff assistance with transfers and mobility. Review of Resident 2's Care Plan revealed the resident is at risk for falls related [MEDICAL CONDITION](a stroke - when blood flow to a part of the brain is stopped by a blockage or the rupture of a blood vessel) and poor balance. The goal was for Resident 2 to have no injuries from falls, and interventions included transferring and ambulating with the assistance of 2 staff members, having the resident's bed in the lowest position at all times, ensuring the resident's call light and other frequently used items are within reach when in the room, wearing non-skid footwear, and short term purposeful rounding. It was also noted the resident refused to wear a gait belt. Documentation regarding a motion sensor alarm was not noted on the care plan. Observation on 8/7/19 at 9:19 AM of Resident 2 in the resident's room revealed the motion sensor alarm was on the floor in the middle of the room. The resident's recliner was positioned so it faced the bed, and the right side of the recliner faced the motion sensor. The alarm was set off by the resident's movement, and the ADM (Administrator) entered the room and asked if the resident wanted assistance to the bathroom. The ADM cued the resident to turn on the call light, and was chatting with the resident in the room. Observation on 8/7/19 at 11:04 AM of Resident 2 in the resident's room revealed the motion sensor alarm was on the floor in the middle of the room, and the alarm was set off by the resident's movement. A housekeeping staff member entered the room and reoriented Resident 2 to the location of items in the room, and told the resident that the housekeeping staff member would let nursing know that the resident needed something. Observation on 8/7/19 at 3:30 PM of Resident 2 in the resident's room revealed a motion sensor alarm was on the floor in the middle of the resident's room. The floor sensor alarm was set off due to the resident rising from the recliner. An NA (Nurse Aide) entered the room and assisted the resident into the wheelchair. The NA chatted with the resident and offered the resident water and a walk around the facility. The resident declined the offers but sat in the room doorway, speaking to staff who walked by in the hall. Observation on 8/7/19 at 3:40 PM of Resident 2 in the 200 hall hallway revealed the resident was in a wheelchair and self-propelled into the hallway, but was still sitting by the resident's room door. When staff stopped to speak to the resident, the resident was conversing and answering questions appropriately. When the resident was not interacting with staff, the resident was becoming frustrated and saying there were children playing in the upstairs bedrooms, and the children should not be up there. The resident self-propelled across the hall and was attempting to open the door to another resident's room when an NA approached the resident and assisted the resident to the bathroom. Interview on 8/7/19 at 4:15 PM with the DON (Director of Nursing) revealed Resident 2 had increased confusion over the last few weeks. Interview on 8/8/19 at 9:00 AM with the DON revealed Resident 2 fell in the resident's room on 8/7/19, sometime after 6:00 PM. The DON revealed the resident had a laceration (a deep cut or tear in the skin or flesh) to the back of the head and complained of hip pain. Resident 2 was sent to the emergency room for evaluation, then was sent on to a different hospital due to a [MEDICAL CONDITION]. Review of Resident 2's fall investigation dated 8/8/19 revealed on 8/7/19 at 6:15 PM the resident was reaching for the bathroom door when the resident fell from the wheelchair. Review of Resident 2's Fall Risk assessment dated [DATE] revealed the resident was assessed to be a high risk for falls. Review of Resident 2's electronic medical record revealed an absence of Fall Risk Assessments completed after 12/21/18. Interview on 8/8/19 at 12:25 PM with the DON revealed there was no record of Fall Risk Assessments completed after 12/21/18 due to a problem with the computer program the facility used. The assessments were not being saved the correct way, so the assessments were not saved into the resident's medical record. D) Resident #8 08/05/19 01:43 PM Progress note dated 07/12/19 resident slid out of chair Resident stood up from the table in the day area. She had moved a chair away from the table and was leaning forward to attempt to self-transfer. Wheels were not locked and the chair alarm was in place both Nurse and MA were approx 15 feet away and could not make it to her before she slid out of the chair. She didn't hit head and was smiling but touched her chest. She was assessed and lifted back into her wheel chair. No injuries noted at this time Fall non employee dated 07/12/19 revealed; staff was standing at the desk and noticed the resident leaning forward. Resident buttocks slid out of chair and landed on the floor before staff could reach her. NO environmental factors, NO medications were identified, No patient related factors were identified, chair alarm was in place, fall prevention device was chair alarm, Supervisor was notified, family was notified, No injuries, NO additional tests, Post vital signs 108/64, 64, 18, 97.6, 95%. Interventions post fall was 1:1 at the table. Care Plan reviewed Revealed that no intervention was put in place post fall on 7/12/19. Last fall assessment was on 11/19/18. Fall risk assessment dated [DATE] revealed: Disoriented, no falls in last 3 months, adequate vision, requires a device for ambulation, Takes 1-2 medications, no [DIAGNOSES REDACTED]. Orient resident to environment Bed in low position Night light in use during night assess room remove obstacles Assist with ADL and elimination as needed Keep necessary items, call light and H2O in reach use non skid foot wear Educate family and resident regarding fall prevention and frequently reinforce Medication review revealed [MEDICATION NAME] Fall assessment 08/12/19 08:25 AM With DON had calls out to AHT on assessment. E) Resident #12 08/05/19 10:43 AM fell from bed a couple weeks ago. then had injections to the lower back was helpful for the pain- Family was glad for the fall the back pain had been increasing and they had the injections and this had helped with the walking. On the floor in the room next to his bed. Cognitive impairment Intervention was purposeful rounding. Care Plan intervention was purposeful rounding. 7/27/19 Record review of falls (non-employee related) revealed; LPN notified nurse on call on 7/27/19 that Resident 12 was laying in his room in his own bed as she walked by then minutes later he was found laying on the floor in his room next to his bed. Vitals were obtained Dr notified of fall, and resident complain of increased back and shoulder pain. Resident 12 was sent to the ER for evaluation no fracture noted. POA notified. NO environmental factors, Medication at the time of the fall -NO, Resident related factors -cognition. Devices-none, fall prevention interventions in place- Purposeful rounding, call light in reach, On duty supervisor notified, Dr was notified, POA was notified, no injury noted, Neuro WNL ER visit all scans normal, Vitals 99.3, 99% RO, 24, 109/64, Resident was sent to ER for evaluation, interventions that were implemented after this occurrence- purposeful rounding. Factors contributing cognitive impairment. Last fall assessment was dated (MONTH) 12/21/18 revealed intermittent confusion, no falls last 3 month, vision adequate, gait/balance was jerking or unsteady when making turns, no blood pressure drop between lying and standing, takes 3-4 of the medications, non of the predisposing diseases. Level one and II are not used . Level 1 was not used -orientation due to cognitive status and [DIAGNOSES REDACTED]. Orient resident to environment, bed in low position, assess room, remove obstacles, assist with ADL's and elimination as needed, Keep necessary items within reach, Use non skid footwear, educate family and resident regarding fall prevention and frequency reinforce. Record review of Face Sheet revealed that resident 12 had dx of unspecified dementia with behavioral disturbance, major [MEDICAL CONDITION], hx of TIA, Scoliosis, hx of fracture T11-12 vertebra. Record review of Care Plan for falls interventions dated-3/21/18 revealed; resident cannot remember to pull the call light prior to getting up, When getting up, ambulate with him with a gait belt. resident does not use a walker. Make sure resident has non skid footwear on when up and about. Keep room free of clutter. Make sure resident bed is in the lowest position at all times, Make sure his call light and frequently used items are within reach at all times when in room. if resident becomes unsteady encourage resident to sit down for a little while or help him to lie down. He uses a w/c for long distances. Record review of updated Care plan for falls revealed intervention dated 7/27/19 for purposeful rounding. Record review of Assessment due on 3/2019 and 6/2019 no documentation provided by the facility. F) Resident #52 08/05/19 10:10 AM fall with fracture fall assessment on 9 At approximately 10:50 AM yelling in the bathroom. When entered restroom resident was noted to be on floor. Resident was sitting-up leaning against wall in bathroom in front of toilet under grab bar. Resident reports she slipped and fell . Resident is independent with ambulation and ADL's. NO moisture noted to the floor and good traction present to floor. No debris on floor. Resident denies feeling light headed or dizzy prior to fall. Resident has legs stretched out in front of her Right Leg was noted to be externally rotated with shortening noted. Resident yell in pain to the right inner groin. Resident taken to the ER, DON, 06/25/19 call from daughter revealed that the resident has a [MEDICAL CONDITION]. Resident was transferred to Bryan Hospital Fall Non Employee Related dated 6/25/19 revealed that the Resident was found on the floor in the restroom. Right Lower Extremity was noted to be externally rotated with shortening present. Resident reports severe pain to the right Groin. Resident related and care for in SMC ER transferred to higher level of care resident returned to DMS LTC for skilled nursing and working with therapy. Purposeful Rounding initiated. Occurrence closed 7/1/19. No environmental factors contributed, Medications were antihypertensive medication. No patient related factors. No devices. What fall preventions were in place N/A DON notified sent to ER, PCP was faxed, POA called left message to return call. Injury to right hip sent to ER to be evaluated. Test sent to ER for Xray. Vitals post fall 98.6-68-22-214/119. Unassisted fall. What intervention implemented after fall -YES was the response. Please indicate factors that may have contributed to occurrence. New medications?Mental status Change? Resident resides on a lock memory unit Record review of Fall assessment dated [DATE] revealed that Resident 52 had intermittent confusion. History of 1-2 falls per month, ambulatory and continent. Vision adequate, Gait balance normal, No noted drop between laying and standing BP. No medication taken in the last 7 days (anesthetic, [MEDICATION NAME], antihypertensive, [MEDICAL CONDITION], Benzodiazapine, cathartics, Diuretics, Hypoglycemics, Narcotics, [MEDICAL CONDITION], sedatives and Hypnotics. Predisposing diseases: HTN< [MEDICAL CONDITION]< [MEDICAL CONDITION]< Loss of limb> arthritis, [MEDICAL CONDITION], fractures None. TOTAL SCORE WAS: 0-10-- a 6 Initiate Universal Safety Precautions on all residents. LEVEL Record review of Physician Orders record revealed that Resident 52's medications were [MEDICATION NAME] 25mg (Hypertension) PO daily date initiated 11/21/18, ASA 81 mg (CAD) daily initiated 8/15/18, [MEDICATION NAME] 20mg (HTN) daily initiated 11/12/18, [MEDICATION NAME] 3mg 1 hour before bed, [MEDICATION NAME]-S PO Q HS (constipation), Milk of magnesia 30ML PO daily PRN (Constipation), [MEDICATION NAME] 10 mg suppository Daily PRN (Constipation), [MEDICATION NAME] 20 mg tablet daily PRN for (seasonal allergies [REDACTED].) Tylenol 325-650 mg, Q 4-6 hours (fever), Tylenol 325-650 mg Q4-6 hours (mild pain), [MEDICATION NAME] 4mg PO Q8 hours (NV), [MEDICATION NAME] 5/325mg Q6 hours PRN (Pain) Fall assessment dated [DATE] revealed that Resident 52 had intermittent confusion. History of 1-2 falls per month, chair bound and or assist with ambulation. Poor with or without glasses, Gait balance problem with standing and walking and requires an assistive device while walking, no noted drop between laying and standing BP. Takes 3-4 of these medications (anesthetic, [MEDICATION NAME], antihypertensive, [MEDICAL CONDITION], Benzodiazepine, cathartics, Diuretics, Hypoglycemic, Narcotics, [MEDICAL CONDITION], sedatives and Hypnotics. Predisposing diseases: HTN< [MEDICAL CONDITION]< [MEDICAL CONDITION]< Loss of limb> arthritis, [MEDICAL CONDITION] fractures 1-2 of these. TOTAL SCORE WAS: 0-10-- a 19 Initiate Universal Safety Precautions on all residents and Level II LEVEL I The facility was unable to provide a fall assessment for Feb or (MONTH) 2019. Added medication Dated 4/29/19 was [MEDICATION NAME] 3 MG 1 hour before bed. [MEDICATION NAME] 20 mg daily 11/12/18 HTN, [MEDICATION NAME] 5/1/19 was [MEDICATION NAME] S PO HS for constipation, claritan 10mg daily PRN Noted to have an order dated 11/12/18 Resident 52 [MEDICATION NAME] 20 mg daily report BP's in 2 weeks. Blood pressures are done. Sleep assessment Resident 52 has [MEDICATION NAME] order 3mg Give 1 hour before Bedtime. 08/08/19 02:22 PM An interview with the DON confirmed that Resident 52 did not have a sleep study done for the start of the [MEDICATION NAME] and that the staff is not reporting blood pressure every 2 weeks. Fall Care Plan revealed dated 8/13/19 revealed call light in reach, encourage rest periods throughout day, Fall Risk Quarterly and PRN, Keep Pathways clear, Keep surroundings familiar. Remind to call for assist, reorientation resident to self and environment as needed, dated 7/29/19 Resident has silent pressure alarm in place to alert staff to unsafe movement. MDS dated [DATE] revealed C BIMS 03 G0110A1 0/0, GA0110B 0/0, C 0/0 D 1/0, [NAME] 1/0, F1/0, G 2/2, H 1/1, I 3/2, J 2/2, G0300 A-E revealed that the resident was steady at all times. I-HTN, Non -alzhiemers dementia, IBS, Unspecified dementia without behavioral disturbance, MDS dated 9 revealed C BIMS 04 G0110A1 0/1, GA0110B 1/1, C 0/1 D 1/1, [NAME] 1/1, F1/1, G 2/2, H 1/1, I 3/2, J 2/2, G0300 A-E revealed that the resident was steady at all times. I-HTN, Non -alzhiemers dementia, IBS, Unspecified dementia without behavioral disturbance, Record review of the Medication Administration Record [REDACTED]. 6 An interview 08/12/19 12:27 PM with the MDS Coordinator confirmed that the process to update care plans prior to the assessment due date. AHT had told them that the process to save the assessments was not done correctly and that they would not be saved.

Based on interview and record review, the facility failed to document advance directives on the care plan for 1 resident (Resident 9). This had the potential to affect all residents in the facility. Facility census was 58. Findings are: Review of Resident 9's Face Sheet dated 8/5/19 revealed the advance directives listed the resident's resuscitation status as do not resuscitate. Review of Resident 9's Care Plan dated 8/5/19 revealed an absence of documentation related to advance directives. Review of Residents' Rights Regarding Treatment and Advance Directives effective 8/2019 revealed advance directives would be periodically reviewed as part of the care planning process, and any decision-making regarding a resident's choices would be documented in the resident's medical record and communicated to staff responsible for the resident's care. Interview on 08/07/19 at 10:40 AM with the MDS-C (Minimum Data Set Coordinator) revealed Resident 9's advance directives were not documented on the care plan, and the facility did not include advance directives on any of the resident's care plans.