Every finding on record at Southlake Village Rehabilitation & Care Center

Licensure Reference Number 175 NAC 12-006.04(B)(ii)1Based on record review and interviews, the facility failed to ensure 1 out of 5 Nursing Assistant (NA) sampled nurse aides had completed at least 12 hours ongoing training, including abuse prevention and dementia management training annually based upon their employment date as required and the facility failed to ensure 1 (NA) out of 5 sampled NA's had a performance review at least once every 12 months as required. This had the potential to affect all residents who reside within the facility. The facility had a census of 123 at the time of survey. Findings are:Record review of the facility's Facility Assessment with a revision date of 8/1/2025 revealed a facility must develop, implement and maintain an effective training program for all new and existing staff.Review of undated facility policy, titled NetLearning enrollment and Completion Tracking revealed:-all team members are expected to complete their assigned NetLearnings prior to annual review date.-this ensures that all team members are current on all required education as part of their performance evaluation process. -NetLearning generates weekly email notifications to leadership and department supervisors and supervisors are expected to meet with team members one-on-one to discuss outstanding NetLearnings and provide a printed copy of the conversationReview of the facility Employee Handbook dated 1/2024 revealed that several years ago a team met to redesign the Performance Evaluation and that team members will have the opportunity to discuss their job and performance improvement annually. The facility provides the opportunity for the supervisor and team member to discuss the team members strengths and future growth plans. Department supervisors are responsible for conducting the discussion. A record review of an undated facility provided list of staff names and dates of hire revealed that NA - B was hired on 11/22/2022.A record review of NA - B's NetLearning Transcript as of 9/2025 revealed no course transcript for the last year.A record review of the staffing schedule dated 8/24/25 through 9/25/25 revealed that NA - B worked the floor on 8/24, 8/30, 8/31, 9/6, 9/7, 9/13, 9/14, 9/20, and 9/21/25. During an interview on 09/25/2025 at 2:24 PM with NA - C (staffing scheduler) confirmed that NA-B did work the floor on 8/24, 8/30, 8/31, 9/6, 9/7, 9/13, 9/14, 9/20, and 9/21/25. During an interview on 09/25/2025 at 12:55 PM the Director of Nursing (DON) confirmed that (gender) does the annual review for nursing staff and reviews their NET learning.During an interview on 09/25/2025 at 1:40 PM Licensed Practical Nurse (LPN) - A confirmed that all staff need to have 12 hours of training each year. During an interview on 09/25/2025 at 1:44 PM Clinical Support Liaison (CSL) confirmed that NA - B hasn't had their required education for the past 2 years. Last year NA - B was not in compliance and did not have any abuse prevention or dementia management training. During an interview on 09/25/2025 at 2:31 PM the DON confirmed that NA - B did not complete the paperwork or meet criteria for [DATE] and she did not get an evaluation. During an interview on 09/25/2025 at 2:35 PM CSL confirmed that the Building the Best of the Best (BBB) program does not believe the annual evaluation is about the past mistakes, it is supposed to focus on the future. All staff members are in a constant evaluation.A record review of NA - B's personal file revealed there was not a PIP (performance improvement plan) in place regarding continuing education and that there was not a performance evaluation.Record review of NA - B's nurse aide/med aide competency check off dated 7/22/25 revealed skills reviewed. It did not reveal performance evaluation or continuing education. During an interview on 9/25/2025 at 2:41 PM CSL also confirmed that NA - B was not on a performance improvement plan and her training/education had been acknowledged but was not addressed.During an interview on 09/25/2025 at 3:29 PM the Administrator (Adm) confirmed that NA - B had not had a performance evaluation in over a year. The last documented addressed concern with NA - B was dated January of 2024. The Adm also confirmed there was no facility policy regarding performance evaluations.

Licensure Reference Number 175 NAC 12-006.11 Based on observations, record reviews and interviews, the facility failed to follow the menu when preparing food for residents on pureed diet. This had the potential to affect 6 residents who receive a pureed diet. The facility census was 123. A record review of residents receiving pureed diets revealed that there are six residents receiving pureed diets.A record review of the recipe for Pureed Beef Stroganoff Casserole revealed: A recipe for 5 servings:Beef, Stroganoff entree, 1 quart 2 cups, Beef Broth 2 cupsPlace prepared stroganoff casserole and broth in a food processor, blend until smooth. Add any food thickener as needed. Portion size 2- #8 scoops. A observation on 9/29/25 at 7:00 AM revealed that the Production [NAME] (PC) was preparing pureed Beef Stroganoff Casserole. PC was wearing a skull cap with hair on the back of her neck/ears/and bangs being exposed. PC had a 1 quart container of noodles already cooked and PC then poured the noodles into the food processor. PC then went to the refrigerator and pulled a pan of beef tip and gravy out and placed on the counter. PC took out a spatula and did 2 spatulas scoops of the beef tips and placed in the food processor with the noodles. PC had 2 cups of beef broth in a measuring cup and poured a little at a time into the blender till PC got the consistency of applesauce. Approximately 1/2 cup of the beef broth was left in the measuring cup. PC then placed the pureed mixture into metal pans and then covered the pans with lids and placed in oven. A record review of the Policy: Standardized recipes are used when preparing menu items with no dated revealed: Cooks are trained and expected to use and follow the recipes provided. An interview on 09/29/2025 8:50 AM with the Registered Dietician (RD) confirmed that PC should of used a scoop that has measurements on them instead of a spatula. RD confirmed that PC should of followed the recipe and PC did not follow the recipe.

Licensure Reference Number: 175 NAC 12-006.05(H)(vi)(3)(g)Based on record review and interview, the facility failed to ensure that valid and appropriate Power of Attorney (POA - a legal document that allows someone to act on another person's behalf) and advance directive documentation (a legal document that states a person's wishes about medical care if they can no longer make decisions) were maintained for Resident 9, who had severe cognitive impairment (a condition where thinking, memory, and decision-making abilities are significantly reduced). This affected 1 of 4 sampled residents. The facility census was 123. Findings are:Record review of Resident 9's admission Social Services Review dated [DATE] said no advance directives or POA were on file. Documentation showed a call was made to the daughter regarding POA, but no response was received. The record also showed a Brief Interview for Mental Status (BIMS - a test used in nursing homes to measure thinking ability, scored 0-15) with a score of 2, which indicates severe cognitive impairment, confirming inability to make legal or medical decisions.Record review of Resident 9's Quarterly Social Services Review dated [DATE] said no POA was on file and that staff had not received responses from the daughter regarding follow-up care needs.Record review of progress notes through [DATE] revealed no documentation of POA acquisition. On [DATE], the facility produced a faxed copy of a General Power of Attorney form dated [DATE], obtained from a prior facility. The document designated the daughter as attorney-in-fact (a person allowed to act under a POA) but was a general POA only and did not designate medical (health care) or financial authority.Record review of Resident 9's Do Not Resuscitate (DNR - a legal order not to perform CPR if breathing or heartbeat stops) form showed two signatures: one by the resident and a second entry showing the daughter's name written with a forward slash beside it. The daughter's name appeared as though she signed in place of the resident, despite not holding medical or financial POA authority.Record review of the Clinical Resident Profile dated [DATE] showed the resident's code status listed as DNR/Do Not Attempt Resuscitation. The profile documented POA invoked for resident: No. The daughter was listed only as Emergency Contact #1 and Responsible for Trust, but not as medical or financial POA. This conflicted with the General Power of Attorney document faxed to the facility on [DATE], which was limited to general powers and did not authorize medical or financial decision-making.An interview with the Social Services Coordinator on [DATE] at 10:48 AM confirmed that the facility tracks POA status during quarterly assessments (reviews of care done every three months) and attempts outreach (phone calls or emails) when documentation is missing. The Social Services Coordinator stated the only documented outreach for Resident 9 was on [DATE], with no follow-up documentation until the general POA was received via fax to the current facility on [DATE] from a previous facility where Resident 9 had resided. The Social Services Coordinator confirmed the POA form on file is general only and does not grant medical or financial authority.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, record reviews and interviews, the facility failed to contain hair while preparing meals for the residents. This had the potential to affect all residents in the facility. The facility census was 123. An observation on 9/24/25 at 8:00 AM in the kitchen revealed that Production cook (PC) was wearing a skull cap. PC had bangs hanging out of skull cap, and hair hanging on both ears and hair hanging out of the skull cap down to the neckline. PC was preparing the lunch meal.An observation on 9/25/25 at 9:30 AM revealed that PC was wearing a skull cap. PC had bangs hanging out of skull cap, and hair hanging on both ears and hair hanging out of the skull cap down to the neckline. PC was preparing the lunch meal. An observation on 9/29/25 at 7:00 AM revealed that PC was preparing pureed Beef Stroganoff Casserole. PC was wearing a skull cap with hair on the back of her neck/ears/and bangs being exposed. An observation of Culinary Chef (CC) was wearing a skull cap with hair hanging down on ears and back of neck and forehead. CC was putting food away from delivery in the freezers. An observation of PC (wearing the skull cap with bangs hanging out of skull cap, and hair hanging on both ears and hair hanging out of the skull cap down to the neckline) had a 1-quart container of noodles already cooked and poured the noodles into the blender. PC then went to the refrigerator and pulled a pan of beef tip and gravy out and placed it on the counter. PC took a spatula and did 2 scoops of the beef tips and placed the beef tips in the blender with the noodles. PC had 2 cups of beef broth in a measuring cup and poured a little at a time into the blender till cook 1 got the consistency of applesauce. PC then placed the pureed mixture into metal pans and then covered the pans with lids and placed it in the oven. A record review of the Policy: Satellite Kitchen responsibility with no date revealed:Clock in, place on hair covering, wash hands. A review of the food code 2-402 Hair Restraints 2-402.11 EffectivenessFood employees shall wear hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. An interview on 9/29/25 at 9:30 AM with the Dietician confirmed that the hair is restraint but not completely covered. The dietician confirmed that all the hair should be covered and the hair is not.

Licensure Reference Number 175 NAC 12.007.04(D) ventilation systemBased on observation, interview, and record review, the facility failed to have functional bathroom ventilation in six resident rooms (rooms 302, 309, 312, 313, 316, and 418) out of 30 rooms surveyed. The facility census was 123.Findings: An observation on 9/24/2025 during the initial tour, it was revealed rooms (302, 309, 312, 313, 316, and 418) bathroom vents were not functioning when tested with one ply tissue. An observation on 9/29/2025 at 7:23 AM revealed rooms (302, 309, 312, 313, 316, 414, and 418) bathroom vents were not functioning when tested with one ply tissue. On 9/29/2025 at 7:46 AM during a tour with maintenance, it was revealed the bathroom vents in rooms (302, 309, 312, 313, 316, and 418) were not functioning. In an interview on 9/29/2025 at 7:46 AM, maintenance confirmed the bathroom vents were not functioning in rooms (302, 309, 312, 313, 316, and 418) during the tour. It was confirmed that the preventative maintenance is performed quarterly, and the filters were due to be changed soon, and there was possibly dust build up. In a record review of the Facility's undated Logbook Documentation titled Inspect exhaust fans for proper operation and clean if necessary revealed the inspection of the vent fans include proper functioning and cleanliness. In a record review of the Facility's Logbook Documentation dated 6/19/2025, 7/16/2025, 8/1/2025, and 9/17/2025 revealed the vent inspections were marked as being completed on-time but did not reveal the status of the inspections. In an interview on 9/29/2025 at 12:53 PM with maintenance confirmed when the inspections are completed, a note is placed in the system regarding the status of the inspection. In a record review on 9/29/2025 at 12:56 PM of the Facility's Work History Report dated for the past 12 months revealed the exhaust fans were inspected and functional as of 6/30/2025. The monthly inspections dated 7/31/2025, 8/31/2025, and 9/30/2025 were marked as completed but did not indicate the status of the inspection. In an observation on 9/30/2025 it was revealed the bathroom vents were not functioning in rooms (302, 306, 309, 316, and 418).

Licensure Reference Number 175 NAC 12-006.17D Based on observation, interviews, and record review, the facility failed to ensure that staff performed hand hygiene (sanitizing)using hand sanitizer or wash hands with soap and water for at least 20 seconds during resident treatment to prevent cross contamination for 1(Resident 17 )of 4 sampled resident. The facility census was 116. Finding are: An observation of wound care on Resident 17's left foot on 8/2/23 at 6:45 AM revealed Licensed Practical Nurse(LPN-A)gathered supplies for wound care, walked into Resident 17's room, and placed supplies on bedside table that had a barrier. LPN-A applied gloves without performing hand hygiene and removed Resident 17's dressings from left foot. LPN-A then changed gloves without performing hand hygiene. LPN-A cleansed the wounds with wound cleanser. LPN-A measured the wounds then removed gloves and donned new gloves on without performing hand hygiene. LPN-A applied Medihoney ointment with a Q-tip to lateral(outer area)of left foot wound bed and covered wound with Allevyn dressing. LPN-A then applied skin prep to medial(inside area)of left foot toe wound and covered with Allevyn dressing. LPN-A removed gloves and placed them in the trash bag. LPN-A then washed her hands with soap and water for 20 seconds. An Interview with LPN-A on 8/2/23 at 6:59 AM confirmed that hand washing needed to be completed prior to wound cares and when finished with wound cares. LPN-A confirmed that hand hygiene should be performed between changing of gloves. An Interview with Director of Nursing(DON on 8/2/23 at 9:45 AM confirmed that the expectation for hand hygiene with wound dressing changes is to perform hand hygiene prior to dressing change, in between changing the gloves, and when wound care is finished. Record review of Hand Hygiene Policy dated 9/12/17 revealed Procedure: 1. Hand hygiene is to occur: Before and after patient contact After removing and disposing of gloves and other protective equipment After contact with blood, body fluids, mucous membranes, non-intact skin, and wound dressings After contact with inanimate objects or medical equipment close to patient Record review of Hand Hygiene Competency form dated 12/2019 revealed Procedure Step: When to wash hands: Before each resident contact Before and after gloving. Hand Hygiene using Hand Sanitizer: Examples: Before and after direct contact with resident After removing gloves or between changing gloves

Licensure Reference Number 175 NAC 12-006 Based on observation and interview; the facility failed to ensure that the medication cart was secured when left unattended to prevent the potential for diversion of medications for 2 out of 6 medication carts in the building. The facility census was 118 at the time of survey. Findings are: A. An observation on 1/24/23 at 10:56 AM on the College View Hall medication cart was found to be unlocked with the keys in the top drawer. An interview on 1/24/23 at 10:59 AM with Registered Nurse (RN) - B (ADON) Assistand Director of Nurses confirmed that the medication cart should have been locked and the keys should not have been in the cart. B. An observation on 1/24/23 at 11:28 AM on the [NAME] Hall the medication cart was found to be unlocked. An interview on 1/24/23 at 11:32 with Licensed Practical Nurse (LPN) - A confirmed that the medication cart should have been locked.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and interview; the facility staff failed to implement ordered interventions to prevent pressure ulcers for 1 (Resident 4) of 4 sampled residents. The facility staff identified a census of 118. Findings are: Record review of Resident 4's Minimum Data Set (MDS; a federally mandated assessment tool used in care planning) dated 1-19-2023 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was a 2. According to the MDS Manuel a score of 0 to 7 indicate severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -Had pain indicators. -At risk for the development of pressure ulcers. Record review of Resident 4's Comprehensive Care Plan (CCP) dated printed on 1-25-2023 revealed Resident 4 was at risk for decreased skin integrity and/or pressure ulcers related to decreased mobility. The goal identified for Resident 4 was that Resident 4's skin would be free from complication. Interventions identified on Resident 4's CCP printed on 1-25-2023 included encouraging Resident 4 to elevate the legs when resting, float heels using pillows or off loading boots as needed and provide pressure relieving devices to the chair and bed at all times. Record review of Resident 4's Order Summary Report signed by Resident 4's practitioner on 1-12-2023 revealed Resident 4 was to wear Prevalon boot ( type of pressure reliving foot wear) to both feet at all times. Observation on 1-24-2023 at 11:50 revealed Resident 4 was up in a wheel chair seated at the dinning room table. Resident 4 did not have the Prevalon boots on. Observation on 1-24-2023 at 1:08 PM revealed Resident 4 was seated in the recliner and did not have the Prevalon boots on. Observation on 1-24-2023 at 2:37 PM revealed resident 4 was seated in a recliner and did not have the Prevalon boots on. Observation on 1-24-2023 at 3:20 PM revealed Resident 4 was seated in a recliner and did not have the Prevalon boots on. Observation on 1-24-2023 at 3:45 PM revealed Resident 4 remained seated in a recliner and did not have the Prevalon boots on. Observation on 1-25-2023 at 7:20 AM revealed resident 4 was seated in a wheel chair in the dinning room. Resident 4 did not have the Prevalon boots on. Observation on 1-25-2023 at 9:30 AM revealed resident 4 was seated in a recliner and did not have the Prevalon boots on. On 1-25-2023 at 9:40 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview LPN D confirmed Resident 4 did not have the Prevalon boots on. When asked if Resident 4 was to wear the Prevalon boots at all times, LPN D reviewed Resident 4's Order Summary Report sheet signed on 1-12-2023 and confirmed Resident 4 was to wear the Prevalon boots at all times.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observations, record review and interview; the facility staff failed to implement interventions to manage pain for 1 (Resident 4) of 1 sampled resident. The facility staff identified a census of 118. Findings are: Record review of Resident 4's Minimum Data Set (MDS; a federally mandated assessment tool used in care planning) dated 1-19-2023 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was a 2. According to the MDS Manuel a score of 0 to 7 indicate severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -Had pain indicators. -At risk for the development of pressure ulcers. Record review of Resident 4's Comprehensive Care Plan (CCP) printed on 1-25-2023 revealed Resident 4 was identified as having pain related to generalized discomfort. The goal identified for Resident 4 was to be free of any discomfort or adverse side effects from pain medications. Intervention included the following: -Assessing the need for preventative pain measures prior to Activities of Daily Living (ADL's), treatments, exercise and etc. -Medications per practitioner's orders. -Non-pharmacological interventions such as offering repositioning, warm/cold compresses's, lighting changes, etc. Observation on 1-25-2023 at 9:30 AM of a wound treatment to Resident 4's back revealed Licensed Practical Nurse (LPN) D and Nursing Assistant (NA) E donned gloves and explained to Resident 4, while seated in a recliner, that the treatment to Resident 4's back was going to start. NA E began to pull Resident 4 forward in the recliner causing Resident 4 to yell out that hurts, that hurts, oh, that hurts with Resident 4's face becoming red and indications of holding the breath with mouth clinched. Both NA E and LPN D both said I know; I know and continued with the treatment. LPN D removed the dressing from the back of Resident 4's wound area causing Resident 4 to yell out Oh my god that hurts, that hurts. Both LPN D and NA E stated I know, we're almost done. Staff did not stop the treatment and offer interventions to manage Resident 4's pain. LPN D obtained a 4 by 4 gauze sponge, applied soap as order and began to cleans the wound on Resident 4's back. Resident 4 yelled out oh that hurts, that hurts as LPN continued to cleanse the wound. Resident 4's face was redden as LPN D continued to cleanse the wound. Observation of the wound revealed area measured approximately the size of a nickel. Staff do not stop the treatment and offer pain medications, or other interventions to manage Resident 4's pain. LPN D obtained the ordered ointment and using a Q-Tip applied the ointment to Resident 4's wound. Resident 4 yelled out oh that hurts, that hurts. LPN D obtained and applied the cover dressing to Resident 4's back. On 1-25-2023 at 9:40 AM an interview was conducted with LPN D. During the interview LPN D confirmed Resident 4 had pain. When asked what was to happen if Resident 4 had pain, LPN D stated we are supposed to stop and see if they need something else and give them a break. Record review of the facility Pain Management Standard policy dated 1-2017 revealed the following: -Key Elements: -Residents will be pain free, or pain will be managed to the level that is acceptable to the resident. -Pain is frequently under-treated in cognitively impaired residents. -Elderly may show atypical signs of pain or may not exhibit the expected signs and symptoms to the degree as younger patients. -Potential Causes of Pain in the Elderly: -Stiffness due to inactivity. -Pressure ulcers. -Spinal column disorders. -Persistent back pain. -Non-specific signs and symptoms that may suggest the presence of pain: -Bracing, guarding or rubbing. -Frowning, grimacing, fearful, facial expressions, grinding of teeth, groaning, breathing heavily. -Pain Prevention: -2. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations record review and interview; the facility staff failed to ensure 1(Resident 2) of 12 sampled residents were free of significant medication errors. The facility staff identified a census of 118. Findings are: Record review of Resident 2's Order Summary Report sheet printed on 1-24-2023 revealed Resident 2's practitioner ordered medications that included Novolog insulin. According to the ordered instructions for the administration of the Novolog insulin, staff were to hold the Novolog insulin if Resident 2 skips a meal. Observation on 1-24-2023 at 10:40 AM revealed Licensed Practical Nurse (LPN) F prepared Resident 2's medications not including the Novolog insulin and administered the medications to Resident 2. LPN F reported Resident 2's Novolog insulin would be held until Resident 2 ate lunch. Observation on 1-24-2023 at 11:50 AM revealed LPN prepared Resident 2 Novolog insulin of 10 units to be given. On 1-24-2023 at 11:50 AM a interview was conducted with LPN F. During the interview LPN F reported Resident 2 had eaten lunch. When asked if LPN F was going to administer the Novolog insulin, LPN F stated yes. During the interview review of Resident 2's Novolog insulin orders were reviewed. During the interview LPN F confirmed the Novolog insulin was to be held if Resident 2 skips a meal. LPN F confirmed Resident 2 did not eat breakfast and confirmed that would be considered skipping a meal and the Novolog insulin should have been held. LPN F confirmed that would be a significant medication error.

Licensure Reference Number 175 NAC 12-006.17A(1) Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) required Personal Protective Equipment (PPE) for a resident in a Gray Zone isolation room. This had the potential to affect all residents that resided in the facility. Total census is 117. Findings are: An observation on 08/24/2022 at 11:58 AM revealed Physician's Assistant (PA)-E, and Medication Aide (MA)-F entered Resident 7's room, visited with the resident, and exited Resident 7's room. Both PA-E and MA-F only had a surgical mask on during the visit. In an interview on 08/24/2022 at 11:58 AM, Registered Nurse (RN)-G confirmed PA-E and MA-F was not wearing an N95 mask, eye protection, gown, or gloves when entering Resident 7's room and should have been. In an interview on 08/24/2022 at 01:40 PM, the Director of Nursing (DON) confirmed NA-D, PA-E, and MA-F should have donned an N95 mask, eye protection, gown, and gloves before entry into Resident 7's room per the sign posted on the door that it was a Gray Zone Isolation room and what PPE was required.

Licensure Reference Number 175 NAC 12-006.11C Based on observation, interview, and record review, the facility failed to ensure the ovens, ranges, utensils, and backsplashes had been maintained in a clean and safe operating condition to prevent the potential for food-borne illness, and the facility failed to ensure meals were served without the potential for cross contamination by gloves worn and not changed between tasks, thumbs touching the eating surfaces of plates, and no eye protection worn in the dining room. This had the potential to affect 111 residents consuming food from the kitchen. Total census was 114. Findings are: A. Record review of the undated Sanitation Policy revealed the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves and equipment shall be kept clean. Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequent enough to prevent accumulation of grime. An observation 500 hall kitchen on 05/12/2022 at 07:30 AM revealed the range, the oven, and the range backsplash had a sticky coating of grease and debris on the surfaces. 2 of the hanging ladles (scoops) were visibly soiled and 1 had debris on it. There was a white crust and debris on the floor behind the ice maker. An observation of the 300-hallway kitchen on 05/12/2022 at 07:45 AM revealed a thick layer of a gray, fuzzy substance on the chemical cleaning system above the sink. The reach-in refrigerator vents had a gray, fuzzy substance on the surface. The range had a thick black, crusty substance on the burners. The range backsplash had a sticky, brown, fuzzy substance on the vertical surface. The oven had several streaks of a sticky brown substance on the sides. There was a dried green substance on the back of the bottom shelf of the steam table where cookware was stored. In an interview on 05/12/2022 at 08:24 AM, the Dietician confirmed the Dietician seen the 500 hall kitchen range, oven, range backsplash had a sticky coating of grease and debris on the surfaces, there was a white crust and debris behind the ice maker, there was a gray fuzzy substance on the chemical system above the sink in the 300 hall kitchen, there was a green crusty substance on the bottom shelf of the 300 hall steamtable, the range had a thick black crust on it, and the oven and range backsplash of the 300 hall kitchen had a sticky, brown substance and debris on the surfaces and all should have been clean. B. An observation on 05/09/2022 at 11:32 AM revealed Nursing Assistant (NA)-N walking down the 500 resident hall and serve 4 residents in the 500 resident hall dining room with NA-N's eye shield on top of the head. An observation on 05/09/2022 at 11:37 AM revealed NA-O serving 6 residents in the 500 hall dining room without performing hand hygiene (cleaning). An observation on 05/10/2022 at 06:50 AM revealed Dietary Cook-R perform an 8 second hand wash with soap and water between puree (cooked food that has been ground, pressed, or blended to the consistency of a creamy paste or liquid) processes and a 10 second handwash with soap and water between puree processes. An observation on 05/10/2022 at 07:45 AM revealed the Dietician performed an 8 second hand wash with soap and water prior to starting the food prep process and a 5 second hand wash with soap and water prior to the puree process. An observation on 05/10/2022 at 07:45 AM revealed Dietary Cook-K touched the inside of a food bowl with his gloved thumb. An observation on 05/11/2022 at 12:30 AM revealed Dietary Cook-L performed a 10 second hand washing with soap and water during the food prep process and touched the sides of the mixer bowl and then use the same gloved hand to wipe the cake batter out of the mixer bowl into the cake pan. An observation on 05/12/2022 at 07:30 AM revealed Dietary Cook-M touched the eating surfaces of the plates and bowls during the serving process. In an interview on 05/11/2022 at 04:01 PM, the Dietician confirmed that handwashing should be a full 20 seconds with soap and water. In an interview on 05/12/2022 at 08:24 AM, the Dietician confirmed that plate and bowl serving surfaces were not to be touched prior to serving the residents. In an interview on 05/12/2022 at 12:30 PM the Director of Nursing (DON) confirmed that staff was not to touch the top or food surfaces of plates, bowls, or glasses. The DON confirmed that the staff is to wear eye protection over the eyes in all resident care areas. An observation on 05/10/22 at 08:15 AM revealed NA-AA to be passing meal trays and liquids, getting cups out of the cupboard with gloves on, then sat down to assist a resident with the meal and did not change gloves or perform hand hygiene. An observation on 05/10/22 at 08:17 AM revealed LPN-W in the dining room during breakfast and began checking oxygen saturation levels and a resident temperature while residents were having breakfast. An observation on 05/10/22 at 08:35 AM revealed that LPN-W had served a piece of toast to a resident while touching the eating surface of the plate with the thumb. An interview on 05/12/22 at 12:25 PM with the DON confirmed gloves should be changed and hand hygiene performed between tasks in the dining room and plates should be delivered in a manner that eating surfaces are not touched.

Licensure reference 175 NAC 12-006.12E7 Based on observation and interviews, the facility failed to ensure potentially expired and expired medications weren't available for resident use and outdated lab supplies weren't available for resident use on six of eight medication and treatment carts and in the medication room. The facility also failed to ensure medications left in rooms for 2 (Resident 3 and Resident 100) were secured. Sample size was 24 sampled residents. The facility census was 114. A. Observation on 05/10/22 at 2:00 PM of the 200 Hall medication cart revealed: -1 open and undated [MEDICATION(S)] insulin vial. -1 open and undated [MEDICATION(S)] insulin pen. -1 open and undated bottle of Artificial Tears eyedrops. -1 open and undated bottle of [MEDICATION(S)] gel drops. -1 open and undated bottle of [MEDICATION(S)] nose spray. -1 open and undated bottle Gentle Tears. Observation on 5/10/22 at 2:05 PM of the as needed medications on 200 Hall revealed: -1 expired bubble pack of [MEDICATION(S)] capsules. -1 expired bubble pack of Mucinex tablets. -1 open and expired tube of [MEDICATION(S)] ointment. -3 open and expired bottles of Nyacinamide powder. -1 open and expired tube of Arthritis Pain Cream. -1 open and expired bottle of Caladryl lotion. -1 open and expired box of Ipratroprium-[MEDICATION(S)] breathing treatments. Interview with Licensed Practical Nurse (LPN)-W on 5/10/22 at 2:30 PM confirmed the expired and undated medications on the 200 Hall medication cart. B. Observation on 5/10/22 at 2:30 PM of 600 Hall medication cart revealed: -1 open and undated bottle of [MEDICATION(S)] eye drops. -1 open and undated bottle of Latanaprost eye drops. -1 open and undated bottle of Ketotifen eye drops. -1 open and undated bottle of Latanoprast eye drops. -1 open and undated [MEDICATION(S)] Insulin pen. Interview with LPN-G on 5/10/22 at 2:35 confirmed the undated medications on the 600 Hall medication cart. C. Observation on 5/10/22 at 2:40 PM of 100 Hall medication cart revealed: -2 open and undated bottles of [MEDICATION(S)] eye drops. -1 expired bubble pack of [MEDICATION(S)] tablets. -1 expired bubble pack of [MEDICATION(S)] tablets. -1 open and undated vial of [MEDICATION(S)] insulin. -1 open and expired tube of Hydrocortisone cream. -1 open and expired tube of Triple Antibiotic ointment. Interview with RN-X on 5/10/22 at 2:45 confirmed the expired and undated medications on the 100 Hall medication cart. D. Observation on 5/10/22 at 2:15 PM of 500 Hall medication cart revealed: -1 open and undated bottle of Olopataline eyedrops Interview with LPN-I on 5/10/22 at 2:18 PM confirmed the open and undated medication on the 500 Hall medication cart. E. Observation of the Medication storage room with the Administrator (ADM) revealed: -1 open and expired package of blue top blood draw tubes that was 3/4 full. Interview with ADM on 5/10/22 at 2:55 confirmed the open and expired lab supplies. F. An observation on 05/09/22 at 01:21 PM revealed [MEDICATION(S)] powder (used to treat fungal skin infections) was at the bedside in room [ROOM NUMBER] for Resident 100. An observation on 05/10/22 at 10:19 AM revealed [MEDICATION(S)] powder remained in the room on nightstand for Resident 100. An interview with the DON (Director of Nursing) on 05/11/22 at 08:55 AM revealed that the facility standard practice was that self-medication administration assessments were completed only when the resident requested to keep a med at bedside or requested to self-administer their medications. G. An observation on 05/11/22 at 08:15 AM revealed a plastic cup with pills in it setting on Resident 3's table. When asked if this was normal practice, Resident 3 stated normally they stand over me An interview on 05/11/22 at 08:20 AM with RN-Z, when asked about medications left in room [ROOM NUMBER] with Resident 3, voiced I left them with her because she asked me to, I was going back in but haven't made it yet. When asked if Resident 3 had a self-med assessment showing the ability and knowledge to self-administer medications, RN-Z voiced I don't know. An interview with the DON (Director of Nursing) on 05/11/22 at 08:55 AM revealed that the facility standard practice was that self-medication administration assessments were completed only when the resident requested to keep a med at bedside or requested to self-administer their medications. The interview confirmed that medications should not be left in resident rooms.

Licensure Reference 175 NAC 12-006.04C3a(6) Based on record review and interviews, the facility failed to notify the physician of a 17.27 % weight loss for Resident 44. This affected 1 of 1 residents sampled for notification of changes in condition. The facility census was 114. Findings are: A record review of Resident 44's weights revealed that on 12/08/2021, the resident weighed 124.5 pounds. On 02/28/2022, the resident weighed 103 pounds which is a -17.27 % Loss. A record review of the resident's Progress Notes from 12/25/21 to 5/9/22 at 6:13 AM revealed a Nutrition/Dietary Note from 3/9/22 at 9:28 PM that stated Nutrition quarterly assessment completed. [Resident 44] receives heart healthy diet with regular texture and thin consistency liquids as ordered. [Weight] on 2/28/22 was 103 [pounds]. [Body Mass Index] 17.1 is in underweight range. [Weight] down 11 [pounds] this assessment period. A Physician Visit/Communication Form was sent to Resident 44's provider on 4/12/22 reporting the resident's weight loss and requesting a nutritional supplement. A review of the Nutritional Status Documentation Audit with Revision date 4/2022 revealed: -Nutritional assessments are completed upon admission, every 90 days, and when there is a change of condition which impacts the ability to maintain acceptable parameters of nutritional status. -Care plans are kept current. -The physician is notified of all significant weight changes. An interview with the Food Service Supervisor/Registered Dietitian (FSS/RD) on 5/12/22 from10:15 to 10:30 AM confirmed that Resident 44's weight loss was documented on 3/9/22 and the physician was not notified until 4/12/22.

Licensure Reference 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) regarding weight loss for Resident 44 reflected the resident's current status at the time of the assessment. This affected 1 of 1 residents sampled for MDS accuracy. The facility census was 114. Findings are: A review of Resident 44's Quarterly MDS from 3/7/22 revealed the resident's weight as 110 pounds, and stated No or unknown for question K0300 loss of 5% or more in the last month or loss of 10% or more in last 6 months. A record review of Resident 44's weights since 12/8/21 revealed that the resident's most recent weight prior to the MDS was on 2/28/22 and was 103.5 pounds, which was more than a 10% loss. An interview with the facility dietician on 05/12/22 at 11:18 AM confirmed that the MDS dated [DATE] was inaccurate.

Licensure Reference Number 175 NAC 12-006.09C Based on observation, interview, and record review, the facility failed to include [CONDITION(S)]/BiLevel (a device used to deliver positive air pressure to a resident's airway to prevent closure during sleep) Unit in the Comprehensive Person-Centered Care Plan (a plan that provides direction on the type of nursing care the resident may need) for Resident 6, 33, and 61 and [CONDITION(S)] (puffiness caused by excess fluid trapped in the body's tissues) for Resident 89. This affected 4 of 5 sampled residents. Total census was 114. Findings are: A. Record Review of the facility's Comprehensive Care Plans Policy dated 11/28/2016 revealed the care planning process will include an assessment of the resident's needs and will described the services that were to be provided. An observation on 05/09/2022 at 10:38 AM of Resident 6's room revealed the resident had a [CONDITION(S)]/BiLevel unit on the nightstand with a visibly soiled mask draped over the unit and no black infection prevention bag was observed in the room. There was an oxygen machine in the restroom with tubing that was ran to the [CONDITION(S)]/BiLevel unit that was dated 02/06/2022. An observation on 05/10/2022 at 02:31 PM revealed Resident 6's [CONDITION(S)]/BiLevel unit was located on the nightstand with a visibly soiled mask on top of it. No black infection prevention bag was located in the room and the oxygen tubing was still dated 02/06/2022. An observation on 05/11/2022 at 06:35 AM revealed Resident 6's [CONDITION(S)]/BiLevel unit was located on the nightstand and the mask was in a different spot and visibly soiled. Oxygen tubing was dated 02/06/2022. Record review of Resident 6's medical record revealed that the resident's [CONDITION(S)]/Bilevel unit was not on the Comprehensive Person-Centered Care Plan. In an interview with the Health Information Manager (HIM) on 05/11/2022 at 07:33 AM confirmed Resident 6's [CONDITION(S)]/BiLevel unit should have been on the Comprehensive Person-Centered Care Plan but was not. B. Record Review of the facility's Comprehensive Care Plans Policy dated 11/28/2016 revealed the care planning process will include an assessment of the resident's needs and will described the services that were to be provided. An observation on 05/10/2022 at 08:34 AM of Resident 33's room revealed the resident had a [CONDITION(S)]/BiLevel unit on the nightstand with a visibly soiled mask laying on the nightstand. There was an oxygen machine in the room with tubing that was not dated. An observation on 05/10/2022 at 01:53 PM revealed Resident 33's [CONDITION(S)]/BiLevel unit was located on the nightstand with a visibly soiled mask laying on top of the nightstand. The undated oxygen tubing was laying on the bed. Record review of Resident 33's medical record revealed that the resident's [CONDITION(S)]/Bilevel unit was not on the Comprehensive Person-Centered Care Plan. In an interview with the Health Information Manager (HIM) on 05/11/2022 at 07:33 AM confirmed Resident 33's [CONDITION(S)]/BiLevel unit should have been on the Comprehensive Person-Centered Care Plan but was not. C. Record review of Resident 61 chart revealed use of a [CONDITION(S)] at night. Review of Resident 61's current comprehensive care plan revealed no indication on the care plan for the use of [CONDITION(S)]. On 5/11/22 at 2:00 PM an interview was conducted with LPN B (Licensed Practical Nurse) which confirmed that the [CONDITION(S)] was not addressed on the care plan. D. Observation on 05/09/22 at 01:50 PM of Resident 89's bilateral lower extremities revealed lower extremities were swollen. Observation on 5/10/22 at 10:25 AM revealed Resident 89's lower extremities were swollen. Record review of the current Comprehensive Care Plan revealed no indication that [CONDITION(S)] was addressed. Interview conducted with RN C (Registered Nurse) at 10:20 AM on 5/12/22 confirmed that [CONDITION(S)] had not been addressed on the care plan and that it should have been addressed as a problem. Review of the Comprehensive Care Plans Policy dated 6.2017 revealed The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and as needed.

Licensure Reference 175 NAC 12-006.09D3(5) Based on record review and interviews, the facility failed to prevent constipation for 1 resident (82) out of 1 sampled for constipation. The facility census was 114. Findings are: During the initial interview on 5/9/22 10:42 AM, Resident 82 revealed that (gender) suffered from constipation, and that sometimes it's so big it hurts to go. A review of Resident 82's bowel record from 4/13/22 to 5/11/22 revealed that from 4/27/22 to 5/2/22 the resident was marked as having no bowel movement (BM) for a total of 6 days, and that from 5/4/22 to 5/8/22 the resident was marked as having no BM for a total of 5 days. The resident was marked as having had a medium BM on 5/3/22. A review of Resident 82's Progress Notes revealed that the resident refused a Dulcolax (a [MEDICATION(S)]) suppository on 5/2/22 at 12:25 PM, and did receive some prune juice on 5/3/22 at 12:30 AM. A review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR further revealed that the resident received a Dulcolax suppository on 5/3/22 at 1:18 AM. The suppository was marked U for follow up, which is defined in the chart codes box on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with the Director Of Nursing (DON) on 5/11/22 at 8:55 AM revealed that the facility did not have a bowel care policy. An interview with the DON on 5/11/22 at 12:15 PM confirmed that the resident did not have a BM from 4/27/22 to 5/2/22 and from 5/4/22 to 5/8/22. After review of the bowel care record, the DON further confirmed that the resident's bowel care did not meet professional standards.

Licensure reference 175 NAC 12-006.09D5 Based on record review, interviews, and observations, the facility failed to implement a toileting program on 1 (Resident 74) of 1 sampled resident. The facility identified a census of 114. Record review of the Minimum Data Set (MDS: an assessment used to determine cares) for Resident 74, dated 1/6/22 revealed: the resident had a foley catheter for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS confirmed the resident was not on any type of toileting program. Resident 74 had a Brief Interview for Mental Status (BIMS) of 0. During observations the resident demonstrated the ability to answer Yes when asked if needed to use the restroom. Observation of Resident 74 on 05/11/22 at 8:55 AM revealed Resident 74 was sitting in the recliner and eating breakfast. Half of the breakfast remained on the tray and the resident was moving and restless in the recliner. Interview with Nursing Assistant (NA)-S on 05/11/22 at 10:13 AM revealed Resident 74 was a 2 assist pivot transfer, and NA-S verbalized that the resident used the bedpan in bed at times. Interview with NA-S on 05/11/22 at 12:33 PM confirmed the resident had been in the recliner since breakfast and that staff would be repositioning the resident after supper at bedtime. Observation of Resident 74 on 05/11/22 at 1:55 PM revealed the resident sitting in the recliner attempting to get out of the recliner with the left leg hanging over the side. The staff entered the room and asked the resident if (gender) needed to use the restroom and the resident said yes. NA-U and NA-V transferred the resident to the bed from the recliner. The resident repeatedly said no, the bed is wet. Once the transfer was complete the resident's brief was removed and the resident had been incontinent of BM. NA-U and NA-V performed peri-care (hygiene to clean stool) for the resident. Interview with NA-V on 5/11/22 at 2:20 PM confirmed the resident had not been toileted all day. Interview with NA-T on 05/11/22 at 3:41 PM revealed Resident 74 was a 2 assist pivot transfer and NA-T verbalized the resident has a catheter, and doesn't have very big BMs so we just change the resident's brief. NA-T confirmed that resident is not placed on the toilet. Record review on 05/12/22 of the BM report for April 2022 revealed 14 episodes of incontinent BMs between 7:08 PM and 9:48 PM, and no evidence of the resident being toileted. Record review of the BM report for May 1 -May 11, 2022 revealed 11 episodes of incontinent BMs between 7:08 PM and 9:48 PM, and no evidence of the resident being toileted. Interview with the Assistant Director of Nursing (ADON)-A on 05/12/22 at 1:39 PM confirmed there was a trend of Resident 74 being incontinent of BMs between 7:08 PM and 9:48 PM in the months of April and May, and no evidence of the resident being toileted. Record review of Resident 74's Activities of Daily Living (ADL) care plan with a revised date of 6/24/21 revealed the resident was a pivot transfer with 2 assist. The alteration in bowel elimination careplan revealed there was no evidence of a toileting method, a toileting schedule or plan, and the type of bowel incontinence was not identified. Interventions were not included in the careplan. Interview with ADON-A on 5/12/22 from 8:00-8:30 AM confirmed the careplan had no documentation relating to toileting method, toileting schedule/plan, and the type of bowel incontinence was not identified, as well as no interventions were included in the careplan. Record review of the BM report for March 2022 revealed no BM from 3/18/22 to 3/ 23/22 (6 days), and for April 2022 revealed no BM from 4/17/22 to 4/23/22 (7 days). Interview with ADON-A on 05/12/22 from 8:00 - 8:30 AM confirmed that the resident went without a BM from March 18 through the 23 and April 17 through the 23. Record review of the Bowel Assessment Form dated 4/14/21 revealed the form was marked no risk factors, and there were 3 blank areas and no treatment/managment program decisions were documented. Record review of the Bowel Assessment form dated 10/5/21 revealed the assessment was not complete, 2 sections were blank and no treatment/management program decisions were documented. Record review of the Bowel Assessment form dated 1/4/22 revealed the assessment was not complete, 4 sections were blank and no treatment/management program decisions were documented. Record review of the Bowel Assessment form dated 4/4/22 revealed the assessment was not complete, 4 sections were blank and no treatment/management program decisions were documented. Interview with ADON-A on 5/12/22 at 8:00 AM confirmed the Bowel Assessment Forms dated 4/14/21, 10/5/21, 1/4/22, 4/4/22 were not incomplete and didn't reflect the resident's needs. Record review of the Bowel and Bladder Management Standard Policy revised 4/18/17 revealed : Residents with fecal incontinence must receive the appropriate treatment and services to restore as much normal bowel function as possible and the resident's careplan should indicate the type of incontinence identified and shall include appropriate care plan interventions to address identified risk areas. Interview with ADON-A on 05/12/22 from 8:00 - 8:30 AM confirmed that the resident did not have a toileting plan and that it was a concern that staff were leaving the resident sit in the recliner all day without toileting.

Licensure Reference Number 175 NAC 12-006.09D6(5,6,7) Based on observation, interview, and record review, the facility failed to ensure Resident's 6, 33, 61, and 107 respiratory supplies were cleaned daily, changed monthly, and stored in a black infection prevention bag when not in use to prevent cross contamination. This affected 4 of 4 sampled residents. Total census was 114. Findings are: A. Record of the undated Your [CONDITION(S)]/BiLevel (a device used to deliver positive air pressure to a resident's airway to prevent closure during sleep) Unit Policy revealed the staff was to clean the [CONDITION(S)]/Bi-Level mask and humidifier chamber daily and clean the headgear, mask, and tubing weekly. Record review of the undated Night Shift Responsibilities document revealed the staff was to change the oxygen tubing every Sunday night and change the respiratory bags monthly. An observation on 05/09/2022 at 10:38 AM of Resident 6's room revealed the resident had a [CONDITION(S)]/BiLevel unit on the nightstand with a visibly soiled mask draped over the unit and no black infection prevention bag was observed in the room. There was an oxygen machine in the restroom with tubing that was ran to the [CONDITION(S)]/BiLevel unit that was dated 02/06/2022. An observation on 05/10/2022 at 02:31 PM revealed Resident 6's [CONDITION(S)]/BiLevel unit was located on the nightstand with a visibly soiled mask on top of it. No black infection prevention bag was located in the room and the oxygen tubing was still dated 02/06/2022. An observation on 05/11/2022 at 06:35 AM revealed Resident 6's [CONDITION(S)]/BiLevel unit was located on the nightstand and the mask was in a different spot and visibly soiled. Oxygen tubing was dated 02/06/2022. In an interview on 05:11/2022 at 07:20 with Resident 6, Resident 6 confirmed that the oxygen and [CONDITION(S)]/BiLevel unit was used about every night and the staff did not clean either one. In an interview with Licensed Practical Nurse (LPN)-P on 05/11/2022 at 06:41 AM confirmed the staff is to clean all of Resident 6's [CONDITION(S)]/BiLevel equipment and supplies everyday with soap and water. LPN-P did not know the settings. LPN-P was unsure how often the [CONDITION(S)]/BiLevel supplies were to be changed. LPN-P confirmed the oxygen tubing was to be changed weekly. LPN-P confirmed there was not an order in the system to change the [CONDITION(S)]/BiLevel supplies, or oxygen tubing and the staff would go off the order in the system to change the supplies. In an interview on 05/11/2022 at 07:33 AM with the Health Information Manager (HIM), The HIM confirmed there should have been and order in the system to clean and replace Resident 6's respiratory supplies but there was not. The HIM confirmed all respiratory supplies were to be cleaned daily and replaced monthly. In an interview with the HIM on 05/11/2022 at 08:28 AM, the HIM confirmed that the information given in the interview on 05/11/2022 at 07:33 AM was inaccurate and Resident 6's respiratory supplies were to be changed weekly. In an interview with the Director of Nursing on 05/11/2022 at 08:33 AM, the DON confirmed that all of Resident 6's respiratory supplies were to be cleaned daily and changed monthly, there was not an order in the system for that to be done, and that it was not charted anywhere in the medical record. In an interview on 05/11/2022 at 08:49 AM with Registered Nurse (RN)-Q, RN-Q confirmed there was not an order in the system to clean or replace the respiratory supplies, so the system did not notify the staff that the respiratory supplies needed to be cleaned or replaced. RN-Q confirmed the respiratory supplies for Resident 6 were not being cleaned or replaced. B. Record of the undated Your [CONDITION(S)]/BiLevel Unit Policy revealed the staff was to clean the [CONDITION(S)]/Bi-Level mask and humidifier chamber daily and clean the headgear, mask, and tubing weekly. Record review of the undated Night Shift Responsibilities document revealed the staff was to change the oxygen tubing every Sunday night and change the respiratory bags monthly. An observation on 05/10/2022 at 08:34 AM of Resident 33's room revealed the resident had a [CONDITION(S)]/BiLevel unit on the nightstand with a visibly soiled mask laying on the nightstand. There was an oxygen machine in the room with tubing that was not dated. An observation on 05/10/2022 at 01:53 PM revealed Resident 33's [CONDITION(S)]/BiLevel unit was located on the nightstand with a visibly soiled mask laying on top of the nightstand. The undated oxygen tubing was laying on the bed. In an interview with Licensed Practical Nurse (LPN)-P on 05/11/2022 at 06:41 AM confirmed the staff is to clean all of Resident 33's [CONDITION(S)]/BiLevel equipment and supplies everyday with soap and water. LPN-P did not know the settings. LPN-P was unsure how often the [CONDITION(S)]/BiLevel supplies were to be changed. LPN-P confirmed the oxygen tubing was to be changed weekly. LPN-P confirmed there was not an order in the system to change the [CONDITION(S)]/BiLevel supplies, or oxygen tubing and the staff would go off the order in the system to change the supplies. In an interview on 05/11/2022 at 07:33 AM with the Health Information Manager (HIM), The HIM confirmed there should have been and order in the system to clean and replace Resident 6's respiratory supplies but there was not. The HIM confirmed all respiratory supplies were to be cleaned daily and replaced monthly. In an interview with the HIM on 05/11/2022 at 08:28 AM, the HIM confirmed that the information given in the interview on 05/11/2022 at 07:33 AM was inaccurate and Resident 33's respiratory supplies were to be changed weekly. In an interview with the Director of Nursing on 05/11/2022 at 08:33 AM, the DON confirmed that all of Resident 33's respiratory supplies were to be cleaned daily and changed monthly, there was not an order in the system for that to be done, and that it was not charted anywhere in the medical record. In an interview on 05/11/2022 at 08:49 AM with Registered Nurse (RN)-Q, RN-Q confirmed there was not an order in the system to clean or replace the respiratory supplies, so the system did not notify the staff that the respiratory supplies needed to be cleaned or replaced. RN-Q confirmed the respiratory supplies for Resident 33 were not being cleaned or replaced. C. On 05/10/22 at 01:26 PM an observation of Resident 61's [CONDITION(S)] (Continuous Positive Airway Pressure; used for sleep apnea) mask and headgear was uncovered and laying across the bedside table. On 5/11/22 at 09:33 AM an observation of Resident 61's [CONDITION(S)] mask and headgear was uncovered and laying on the bedside table. Record review of Resident 61's current physician orders revealed no order for daily cleaning or weekly cleaning of the [CONDITION(S)] mask and headgear. Record review of Resident 61's Treatment Administration Record revealed no documentation of cleaning of the [CONDITION(S)] mask and headgear. An interview with Health Information Management on 5/11/22 at 07:25 AM revealed the [CONDITION(S)] mask and headgear should be placed in a bag when not in use and the equipment is changed monthly. There is no documentation of when the equipment is changed or cleaned. An interview with LPN G on 5/11/22 at 08:12 AM revealed the [CONDITION(S)] mask and headgear is washed weekly by the night shift and is documented on the TAR. Staff are to wipe out the [CONDITION(S)] mask after every use. The [CONDITION(S)] mask is changed out monthly. An interview with LPN I on 5/11/22 at 08:30 AM revealed the night shift changes the [CONDITION(S)] equipment but was unsure how often. LPN I looked at the physician orders for orders to change the [CONDITION(S)] and was unable to locate any. Interview with the Director of Nursing on 5/11/22 at 08:20 AM revealed that [CONDITION(S)] equipment is changed monthly and they do not document that anywhere. D. An observation on 05/09/22 at 01:23 PM revealed Resident 107 to be receiving nebulizer breathing treatments, and the Nebulizer kit (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was intact and resting on the machine. An observation on 05/10/22 08:55 AM revealed Resident 107 Nebulizer kit was intact and resting on the machine. A record review of the facility policy titled Nebulizer therapy, small volume and dated 11/17/2017 contained the following instructions related to cleaning and storage: Rinse the nebulizer with sterile water and allow it to air-dry or discard it after the treatment Dispose of used supplies in appropriate receptacles An interview with the DON (Director of Nursing) on 5/11/22 at 08:55 AM confirmed that the respiratory equipment including nebulizer kits were to be stored in an IP (Infection Prevention) bag after cleaning and when not in use.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview, the facility failed to monitor pain levels and the effectiveness of routine pain medications for Resident 3 and 268. The sample size was 5. The facility census was 114. FINDINGS ARE: A. A record review of the Admission Record for Resident 3 revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 4/27/22, Section C revealed Resident 3 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14. A record review of the MAR (Medication Administration Record) dated May 2022 for Resident 3 revealed the following orders for pain: -Acetaminophen Tablet 500 MG Give 2 tablet by mouth three times a day for pain Do not exceed 4G in 24 hr -[MEDICATION(S)] HCl Tablet 2 MG Give 1 tablet by mouth every 4 hours as needed (PRN) for Moderate Pain A record review of the MARs dated April 2022 and May 2022 for Resident 3 revealed no pain ratings or monitoring of effectiveness with the Acetaminophen. A record review of the April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review revealed pain ratings, on a 1-10 scale, with the [MEDICATION(S)] of 0 once, 3once, 5once, 7 on 4 occasions, 8once and 10once. A record review of the document titled Pain Review (V2) dated 11/3/2021 for Resident 3, question 8j read: Resident's acceptable pain level with a response of 5. A record review of the facility policy titled Pain Management Standard dated 1/2017, contained the following: -If reassessment findings indicate pain is not adequately controlled, revise the pain management regimen and care plan as indicated. -Evidence suggests that pain is often poorly assessed and poorly managed. -Pain Recognition: Every resident should be regularly and systematically evaluated for pain. At least daily for residents with a known painful conditions. -Monitoring: Reassess residents with pain regularly. An interview on 5/11/22 at 1:58 PM with the DON (Director of Nursing) confirmed that the facility expectation for pain monitoring was 1-2 times per shift at a minimum when routine pain meds are being given. After review of the MARs dated April 2022 and May 2022 for Resident 3, the interview with the DON confirmed that pain assessments should have been done and were not. B. A record review of the Admission Record for Resident 268 revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 4/26/22, Section C revealed Resident 268 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15. An interview on 05/09/22 at 02:01 PM revealed Resident 268 had voiced having a lot of pain yet also acknowledged being on routine pain meds. A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Acetaminophen Tablet 500 MG Give 2 tablet by mouth every 6 hours for pain Max dose is 3G in 24 hour. -[MEDICATION(S)] HCl Tablet 50 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain. -[MEDICATION(S)] Patch Weekly 7.5 MCG/HR Apply 1 patch trans-dermally in the morning every Mon for pain patient may refuse and remove per schedule. A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review revealed pain ratings with the PRN [MEDICATION(S)] of 4 twice, 5 four times, 6 twice and 8 once. A record review of the document titled Pain Review (V2) dated 4/20/22 for Resident 268, question 8j read: Resident's acceptable pain level with a response of 2. An interview on 5/11/22 at 1:58 PM with the DON confirmed that the facility expectation for pain monitoring was 1-2 times per shift at a minimum when routine pain meds are being given

Licensure Reference Number 175 NAC 12.006.09D7b Based on record review and interview, the facility failed to ensure safety interventions were appropriate to prevent injury during a fall for two of three residents reviewed (Residents 5 and 235). The facility also failed to identify causal factors related to resident falls for one of three residents reviewed (Resident 235). The facility census was 114. Findings are A. A review of the Community Transfer Form for Resident 5 dated [DATE] revealed: the resident fell and fractured left hip at the Assisted Living Facility where the resident resided in the Memory Support area prior to admission to the Facility. Resident 5 had a [DIAGNOSES REDACTED]. The resident: was alert and oriented to self only, needed assistance with eating and had torn the hip dressing off several times when restless. A review of the Care Plan dated [DATE] revealed interventions the facility put into place upon admission included: appropriate foot wear, call light, frequent checks, and to remind/encourage to use the call light. The Care Plan did not include recommendations related to Resident 5's transfer ability with order for 50% weight bearing to left lower extremity, or toileting needs for the resident who was incontinent of Bowel and Bladder. A review of the facility's Incident Report and Fall Huddle information revealed that, on [DATE] at 8:00 PM, Resident 5 was found on floor, not able to describe what was doing, confused, walker was next to the resident but (gender) didn't use it, needed to go to the bathroom, complaints of pain, and was sent to Hospital returning to the facility the same day . Further review revealed the resident had a Urinary Tract Infection (UTI) with new orders for an Antibiotic. Interventions put into place included: having the resident's room close to the nurses station, try to anticipate residents needs by placing frequently used items within the residents reach, and hourly safety checks/rounding. Further review of the facility reports revealed Resident 5 fell again on [DATE] at 0300 receiving a fracture to right hip. Factors of the fall included: confusion, found on floor unwitnessed, and UTI. A review of the facility's FALL PREVENTION/MANAGEMENT STANDARD dated February 2015 revealed each resident would receive adequate supervision and assistance to prevent accidents. The facility maintained a practice that allows for a safe environment for all residents. This includes appropriate assessment of all residents for factors that could place them at risk for accidents and falls. An interview on [DATE] at 2:48 PM with the Administrator revealed it was the expectation that staff complete hourly rounds/safety checks on all residents and the rounding was not documented. The Administrator confirmed the safety interventions put into place for Resident 5, upon admission to the facility, were probably not enough to prevent the resident with a [DIAGNOSES REDACTED]. B. Review of the Face Sheet, dated [DATE], for Resident 235 revealed an admission date of [DATE].Further review revealed Resident 235 had the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 235 had no cognitive impairment. Resident 235 required extensive assistance of one staff for bed mobility, toileting, and dressing. The resident required limited assistance of one staff for transfers, locomotion on and off the unit, and personal hygiene. Resident 235 required supervision with set up help only for eating. The resident was not observed ambulating during the assessment period. Resident 235 had no falls and was on hospice. Review of Resident 235's Progress Notes revealed that, on [DATE] on the night shift, the resident was restless off and on throughout the night. The resident attempted to transfer self independently without calling for staff first to use the bathroom. Resident 235 asked the NA (Nurse Aide) to sit with (gender) most of the night. A PRN (as needed) Ativan (medication for anxiety) was given with little effective results noted. Morphine (a medication used for pain and to ease respirations in hospice patients) was given PRN for discomfort/ and shortness of breath. At 02:30 AM, the resident requested to get up and dressed which the staff assisted with and placed the resident in the recliner in the resident's room. At 04:25 AM, the resident was found sitting on the floor in front of the recliner. The resident revealed the resident was getting up from the recliner to go to the bathroom. Review of the care plan, dated [DATE], revealed the intervention initiated on [DATE] was to give verbal reminders not to ambulate or transfer without assistance PRN. Interview on [DATE] at 3:42 PM with the ADM (Administrator) revealed the resident was very alert and oriented and tried to be independent even though the resident required assistance with transfers and was non-ambulatory. Resident 235 refused fall alarms. The ADM revealed the staff completed rounds every 2 hours and toileted the residents at that time. The ADM denied, after reviewing the medical record, that a bladder assessment or diary had been completed on the resident to determine the resident's pattern, the time of day most likely to need to be toilet, or that a change in the resident's toileting schedule was initiated. Review of the Progress Notes dated [DATE] revealed Resident 235 was observed lying on the bathroom floor at 1:13 PM with blood present on the floor. The resident complained of pain with movement of the right shoulder and arm and a scalp laceration was observed. The resident was transferred to the emergency room for a laceration repair to the scalp. The resident returned to the facility on [DATE] at 6:23 PM. Review of the call light report obtained from the ADM for the date of [DATE] for Resident 235's room revealed the call light in the resident's bathroom was turned on at 12:35:18 PM and turned off at 1:14:08 PM. Interview on [DATE] at 3:42 PM with the ADM revealed an investigation had not been completed to review if the long call light was a causal factor to the resident's fall. Review of the care plan dated [DATE] revealed the intervention initiated on [DATE] was to encourage the resident to wear elastic waistband pants or alter current pants. On [DATE] at 1:28 PM, the SW (Social Worker) entered a note which revealed the SW spoke with the family to obtain some elastic waist dress pants. The family agreed and would address the next day. Interview on [DATE] at 3:42 PM with the ADM confirmed no other new fall intervention was put into place before the family or the facility obtained the resident some clothes with elastic pants. Review of the Progress Notes dated [DATE] revealed the Resident 235 was found on the floor at 5:13 PM in the resident's room. While the staff were moving the resident, the resident became unresponsive, ceased breathing and expired. Interview on [DATE] at 3:50 PM with Staff B revealed when the resident was found on the floor on [DATE] at 5:13 PM, the resident was found in the bathroom, had been on the toilet. and must have been trying to go back to the recliner.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview, the facility failed to ensure residents were free from significant medication errors on 1 resident (Resident 213) out of 27 residents reviewed. The facility census was 107. Findings are: Interview on 10-5-16 at 2:00 PM with the DON (Director of Nursing) revealed Resident 213 received another resident's (Resident 271) medications from RN-D (Registered Nurse) and this resulted in Resident 213 having an adverse reaction of a low blood pressure of 50/30. The facility notified the Physician. The Physician ordered the resident to be sent to the emergency room by way of 911. Resident 213 was admitted to the hospital. Review of the Progress Notes dated 10-5-16 at 07:50 AM revealed the following medications were administered to Resident 213: -[MEDICATION NAME] CD capsule ER 240mg (milligram), a medication used to treat high blood presssure. -[MEDICATION NAME] 25mg, a medication used to treat high blood pressure. -[MEDICATION NAME] 20 mg, a medication used to treat high blood pressure. -Aspirin 325 mg given as a preventative measure for cardiac events. -[MEDICATION NAME] sulfate 200mg, a medication used to treat the inflammation of [MEDICAL CONDITION] arthritis. -[MEDICATION NAME] 15mg, a nonsteroidial anti-[MEDICAL CONDITION] medication. -[MEDICATION NAME] DR 20 mg, a medication used to treat stomach acid. -Calcium [MEDICATION NAME] 600 mg, a calcium supplement. -[MEDICATION NAME] 325 mg, an iron supplement. The Progress Notes further revealed that at 08:00 AM the Physician was called to report the medication error, but the office was closed. At 09:00 AM a status change was observed in the resident. The resident had slurred speech, weakness, decreased level of alertness, dizziness, drooling from the mouth and was leaning toward the left side. Resident 213's blood pressure was assessed at less than 56/33 and the heart rate was 58. The Physician was notified and orders received to send to the emergency room for evaluation. Interview on 10-05-16 at 5:00 PM with the DON revealed the investigation of the medication error was completed and RN-D and confirmed that RN-D had not identified Resident 213 verbally but by the picture on the MAR (Medication Administration Record) only. RN-D revealed the two residents had similar traits and Resident 213 had sat in the dining room chair that Resident 271 usually sat in. The DON revealed it was the facility practice to state the resident's name or ask the resident to state their name if the resident was capable. Review of Resident 213's MDS (Minimum Data Set, a federally mandated comprehensive assessment) dated 09-24-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which revealed the resident had no cognitive impairment. Interview on 10-05-16 at 2:30 with Resident 213's family revealed the family member visited often and had not observed on previous visits that the staff identified the resident by having the resident to state their name. Review of the Facility policy Administering Medications revised April 2010 revealed the staff who administer medications must verify the resident ' s identity before giving the resident the medication. Ways to identify the residents include checking the identification band, checking the resident photo, calling the resident by name, and if necessary verify the resident with other staff.