Every finding on record at St. Joseph's Rehabilitation and Care Center

Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review; the facility failed to provide care and services to manage edema (buildup of fluid in the body's tissues that causes swelling) and to identify a change in condition for 1 (Resident 1) of 7 sampled residents. The facility census was 65.The findings are:Review of the facility policy Change in Condition dated 4/25 revealed it was the policy of the facility to ensure each resident received quality care to attain and maintain the highest practicable well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Examples of a change in condition included but were not limited to:-change in vital signs which included temperature, pulse, blood pressure, heart rate and oxygen saturation.-change in ability or decline in physical function.-change in mental status.-any signs of infection.-changes in weight and/or intake. The Charge Nurse was to perform and document an assessment of the resident and identify need for additional interventions and to communicate with the physician the need to obtain new orders or interventions.Review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool used for care planning ) dated 8/5/26 revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure, high blood pressure, wound infection and respiratory failure. The assessment identified the following regarding the resident:-cognition was moderately impaired.-dependent on staff to assist with toileting hygiene, dressing, and transfers.-occasionally incontinent of bladder.-short of breath or trouble breathing with exertion, when sitting at rest, and when lying flat.-weight was 359 pounds (lbs.) which was a gain of 5 percent (%) in the last month or a gain of 10 % or more in the last 6 months. The resident was not on a prescribed weight gain regimen.-medications included an antibiotic and a diuretic (medication that makes the kidneys produce more urine). Review of Resident 1's undated current Care Plan revealed the resident was at risk for fluid volume excess related to diagnoses of heart failure, and chronic respiratory failure. Interventions included use of Bipap (bilevel positive airway pressure- non-invasive medical device that uses a mask to push air into the lungs. It alternates between two distinct pressures, higher level when you breathe in and a lower level when you breathe out) at night; oxygen therapy 1-4 liters to maintain oxygen saturation at or above 90%; 2000 cubic centimeter (cc) fluid restriction per 24 hours. Nursing to give 360 cc on the day shift/evening shifts and 200 cc for the night shift for a total of 920. Remainder of fluids were to be provided with meals. Resident identified as non-compliant with fluid restriction; administer aerosol or bronchodilators (medication which makes breathing easier by relaxing the airway muscles); monitor for signs of acute respiratory insufficiency (anxiety, confusion, restlessness, shortness of breath at rest, cyanosis (bluish or purplish color of the skin, lips, or nail beds when there is reduced oxygen in the blood); increased sleepiness; and monitor/document/report any signs of respiratory infection. Review of the resident's Weights and Vitals Summary Form (a document used to record the resident's weights) revealed the resident's weight on 7/4/26 was 325 lbs. Review of the resident's Nursing Progress Notes revealed the resident requested and received albuterol aerosol inhaler (handheld device that delivers a specific puff of liquid medication through a chemical propellant into the lungs used to treat breathing difficulties such as shortness of breath and wheezing) on 7/4/26 at 7:11 PM, 7/5/26 at 3:19 PM, 7/6/26 at 6:37 PM, 7/7/26 at 8:21 PM, 7/12/26 at 5:09 AM, 7/14/26 at 6:05 PM, 7/15/26 at 10:28 AM (received the albuterol inhaler 7 out of 12 days for shortness of breath and wheezing). Review of a Physician's Orders Detail dated 7/8/26 from the Wound Care Clinic revealed a recommendation to continue to wear the support stockings during the day and remove at night with a new order to wear edema wear to the resident's left lower extremity at night due to increased edema. Review of the resident's Nursing Progress Notes revealed the resident requested and received Albuterol aerosol inhaler on 7/18/26 at 9:15 PM, and 7/19/26 at 9:34 AM and at 6:16 PM. Review of a Facsimile (Fax) Transmission/Phone Orders form dated 7/21/26 at 10:19 AM revealed the resident had experienced a gradual weight increase. The resident's current weight was 325 lbs. and the resident's weight on 5/7/26 was 305 lbs. (an increase of 20 lbs.). The resident was having increased shortness of breath and edema to bilateral lower extremities. A new order was received to double the dose of the resident's current Lasix (diuretic medication) for the next 3 days then return to the previous dose. Review of the resident's Weights and Vitals Summary Form revealed no weights were documented for Resident 1 from 7/4/26 to 7/23/26. The weight sent to the resident's physician dated 7/21/26 had been obtained on 7/4/26. Further review revealed the resident's weight was 349 lbs. on 7/23/26, a gain of 24 lbs. from 7/4/26 (19 days). During an interview on 8/18/26 at 9:44 AM, Nurse Aide (NA)-A reported the nursing staff were responsible for documenting fluid intakes at the resident's meals. NA-A was aware the resident was on a fluid restriction but did not know how much the resident was allowed each meal/each shift. Further interview revealed the resident always seemed to have fluids available in the resident's room. Interview with the Director of Nursing on 8/19/26 at 9:12 AM confirmed the following regarding Resident 1:-continued use of the Bipap and compliant with use.-used oxygen at all times, from 1-4 liters. -amount of fluid to be provided at each meal was not designated, only the amount the resident was allowed to be given by nursing throughout each shift. Fluid intakes were documented by the nursing staff. -the resident was non-compliant with fluid intakes.-the resident's physician was not kept updated regarding the resident's non-compliance with fluid intakes.-the resident was routinely requesting the albuterol inhaler for shortness of breath and wheezing but there was no evidence the resident's lung sounds were assessed. -the physician was notified on 7/23/26 the resident had a gradual weight gain from 5/7/26. However, the weight sent to the doctor dated 7/23/26 was acquired on 7/4/26 as no weights were obtained for Resident 1 from 7/4/26 until 7/23/26. -the resident's weight on 7/4/26 was 325 lbs. When the resident was finally weighed on 7/23/26, the resident's weight was 349 lbs. for a weight gain of 24 lbs. in 19 days.-the resident's physician was never notified of the 24 lb. weight gain from 74/26 to 7/23/26.

Licensure Reference Number 175 NAC 12-006.18Based on observation, interview, and record review; the facility failed to ensure infection control measures including the use of Enhanced Barrier Precautions (EBP-targeted use of Personal Protective Equipment (PPE-use of protective wear such as gown, gloves, and eye shields) during the provision of care to prevent potential transmission of Multi-Drug Resistant Organisms (MDRO's- germ/pathogen that has developed resistance to multiple classes of antimicrobials [antibiotics or antifungals]) was implemented for Resident's 2, and 3, and infection control measures to prevent potential infections during wound care were followed for Residents 2 and 4. The sample size was 4 and the facility census was 63.Findings are: A. Review of the facility policy Standard and Transmission Based Precautions with a revision date of 4/2025 revealed the facility implemented infection control measures to prevent the spread of communicable diseases and conditions. Standard Precautions (applied to the care of all residents) were implemented regardless of suspected or confirmed infection or colonization (infection absent of illness). Enhance Barrier Precautions were used in conjunction with Standard Precautions and expanded the use of Personal Protective Equipment (PPE) through the use of gown and gloves during high-contact resident care activities which provided opportunities for indirect transfer of MDRO's to staff hands and clothing and the indirect transfer to residents. Residents with wounds and/or indwelling medical devices were at especially high risk of both acquisition and/or colonization with MDRO's. The use of gown and gloves was indicated for wound care, for residents with known or colonized MDRO's, and for resident's with indwelling medical device during the provision of high-contact care activities including wound care, dressing, bathing, transferring, hygiene provision, changing of linens, toileting assistance, changing of incontinence products, and device care (such as urinary catheters, dialysis catheter, feeding tubes, and ventilators). Review of the facility policy Hand Hygiene with a revision date of 4/2025 revealed the facility provided the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene, which was the most effective measure to prevent the spread of infection, based on accepted standards. Hand hygiene was a general term that applied to hand washing, antiseptic hand wash, and alcohol-based hand rub. Hand Hygiene was indicated on multiple occasions including but not limited to when hands were visibly soiled, before and after reporting to duty, before and after direct contact with residents, before and after putting on gloves, and whenever moving from a contaminated body site to a clean body site, any contact with bodily fluids, after handling contaminated dressings or equipment and after removal of PPE. Review of the facility policy Skin and Wound Monitoring and Management with a revision date of 12/2023 revealed the facility provided the necessary treatment of wounds to promote healing and prevent infection. B. Review of Resident 2's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 4/28/26 revealed the resident was dependent on staff for Activities of Daily Living (ADL's) including all hygiene, dressing, transfers, and bed mobility. The resident was involuntary of bowel and incontinent of bladder. Diagnoses included brain dysfunction, dementia and arthritis. The resident was at risk for a had a pressure ulcer (skin and tissue damaged caused by prolonged pressure, friction, or moisture). Review of Resident 2's Care Plan with a revision date of 6/25/26 revealed the resident had impaired skin integrity related to fragile skin, had impaired cognition, and required staff assistance with ADL's. In addition, staff were to implement EBP during care. During an observation of the provision of care for Resident 2 on 7/13/26 at 11:05 AM Nurse Aides (NA's) H and I entered the resident's room, completed hand hygiene and donned (put on) gloves, and the transferred the resident from bed to a wheelchair using a mechanical stand-up lift and transferred the resident from the wheelchair to the toilet. The resident used the toilet and staff performed toileting care however, staff did not wear gowns which was required for Resident 2 due to chronic pressure sore/wound and the need for EBP. During an observation of the provision of wound care for Resident 2 on 7/14/26 at 7:15 AM Registered Nurse (RN)-K obtained supplies to complete wound care, entered the residents' room and placed the wound care supplies directly on the bedside stand, completed hand hygiene and then without wearing gloves, removed a positioning bolster from behind the resident, positioned the resident on the left side, then donned gloves but no gown. The RN then cleaned the wound on the resident's buttock/removed gloves and completed hand hygiene. Next RN-K donned clean gloves and applied a clean dressing to the wound. After that RN-K removed the gloves, and assisted the resident to reposition, reapplied the positioning bolsters, covered the resident and completed hand hygiene. The RN then gathered the unused wound care supplies that were placed directly on the resident's bedside stand and returned an opened container of gauze sponges to the treatment cart (used for treatments for other residents of the facility). During an interview on 7/14/26 at 11:55 AM the Assistant Director of Nursing (ADON) revealed Resident 2 was on EBP's due to the presence of a chronic wound and required the use of gown and gloves during the provision of high contact care provision including transfers, toileting, and wound care. In addition, the ADON confirmed that care including transfers, toileting, on 7/13/26 by NA's H and I, and wound care by RN-K had all been completed while not wearing the required gowns to prevent transmission of potential pathogens to staff's hands or clothing and then potentially to other residents. The ADON also confirmed that wound care supplies brought into a resident's room should be placed on a clean surface and/or not come in contact with surfaces that were potentially unclean and those items not used should be discarded and not returned to the treatment cart for use. C. Review of Resident 3's MDS dated [DATE] revealed the resident had cognitive impairment and received assistance with hygiene, dressing, transfers, and bed mobility. The resident was involuntary of bowel and had a urinary bladder catheter. In addition, the resident had diagnoses including multiple trauma including fractures, Obstructive Uropathy (obstruction of the urinary system),and heart disease. The resident was at risk for and had pressure sores. Review of Resident 3's Care Plan with a revision date of 5/5/26 revealed the resident had impaired cognition, self-care deficits, a gluteal (buttock) pressure ulcer, an indwelling urinary catheter due to obstruction or urinary flow, and staff were to use EBP during care provision as indicated. During an observation of the provision of care on 7/13/26 at 11:20 AM Resident 3 was transported using a wheelchair to the bathing room to bathe. NA-O donned gloves and assisted the resident to stand and transfer into bathing chair using a walker and gait belt to support the resident. The resident required substantial physical assistance and verbal directions. The resident's urinary catheter drainage bag was secured by NA-O to the walker for the transfer and then to bathing chair post transfer. NA-O then assisted the resident to remove clothing with substantial assist. NA-O was wearing gloves but no gown despite the presence of the indwelling urinary catheter and pressure sore on the resident's buttocks. During an interview with NA-O on 7/13/26 at 11:30 AM the NA confirmed having no awareness of any additional measures including EBP needed during the transfers, dressing/undressing, bathing, and or care of the resident's urinary catheter.During an interview on 7/14/26 at 11:50 AM the Director of Nursing (DON) confirmed Resident 3 was to have EBP implemented for high contact care provision such as transferring, undressing, catheter care and bathing. D. Review of Resident 4's MDS dated [DATE] revealed the resident had kidney disease, and Peripheral Vascular Disease (PVD - condition affecting circulation and blood flow to the extremities which can result in skin breakdown including skin ulcers). The resident also received Hospice services. Review of Resident 4's Care Plan with a revision date of 6/12/25 revealed the resident had end stage disease secondary to kidney failure and was receiving Hospice services. The resident had the potential for developing skin integrity issues due to picking at skin, chronic kidney failure and multiple health problems. In addition, the resident had open areas on the left inner ankle and left lower leg. Staff were to implement EBP as indicated during care. During an observation of wound care For Resident 4 on 7/14/26 at 7:50 AM Licensed Practical Nurse (LPN)-M entered the resident room completed hand hygiene and donned (put on) a gown and gloves. LPN-M placed supplies for treating a wound on a clean disposable surface and moistened a gauze pad with wound cleanser and cleaned all 4 wound sites with the same gauze and gloves. After changing gloves and completing hand hygiene LPN-M then redressed the wounds and disposed of the soiled dressing and remaining dressing supplies. It was noted LPN-M did not use clean gauze pads for each area for cleaning and did not change gloves between sites to ensure any potential infection was not spread between the sites. During an interview on 7/14/26 at 8:50 AM LPN-M confirmed being unaware that each treated area for Resident 4 should have been treated individually to prevent cross contamination. Further interview confirmed that each area was cleaned with the same gauze and all areas were redressed wearing the same pair of gloves. During an interview on 7/14/26 at 11:50 AM the ADON confirmed that wound care for Resident 4 required treating each wound individually and cleaning all wounds with the same gauze had the potential to introduce infection from one wound to another. In addition, glove changes should have occurred between each site and when going from a dirty site to a clean site. Further interview confirmed LPN -M did not treat each wound site individually or change gloves between wound sites. This had the potential to spread infection from one site to another.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit an investigation related to the unexpected death of Resident 1 to the State Agency within the required time frames. The sample size was 4 and the facility census was 56.Findings are: A. Review of the facility Abuse: Prevention of and Prohibition Against Policy dated 4/25 revealed the following;-the policy of the facility was to ensure each resident was free from abuse neglect, and misappropriation of resident property, exploitation, and mistreatment.-the facility was to provide oversight and monitoring to ensure that its staff delivered care and services in a way that promoted and respected the rights of the residents to be free from abuse, neglect, misappropriation of resident property, exploitation, or use of technology to infringe on the resident's rights. -to assist the facility staff in recognizing incidents of possible abuse, neglect, misappropriation, or exploitation definitions were provided which included adverse events. An adverse event was described as an untoward, undesirable, and usually an unanticipated event that caused death or serious injury, or the risk thereof.-all allegations of potential abuse, neglect, exploitation, or misappropriation were to be reported immediately to the administrator.-allegations of abuse, neglect, misappropriation of resident property or exploitation was to be reported to the appropriate State or Federal agencies in the applicable timeframes. The facility was to notify law enforcement in the event of a potential crime, and Adult Protective Services within 2 to 24 hours depending upon the nature of the case and complete a written report which was to be submitted to the State Agency within 5 business days of the allegation. B. Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 1/27/26 revealed the resident was admitted [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical, systemic, or organ-system failures), end-stage kidney disease, chronic respiratory failure, anemia, heart failure, diabetes and chronic obstructive pulmonary disease. The resident's cognition was moderately impaired and the resident did not have a condition or a chronic disease that might result in a life expectancy of less than 6 months. Review of the resident's current Care Plan undated revealed the resident needed hemodialysis (life-saving medical procedure that filters waste, toxins, and excess fluids from the blood when the kidneys fail) due to renal failure. The resident had occasionally refused to go to dialysis and to take ordered medications. Interventions included the following:-check fistula (surgically created connection between an artery and a vein, typically in the arm, designed to provide long-term, high-flow access to blood for hemodialysis) in left arm daily for bruit (an abnormal, blowing, or whooshing sound heard through a stethoscope during medical auscultation, indicating turbulent blood flow, usually caused by narrowed or diseased arteries) and thrill ( palpable, vibratory sensation felt by a clinician during physical examination, usually indicating turbulent blood flow). -encourage the resident to go to scheduled dialysis appointments.-monitor for any signs of infection to fistula site. Review of Resident 1's Nursing Progress Notes revealed on 4/19/26 at 12:40 AM the resident was found nonresponsive with no pulse and was not breathing. The resident was lying in bed with blood around the resident's body and on the floor. The resident was observed to have a small open area to the bottom of the fistula of the resident's left arm and blood to the tips of fingers to the resident's right hand. There was no sign of trauma to the site and no sharp objects located next to the resident's body. Review of the Facility Reported Incidents for 2026 revealed no evidence the facility reported Resident 1's unexpected death to the State Agency. During an interview with the Director of Nursing (DON) on 4/29/26 at 11:00 AM the DON confirmed the resident's death was unanticipated and untoward. The facility did complete an investigation to ensure no neglect was attributed to the resident's death however, the facility failed to report Resident 1's unexpected death and to then send the results of the facility investigation to the State Agency within the required timeframe.

Licensure Reference Number 175 NAC 12-006.11 (E)Based on observation, record review, and interview; the facility failed to ensure food safety through safe food holding temperatures and evidence of dishwasher temperature checks for adequate sanitation. This practice had the potential to affect all residents. The facility census was 62. Findings are:A.Review of the facility policy Dishwasher Temperature Policy revised 8/18 revealed the following:-High Temperature Dishwashers (Heat Sanitization) machines relied on extreme heat rather than chemicals to kill pathogens.-Wash cycle was to reach between 150 degrees and 165 degrees,-Dual temperature machine final rinse cycle was to reach a temperature of at least 180 degrees to ensure the dishes themselves reach the 160 degrees.-The facility must maintain a daily temperature/chemical log (often three times a day) signed by staff to prove compliance.-Staff must use test strips or maximum registering thermometers to verify that dish surfaces actually hit required temperatures.-All items must be air-dried, towel-drying is prohibited as it can reintroduce bacteria.Review of the February 2026 Dishwasher Temperature Log revealed staff were to document the dishwasher temperatures with each meal. Dishwasher temperatures were to be between 150 degrees and 165 degrees and the rinse cycle was to be 180 degrees. If the temperatures were below the manufacturers' recommendation, the staff were to stop using the machine until the temperatures reached the required range. If the desired temperatures were not reached, then staff were to notify the maintenance department or the manufacturer. Further review revealed the staff failed to document dishwasher temperatures at the breakfast meal on 2/7, 2/8, 2/9, 2/10, 2/12, 2/13, 2/14, 2/16, 2/18, 2/20, 2/27 and on 2/28 (12 out of 28 days).The staff failed to document dishwasher temperatures for the noon meal on 2/3, 2/4, 2/6 to 2/12, 2/16, 2/18 to 2/20, 2/22, to 2/24, and 2/26 to 2/28 (20 out of 28 days).No dishwasher temperatures were documented for the evening meal on 2/1-2/4, 2/6-2/9, 2/11, 2/12, 2/14, 2/17-2/22, and 2/25-2/28 (21 out of 28 days).Further review revealed dishwasher temperatures were out of range at the breakfast meal on 2/3-2/5, 2/19, 2/21, 2/22 and 2/23; at the noon meal on 2/21; and at the evening meal on 2/5, 2/13, 2/23 and on 2/24. An observation on 2/25/26 at 7:35 AM revealed the Certified Dietary Manager (CDM-M) placed dishes in the dishwasher and started the dishwasher. The water temperature during the wash cycle was 158 degrees and the rinse cycle temperature reached 186 degrees. An observation on 2/26/26 at 1:45 PM revealed the CDM-M placed dishes in the dishwasher, and the dishwasher was started. The water temperature during the wash cycle was 154 degrees and the rinse cycle temperature reached 186 degrees. An interview with CDM-M on 2/26/26 at 2:00 PM confirmed that the dishwasher was a high temperature dishwasher, the wash cycle was to reach a temperature between 150 degrees and 165 degrees, the rinse cycle was to reach a temperature of at least 180 degrees. A representative from the company that maintained and serviced the dishwasher was in the facility on the evening of the 24th due to water temperatures being out of range. The facility was unable to provide a report of services provided to the dishwasher on the evening of the 24th. CDM-M confirmed that the dishwasher temperatures for the month of February 2026 were not being completed and logged after each meal and there were water temperatures logged that were not at the correct temperature range. There was no evidence that staff notified maintenance or the Dishwasher Manufacturer when the temperatures were out of range until 2/24/26. B.Review of the facility policy Checking Food Temperatures revised 8/18 revealed the following:-Meals would be served at the appropriate temperatures to ensure food safety and to prevent cross contamination.-Hot foods would be held at or above 135 degrees.-Cold foods would be held at or below 41 degrees.-Food temperatures should be taken periodically to ensure hot foods stay above 135 degrees and cold foods stay below 41 degrees during the portioning, transporting and serving process until received by the customer. An observation on 2/26/26 at 1:40 PM revealed the following observations:-Chicken Fried Chicken temperature was 116.1 degrees. An interview on 2/26/26 at 1:40 PM with Cook-L confirmed that the chicken fried chicken would have been delivered to the resident with the food being served at incorrect temperatures, the food would have been served cold. An interview with CDM-M on 2/26/26 at 2:00 PM confirmed that the chicken on the meal tray at 1:40 PM would have been served at temperatures that were not palatable.

Licensure Reference Number 175 NAC 1-005.06CBased on record review and interview; the facility failed to have evidence of an active Antibiotic Stewardship Program this had the potential to effect all residents. The facility census was 62. Findings are:Review of the facility policy Antibiotic Stewardship with a revision date of 1/2022 revealed the facility implemented an Antibiotic Stewardship Program that was incorporated in the overall infection Prevention and Control Program which promoted appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. The policy had the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. Nursing home ASP activities at a minimum, included the basic elements of leadership, accountability, drug expertise, and actions to implement recommended policies or practices, tracking measures, reporting data, education of clinicians, staff, residents, and families about antibiotic resistance and opportunities for improvement. This included monitoring antibiotic use and assessing residents for infections using McGreer's criteria (standardized definitions used for infection surveillance in long-term care to consistently identify infections and ensure accurate reporting and determining true infections). Feedback was provided to physicians on their prescribing patterns of cultures ordered and antibiotics prescribed. Review of the facility Infection Surveillance from January 2025 through February 2026 revealed no evidence the facility had identified culture information for infections treated with antibiotics and/or any criteria to determine if antibiotics were being prescribed in accordance with the facility ASP. During an interview 3/3/26 from 11:09 AM through 11:17 AM the facility Infection Preventionist confirmed the facility had not used any criteria or tracking of/or determination of offending organisms to determine if the antibiotics ordered were meeting prescribing standards outlined through an ASP. In addition, the facility had not provided information to prescribing providers as to whether or not the antibiotics ordered had met the criteria of the ASP.

Licensure Reference Number 175 NAC 12-006.06B Based on record review and interviews; the facility failed to address repeat grievances, and to ensure sustainable resolutions of concerns related to long call light response times and cold food temperatures. The total sample size was 26 and the facility census was 62. Findings are:Review of the Resident and Family Concerns/Grievances Policy with a revision date of 11/2019 revealed it was the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Explanation and Compliance Guidelines:-Social Service Director (SSD), was designated as the grievance official.-The grievance official was responsible for overseeing the grievance process and receiving and tracking grievances through to their conclusion. -A resident or family member could voice a grievance with respect to care and treatment which was furnished as well as that which had not been furnished, the behavior of staff and other residents, and other concerns regarding the facility. -Information on how to file a grievance or concern was to be furnished to the resident and was to include: the contact information of the grievance official with whom a grievance can be filed; the time frame that a resident could expect completion of the review of a grievance and a written decision regarding their grievance. Procedure:-The staff receiving a grievance was to record the nature and the specifics of the grievance on the designated grievance form or assist with completion of form. -Take any immediate action needed to prevent further potential violations of any resident rights.-Report allegations involving neglect, abuse, injuries of unknown origin, and/or misappropriation of resident property immediately to the Director of Nursing (DON), or designee.-Forward the form to the grievance official as soon as possible. -The grievance official to take steps to resolve the grievance and record information about the grievance and those actions on the grievance form. -Steps to resolve the grievance may involve forwarding the grievance to the appropriate department head for follow up. -All staff involved in the investigation or resolution were to make prompt efforts to resolve the grievance and return the grievance form to the grievance official.-In accordance with the resident's rights, right to obtain a written decision regarding his or her grievance, the grievance official will issue a written decision regarding their decision at the end of the investigation. Review of the facility Grievances from 1/16/25 to 12/1/25 revealed the facility received 13 grievances involving call light response times and 8 grievances related to cold food temperatures. There was no evidence that the facility had implemented corrective actions or sustained resolutions to the grievances to prevent repeated concerns from occurring. Review of Resident Council Meeting minutes from 2/5/25 to 2/6/26 revealed the following concerns: -2/5/25 the residents voiced concerns regarding call light response times.-3/5/25 the residents indicated the call lights were still taking a long time to be answered. 4/2/25 the residents voiced complaints of long call light response times in the evenings.-5/5/25 the residents complained of call light response times in the morning.-7/11/25 the residents agreed call lights continued to be long at times. -8/8/25 concerns by residents related to long call lights in the early mornings and in the evenings.-9/15/25 continued concerns related to call light response times in the early mornings and in the evenings. -10/3/25 call lights in the evenings and the early mornings remained long but did show improvement.-11/14/25 concerns voiced about cold food temperatures. -12/12/25 continue to work on cold food temperatures. -1/2/26 concerns regarding the amount of time it was taking to get food delivered at meals and of continued cold food. -2/6/26 continue to voice concerns about cold food and the amount of time to it was taking to serve the meals. On 3/3/2026 at 11:16 AM, a Resident Council meeting was conducted with Residents 23, 32, 36, 42 and 51 and the following concerns were identified:-The residents had filed grievances related to long call light response times and to cold food temperatures.-The residents were told the staff would look into their concerns but no further interventions were identified to address their concerns. -The staff continue to ask about cold food temperatures and call light response times every month at the Resident Council meetings, but the residents continued to have the same concerns which remained unresolved. During an interview on 3/3/2026 at 12:40 PM, with the Administrator, the Director of Nursing (DON), and the Registered Nurse Consultant the following was confirmed:-The facility was aware of ongoing concerns from the Resident Council and from facility grievances related to call light response times and food temperatures.-Grievances were to be addressed by the department heads and then the grievances were to be given to the administrator for review. Each grievance was to have a documented resolution and in addition, the staff were to document a follow up with the resident to ensure continued resolution of the concerns.-Review of the Resident Council meeting minutes and the grievances revealed the staff failed to ensure a resolution and a follow up of the resolutions were documented. -The facility was able to print a report with the call light response times, but the facility had failed to review response times despite continued complaints of long call lights.

Licensure Reference Number 175 NAC 12-006.09(J)(i)Based on observation, interview and record review; the facility failed to ensure food was served at palatable (pleasant to taste) temperatures. The total sample size was 26 and the facility census was 62. Findings are:Review of the facility policy Checking Food Temperatures revised 8/18 revealed the following:-Meals would be served at the appropriate temperatures to ensure food safety and to prevent cross contamination.-Hot foods would be held at or above 135 degrees.-Cold foods would be held at or below 41 degrees.-Food temperatures should be taken periodically to ensure hot foods stay above 135 degrees and cold foods stay below 41 degrees during the portioning, transporting and serving process until received by the customer. Review of the Food Temperature Log revealed the following:-Poultry was to be cooked to 165 degrees.-Seafood, Eggs, Beef and Pork was to be cooked to 145 degrees.-Holding temperature of food was 135 degrees.An observation on 2/26/26 from 11:45 AM to 1:40 PM revealed the following observations:-12:40 PM Dietary Manager (DM-K) grilled 4 hamburger patties and 3 hotdogs. Temperature of the hamburgers and hot dogs were not checked when removed from the grill.-12:50 PM Hotdogs and hamburgers were placed in a metal container and placed on the steam table. 1 hamburger and 1 hot dog was served for noon meal.-12:50 PM DM-K Heated cold chicken noodle soup in the microwave and served bowl of soup directly after removed from the microwave (did not check the temperature of the soup).-1:40 PM Temperature of food on meal tray to be served revealed the following:-Chicken Fried Chicken temperature was 116.1 degrees.-Mashed Potatoes temperature was 112.0 degrees.-Brussel Sprouts/Squash temperature was 109.0 degrees. An interview on 2/26/26 at 1:40 PM with Cook-L confirmed that the meal tray would have been delivered to the resident with food being served at incorrect temperatures, the food would have been served cold. An interview with Certified Dietary Manager-M on 2/26/26 at 2:00 PM confirmed that the chicken, potatoes and vegetables on the meal tray at 1:40 PM would have been served at temperatures that were not palatable. Temperature of foods were to be checked after foods were cooked to determine foods were at proper temperatures - poultry was to be cooked to 165 degrees, beef and pork were to be cooked to 145 degrees. The chicken noodle soup, hamburgers and hot dogs temperature were not checked to make sure the temperatures were at or above the minimum cooking temperatures.

Licensure Reference Number 175 NAC 006.18(B)(D)Based on observations, interviews and record review; the facility failed to perform hand hygiene at appropriate intervals during the provision of care and medication provision, failed to ensure proper use of Personal Protective Equipment (PPE-equipment such as gowns and gloves used by health care workers to minimize exposure to potential hazards including infectious materials, blood-borne pathogens and/or hazardous substances to create a barrier to reduce transmission between patients/residents) for Residents 2, 9, 39, and 41, and failed to implement Enhanced Barrier Precaution (EBP-targeted use of PPE during high-contact care provision for those resident identified as being at high risk for acquiring or transmitting Multi-Drug-Resistant Organisms (MDRO's-bacteria or germs resistant to major classes of antibiotic (often known as super-bugs) to staff's hands and clothing then indirectly transferring the MDRO from resident to resident) during the care of Resident 3. The sample size was 26 and the facility census was 62. Findings are: A. Review of the facility policy Infection Control with a revision date of 12/2025 revealed the facility had a facility-wide effort involving all disciplines and QAPI Quality Assurance Performance Improvement (QAPI) involvement. The program consisted of coordination/surveillance, data analysis, education, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program was carried out by the facility Infection Preventionist (IP). The facility provided the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. The goal was to decrease infection risk, recognize infection control patterns while providing care, ensuring compliance with regulations, and promoting resident's rights and well-being all while trying to prevent the spread of infection. B. Review of the facility policy Standard and Transmission Based Precautions with a revision date of 12/2025 revealed the facility implemented infection control measures to prevent the spread of communicable diseases and conditions. The facility individualized decisions regarding resident placement, balancing infection risk, likelihood of infection transmission, and the potential for adverse psychological impact on the infected resident. EBP was the expanded use of PPE during high contact resident care activities that provided opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferring the MDRO from resident to resident. Residents with wounds and or indwelling medical devices were at an especially high risk of acquiring or transmitting the MDRO's. -The use of gown and gloves for high-contact resident care activities was indicated when more stringent measures did not apply. This included residents with wounds or indwelling medical device/s. -Examples of high-contact resident care included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs and/or toileting, device care, and wound care. C. Review of the undated facility policy Handwashing revealed the stated purpose was for good hygiene, infection control, and promotion of a healthy environment. The facility staff washed or sanitized with hand sanitizer before and after each glove use and between all glove changes. D. Review of Resident 3's Care Plan with a revision date of 2/12/26 revealed the resident had impaired cognitive function related to Alzheimer's Disease. The resident had a deficit in self-care and required the assistance of 1 staff member for bathing, dressing, transfers, toilet use, hygiene needs, and bed mobility. The resident used a wheelchair for mobility. In addition, the resident was incontinent of bladder, had impaired skin integrity, and fragile skin. Further review revealed no evidence the resident was on EBP's. Review of Resident 3's Progress Notes dated 2/24/26 at 1:49 PM revealed that the resident had a Stage 3 Pressure Ulcer (wound/ulcer involving full thickness skin loss that extends through the dermis and fat layer) to the resident's coccyx (tail-bone area) which had healed. During an interview on 2/26/26 at 9:50 AM with Nurse Aid (NA)-I revealed having worked in the facility for around 9 months. NA-I had no knowledge of Resident 3 ever being on EBP. In addition, NA-I confirmed being aware the resident had a recently healed pressure ulcer. During an interview on 2/26/26 at 9:52 AM NA-F reported working in the facility for a little less than 2 months. NA-F had no knowledge of Resident 3 having ever been on EBP. During an interview on 3/3/26 from 11:09 AM through 11:17 AM the Infection Preventionist (IP) confirmed EBP's should be in place for all residents with open wounds, catheters, indwelling medical devices and for all residents with an active and/or a history of infection with a MDRO. In addition, the IP confirmed Resident 3 required EBP due to the presence of a pressure ulcer prior to the ulcer healing, however, was unsure if EBP had been implemented for Resident 3. Further interview on 3/4/26 at 4:00 PM the IP confirmed Resident's 3 Care Plan did not indicate the resident was on EBP during the course of treatment of the pressure ulcer. E. Review of Resident 39's Care Plan revealed the resident had a diagnosis of Extended Spectrum Beta Lactamase Resistance (ESBL-an MRDO). The resident had a self-care deficit that required the assistance of 1-2 staff members for toilet use/hygiene, transfers, bed mobility, bathing, and dressing. In addition, Resident 39 required some set-up assistance with oral hygiene. During an interview on 2/26/26 at 8:00 AM NA-I confirmed being aware Resident 39 was on EBP's and reported receiving training in the implementation of EBP. During an observation of care provision for Resident 39 on 2/26/26 at 8:10 AM NA's (G and I) donned gowns and gloves and entered the resident room to assist the resident to get up for the day. While lying in bed the resident's brief was changed, and perineal care was provided. NA-I then removed and discarded the gloves, did not perform hand hygiene, gathered supplies (clothing, comb, washcloth and items for oral cares) all while not wearing gloves. NA-I then put on the resident's socks and assisted the resident from lying to sitting while not wearing gloves. After assisting the resident to sit on the edge of the bed, NA-I then put on clean gloves without performing any hand hygiene and assisted the resident to dress. Again NA-I removed the gloves, did not perform hand hygiene and set the resident up for oral care. NA-I then placed a gait belt on the resident and provided assist to stand and transfer while not wearing gloves. During an interview on 3/3/26 from 11:09 AM through 11:17 AM the IP confirmed the following:-Hand hygiene needed to be completed each time disposable gloves are removed. -Enhanced Barrier Precautions were to be in place for all residents with open wounds, catheters, indwelling medical devices and for all residents with active and a history of infection with an MDRO.-Gloves should be worn during the care of a resident on EBP during high contact care such as transfers and assisting with dressing and hygiene needs. F. Review of Resident 2's Care Plan with a revision date of 2/4/26 revealed the resident had a self-care deficit, was severely obese, had limited mobility and required assistance with toilet use and toilet hygiene, bathing, bed mobility, hygiene, dressing, and transfers. There was no evidence the resident had any conditions, devices, or diagnoses that indicated the implementation of EBP were needed. Review of a facility list for Enhanced Barrier Precautions revealed no evidence Resident 2 was on EBP's. During an observation of the provision of care for Resident 2 on 2/26/26 at 8:35 AM NA-I entered Resident 2's side of the shared room and removed the gloves worn while caring for Resident 39 (who was on EBP) but did not remove the gown, completed hand hygiene and put on clean gloves. NA-I then awakened Resident 2 and assisted the resident to a sitting position, applied a gait belt and walked with the resident to the bathroom about 10 feet using a wheeled walker. NA-I removed the resident's wet incontinence brief and assisted the resident to sit. NA-I then removed the gloves and performed hand hygiene, and then without putting on gloves assisted the resident to dress. During the entire care provision NA-I continued to wear the same gown worn while caring for Resident 39. During an interview on 3/3/26 from 11:09 through 11:17 AM the IP confirmed the following: -When one resident in a room is on EBP and the roommate is not, staff should not wear a gown used for the resident on EBP for the Resident who was not on EBP. G. During an observation of Medication Administration on 3/2/25 between 7:45 AM and 9:30 AM the following was observed. -Medication Aide (MA)-Q entered a resident room and provided oral medications to the resident, then applied a gait belt to the resident and assisted the resident to transfer from the bedside to a recliner, exited the room, did not complete hand hygiene, returned to the medication cart and without completing hand hygiene opened the cart and prepared medication for another resident. -Licensed Practical Nurse (LPN)-S obtained insulin pens and a blood glucose monitor from the medication cart, prepared the medications for administration, and the Blood Glucose Meter (BGM) for testing, placed both insulin pens and the BGM on the resident's roommate over the bed table without cleaning the surface or placing a clean barrier and performed to test the resident's blood glucose, and administered the insulin. Then without cleaning any of the items, LPN-S exited the room without performing hand hygiene and returned both pens and the blood glucose monitor to the medication cart. During an interview on 3/3/26 between 11:09 and 11:17 AM the IP confirmed that-during the provision of medications staff should complete hand hygiene after providing hands on care to residents and when using equipment such as Blood Glucose Meters and insulin pens. Further interview confirmed staff needed to create a clean barrier prior to setting insulin pens and/or BGM down in residents room to assure they were clean when returned to the medication cart. H. Review of Resident 9's Care Plan with a revision date of 10/07/25 revealed the resident had a self-care deficit and required the assistance of one staff member for toilet use, transfers, bathing, bed-mobility, dressing and hygiene needs. The resident used a wheelchair for mobility. Review of Resident 9's Medication Administration Record dated February 2026 revealed an order for EBP required for high resident contact care activities due to dialysis port to right chest. During an interview on 2/26/26 at 11:10 AM NA-G revealed having worked in the facility for over 20 years. NA-G had no knowledge of Resident 9 being on EBP. During an interview on 2/26/26 at 11:10 AM NA-F reported worked in the facility for less than 2 months. NA-F had no knowledge of Resident 9 being on EBP. During an observation of care provision for Resident 9 on 2/26/26 at 11:10 AM there was not an EBP sign on Resident 9's door or PPE for Resident 9's room. The Director of Nursing (DON) confirmed that Resident 9 was in EBP due to dialysis port. Licensed Practical Nurse (LPN)-E, NA-G and NA-F confirmed that Resident 9's toileting cares and skin treatments would have been completed without the use of PPE due to staff being unaware that resident was in EBP and no EBP sign or PPE on Resident 9's door. An interview with the facility IP on 3/3/26 at 11:20 AM confirmed that Resident 9 was in EBP related to a dialysis port and Resident 9's Care Plan did not indicate the resident was on EBP. I. Review of Resident 41's Care Plan with a revision date of 2/25/26 revealed the resident had a self-care deficit and was dependent on staff for toileting cares, transfers, bed-mobility, bathing and dressing. The resident required one assist with personal hygiene. Resident 41 had an indwelling catheter and had an intervention to use EBP with high contact cares and catheter cares. An interview on 2/25/26 at 8:45 AM with the DON confirmed that Resident 41 was in EBP related to having a catheter. During an observation of care provision on 2/26/26 at 8:06 AM NA-I pivot transferred Resident 41 from the bed to the wheelchair, NA-I did not have a gown or gloves on. An interview with the DON on 2/26/26 at 8:10 AM confirmed that staff were to wear gowns and gloves when transferring the resident from the bed to the wheelchair. An interview on 2/26/26 at 8:15 AM with NA-I revealed having worked in the facility for approximately 9 months. NA-I confirmed that Resident 41 was in EBP and staff were to wear gowns and gloves when doing high contact cares as listed on the sign on the resident's door. NA-I confirmed that when transferring Resident 41 no gown or gloves were worn.

Licensure Reference Number 175 NAC 12-006.09(B)Based on interview and record review; the facility failed to ensure the Minimum Data Sets (MDS-federally mandated assessment used to develop resident care plans) were coded accurately regarding Resident 8's Preadmission Screening and Resident Review (PASRR-federally mandated screening completed prior to Nursing Facility admission, to determine if residents had Major Mental Illness (MMI), Intellectual Disability (ID) or a Related Disorder (RD) to determine appropriate placement or the need for special services) and Resident 2's Major Mental Illness Diagnoses. The sample size was 30 and the facility census was 62. Findings are:A.Review of the Resident Assessment Instrument (RAI-manual for accurate completion of MDS assessments) Section A. revealed PASRR review identifies that all individuals admitted to nursing facilities and who have or are suspected to have Major Mental Illness (MMI), Intellectual Disability (ID) or Related Disorders (RD) may require certain care and services provided by the nursing facility and/or specialized services provided by the State. Further review revealed Section I was intended to code diseases that had a direct relationship to the resident's current functional status, cognitive status, mood and behavior status, medical treatments, nursing monitoring, or risk of death. B.Review of Resident 8's PASRR level 2 screen dated 11/26/25 revealed the resident had a Major Mental Illness. Review of Resident 8's MDS dated [DATE] indicated the resident had not been determined by the state PASRR level 2 process to have a serious mental illness, intellectual disability or related disorder. During an interview on 3/2/25 at 2:35 PM Registered Nurse (RN)-B confirmed Resident 8's MDS dated [DATE] was not accurately coded to reflect that Resident 8 had been determined by a level 2 PASRR screen to have a Major Mental Illness. C.Review of Resident 2's MDS dated [DATE] revealed diagnoses including Depression, Anxiety Disorder, and a Psychotic disorder.Review of Resident 2's Care Plan dated 2/4/26 revealed mental health diagnoses including Major Depressive Disorder, Anxiety Disorder, Hallucinations, and Mood (affective) Disorder but no diagnoses of a Psychotic Disorder. During an interview on 3/2/25 at 2:35 PM, RN-B confirmed Resident 2's MDS completed on 12/30/25 was not coded accurately to reflect diagnoses directly related to the resident's current status and the resident did not have a diagnosis of a Psychotic Disorder.

Licensure Reference Number 175 NAC 12-006.09(B)Licensure Reference Number 175 NAC 12-006.09(E) Based on interview and record review; the facility failed to ensure Resident 2's Preadmission Screening and Resident Review (PASRR-federally mandated screening completed prior to Nursing Facility admission, to determine if residents had Major Mental Illness (MMI), Intellectual Disability (ID) or a Related Disorder (RD) to determine appropriate placement or the need for special services) level 1 was completed accurately and failed to care plan Resident 25's PASRR results related to MMI. The sample size was 3 and the facility census was 62. Findings are:A.Review of the facility Policy for Resident Assessment, Preadmission Screening for MI/DD with a revision date of 4/2021 revealed the facility ensured each resident was properly screened using the PASRR specified by the State and the facility did not admit residents with MI or DD to ensure proper referral to appropriate agencies for the provision of specialized services, to ensure the care plan reflected any specialized services. B.Review of Resident 2's Minimum Data Set (MDS-federally mandated assessment used in the development of care plans) revealed the resident was admitted to the facility of 1/30/26 and the PASRR screen did not indicate the resident had a level 2 PASRR determination (level 2 screening conducted based on the level 1 screening and is completed for those residents determined to have a MMI, ID, or RD to establish appropriate placement and specialized services). The resident had diagnoses including Anxiety, Depression, and a Psychotic Disorder. Review of Resident 2's PASRR (level 1) dated 1/29/26 revealed that the resident had no signs of serious mental illness, intellectual disability, or a related disorder found during the level 1 screen. Further review revealed the screen indicated the resident had no known or suspected mental health diagnosis. Review of Resident 2's Care Plan dated 2/4/26 revealed diagnoses including Major Depressive Disorder, Generalized Anxiety Disorder, Unspecified Mood (affective) Disorder and Hallucinations. The resident had depression and anxiety that could affect activity participation and took psychotropic (drugs that affect a person's mental state) medications for treatment of the depression and anxiety. Mood and behavior were monitored, including monitoring for hallucination, delusions, and self-isolation. In addition, the care plan indicated the need for monitoring for adverse effects of psychotropic medication. During an interview on 3/2/26 at 2:45 PM Registered Nurse (RN)-B confirmed Resident 2's PASRR level 1 screen did not accurately contain the mental health diagnosis present to determine if a level 2 screening was needed. C.Review of Resident 8's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] and had diagnoses including Anxiety, Depression, and Schizophrenia. Review of Resident 8's PASSR dated 11/21/25 revealed the resident had signs of a serious mental illness, intellectual disability, and/or related disorder and Level 2 evaluation was to be completed. Further review revealed the level 2 evaluation determination (11/26/25) found the resident did have a serious mental illness, was appropriate for nursing facility services and did not currently require specialized services. In addition, the resident had a history of psychiatric hospitalization 3 times in the past and had seen psychiatry while at the nursing facility on a regular basis. The resident had a history of noncompliance with medications resulting in delusions and hallucinations. Review of Resident 8's Care Plan with a revision date of 12/18/25 revealed the resident had Schizophrenia, Bipolar Disorder, Anxiety, and Depression, however there was no evidence a Level 2 PASRR screen had been completed and no evidence the resident had been hospitalized 3 times in the past for treatment of the MMI. During an interview on 3/2/25 at 2:35 PM, RN-B confirmed Resident 8's Care Plan did not include Resident 8's PASRR level determination.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation, interview, and record review; the facility failed to provide routine hygiene (shaving) for Resident's 3, 10, and 14. The facility census was 62. Findings are:A. Review of the facility policy Activities of Daily Living (ADL)'s, Services to Carry Out with a revision date of 7/2021 revealed the facility provided treatment and services to attain and maintain the highest practicable physical, mental, and psychological well-being of each resident in accordance with the plan of care. If residents were unable to carry out ADL's, the necessary services to maintain good nutrition, grooming, mobility, and personal oral hygiene was provided by qualified staff. The residents' needs were outlined in the plan of care. B. Review of Resident 3's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 12/23/25 revealed the resident had severe cognitive impairment and staff completed all hygiene needs, dressing, transferring and provided substantial assistance with bed mobility. In addition, the resident was frequently incontinent of bladder. Review of Resident 3's Care Plan with a revision date of 3/2/26 revealed the resident had self-care deficits and required assistance of staff for personal and oral hygiene. There was no documented resident preference for frequency of shaving. Observations of Resident 3 from 2/26/26 through 3/3/26 revealed the following:-On 2/26/26 at 6:45 AM the resident was lying in bed and noted to be unshaven (facial and upper neck) with several days of beard growth.-On 2/26/26 at 9:18 AM the resident was assisted with morning care, with staff providing substantial assistance. The resident was dependent for changing an incontinence brief, perineal care, and dressing. Substantial assistance was provided for oral care and the resident was dependent for personal hygiene (face washing and applying deodorant). The resident was not shaved despite several days of beard growth. -On 2/26/26 at 2:40 PM the resident was sitting in a public area in a wheelchair and remained unshaven. -On 3/2/26 at 11:00 AM the resident was sitting in a wheelchair in the resident's room. The resident was not shaven, and the facial hair was substantially longer than when observed on 2/26/26.-On 3/3/26 at 2:50 PM The resident was lying in bed and continued to be unshaven. -On 3/3/26 at 6:54 AM the resident was sitting up in a wheelchair. Face was shaven, however the upper neck area remained unshaven. C. Review of Resident 10's MDS dated [DATE] revealed the resident was provided with set-up and/or supervision with personal hygiene. Review of Resident 10's Care Plan with a revision date of 11/20/25 revealed the resident needed assistance for personal and oral hygiene. There was no documented resident preference for frequency of shaving. Observations of Resident 10 from 2/25/26 through 3/3/26 revealed the following:-On 2/26/26 at 9:50 AM the resident was unshaven (face and neck).-On 2/27/26 at 12:30 AM the resident was sitting in the dining room and remained unshaven. -On 3/2/26 at 10:00 AM the resident was walking in the hallway with staff providing supervision. The resident was still unshaven and facial and neck hair were very long. -On 3/2/26 at 12:20 PM the resident was sitting in the dining room and ate independently. The resident continued to be unshaven. -On 3/2/26 at 3:00 PM the resident was sitting in a recliner in the resident's room and still was unshaven.-On 3/3/26 at 7:59 AM the resident was self-motivating using a wheelchair down a facility hallway and remained unshaven. During an interview on 3/2/26 at 11:10 AM Resident 10's daughter voiced a concern with lack of nursing staff sufficient to get things done timely. Further interview revealed Resident 10's electric razor cord had come up missing through multiple room changes, and a new cord was ordered by family, however family was unsure why the facility hadn't found an alternate way to ensure Resident 10 was being shaved. D. During an interview on 3/3/26 at 8:20 AM with Nurse Aide (NA)-I revealed never being informed that men needed to be shaven daily and/or was based on the plan of care. NA-I reported the residents were only shaved when they are bathed. During an interview on 3/3/26 at 9:25 AM the Director of Nursing (DON) confirmed residents should be shaved per their preference, which should be included in the plan of care. In addition, confirmed the shaving once weekly which was the average frequency of bathing in the facility, in most cases would not meet resident preference. E. Review of Resident 14's MDS dated [DATE] revealed the resident was admitted on [DATE]; had moderate cognitive impairment; had diagnoses of High Blood Pressure, Wound Infection, and Malnutrition; and required staff assistance with dressing, bathing, toileting, bed mobility and personal hygiene. Review of Resident 14's Care Plan (undated) revealed the resident was admitted on [DATE] with diagnoses of weakness and need for assistance with personal care; has impaired cognition; and required staff assistance with toileting, oral cares, personal hygiene, dressing, transfers and toileting. Observations of Resident 14 included the following: -On 2/26/26 at 7:35 AM the resident was lying in bed under the covers with several days of beard growth.; -On 2/26/26 at 8:30 AM the resident was in the dining room awaiting the breakfast meal and the resident was noted to not have been shaven with several days of beard growth visible.; -On 2/26/26 at 2:05 PM the resident was lying in bed with they eyes closed and continued to be unshaven.; -On 3/2/26 at 7:30 AM the resident was in the dining room and was unshaven and had several days of growth; -On 3/2/26 at 12:30 PM the resident was in the dining room and had not been shaved with several days of growth.; -On 3/2/26 at 2:50 PM the resident was sitting in a straight back chair in the resident room and the resident continued to be unshaven.; and -On 3/326 at 9:35 AM the resident was lying in bed on their left side watching tv and continued to be unshaven with several days of beard growth. F. Interview on 3/2/26 at 2:05 PM with NA-M and Assistant DON-D confirmed residents should be shaved every day. Interview on 3/3/26 at 9:35 AM with Resident 14 revealed the resident had not been shaven for several days, the resident needed to be shaved and the resident preferred to be shaved at least every 2 days. Interview on 3/3/26 at 1:00 PM with Registered Nurse (RN)-B confirmed the resident was not getting shaved per the resident's preference.

Licensure Reference Number 175 NAC 12-006.09(J)(i)1Based on record review and interview; the facility failed to prevent weight loss for 1 (Resident 67) of 3 sampled residents. The facility census was 62. Findings are:Review of the facility policy Weight Policy last revised 5/2007 revealed the resident's weight would be recorded monthly unless otherwise indicated by the physician. Weight changes of 5% within a 30-day period, 7.5% within a 90-day period, and 10% in a 180-day period would be reported to the physician. The resident's weight would be taken and recorded at the time of admission. If the resident could not be weighed on admission due to condition, this would be documented and the weight would be obtained as soon as the resident was able to be weighed. If the resident was unable to be weighed, the reason would be recorded and other provisions to monitor the resident's nutritional status would be taken. The resident's weight would be taken monthly in accordance with the weighing schedule and recorded in the electronic health record. The Registered Dietician (RD) would review and oversee weights and nutritional status quarterly and as needed with a significant change.Review of the facility policy Nutritional Status Management, last revised 4/2025 it is the policy of this facility to assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status. Each resident's nutritional status would be assessed on admission and at least quarterly thereafter. Each resident was to be weighed upon admission, then weekly for four weeks and monthly thereafter. The weight would be entered into the electronic health record. Monthly weights were to be taken starting the first day of the month and would be reviewed by the Director of Nursing (DON)/designee. Dietary evaluations would include determining ideal body weight range, usual body weight, current diet order, percentage of food eaten, possible dental problems, current illness, resident likes and dislikes, psychological needs, and any other change in medical condition that may impact weight gain or loss. If there was a significant change in the residents condition related to weight or nutrition, the RD would make recommendations to offer additional nutrition to those residents including all high-risk residents. Options include, but are not limited to, fortified cereal, large portions, between meal snacks, and commercial nutritional supplements. The Interdisciplinary Team (IDT) and/or RD would monitor and evaluate the resident's response or lack of response to the interventions and revising or discontinuing the approaches or justifying the continuation of current approaches. Nutritional Assessment may include: weighing and weight changes, oral intake of floods/fluids, IV therapy, nutrition prescriptions/macronutrients, functional status (assistive devices), medications (affecting taste, causing anorexia, increasing appetite), oral health (oral cavity lesions, mouth pain, decayed teeth, poorly fitting dentures), chewing and swallowing problems, affective and behavioral disorders, relevant conditions, hypermetabolic states (continuous wandering, skin breakdown), abnormal labs, overall prognosis/condition, resident choice (advanced directives).Any resident weight that varied from the previous reporting by more than 5% in 30 days, 7.5% in 90 days, and 10% in 180 days will be evaluated by the IDT to determine cause of weight loss/gain with interventions. Any resident meeting criteria for weight loss and any resident at risk would be weighed weekly with the weight entered into the electronic health system. Weekly weights would be reviewed by the RD. The IDT would update the care plan as appropriate. Review of Resident 67's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 1/16/26 revealed the following: the resident was admitted on [DATE] with diagnoses of Hip Fracture, Anemia, and Depression; had severe cognitive impairment; no known weight loss or gain; and was dependent with eating, oral hygiene, transfers, dressing and bed mobility. Review of Resident 67's Care Plan (undated) revealed the resident was a nutritional risk with interventions of 2Cal (nutritional supplement that is high in calories) 60 cubic centimeters (cc) three times a day started 2/24/26, mechanical soft diet, if the resident consumed less than 50% the staff were to offer a meal replacement, the resident was to eat meals in the dining room if they were agreeable, and weights as ordered.Review of the facility form RD-Nutrition Risk Review dated 1/20/26 for Resident 67 revealed the resident consumed 50-100% of meals. admission weight was 192 pounds (lbs.) and some weight loss was desirable. Intakes were adequate to meet estimated caloric needs. No new recommendations and the RD would follow up as needed.Review of the facility form Weights and Vital Summary dated 3/3/26 revealed the following weights for Resident 67:-1/13/26 (day of admission) 194 lbs;-1/16/26 (3 days after admission) 192 lbs;-2/4/26 (22 days after admission) 173 lbs (21 lb weight loss from admit weight which was a loss of 10.8%);-2/5/26 167.5 lbs;-2/13/26 168 lbs;-2/17/26 165 lbs;-2/18/26 162.5 lbs;-2/24/26 162 lbs; and-3/2/26 (48 days after admission) 159.2 lbs (34.8 lb weight loss from admit which was a 17.9% loss). There was no documentation to show the resident was weighed weekly for the first 4 weeks per the facility policy. Review of the Progress Notes for Resident 67 revealed the following entries:-On 1/27/26 at 12:33 PM a skilled note that said the resident has 2+ edema (moderate swelling on a scale of 1-4) to both feet.;-On 1/30/26 a Weight Change Note documented by the RD revealed the residents weight was 172 lbs which was an 11.3% loss since admit and the RD was requesting a re-weigh to be completed (review of the residents weights revealed no re-weigh documented in the electronic health record until 2/4/26).;-On 2/9/26 at 12:47 PM by the RD revealed the resident's weight was 167.5 lbs which was a decrease of 13.7%. The RD recommended to start 2Cal 60cc twice per day related to weight loss.;-On 2/23/26 at 7:27 PM by the RD revealed the resident's weight was 162.5 lbs which was a significant weight loss of 15.4% in 30 days. The resident on average was consuming 50-100% of meals and was receiving 60cc of 2Cal twice per day with a recommendation to increase the 2Cal to 60cc three times per day related to the weight loss.; and-On 3/3/26 at 10:59 AM a skilled note reported no edema. Review of the Medication Administration Record for January and February 2026 revealed the resident received the following medications: Furosemide (a diuretic medication) 20 milligrams (mg) daily and once daily as needed (no documentation of as needed administrations) for swelling; Mounjaro (a medication for diabetes which can reduce appetite and slow digestion) 10mg injection weekly for Diabetes; and Spironolactone (a diuretic medication) 25mg daily for swelling. 2Cal 60cc twice per day was started on 2/24/26 at 8:00 PM and was increased on 2/24/26 at 3:00 PM. Review of Resident 67's meal intakes for 2/3/26 through 3/2/26 revealed the resident refused meals on 2/27/26 (Breakfast, Lunch, and Dinner) and 2/28/26 (Breakfast and Lunch), consumed 25% on 2/14/26 at Dinner and 2/28/26 at Dinner and consumed 50-100% of the rest of the meals.Review of Resident 67's meal replacement intakes revealed the resident no evidence the resident was offered a meal replacement when the resident consumed less than 50% on 2/14/26 at Dinner, 2/18/26 at Dinner, 2/27/26 at Breakfast, Lunch and Dinner, 2/28/26 at Breakfast and Lunch, and 3/1/26 at Lunch.Review of the email dated 3/3/26 at 1:49 PM from the RD to the RN Consultant revealed nursing was unsure when the resident was admitted if the 1st two weights were accurate. The RD was unsure of the reason for the initial 20 lb weight loss and thought the first weight was not accurate but could not verify that.An interview on 3/3/26 at 9:15 AM with the Director Of Nursing (DON) revealed the facility does have a weight loss committee but the DON did not think the resident was being looked at by the committee. Further interview revealed the resident had not been re-weighed (as of this interview) after the weight of 159.5 was obtained on 3/2/26. The DON confirmed the IDT had not evaluated the residents weight loss to determine a causal factor and assess the effectiveness of current interventions to determine the need for revision or additional interventions.An interview on 3/3/26 at 2:25 PM with the RN Consultant confirmed a re-weigh was not documented after the weight warning on 1/30/26 (a 22 lb difference from admission) until 2/4/26 and no interventions were put into place to prevent further weight loss from 1/13/26 through 2/9/26.

Licensure Reference Number 175 NAC 12-006.04(G)Based on observation, interview, and record review; the facility failed to have sufficient staff to meet the hygiene needs of Residents 3, 10, and 14 and to ensure timely call light response. This had the potential to affect all facility residents. The facility census was 62. Findings are: A. Review of the facility policy Activities of Daily Living (ADL)'s, Services to Carry Out with a revision date of 7/2021 revealed the facility provided treatment and services to attain and maintain the highest practicable physical, mental, and psychological well-being of each resident in accordance with the plan of care. If residents were unable to carry out ADL's, the necessary services to maintain good nutrition, grooming, mobility, and personal oral hygiene was provided by qualified staff. The residents' needs were outlined in the plan of care. B. Review of Resident 3's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 12/23/25 revealed the resident had severe cognitive impairment and staff completed all hygiene needs, dressing, transferring and provided substantial assistance with bed mobility. In addition, the resident was frequently incontinent of bladder. Review of Resident 3's Care Plan with a revision date of 3/2/26 revealed the resident had self-care deficits and required assistance from staff for personal and oral hygiene. There was no documented resident preference for frequency of shaving. Observations of Resident 3 from 2/26/26 through 3/3/26 revealed the following: -On 2/26/26 at 6:45 AM the resident was lying in bed and was noted to be unshaven (facial and upper neck) with several days of beard growth.-On 2/26/26 at 9:18 the resident was assisted with morning care, with staff providing substantial assistance. The resident was dependent for changing an incontinence brief, perineal care, and dressing. Substantial assistance was provided for oral care, and the resident was dependent for personal hygiene (face washing and applying deodorant). The resident was not shaved despite several days of beard growth. -On 2/26/26 at 2:40 PM the resident was sitting in a public area in a wheelchair and remained unshaven. -On 3/2/26 at 11:00 AM the resident was sitting in a wheelchair in the resident's room. The resident was not shaven, and the facial hair was substantially longer than when observed on 2/26/26.-On 3/3/26 at 2:50 PM The resident was lying in bed and continued to be unshaven. -On 3/3/26 at 6:54 AM the resident was sitting up in a wheelchair. Face was shaven, however the upper neck area remained unshaven. C. Review of Resident 10's MDS dated [DATE] revealed the resident was provided with set-up and/or supervision with personal hygiene. Review of Resident 10's Care Plan with a revision date of 11/20/25 revealed the resident needed assistance for personal and oral hygiene. There was no documented resident preference for frequency of shaving. Observations of Resident 10 from 2/25/26 through 3/3/26 revealed the following:-On 2/26/26 at 9:50 AM the resident was unshaven (face and neck).-On 2/27/26 at 12:30 AM the resident was sitting in the dining room and remained unshaven. -On 3/2/26 at 10:00 AM the resident was walking in the hallway with staff providing supervision. The resident was still unshaven and facial and neck hair were very long. -On 3/2/26 at 12:20 PM the resident was sitting in the dining room and ate independently. The resident continued to be unshaven. -On 3/2/26 at 3:00 PM the resident was sitting in a recliner in the resident's room and still was unshaven.-On 3/3/26 at 7:59 AM the resident was self-motivating using a wheelchair down a facility hallway and remained unshaven. D. During an interview on 2/26/26 at 9:10 AM Nurse Aide (NA)-F reported having worked at the facility for less than 2 months. NA-F has concerns about the number of nurse aides staffed and the amount of care required by the residents. NA-F reported that often staff were too few to get the residents up in time for a timely breakfast, and often after 2:00 PM there were only 3 nurse aides to provide care until at least 6:00 PM for nearly 70 residents. In addition, long call lights responses happened daily. E. During an interview on 3/2/26 at 11:10 AM Resident 10's daughter voiced a concern with lack of nursing staff sufficient to get things done timely. Further interview revealed Resident 10's electric razor cord had come up missing through multiple room changes, and a new cord was ordered by family, however family was unsure why the facility didn't find an alternate way to ensure Resident 10 was being shaved. F. Review of Resident Council Meeting minutes from 2/5/25 to 2/6/26 revealed the following: -2/5/25 the residents voiced concerns regarding call light response times. -3/5/25 the residents indicated the call lights were still taking a long time to be answered. -4/2/25 the residents voiced complaints of long call light response times in the evenings. -5/5/25 the residents complained of call light response times in the morning. -7/11/25 the residents agreed call lights continued to be long at times. -8/8/25 concerns by residents related to long call lights in the early mornings and in the evenings. -9/15/25 continued concerns related to call light response times in the early mornings and in the evenings. -10/3/25 call lights in the evenings and the early mornings remained long but did show improvement. G. Review of the facility Grievances from 1/16/25 to 12/1/25 revealed the facility received 13 grievances involving call light response times. There was no evidence that the facility had implemented corrective actions or sustained resolutions to the grievances to prevent repeated concerns from occurring. H. Review of the facility Device Activity Report (record of call light activations and responses) from 2/27/26 through 3/2/26 revealed the following call light response times greater than 15 minutes: -2/27/26 at 4:12 AM call light was on in resident room [ROOM NUMBER] for 18.20 minutes. -2/27/26 at 5:00 AM call light was on in resident room [ROOM NUMBER] for 17.30 minutes. -2/27/26 at 5:11 AM call light was on in resident room [ROOM NUMBER] for 16.58 minutes. -2/27/26 at 5:32 AM call light was on in resident room [ROOM NUMBER] for 30.40 minutes. -2/27/26 at 5:32 AM call light was on in resident room [ROOM NUMBER] for 26.14 minutes. -2/27/26 at 6:12 AM call light was on in resident room [ROOM NUMBER] for 132.13 minutes. -2/27/26 at 6:17 AM call light was on in resident room [ROOM NUMBER] for 16.28 minutes. -2/27/26 at 6:19 AM call light was on in resident room [ROOM NUMBER] for 28.9 minutes. -2/27/26 at 6:26 AM call light was on in resident room [ROOM NUMBER] for 29.25 minutes. -2/27/26 at 6:34 AM call light was on in resident room [ROOM NUMBER] for 34.49 minutes. -2/27/26 at 6:39 AM call light was on in resident room [ROOM NUMBER] for 41.53 minutes. -2/27/26 at 7:00 AM call light was on in resident room [ROOM NUMBER] for 34.6 minutes. -2/27/26 at 7:00 AM call light was on in resident room [ROOM NUMBER] for 22.34 minutes. -2/27/26 at 7:05 AM call light was on in resident room [ROOM NUMBER] for 59.54 minutes. -2/27/26 at 7:08 AM call light was on in resident room [ROOM NUMBER] for 26.47 minutes. -2/27/26 at 7:08 AM call light was on in resident room [ROOM NUMBER] for 35.40 minutes. -2/27/26 at 7:13 AM call light was on in resident room [ROOM NUMBER] for 25.22 minutes. -2/27/26 at 7:24 AM call light was on in resident room [ROOM NUMBER] for 66.30 minutes. -2/27/26 at 7:27 AM call light was on in resident room [ROOM NUMBER] for 75.4 minutes. -2/27/26 at 7:49 AM call light was on in resident room [ROOM NUMBER] for 59.16 minutes. -2/27/26 at 7:53 AM call light was on in resident room [ROOM NUMBER] for 37.20 minutes. -2/27/26 at 7:57 AM call light was on in resident room [ROOM NUMBER] for 17.34 minutes. -2/27/26 at 8:14 AM call light was on in resident room [ROOM NUMBER] for 32.50 minutes. -2/27/26 at 8:14 AM call light was on in resident room [ROOM NUMBER] for 17.23 minutes. -2/27/26 at 8:22 AM call light was on in resident room [ROOM NUMBER] for 18.5 minutes. -2/27/26 at 8:34 AM call light was on in resident room [ROOM NUMBER] for 72.42 minutes. -2/27/26 at 8:43 AM call light was on in resident room [ROOM NUMBER] for 17.22 minutes. -2/27/26 at 8:44 AM call light was on in resident room [ROOM NUMBER] for 18.20 minutes. -2/27/26 at 8:44 AM call light was on in resident room [ROOM NUMBER] for 32.52 minutes. -2/27/26 at 8:48 AM call light was on in resident room [ROOM NUMBER] for 53.43 minutes. -2/27/26 at 8:50 AM call light was on in resident room [ROOM NUMBER] for 39.16 minutes. -2/27/26 at 8:51 AM call light was on in resident room [ROOM NUMBER] for 57.37 minutes. -2/27/26 at 9:04 AM call light was on in resident room [ROOM NUMBER] for 45.32 minutes. -2/27/26 at 9:04 AM call light was on in resident room [ROOM NUMBER] for 18.1 minutes. -2/27/26 at 9:16 AM call light was on in resident room [ROOM NUMBER] for 21.28 minutes. -2/27/26 at 9:18 AM call light was on in resident room [ROOM NUMBER] for 36.59 minutes. -2/27/26 at 9:19 AM call light was on in resident room [ROOM NUMBER] for 36.35 minutes. -2/27/26 at 9:31 AM call light was on in resident room [ROOM NUMBER] for 26.43 minutes. -2/27/26 at 9:34 AM call light was on in resident room [ROOM NUMBER] for 21.45 minutes. -2/27/26 at 9:54 AM call light was on in resident room [ROOM NUMBER] for 18.3 minutes. -2/27/26 at 11:36 AM call light was on in resident room [ROOM NUMBER] for 25.23 minutes. -2/27/26 at 11:44 AM call light was on in resident room [ROOM NUMBER] for 26.36 minutes. -2/27/26 at 1:15 PM call light was on in resident room [ROOM NUMBER] for 21.37 minutes. -2/27/26 at 1:53 PM call light was on in resident room [ROOM NUMBER] for 36.29 minutes. -2/27/26 at 2:05 PM call light was on in resident room [ROOM NUMBER] for 28.57 minutes. -2/27/26 at 2:05 PM call light was on in resident room [ROOM NUMBER] for 37.13 minutes. -2/27/26 at 2:05 PM call light was on in resident room [ROOM NUMBER] for 41.22 minutes. -2/27/26 at 2:41 PM call light was on in resident room [ROOM NUMBER] for 31.58 minutes. -2/27/26 at 3:20 PM call light was on in resident room [ROOM NUMBER] for 25.3 minutes. -2/27/26 at 3:23 PM call light was on in resident room [ROOM NUMBER] for 27.55 minutes. -2/27/26 at 3:48 PM call light was on in resident room [ROOM NUMBER] for 24.40 minutes. -2/27/26 at 4:23 PM call light was on in resident room [ROOM NUMBER] for 36.25 minutes. -2/27/26 at 4:24 PM call light was on in resident room [ROOM NUMBER] for 28.49 minutes. -2/27/26 at 4:38 PM call light was on in resident room [ROOM NUMBER] for 54.13 minutes. -2/27/26 at 4:42 PM call light was on in resident room [ROOM NUMBER] for 35.7 minutes. -2/27/26 at 4:46 PM call light was on in resident room [ROOM NUMBER] for 84.43 minutes. -2/27/26 at 4:54 PM call light was on in resident room [ROOM NUMBER] for 19.49 minutes. -2/27/26 at 4:58 PM call light was on in resident room [ROOM NUMBER] for 58.31 minutes. -2/27/26 at 5:04 PM call light was on in resident room [ROOM NUMBER] for 44.7 minutes. -2/27/26 at 5:18 PM call light was on in resident room [ROOM NUMBER] for 17.27 minutes. -2/27/26 at 5:42 PM call light was on in resident room [ROOM NUMBER] for 28.53 minutes. -2/27/26 at 5:58 PM call light was on in resident room [ROOM NUMBER] for 25.53 minutes. -2/27/26 at 6:09 PM call light was on in resident room [ROOM NUMBER] for 18.25 minutes. -2/27/26 at 6:24 PM call light was on in resident room [ROOM NUMBER] for 21.19 minutes. -2/27/26 at 6:24 PM call light was on in resident room [ROOM NUMBER] for 20.25 minutes. -2/27/26 at 6:33 PM call light was on in resident room [ROOM NUMBER] for 23.42 minutes. -2/27/26 at 6:37 PM call light was on in resident room [ROOM NUMBER] for 44.31 minutes. -2/27/26 at 6:45 PM call light was on in resident room [ROOM NUMBER] for 36.23 minutes. -2/27/26 at 7:02 PM call light was on in resident room [ROOM NUMBER] for 38.24 minutes. -2/27/26 at 7:12 PM call light was on in resident room [ROOM NUMBER] for 17.30 minutes. -2/27/26 at 7:20 PM call light was on in resident room [ROOM NUMBER] for 28.7 minutes. -2/27/26 at 7:23 PM call light was on in resident room [ROOM NUMBER] for 24.34 minutes. -2/27/26 at 7:25 PM call light was on in resident room [ROOM NUMBER] for 19.54 minutes. -2/27/26 at 7:27 PM call light was on in resident room [ROOM NUMBER] for 31.9 minutes. -2/27/26 at 7:43 PM call light was on in resident room [ROOM NUMBER] for 41.54 minutes. -2/27/26 at 7:45 PM call light was on in resident room [ROOM NUMBER] for 36.23 minutes. -2/27/26 at 7:50 PM call light was on in resident room [ROOM NUMBER] for 69.13 minutes. -2/27/26 at 7:57 PM call light was on in resident room [ROOM NUMBER] for 23.3 minutes. -2/27/26 at 8:03 PM call light was on in resident room [ROOM NUMBER] for 32.48 minutes. -2/27/26 at 8:14 PM call light was on in resident room [ROOM NUMBER] for 20.30 minutes. -2/27/26 at 8:28 PM call light was on in resident room [ROOM NUMBER] for 23.19 minutes. -2/27/26 at 8:30 PM call light was on in resident room [ROOM NUMBER] for 64.27 minutes. -2/27/26 at 8:32 PM call light was on in resident room [ROOM NUMBER] for 26.54 minutes. -2/27/26 at 8:47 PM call light was on in resident room [ROOM NUMBER] for 27.54 minutes. -2/27/26 at 8:48 PM call light was on in resident room [ROOM NUMBER] for 33.27 minutes. -2/27/26 at 8:48 PM call light was on in resident room [ROOM NUMBER] for 68.36 minutes. -2/27/26 at 8:54 PM call light was on in resident room [ROOM NUMBER] for 16.50 minutes. -2/27/26 at 8:59 PM call light was on in resident room [ROOM NUMBER] for 21.1 minutes. -2/27/26 at 9:34 PM call light was on in resident room [ROOM NUMBER] for 28.29 minutes. -2/27/26 at 9:34 PM call light was on in resident room [ROOM NUMBER] for 50.33 minutes. -2/27/26 at 9:35 PM call light was on in resident room [ROOM NUMBER] for 39.50 minutes. -2/27/26 at 10:43 PM call light was on in resident room [ROOM NUMBER] for 27.28 minutes. -2/27/26 at 10:49 PM call light was on in resident room [ROOM NUMBER] for 20.30 minutes. A total of 92 call lights exceeded 15 minutes from 4:00 AM until 11:00 PM on 2/27/26. The longest call light response time was on 2/27/26 at 6:12 AM when the resident in room [ROOM NUMBER] had to wait 1 hour and 32 minutes for the staff to respond to their call light. -2/28/26 at 3:13 AM call light was on in resident room [ROOM NUMBER] for 19.34 minutes. -2/28/26 at 5:56 AM call light was on in resident room [ROOM NUMBER] for 21.29 minutes. -2/28/26 at 6:37 AM call light was on in resident room [ROOM NUMBER] for 37.54 minutes. -2/28/26 at 6:38 AM call light was on in resident room [ROOM NUMBER] for 16.22 minutes. -2/28/26 at 6:42 AM call light was on in resident room [ROOM NUMBER] for 21.32 minutes. -2/28/26 at 7:02 AM call light was on in resident room [ROOM NUMBER] for 32.36 minutes. -2/28/26 at 7:04 AM call light was on in resident room [ROOM NUMBER] for 47.32 minutes. -2/28/26 at 7:10 AM call light was on in resident room [ROOM NUMBER] for 17.42 minutes. -2/28/26 at 7:14 AM call light was on in resident room [ROOM NUMBER] for 41.55 minutes. -2/28/26 at 7:34 AM call light was on in resident room [ROOM NUMBER] for 39.16 minutes. -2/28/26 at 7:38 AM call light was on in resident room [ROOM NUMBER] for 20.54 minutes. -2/28/26 at 7:43 AM call light was on in resident room [ROOM NUMBER] for 16.1 minutes. -2/28/26 at 7:45 AM call light was on in resident room [ROOM NUMBER] for 57.30 minutes. -2/28/26 at 7:53 AM call light was on in resident room [ROOM NUMBER] for 22.23 minutes. -2/28/26 at 8:25 AM call light was on in resident room [ROOM NUMBER] for 41.31 minutes. -2/28/26 at 8:38 AM call light was on in resident room [ROOM NUMBER] for 25.23 minutes. -2/28/26 at 9:33 AM call light was on in resident room [ROOM NUMBER] for 20.49 minutes. -2/28/26 at 9:58 AM call light was on in resident room [ROOM NUMBER] for 25.34 minutes. -2/28/26 at 10:08 AM call light was on in resident room [ROOM NUMBER] for 22.29 minutes. -2/28/26 at 10:12 AM call light was on in resident room [ROOM NUMBER] for 18.53 minutes. -2/28/26 at 10:39 AM call light was on in resident room [ROOM NUMBER] for 28.33 minutes. -2/28/26 at 10:43 AM call light was on in resident room [ROOM NUMBER] for 25.14 minutes. -2/28/26 at 11:30 AM call light was on in resident room [ROOM NUMBER] for 29.54 minutes. -2/28/26 at 11:32 AM call light was on in resident room [ROOM NUMBER] for 39.12 minutes. -2/28/26 at 11:33 AM call light was on in resident room [ROOM NUMBER] for 24.52 minutes. -2/28/26 at 11:48 AM call light was on in resident room [ROOM NUMBER] for 18.59 minutes. -2/28/26 at 11:49 AM call light was on in resident room [ROOM NUMBER] for 20.56 minutes. -2/28/26 at 2:35 PM call light was on in resident room [ROOM NUMBER] for 28.49 minutes. -2/28/26 at 2:35 PM call light was on in resident room [ROOM NUMBER] for 28.40 minutes. -2/28/26 at 2:46 PM call light was on in resident room [ROOM NUMBER] for 26.6 minutes. -2/28/26 at 2:52 PM call light was on in resident room [ROOM NUMBER] for 18.45 minutes. -2/28/26 at 4:39 PM call light was on in resident room [ROOM NUMBER] for 17.45 minutes. -2/28/26 at 4:45 PM call light was on in resident room [ROOM NUMBER] for 21.32 minutes. -2/28/26 at 5:18 PM call light was on in resident room [ROOM NUMBER] for 23.54 minutes. -2/28/26 at 6:18 PM call light was on in resident room [ROOM NUMBER] for 21.49 minutes. -2/28/26 at 6:22 PM call light was on in resident room [ROOM NUMBER] for 50.7 minutes. -2/28/26 at 6:23 PM call light was on in resident room [ROOM NUMBER] for 90.31 minutes. -2/28/26 at 6:25 PM call light was on in resident room [ROOM NUMBER] for 24.7 minutes. -2/28/26 at 6:26 PM call light was on in resident room [ROOM NUMBER] for 53.46 minutes. -2/28/26 at 6:29 PM call light was on in resident room [ROOM NUMBER] for 28.31 minutes. -2/28/26 at 6:39 PM call light was on in resident room [ROOM NUMBER] for 52.5 minutes. -2/28/26 at 6:44 PM call light was on in resident room [ROOM NUMBER] for 59.38 minutes. -2/28/26 at 6:46 PM call light was on in resident room [ROOM NUMBER] for 17.57 minutes. -2/28/26 at 6:51 PM call light was on in resident room [ROOM NUMBER] for 28.20 minutes. -2/28/26 at 6:52 PM call light was on in resident room [ROOM NUMBER] for 22.7 minutes. -2/28/26 at 7:01 PM call light was on in resident room [ROOM NUMBER] for 33.5 minutes. -2/28/26 at 7:02 PM call light was on in resident room [ROOM NUMBER] for 83.8 minutes. -2/28/26 at 7:12 PM call light was on in resident room [ROOM NUMBER] for 17.46 minutes. -2/28/26 at 7:13 PM call light was on in resident room [ROOM NUMBER] for 20.48 minutes. -2/28/26 at 7:18 PM call light was on in resident room [ROOM NUMBER] for 66.57 minutes. -2/28/26 at 7:23 PM call light was on in resident room [ROOM NUMBER] for 34.16 minutes. -2/28/26 at 7:25 PM call light was on in resident room [ROOM NUMBER] for 16.1 minutes. -2/28/26 at 7:27 PM call light was on in resident room [ROOM NUMBER] for 17.4 minutes. -2/28/26 at 7:29 PM call light was on in resident room [ROOM NUMBER] for 83.21 minutes. -2/28/26 at 7:35 PM call light was on in resident room [ROOM NUMBER] for 37.28 minutes. -2/28/26 at 7:45 PM call light was on in resident room [ROOM NUMBER] for 28.49 minutes. -2/28/26 at 7:48 PM call light was on in resident room [ROOM NUMBER] for 50.18 minutes. -2/28/26 at 7:51 PM call light was on in resident room [ROOM NUMBER] for 17.34 minutes. -2/28/26 at 7:53 PM call light was on in resident room [ROOM NUMBER] for 44 minutes. -2/28/26 at 7:59 PM call light was on in resident room [ROOM NUMBER] for 32.43 minutes. -2/28/26 at 7:59 PM call light was on in resident room [ROOM NUMBER] for 18.44 minutes. -2/28/26 at 8:04 PM call light was on in resident room [ROOM NUMBER] for 80.39 minutes. -2/28/26 at 8:04 PM call light was on in resident room [ROOM NUMBER] for 92.57 minutes. -2/28/26 at 8:07 PM call light was on in resident room [ROOM NUMBER] for 31.9 minutes. -2/28/26 at 8:14 PM call light was on in resident room [ROOM NUMBER] for 25.34 minutes. -2/28/26 at 8:24 PM call light was on in resident room [ROOM NUMBER] for 26.26 minutes. -2/28/26 at 8:27 PM call light was on in resident room [ROOM NUMBER] for 103.21 minutes. -2/28/26 at 8:30 PM call light was on in resident room [ROOM NUMBER] for 43.43 minutes. -2/28/26 at 8:33 PM call light was on in resident room [ROOM NUMBER] for 26.46 minutes. -2/28/26 at 8:38 PM call light was on in resident room [ROOM NUMBER] for 24.32 minutes. -2/28/26 at 8:48 PM call light was on in resident room [ROOM NUMBER] for 52.50 minutes. -2/28/26 at 8:53 PM call light was on in resident room [ROOM NUMBER] for 73.31 minutes. -2/28/26 at 8:59 PM call light was on in resident room [ROOM NUMBER] for 53.53 minutes. -2/28/26 at 9:01 PM call light was on in resident room [ROOM NUMBER] for 39.27 minutes. -2/28/26 at 9:06 PM call light was on in resident room [ROOM NUMBER] for 25.26 minutes. -2/28/26 at 9:08 PM call light was on in resident room [ROOM NUMBER] for 26.50 minutes. -2/28/26 at 9:10 PM call light was on in resident room [ROOM NUMBER] for 20.57 minutes. -2/28/26 at 9:11 PM call light was on in resident room [ROOM NUMBER] for 24.41 minutes. -2/28/26 at 9:12 PM call light was on in resident room [ROOM NUMBER] for 60 minutes. A total of 79 call lights exceeded 15 minutes from 3:00 AM until 10:00 PM on 2/28/26. The longest call light response time was on 2/28/26 at 8:27 PM when the resident in room [ROOM NUMBER] had to wait 103.21 minutes for the staff to respond to their call light. -3/1/26 at 5:22 AM call light was on in resident room [ROOM NUMBER] for 16.48 minutes. -3/1/26 at 6:06 AM call light was on in resident room [ROOM NUMBER] for 41.15 minutes. -3/1/26 at 6:33 AM call light was on in resident room [ROOM NUMBER] for 20.57 minutes. -3/1/26 at 7:08 AM call light was on in resident room [ROOM NUMBER] for 25.9 minutes. -3/1/26 at 7:34 AM call light was on in resident room [ROOM NUMBER] for 20.19 minutes. -3/1/26 at 7:42 AM call light was on in resident room [ROOM NUMBER] for 44.35 minutes. -3-/1/26 at 7:51 AM call light was on in resident room [ROOM NUMBER] for 24.35 minutes. -3/1/26 at 7:52 AM call light was on in resident room [ROOM NUMBER] for 21 minutes. -3/1/26 at 8:01 AM call light was on in resident room [ROOM NUMBER] for 28.26 minutes. -3/1/26 at 8:20 AM call light was on in resident room [ROOM NUMBER] for 33.10 minutes. -3/1/26 at 8:31 AM call light was on in resident room [ROOM NUMBER] for 16.26 minutes. -3/1/26 at 8:37 AM call light was on in resident room [ROOM NUMBER] for 16.1 minutes. -3/1/26 at 8:38 AM call light was on in resident room [ROOM NUMBER] for 16.34 minutes. -3/1/26 at 8:53 AM call light was on in resident room [ROOM NUMBER] for 17.7 minutes. -3/1/26 at 8:55 AM call light was on in resident room [ROOM NUMBER] for 17.3 minutes. -3/1/26 at 9:04 AM call light was on in resident room [ROOM NUMBER] for 17.2 minutes. -3/1/26 at 12:42 PM call light was on in resident room [ROOM NUMBER] for 25.36 minutes. -3/1/26 at 2:20 PM call light was on in resident room [ROOM NUMBER] for 16.36 minutes. -3/1/26 at 2:23 PM call light was on in resident room [ROOM NUMBER] for 16.51 minutes. -3/1/26 at 2:58 PM call light was on in resident room [ROOM NUMBER] for 25.52 minutes. -3/1/26 at 3:26 PM call light was on in resident room [ROOM NUMBER] for 95.42 minutes. -3/1/26 at 3:49 PM call light was on in resident room [ROOM NUMBER] for 23.19 minutes. -3/1/26 at 5:12 PM call light was on in resident room [ROOM NUMBER] for 19.46 minutes. -3/1/26 at 6:16 PM call light was on in resident room [ROOM NUMBER] for 20.10 minutes. -3/1/26 at 6:59 PM call light was on in resident room [ROOM NUMBER] for 20.36 minutes. -3/1/26 at 7:07 PM call light was on in resident room [ROOM NUMBER] for 18.2 minutes. -3/1/26 at 7:09 PM call light was on in resident room [ROOM NUMBER] for 51.33 minutes. -3/1/26 at 7:23 PM call light was on in resident room [ROOM NUMBER] for 37.52 minutes. -3/1/26 at 7:26 PM call light was on in resident room [ROOM NUMBER] for 28.32 minutes. -3/1/26 at 7:26 PM call light was on in resident room [ROOM NUMBER] for 26.9 minutes. -3/1/26 at 7:34 PM call light was on in resident room [ROOM NUMBER] for 20.33 minutes. -3/1/26 at 7:36 PM call light was on in resident room [ROOM NUMBER] for 30.32 minutes. -3/1/26 at 7:38 PM call light was on in resident room [ROOM NUMBER] for 23.19 minutes. -3/1/26 at 7:38 PM call light was on in resident room [ROOM NUMBER] for 26.10 minutes. -3/1/26 at 8:27 PM call light was on in resident room [ROOM NUMBER] for 54.44 minutes. -3/1/26 at 8:28 PM call light was on in resident room [ROOM NUMBER] for 38.17 minutes. -3/1/26 at 8:35 PM call light was on in resident room [ROOM NUMBER] for 18.50 minutes. -3/1/26 at 8:49 PM call light was on in resident room [ROOM NUMBER] for 22.32 minutes. -3/1/26 at 10:18 PM call light was on in resident room [ROOM NUMBER] for 17.40 minutes. A total of 38 call lights exceeded 15 minutes from 5:00 AM until 10:30 PM on 3/1/26. The longest call light response time was on 3/1/26 at 3:26 PM when the resident in room [ROOM NUMBER] had to wait 95.42 minutes for the staff to respond to their call light. -3/2/26 at 4:20 AM the call light in resident room [ROOM NUMBER] was on for 16.47 minutes. -3/2/26 at 5:16 AM the call light in resident room [ROOM NUMBER] was on for 17.11 minutes. -3/2/26 at 5:43 AM the call light in resident room [ROOM NUMBER] was on for 24.27 minutes. -3/2/26 at 5:49 AM the call light in resident room [ROOM NUMBER] was on for 17.35 minutes. -3/2/26 at 6:52 AM the call light in resident room [ROOM NUMBER] was on for 43.10 minutes. -3/2/26 at 6:59 AM the call light in resident room [ROOM NUMBER] was on for 58.28 minutes. -3/2/26 at 7:02 AM the call light in resident room [ROOM NUMBER] was on for 18.58 minutes. -3/2/26 at 7:14 AM the call light in resident room [ROOM NUMBER] was on for 42.27 minutes. -3/2/26 at 7:18 AM the call light in resident room [ROOM NUMBER] was on for 40.28 minutes. -3/2/26 at 7:22 AM the call light in resident room [ROOM NUMBER] was on for 52.35 minutes. -3/2/26 at 7:30 AM the call light in resident room [ROOM NUMBER] was on for 46 minutes. -3/2/26 at 7:45 AM the call light in resident room [ROOM NUMBER] was on for 29.19 minutes. -3/2/26 at 7:51 AM the call light in resident room [ROOM NUMBER] was on for 20.41 minutes. -3/2/26 at 8:07 AM the call light in resident room [ROOM NUMBER] was on for 18.15 minutes. -3/2/26 at 8:09 AM the call light in resident room [ROOM NUMBER] was on for 32.9 minutes. -3/2/26 at 8:17 AM the call light in resident room [ROOM NUMBER] was on for 25.22 minutes. -3/2/26 at 8:40 AM the call light in resident room [ROOM NUMBER] was on for 40.39 minutes. -3/2/26 at 8:42 AM the call light in resident room [ROOM NUMBER] was on for 25.20 minutes. -3/2/26 at 8:43 AM the call light in resident room [ROOM NUMBER] was on for 25.59 minutes. -3/2/26 at 9:08 AM the call light in resident room [ROOM NUMBER] was on for 35.19 minutes. -3/2/26 at 9:33 AM the call light in resident room [ROOM NUMBER] was on for 26.9 minutes. -3/2/26 at 9:56 AM the call light in resident room [ROOM NUMBER] was on for 24.49 minutes. -3/2/26 at 10:49 AM the call light in resident room [ROOM NUMBER] was on for 30.16 minutes. -3/2/26 at 10:55 AM the call light in resident room [ROOM NUMBER] was on for 56.53 minutes. -3/2/26 at 10:56 AM the call light in resident room [ROOM NUMBER] was on for 28.13 minutes. -3/2/26 at 10:56 AM the call light in resident room [ROOM NUMBER] was on for 28.4 minutes. -3/2/26 at 10:59 AM the call light in resident room [ROOM NUMBER] was on for 27.21 minutes. -3/2/26 at 11:08 AM the call light in resident room [ROOM NUMBER] was on for 22.5 minutes. -3/2/26 at 11:23 AM the call light in resident room [ROOM NUMBER] was on for 18.49 minutes. -3/2/26 at 11:41 AM the call light in resident room [ROOM NUMBER] was on for 32.47 minutes. -3/2/26 at 12:47 AM the call light in resident room [ROOM NUMBER] was on for 26.2 minutes. -3/2/26 at 1:10 PM the call light in resident room [ROOM NUMBER] was on for 17.3 minutes. -3/2/26 at 1:43 PM the call light in resident room [ROOM NUMBER] was on for 25.36 minutes. -3/2/26 at 12:59 PM the call light in resident room [ROOM NUMBER] was on for 42.49 minutes. -3/2/26 at 1:14 PM the call light in resident room [ROOM NUMBER] was on for 38.10 minutes. -3/2/26 at 1:16 PM the call light in resident room [ROOM NUMBER] was on for 21.19 minutes. A total of 36 call lights exceeded 15 minutes from 4:00 AM until 2:00 PM on 3/2/26. The longest call light response time was on 3/2/26 at 6:59 AM when the resident in room [ROOM NUMBER] had to wait 58.28 minutes for the staff to respond to their call light. I. During a Resident Council meeting conducted on 3/3/2026 at 11:16 AM, with Residents 23, 32, 36, 42 and 51 the following concerns were identified:-The residents had filed grievances related to long call light response times. -The residents were told the staff would look into their concerns but no further interventions were identified to address their concerns. -The staff continue to ask about call light response times every month at the Resident Council meetings, but the residents continued to have the same concerns which remained unresolved. J. During an interview on 3/3/2026 at 12:40 PM, with the Administrator, the Director of Nursing (DON), and the Registered Nurse Consultant the following was confirmed: -The facility was aware of ongoing concerns from the Resident Council and from facility grievances related to call light response times. -Grievances were to be addressed by the department heads and then the grievances were to be given to the administrator for review. Each grievance was to have a documented resolution and in addition, the staff were to document a follow up with the resident to ensure continued resolution of the concerns. -Review of the Resident Council meeting minutes and the grievances revealed the staff failed to ensure a resolution and a follow up of the resolutions were documented. -The facility was able to print a report with the call light response times, but the facility had failed to review response times despite continued complaints of long call lights.

Licensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview; the facility failed to provide Resident 8 with the pneumococcal vaccine that was consented to at the time of admission. The sample size was 5 and the facility census was 62. Findings are:Review of the facility Immunization policy with a revision date of 4/2025 revealed the facility offered and administered influenza, pneumococcal, and COVID-19 immunizations to eligible residents after providing education on the risks and potential side effects of the vaccines and obtaining consent. The purpose was to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal disease, or COVID-19 by ensuring that each resident was informed about the benefits and risks of immunization; and had the opportunity to receive those immunizations unless clinically contraindicated. Review of the facility admission Packet revealed a Resident Consent for Influenza, Pneumococcal and COVID-19 Form that was presented to residents and/or their responsible party at the time of admission. In addition, the admission packet included a copy of the facility Infection Prevention and Control Program that revealed the facility maintained a facility wide effort involving all disciplines and individuals as an integral part of the quality assurance and performance improvement program. The elements of the program included coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and an employee health program. The was comprehensive and addressed detection, prevention and control of infections among residents and personnel. Review of the Resident 8's Consent for Influenza, Pneumococcal, and COVID-10 Vaccination Form dated 10/9/25 revealed the resident received education regarding the Pneumococcal vaccine and reviewed the risks, benefits, and potential side effects of receiving the vaccine, understood there were different types of Pneumococcal vaccines that could be reviewed with the resident's physician and the resident wished to receive the vaccine according the Center to Disease Control (CDC) recommendations. Review of Resident 8's Care Plan with a revision date of 1/6/26 revealed the resident had diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Anemia, Chronic Kidney Disease, and was to be monitored for signs and symptoms of respiratory insufficiency. Review of Resident 8 Electronic Medical Record revealed no evidence the Pneumococcal vaccine had been administered. During an interview on 3/2/26 at 3:00 PM the facility Infection Preventionist confirmed Resident 8 had not received the Pneumococcal vaccine the resident consented to on 10/9/25.

Licensure Reference Number 175 NAC 12-006.09(G)(i)Based on interview and record review; the facility failed to complete Ombudsman notifications and/or comprehensive discharge summaries for Residents 71, 72, and 74. Findings are:A. Review of the facility policy Discharge Summary last revised 4/2025 revealed when the facility anticipated a resident discharge, the discharge summary would include, but not be limited to the following:-a recapitulation of the resident's stay that includes diagnoses, course of illness/treatment or therapy, any pertinent lab, radiology and consultation results;-a final summary of the residents status to include a description of the resident's: identification and demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychological well-being, physical functioning and structural problems, continence, disease diagnosis and health conditions, dental and nutritional status, skin conditions, activity, medications, special treatments, and discharge planning.-a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter); and-a post-discharge plan of care was developed with the participation of the resident and with the resident's consent, the resident representatives assisted the resident to adjust to his or her new living environment and would indicate where the individual planned to reside, any arrangements that had been made for the resident's follow up care, and any post-discharge medical and non-medical services. -the resident, and/or their representative signed a release indicating the information contained on the discharge summary could be provided to the receiving facility. -a final summary of the resident's status at the time of discharge would be filed in the resident's medical record and available for release to authorized persons and agencies, with the consent of the resident or resident's representative. -for residents discharged home: the facility would document in the medical record that written discharge instructions were provided to the resident/resident representative, instructions were discussed with the resident/resident representative, and discharge information was conveyed in a language and manner the resident understood. Review of the facility admission Packet, undated revealed the facility provided written notification to the Resident and the Resident Representative with a copy sent to the representative of the Office of the State Long-Term Care Ombudsman at least 30 days in advance of a transfer or discharge, or if necessary as soon as practicable as permitted under applicable law. B. Review of Resident 71's Minimum Data Set (MDS- federally mandated assessment used to develop resident care plans and provide tracking for residents) Discharge assessment dated [DATE] revealed the resident admitted to the facility on [DATE] and discharged to home/community on 1/17/26. Review of Resident 71's Discharge Summary and Post Discharge Plan of Care dated 1/14/26 revealed no evidence the facility completed the assessment. There was no evidence of a recapitulation of the resident's care and services, no final summary of the resident's status, no evidence of a discharge plan of care, and no evidence of reconciliation of the resident's medication. Review of Resident 71's Electronic Medical Record revealed no evidence the State Ombudsman was notified of the Resident's discharge. During an interview on 3/3/26 at 12:55 PM Registered Nurse (RN)-B confirmed the facility had no evidence the facility had completed a Discharge Summary and Post Discharge Plan of Care. During an interview on 3/3/26 at 1:21 PM the Social Services Director (SSD) confirmed the facility had not notified the State Ombudsman of Resident 71's discharge. C. Review of Resident 72's Discharge MDS dated [DATE] revealed the resident was admitted on [DATE] and discharged with a return anticipated on 8/23/25. Review of Resident 72's Electronic Medical Record revealed no evidence a Discharge Summary was completed and no evidence the State Ombudsman was notified of the Resident's discharge. D. Review of Resident 74's MDS dated [DATE] revealed the resident was admitted on [DATE] and discharged on 1/23/26. Review of Resident 74's Discharge Summary and Post-Discharge Plan of Care dated 1/20/26 revealed no evidence the facility completed the assessment. There was no evidence of a recapitulation of the resident's care and services, no final summary of the resident's status, no evidence of a discharge plan of care, and no evidence of a reconciliation of the resident's medication. Review of Resident 74's Electronic Medical Record revealed no evidence the State Ombudsman was notified of the Resident's discharge. E. During an interview on 3/3/26 at 12:55 PM RN-B confirmed the facility had no evidence the facility had completed Discharge Summaries and Post-Discharge Plan of Care for Residents 72 and 74. Interview on 3/3/26 at 1:21 PM with the SSD confirmed the facility had not notified the State Ombudsman of Resident 72 and 74's discharge.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility staff failed to wash hands and to change gloves to prevent the potential for cross contamination during the provision of a meal service. The facility census was 44 with a total sample size of 44. Findings are: A. Review of the Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-310.14 Food employees shall wash their hands and exposed portions of their arms immediately before engaging in food preparation: -after handling soiled equipment or utensils; and -during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. -3.304.15 (A) Single use gloves shall be used for only one task and should be discarded when soiled or when interruptions occur in the operation. B. During observation of the noon meal service on 12/12/24 at 12:00 PM to 12:40 PM, Dietary [NAME] (DC)-P with gloved hands placed piece of pork loin on the dinner plate, was touching the meat when cutting it into small pieces. DC-P did not change gloves after touching the meat, then touched various kitchen items including resident cards, dishes and serving utensils without changing gloves or washing hands. Interview with Dietary Manager (DM)-Q on 12/12/24 at 2:30PM confirmed staff should have removed gloves after touching the food, washed hands and put on a clean pair of disposable gloves before touching other kitchen items.

Licensure Reference Number 175 NAC 12-006.09(l) Based on observations, record review, and interview; the facility failed to review, revise, and/or implement care plan interventions to prevent falls for Residents 16, 19, and 7. The sample size was 5 and the facility census was 44. Findings are: A. Review of the facility policy Fall Management System last reviewed 12/23 revealed the following: -Residents with high risk factors identified on the Fall Risk Evaluations would have an individualized care plan developed that included measurable objectives and timeframe's, -review of the incident would include an investigation to determine probable causal factors, -the investigation would be reviewed by the interdisciplinary team, -the Resident's care plan would be updated, and -the Quality Assurance Committee would analyze trends related to falls and would determine if further intervention was needed. B. Review of Resident 16's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 10/23/24 revealed the resident had moderate cognitive impairment; required assistance with dressing, transfers, toileting, and hygiene; had diagnoses of Parkinson's Disease, heart failure, and dementia; and had 2 or more falls with no injury and 1 fall with injury in the look back period. Review of Resident 16's Care Plan last revised 10/11/24 revealed the following regarding the resident: -required extensive assistance with transfers, dressing, toileting, and bed mobility, -was a high fall risk, -fall interventions included prompt response to call lights, do not leave unattended in the wheelchair in the resident room, scoop mattress to bed, bed in low position, floor mat, and grip strip material on the floor in front of the resident's recliner. Observations of Resident 16 revealed the following: -on 12/12/24 at 6:50 AM the resident was laying in bed, grip strips were not present to the floor in front of the resident's recliner, -on 12/12/24 at 10:30 AM the resident was visiting with a visitor in the resident room, grip strips were not present to the floor in front of the resident's recliner, -on 12/12/24 at 2:20 PM the resident was sitting in the recliner with feet elevated in the resident room, grip strips were not present to the floor in front of the recliner, -on 12/16/24 at 7:45 AM the resident was resting in bed with eyes closed, grip strips were not present on the floor in front of the recliner, and -on 12/16/24 at 1:40 PM the resident was sitting in the recliner with feet elevated in the resident room, grip strips were not present to the floor in front of the recliner. Interview on 12/16/24 at 3:57 PM with the Director of Nursing (DON) revealed Resident 16 had a fall intervention to have grip strips to the floor in front of the resident's recliner. Further interview confirmed Resident 16 did not have grip strips present to the floor in front of the recliner. C. Review of Resident 19's MDS dated [DATE] revealed the resident had moderate cognitive impairment; required assistance with dressing, toileting, transfers, and hygiene; had diagnoses of a stroke, high blood pressure, dementia, Parkinson's Disease, depression, and psychotic disorder; and had 1 fall with no injury in the look back period. Review of Resident 19's Care Plan last revised 10/9/24 revealed the following regarding the resident: -required extensive assistance with toileting, transfers, dressing, and bed mobility, -was a high fall risk, and -fall interventions included: a pad call light, dycem (non-skid pad) to the wheelchair, offer a snack in the afternoon, non-skid socks, ensure the resident was wearing appropriate shoes, and keep needed items such as water within reach. Review of the facility incident reports regarding Resident 19 revealed the following: -a fall on 10/30/24 at 12:45 AM the resident was found sitting upright on the fall mat with their back against the bed. The resident stated they were picking their nose and it started bleeding and sat on the floor to get a Kleenex. No immediate intervention was implemented, -a fall on 11/28/24 at 2:44 PM the resident was found laying on the floor on the floor mat next to the resident bed. The resident thought it was time to get up. No immediate intervention was implemented, and -a fall on 11/28/24 at 8:15 PM the resident was found sitting on the floor mat with knees up to their chest. The resident was confused. No new immediate intervention implemented. Interview on 12/16/24 at 3:57 PM with the DON confirmed Resident 19's falls on 10/30/24 and 2 falls on 11/28/24 did not have new immediate interventions implemented to prevent future falls. 51391 D. Review of Resident 7's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 10/18/24 revealed that resident had a diagnosis of Anemia, Non-Alzheimer Dementia, Seizure Disorder and Depression. The resident received antipsychotic, antidepressant and anticonvulsant medications and required substantial assistance with transfers and toileting hygiene. Review of Resident 7's Fall Review dated 11/25/24 revealed the resident was sitting on the floor mat next to the bed, the call light was within reach, no gripper socks were on resident's feet and resident was trying to get up on. The resident was unaware of limitations due to a cognitive decline and was confused. The intervention put into place was to complete a Situation, Background, Assessment, and Recommendation (SBAR-structured communication framework that can help teams share information about the condition of a resident). The SBAR was sent to the physician on 11/25/24 to do a urinalysis (UA- a noninvasive medical test that examined urine to check for signs of health issues) due to resident being more tired than usual. The physician's order was received on 11/26/24 to complete a UA and encourage 4 ounces of cranberry juice or another liquid for meals until symptoms resolve. The SBAR order was signed by the facility on 11/28/24, the UA was completed on 11/30/24 and on 12/2/24 UA results were sent to the facility from the physician and stated waiting for the results of a culture (a laboratory procedure where a urine sample is grown to identify specific bacteria or yeast causing an infection). On 12/16/24 the UA results were received with no treatment ordered. During an interview on 12/16/24 at 1:45 PM the DON confirmed that the UA was completed on 11/30/24 and the culture results were received from the physician on 12/16/24 with no treatment. No other fall interventions were put into place.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review, and interview the facility failed to complete hand hygiene at appropriate intervals to prevent the potential spread in infection for Residents 17, 11, and 7, failed to utilize the appropriate Personal Protective Equipment (PPE-the use of protective clothing such as gowns, gloves, or other measures such as face/eye protection used to prevent the spread of infection and or protect care-givers during care) during the provision of care for Residents 34 and 7 who were on Enhanced Barrier Precaution (EBP-infection prevention through expanded use of PPE), and failed to develop and implement measures to prevent the growth of potential water borne illness. The sample size was 21 and the facility census was 44. Findings are: A. Review of the facility policy for Standard and Transmission-Based Precautions with a revision date of 3/2024 revealed the following: -It was the facility policy to implement infection control measures to prevent the spread of communicable diseases and conditions, -balance infection risk factors that increased the likelihood of transmission, -utilized the least restrictive approach possible to adequately protect residents and others, -the use of Enhanced Barrier Precaution (EBP) was used in conjunction with Standard Precautions (infection prevention practices that applied to the care of all residents regardless of suspected or confirmed infection), through expanded use of Personal Protective Equipment (PPE-a term to describe the use of protective clothing such as gowns, gloves, or other measures such as face/eye protection used to prevent the spread of infection and or protect care-givers during care), through the use of gown and gloves during high-contact resident care activities with residents infected or colonized (the presence of an organism without active infection) with Multidrug Resistant Organisms (MDRO's-multidrug resistant organisms that are resistant to multiple antibiotic or antimicrobial agents), -high contact care activities included residents with chronic wounds, indwelling medical devices, and the care of residents with MRDO's (including dressing, bathing, transferring, providing hygiene, changing linens, changing brief or assisting with toileting). B. Review of the undated facility policy Handwashing revealed the purpose was to provide good hygiene, infection control, and a healthy environment and revealed that hands had to be washed or sanitized with hand sanitizer before and after each glove use and between all glove changes. C. Review of Resident 17's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 10/9/24 revealed the resident was dependent for toileting hygiene, received substantial assistance with dressing and received partial assistance with personal and oral hygiene. The resident was frequently incontinent of bladder and involuntary of bowel. Review of Resident 17's Care Plan with a revision date of 10/24/24 revealed the resident required hands on assistance with washing hands, adjusting clothing, cleaning self, and transferring and bed mobility. During an observation of the provision of care for Resident 17 on 12/12/24 at 8:12 AM Nurse Aid (NA)- entered the resident room, did not perform hand hygiene, put on disposable gloves, assisted the resident into a sitting position on the edge of the bed. NA- then identified there was not a sling available for the stand-up mechanical lift so she assisted the resident to lay back down and removed the gloves and again did not perform hand hygiene and exited the room to retrieve a sling for the lift. NA- again entered the room, did not perform hand hygiene and put another pair of disposable gloves on. She secured the resident with the sling, lifted the resident into a standing position, pulled up the resident's pants and transferred the resident into a wheelchair. Again NA - removed the gloves and did not perform hand hygiene before putting on clean gloves. NA- then obtained a washcloth from the bathroom and assisted the resident to wash the face, then retrieved the resident partial denture and put it in the resident's mouth and assisted in brushing teeth, retrieved a comb and combed the resident's hair then removed the gloves and again did not perform hand hygiene and assisted the resident to the dining room in the wheelchair. During an interview on 12/17/24 at 1:04 PM the Director of Nursing (DON) confirmed staff should wash their hands whenever they enter a resident's room, before putting on clean gloves and whenever removing soiled gloves. 51391 D. During an observation of the provision of care for Resident 11 on 12/12/24 at 7:25 AM, NA-C provided toileting and incontinence cares. NA-C entered the resident's room and without washing hands or completing hand hygiene placed disposable gloves on both hands and transferred the resident from the wheelchair to the toilet using the mechanical lift, NA-C removed the resident's incontinent brief which was soiled with urine. NA-C provided toileting hygiene, removed soiled gloves, and still did not complete hand hygiene, then put on clean disposable gloves and placed a clean incontinence brief on the resident. NA-C then adjusted the resident's clothing and transferred the resident into the wheelchair. NA-C removed soiled gloves, cleaned off the mechanical lift and exited the resident's room without washing hands or completing hand hygiene. During an interview on 12/12/24 at 8:00 AM, NA-C, confirmed staff were to wash hands or to use hand sanitizer when entering the resident's room for cares, when removing gloves and when exiting the resident's room. E. Review of the EBP sign posted on Resident 7's room door, from the U.S. Department of Health and Human Services Center for Disease Control and Prevention revealed the following: For EBP Everyone Must: -Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: -Wear gloves and a gown for the following High Contact Resident Care Activities: Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting -Device care or use of the following: A central line, urinary catheter, feeding tube, or tracheostomy. Wound Care for any skin opening requiring a dressing. Review of Resident's 7 Minimum Data Set (MDS - federally mandated comprehensive assessment use to develop resident care plans) dated 10-18-24 revealed the resident had a stage 4 pressure ulcer (the most severe stage of a pressure sore, where the damage extends fully through the skin layers, exposing underlying muscle, tendon, or bone, often visible dead tissue and a high risk of infection) and required substantial assistance with toileting hygiene, bathing, upper body dressing, personal hygiene, bed mobility and transfers and was dependent on staff for lower body dressing and putting on footwear. Review of Resident 7's Care Plan with a date of 11/04/24 revealed the resident had a stage 4 pressure ulcer to the coccyx (last bone at the base of your spine). The resident was on EBP during the provision of close contact care. Review of Resident 7's Treatment Administration Record (TAR) dated December 2024 revealed an order for: -Wound care to medial coccyx-cleansed with normal saline, apply aquacel ribbon to wound. Cover with 4X4 comfort foam border, changed daily and -Enhanced Barrier Precautions for high resident contact activities related to a coccyx wound. During an observation of the provision of care for Resident 7 on 12/16/24 at 7:00 AM, NA-K and NA-L provided toileting and incontinence cares. NA-K had disposable gloves on both hands, NA-L entered the room, washed hands and placed disposable gloves on both hands, neither staff put on gowns. The staff transferred the resident from the wheelchair to the toilet, NA-K removed the resident's incontinent brief, which was soiled with urine, provided toileting hygiene, removed soiled gloves, did not wash hands, put on clean disposable gloves and placed a clean incontinence brief on the resident. NA-K then adjusted the resident's clothing and transferred the resident into the wheelchair, removed the disposable gloves, completed hand hygiene with soap and water and applied clean disposable gloves, then assisted resident with washing hands and face and brushing teeth. NA-L removed the disposable gloves, picked up dirty linens and placed them in a bag, did not complete hand hygiene before leaving the room. The episode of care was provided without wearing the required gown. During an interview on 12/16/24 at 7:30 AM, NA-K verified that Resident 7 was on EBP, gown and gloves should have been worn during high contact resident care and confirmed that no gown was worn when completing cares with the resident. NA-K further confirmed staff were to wash their hands after removal after assisting the resident with toileting hygiene was completed. During an interview on 12/16/24 at 7:30 AM, NA-L verified that Resident 7 was on EBP, gown and gloves should have been worn during high contact resident care and confirmed that no gown was worn when completing cares with the resident. NA-L further confirmed staff were to wash their hands or to use hand sanitizer when removing soiled gloves and when exiting the resident's room. During an interview on 12/16/24 at 8:00 AM, the DON verified that Resident 7 was on EBP, staff should be following the EBP sign on the door and should have been washing their hands following the handwashing policy, washing hands before and after each glove use and between all glove changes. 45739 F. Observation on 12/12/24 at 10:15 AM with LPN-F put a gown on, entered Resident 34's room, performed hand hygiene, and put on gloves. NA-E entered the resident room, performed hand hygiene, put on gloves, and went to the resident's bedside to assist LPN-F. NA-E was not wearing a gown. NA-E, still not wearing a gown assisted Resident 34 to roll to their left side. NA-E's scrub top was touching the residents bed linens. LPN-F performed wound care without any identified concerns. NA-E, still not wearing a gown and LPN-F removed the resident's old brief and applied a new brief. LPN-F then removed their gown and gloves, performed hand hygiene and put on new gloves. LPN-F, without a gown on, went to the resident's bedside to apply biofreeze (a topical pain relief gel used to treat minor aches and pains) to the resident's knees. LPN-F's scrub top and pants were touching the residents bed linens. LPN-F and NA-E covered the resident up, removed their gloves and performed hand hygiene. NA-E removed the trash from the room and disposed of in the appropriate receptacle and performed hand hygiene. 12/12/24 at 2:15 PM interview with NA-E revealed staff only needed to gown if they would be touching the wound. Further interview confirmed NA-E was not wearing a gown during high contact cares. 12/12/24 at 11:25 AM interview with the Infection Preventionist revealed PPE should be worn (gown and gloves) with all high contact cares for residents on EBP. 12/12/24 at 3:49 PM interview with LPN-F confirmed LPN-F was not wearing a gown for the duration of assisting Resident 34 and that LPN-F should have continued to wear PPE to prevent contact with the bed linens. 12/16/24 at 3:57 PM interview with the DON confirmed gown and gloves should be worn during high contact care for residents on EBP. 29638 G. Review of the facility policy Water Safety Management Program (Legionella-bacteria causing a pneumonia like illness that resides in [NAME] environments such as lakes, [NAME], reservoirs, and manufactured water systems) with a revision date of 10/24 revealed the following: -the facility provided maintenance protocol guidelines for plant operations related to water safety management to ensure the reduction in potential growth of Legionella organisms in the water system of the facility. -the facility was to develop and maintain a water management program that included development of a team, a description of the facility water system, a water system diagram that described areas where Legionella could grow and spread with potential triggers and sources of bacteria growth. -the facility was to establish control measures monitoring temperature and disinfectant levels to prevent water stagnation and bacteria growth. During an interview on 12/16/24 at 12:25 PM, the Administrator and the Maintenance Supervisor confirmed the following: -no risk assessment had been completed to identify and evaluate potential sources and areas of risk where Legionella and other waterborne pathogens could grow and spread. -the facility had not identified and/or implemented measures to prevent the growth of Legionella in the facility water systems.

License Reference Number: 175 NAC 12-006.18(A) Based on record review and interviews; the facility failed to ensure 3 (Residents 31, 197 and 244) of 5 sampled residents were offered the Pneumococcal and the Influenza vaccines and/or were educated about the risks and benefits associated with the vaccines. The facility census was 44. Findings are: A. Review of the facility policy Immunizations-Residents with a revision date of 10/24 revealed the receipt of vaccinations was essential to the health and well-being of long-term care residents. Establishment of an immunization program against influenza and pneumococcal disease facilitated achievement of this objective. The following procedures were identified; -residents were to be screened at admission to determine vaccine status and eligibility using current Centers for Disease Control (CDC) guidelines, to receive influenza and pneumococcal vaccines and then annually for the influenza vaccine. -before offering the vaccine each resident and/or their representative were to receive education regarding the benefits and potential side effects of the immunizations. Information related to education or refusal of the vaccine was to be documented in the resident's medical record. -the vaccine could be offered and administered if the benefits of the vaccine outweighed the risks, the resident or the resident's representative provided consent and the resident's physician approved. -individual resident information was to be documented in the resident's electronic medical health record. B. Review of Resident 31's electronic medical record revealed the resident was admitted to the facility on [DATE]. There was no evidence the facility had screened Resident 31 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the influenza and pneumococcal vaccines, or the resident was offered and/or received the influenza/ pneumococcal vaccines. C. Review of Resident 197's electronic medical record revealed the resident was admitted to the facility on [DATE]. There was no evidence the facility had screened Resident 197 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the influenza and pneumococcal vaccines, or the resident was offered and/or received the vaccines. D. Review of Resident 244's electronic medical record revealed the resident was admitted to the facility on [DATE]. There was no evidence the facility had screened Resident 244 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the influenza and pneumococcal vaccines, or the resident was offered and/or received the influenza/ pneumococcal vaccines. E. During an interview with the Director of Nursing (DON) on 12/17/24 at 11:11 AM, the DON, confirmed the facility did not have a process in place and no staff were responsible for screening the resident's immunization status at admission. The DON further confirmed there was no evidence Residents 31, 197 and 244 or their responsible parties received education regarding the risks or benefits of the immunizations and were offered and provided the vaccines for influenza and pneumococcal.

License Reference Number: 175 NAC 12-006.18(A) Based on record review and interviews; the facility failed to provide evidence 3 (Residents 31, 197 and 244) of 5 sampled residents were offered the COVID-19 vaccine and/or were educated about the risks and benefits associated with the vaccines. The facility census was 44. Findings are: A. Review of the facility policy Immunizations-Residents with a revision date of 10/24 revealed the receipt of vaccinations was essential to the health and well-being of long-term care residents. Establishment of an immunization program against influenza and pneumococcal disease facilitated achievement of this objective. The following procedures were identified; -residents were to be screened at admission to determine vaccine status and eligibility using current Centers for Disease Control (CDC) guidelines, to receive COVID-19 vaccine. -before offering the vaccine each resident and/or their representative were to receive education regarding the benefits and potential side effects of the immunizations. Information related to education or refusal of the vaccine was to be documented in the resident's medical record. -the vaccine could be offered and administered if the benefits of the vaccine outweighed the risks, the resident or the resident's representative provided consent and the resident's physician approved. -individual resident information was to be documented in the resident's electronic medical health record. B. Review of Resident 31's electronic medical record revealed the resident was admitted to the facility on [DATE]. There was no evidence the facility had screened Resident 31 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the COVID-19 vaccine, or the resident was offered and/or received the vaccine. C. Review of Resident 197's electronic medical record revealed the resident was admitted to the facility on [DATE]. There was no evidence the facility had screened Resident 197 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the COVID-19 vaccine, or the resident was offered and/or received the vaccine. D. Review of Resident 244's electronic medical record revealed the resident was admitted to the facility on [DATE]. There was no evidence the facility had screened Resident 244 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the COVID-19 vaccine, or the resident was offered and/or received the vaccine. E. During an interview with the Director of Nursing (DON) on 12/17/24 at 11:11 AM, the DON, confirmed the facility did not have a process in place and no staff were responsible for screening the resident's immunization status at admission. The DON further confirmed there was no evidence Residents 31, 197 and 244 or their responsible parties received education regarding the risks or benefits of the COVID-19 immunization and were offered and provided the vaccine.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and staff interview; the facility failed to assess Resident 1's transfer abilities to ensure safe transfers with a mechanical sit-to-stand lift (a mechanical device used to support the resident in a standing position during transfers, with the resident grasping handles on the lift and use of a sling behind the resident's back to assist in supporting the resident's body weight). Resident 1 sustained a fractured scapula (posterior portion of the shoulder blade) after continuing to be transferred with a sit-to-stand lift after the resident had a decline in physical condition. Facility census was 68. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/27/14 revealed the resident had severe cognitive impairment, required extensive assistance with transfers and had no falls since the previous assessment. Review of the current Care Plan (revision date 7/3/14) revealed Resident 1 had a [DIAGNOSES REDACTED]. Interventions included a plan to "Monitor for unresponsive episodes during transfers with the stand lift (sit-to-stand lift), as they have occurred in the past". Further review of the current Care Plan revealed Resident 1 required assistance with activities of daily living with an intervention to transfer the resident with the stand lift and "...2 assist to prevent bumping arms/elbows on door frame when pushing lift into bathroom." During interview on 10/7/14 at 3:40 PM, the Director of Nurses (DON) indicated Therapy (physical therapy) evaluated residents to determine the best method of transfer including the use of the stand lifts. The DON indicated Therapy completed a re-evaluation when there was a decline in resident condition and transfer ability. The DON further indicated staff members could make the decision to use a full mechanical lift (hoyer-mechanical device used to totally lift a resident from one surface to another) instead of the stand lift when transferring a resident, however the staff member was to report this so a decision could be made whether or not to reassess the resident for possible changes in transfer methods. Review of Resident 1's Progress Notes dated 7/28/14 at 7:45 PM revealed the resident "...became lethargic and minimally responsive while on toilet, unable to get up per stand lift, arms and legs weak, transferred from toilet to bed with hoyer lift and 3 staff assist ..." Review of Progress Notes dated 7/29/14 at 5:47 PM indicated Resident 1 was "lethargic". Review of Documentation Survey Report (a form used by nursing assistants to document provision of transfer assistance) for 7/2014 revealed a hoyer lift was used to transfer Resident 1 on 7/29/14 on the evening shift. There was no evidence to indicate Resident 1's transfer ability or continued use of the stand lift was reassessed after the resident became lethargic and had to be transferred with a hoyer lift. Review of Resident 1's Progress Notes dated 7/30/14 at 5:35 AM documented "Resident has been lethargic throughout shift ..." Review of Documentation Survey Report for 7/2014 revealed Resident 1 was transferred with the stand lift on the day and evening shifts on 7/30/14 and 7/31/14, and on the day shift on 8/1/14. Review of Progress Notes dated 8/1/14 at 5:16 PM indicated Resident 1 was "...weaker and had to use hoyer instead of stand lift." Review of Progress Notes dated 8/1/14 at 7:30 PM as a "Late Entry" revealed Resident 1 had difficulty standing up in the stand lift " before supper" as the resident was not wearing tennis shoes. Documentation indicated the resident was later transferred without difficulty onto the toilet with the stand lift while wearing tennis shoes. Further documentation indicated the resident had difficulty standing when transferred off of the toilet and the resident had to be lowered back onto the toilet. The resident complained of pain to the right wrist area and was then assisted off of the toilet and into bed with a hoyer lift and 3 assistants. Review of Progress Notes dated 8/2/14 at 6:45 AM revealed Resident 1 complained of pain in the right arm and was unable to move the right arm at that time. Review of Progress Notes dated 8/2/14 at 9:00 AM revealed Resident 1 was noted to have "slumping" of the right shoulder and "some swelling" by the right side of the neck. Documentation indicated the resident "...was having difficulty yesterday afternoon before supper with transferring per stand lift" as the resident was having "...increased chicken winging" (a position caused by failure of a resident to bear weight on legs and/or to hold onto the stand lift handles causing the resident's elbows to point upward and away from the body). Documentation further indicated "...there was discussion regarding possibly starting to use a hoyer lift for resident instead of a stand lift". Further review of Progress Notes on 8/2/14 from 9:00 AM through 2:30 PM revealed Resident 1 was subsequently transferred to the hospital for evaluation and returned to the facility with [DIAGNOSES REDACTED]. Interview with the DON on 10/8/14 at 1:55 PM revealed an assessment for use of the stand lift for Resident 1's transfers had not been completed for "several years". The DON further indicated Resident 1 had been transferred for several years with the stand lift. The DON verified an assessment for continued use of the stand lift had not been completed after Resident 1 became lethargic on 7/28/14 or prior to the incident on 8/1/14.

Licensure Reference Number 175NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to protect Resident 57 from injury during a transfer with a mechanical lift. In addition, the facility had not developed a plan to ensure lift slings were maintained in appropriate repair. Findings are: Record Review of the Physician orders [REDACTED]. An interview with the Resident 57 on 12/15/10 at 11:37AM revealed that there were two people assisting with the transfer when the sling broke. This resident stated that because of the [DIAGNOSES REDACTED]. Resident 57 stated "I have been here a a year and a half with no lift or transfer problems." Resident 57 was alert and oriented to time, place, and person. Record Review of Resident 57's Care Plan dated 11/25/10 stated problem that the resident fell in room, hoyer strap broke, no injury. Approaches of 1) extensive to total assist of one or two for bed mobility, transfer, dressing, toilet use and personal hygiene 2) hoyer lift for all transfers 3) wheelchair for mobility, is able to wheel self but tires easily so help as needed. Record Review of the Nurses Notes dated 11/25/10 at 12:15:28 revealed the following: Late entry at 1150 reported by the aide that the hoyer malfunctioned and Resident 57 fell to floor hitting head on the trash can. Upon entry to room the nurse found resident on the floor with head and shoulders being supported by the aide. Resident alert and oriented x3, respirations shallow and rapid at 40 respirations per minute. Alerted rescue via 911. Applied oxygen per mask at 6 liters per minute. Oxygen saturation was at 100% and resident continued to complain of shortness of breath. This resident complained of right sided rib pain. Rescue arrived at 1200 noon and the resident was transferred to emergency room (ER) by order of the physican for evaluation. Called ER and gave report of fall and transferred to hospital. An interview with the Resident 57 on 12/16/10 at 11:18AM revealed this resident was in the bed and was going to be transferred from the bed to the wheelchair. Resident 57 stated, "when we were still in the bed we heard an odd noise and the slack wasn't out of the sling yet. The two aides didn't stop when we heard the noise because it didn't sound like "ripping noise." Resident 57 stated "my butt was still grazing the mattress at this time. Then during the transfer when I was up at around 6 inches from the bed to go to wheelchair there was a ripping noise at my ear and then I was on the floor. I hit my head on the waist basket and I couldn't breath because I hit my side on the sling leg. Someone called 911 and they came and transferred me to the emergency room at the hospital." Resident 57 stated "I still don't feel safe in the sling, because of that and I watch to make sure everything is working right. It was same routine staff that transfer me. I still have right sided rib pain from that fall when I hit the leg of the lift with my ribs. Several lift slings are used on me everyday." Observation on 12/16/10 at 10:45AM of the original lift sling used on Resident 57 when the resident fell on [DATE] showed the green loop stitching tore completely away from the larger loop that holds the resident in the sling. This sling had a minute hole at center and another minute hole in upper part of sling when held up to light. There was no date on the sling to show evidence of when it was put into use. Observation on 12/16/10 at 10:00AM of Resident 57 is EZ lift full body x-large sling size in the wheelchair was dated 08/2007 on the tag. Interview with the Administrator and DON on 12/16/10 at 10:18am revealed the strap of the sling broke during the transfer of Resident 57 on 11/25/10. MA A and NA A checked the sling prior to use and when they lifted the resident up the green strap stitching broke causing the resident to fall to the floor. All NAs and MAs are to check the slings for proper repair prior to use . Competency testing on all NAs and MAs will be done by the date of 12/6/2010. If the sling is not in good repair they are to put them in the DON's office or in NCS's office and the DON notifies the NCS of need for new slings to be ordered. Not all lift slings have dates when put into use because they are to be inspected by the staff using them prior to use. Resident 57 was using an x-large sling which holds up to 400 pounds. Record Review of Nursing Department/Employee List dated 12/16/2010 revealed seven out of 54 of the staff were still not competency tested on checking slings for condition and transferring of residents using the lifts. Interview on 12/16/10 at 8:22AM with RN A (Registered Nurse) revealed that all staff are to monitor for the condition of the slings and if frayed or poor condition they are to give them to the DON or the NCS. Soiled slings are to be washed in the laundry in the Assisted Living Facility upstairs by all staff per laundry instructions. Observation of the facility slings with RN A and RN B on 12/16/10 at 08:30AM revealed the following: 1) two small full body slings with no date of when put into service, 2) medium full body sling with no date of when put into service, 3) large full body sling with no date of when put into service, 4) x-large full body sling of no date of when put into service, 5) large full body sling with date on it of 2008 for when put into service, 6) four sit-to-stand slings with no date on them of when put into service. Interview with NA B on 12/16/10 at 1:44PM revealed that soiled lift slings are taken upstairs and washed with metered soap on hot temperature and are not cloroxed. The slings are dried on the regular temperature, when done they bring clean ones back down for use on the wings. Record Review of Safe Resident Handling Policy and Procedure dated 11/18/2010 with a purpose of providing guidelines for lifting and transferring residents to reduce the risk of injury. Policy: For resident care, a licensed nurse will assess each resident's ability to ambulate or assist in his or her transfer. The plan of care will include the appropriate interventions outlined in the policy. Procedure: A) General guidelines; lift loads close to the body, never transfer residents when off balance, a one-person assist can be used if the resident is cooperative, a two-person assist is to be used with residents who are combative. Record Review of the site www.ezlifts.com for EZ Way, Inc. slings and harnesses on 12/16/10 revealed that under form #1-010 the IMPORTANT NOTICE stated EZ Way offers a 6-month warranty on slings and harnesses and recommends replacement after one year or if the sling or harness shows any sign of damage or wear. All slings and harnesses are capable of bearing a 1,000 lb. weight load, but must only be used to hold the amount of weight dictated by the lift or stand capacity.