Every finding on record at St. Joseph Villa Nursing Center

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement intervention to prevent the potential for hot liquid burns on 2 (Residents 1 and 2) of 3 sampled residents. The facility census was 156. Findings are:A record review of the facility's undated Precautions for Handling Hot Beverages education prior to this incident revealed staff shall monitor, serve, and hold hot beverages in a safe manner to prevent burns. The temperature (temp) of any hot beverage would be allowed to cool to 130 degrees Fahrenheit (F). Additional precautions may be implemented based on the needs and make-up of the residents served. These precautions may include: Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. Ensuring staff monitors the identified high-risk residents at mealtimes and when hot beverages were served. Utilizing specialized spill proof lids and cups for those residents identified at high risk for spilling and the potential for burns. Assess individuals who request beverages hotter than 130 F for the ability to independently and safely consume the hot beverage. A record review of the undated Coffee/ Drink Carts: education and procedure prior to this incident revealed that the coffee cart for the main dining room would contain 1 air pot regular coffee, 1 air pot decaffeinated (decaf) coffee, and the coffee would have ice put in it and the coffee temp recorded on the proper form on the cook's counter. The coffee/drink carts for stations 1 and 2 would contain 1 air pot regular coffee, 1 air pot decaffeinated (decaf) coffee, and the coffee would be properly iced. It did not reveal the coffee/drink carts for stations 1 and 2 would have the temps checked or recorded. A record review of the facility's Resource: Serving Line Food Temperature Log dated 05/31/2026 - 06/09/2026 revealed only 1 line for coffee for each day and each meal. It did not reveal coffee temp recording lines or sheets for the coffee/drink carts for stations 1 and 2, or between meals. A record review of the facility's undated Current List Of Devices For Dining Room Or Meals list revealed Resident 1 was added to the list on 06/03/2026 as needing a lidded cup for hot beverages, and Resident 2 was not on the list. A.A record review of Resident 1's Resident Census dated 06/09/2026 revealed the resident was admitted on [DATE]. A record review of Resident 1's Continuity of Care Document dated 06/10/2026 revealed the resident had diagnoses of cognitive communication deficit (difficulty communication due to disruptions in brain function), Parkinson's disease without dyskinesia (a neurological disorder where the resident exhibits symptoms such as tremors, rigidity, and slowed movement), Dysphasia, oropharyngeal phase (difficulty swallowing that originates in the mouth and throat), unspecified convulsions (sudden muscle spasms), unspecified severe protein-calorie malnutrition (extreme deficiency in calorie and protein intake), Other vascular myelopathies (spinal cord injury or dysfunction caused by impaired blood supply), and muscle weakness. A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/22/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) score of 11 which indicated the resident was moderately cognitively impaired (difficulty thinking and comprehending). The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with bathing and toileting, and substantial/maximal assistance with dressing, footwear, and personal hygiene. The resident was independent with rolling in bed, required setup/clean-u assistance with sit to lying, sit to stand, and lying to sitting on the side of the bed, partial/moderate assistance with chair/bed to chair transfer and toilet transfer, and dependent on staff for tub/shower transfers. The resident had no pain or skin problems in the lookback period. A record review of Resident 1's Care Plan with a last care conference date of 05/27/2026 revealed the resident had Problem areas of cognitive loss / dementia, behavioral symptoms, psychotropic (medications that alter the mind) drug use, falls, wandering/elopement risk (walks around aimlessly or exit seeking), and pain. The resident had a focus area of the resident was at risk for dehydration (harmful reduction in the amount of fluid in the body) related to Parkinson's disease, malnutrition, anemia, diverticulosis (bulging pouches in the intestine) and constipation and the interventions with an approach start date of 05/28/2026 included keeping fluids accessible and assisting with fluids as needed. The resident had a Problem area of Nutritional Status and an intervention with an approach start date of 06/04/2026 that was edited on 06/09/2026 included covered cups for all liquids. The resident had a Problem area of Skin, and an intervention with an approach start date of 06/09/2026 that revealed on 06/03/2026, the resident spilt coffee on self resulting in burns to upper right chest/breast, right abdomen (stomach area), and right thigh. The resident was on wound care. Dietary was no longer sending coffee on the hydration stations and nursing staff to assist the resident when getting hot liquids. A record review of the facility's Incident Tracking Form dated June 2026 revealed Resident 1 was on the list for the 06/03/2026 burn because of a coffee spill. A record review of Resident 1's Search Progress Notes dated 05/12/2025 - 06/11/2026 revealed Registered Nurse (RN)-A charted on 06/03/2026 at 5:10 PM that Resident 1 screamed hot. The resident was drinking coffee that the resident had gotten from the coffee Keurig and accidentally spilled on self. The resident's clothes were wet, so the staff took the resident to their room and noticed an open area to the resident's chest/breast, lateral (side of) the abdomen and thigh. The resident's provider was notified and orders were received to apply Xeroform (a wound dressing) to the open areas. On 06/04/2026 at 12:36 AM, RN-A assessed the coffee burnt area, the skin was peeling and a few blisters filled area on the abdomen were noted. On 06/04/2026 at 9:48 AM Licensed Practical Nurse (LPN)-B charted LPN-B observed burn and blisters to Resident 1's right chest/abdomen. Noted multiple blisters throughout the entire area. Blisters were different sizes and some had ruptured (broke), and some were intact. Also noted redness to right anterior (front of) thigh. The progress notes did not reveal any safety assessments for the resident's ability to safely drink hot liquids that was completed prior to the coffee spill burn incident on 06/03/2026. A record review of the Administrator's Witness Statement dated 06/03/2026 revealed that Resident 1 got themself a cup of coffee, spilled it on the resident, and the resident sustained a burn to the right chest, abdomen, and upper thigh that contained blisters. Interviews with the Station 1 staff that was working at the time of the incident revealed they all denied observing the incident. The microwave was moved to an area that the residents could not access it, the coffee push pots temperatures were checked, and were pulled from the stations. A record review of Dietary Assistant (DA)-C's Witness Statement dated 06/03/2026 revealed DA-C was on duty when Resident 1's burn incident happened. DA-C checked the temp of the coffee pots on Station 1 were around 150 degrees F, and Station 2's coffee pots were around 146 degrees F. DA-C brought both pots down to a temperature of under 130 degrees F and then DA-C was instructed to remove the coffee pots from both Stations. A record review of Resident 1's Wound Management Detail Report dated 06/04/2026 revealed the resident had a burn/coffee spill and the wound location was the right chest. The wound was 25 centimeters (cm) long and 10 cm wide. Noted red skin with multiple blisters of different sizes. Some had ruptured, and some were still intact. The right thigh burn was 10 cm long and 8 cm wide. Areas of redness due to coffee spill. A record review of Resident 1's Most Recent Observations list dated 05/19/2026 - 06/09/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids. A record review of Resident 1's Functional Abilities Assessments dated 05/19/2026 and 05/21/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids. A record review of Resident 1's Risk Assessments dated 05/24/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids. A record review of Resident 1's Electronic Medical Record dated 05/19/2026 - 06/09/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids prior to the coffee burn incident on 06/03/2026. A record review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment and Treatment Encounter Notes dated 05/20/2026 - 06/03/2026 did not reveal PT assessed or made recommendations for the resident's ability to safely consume hot liquids. A record review of Resident 1's Occupational Therapy (OT) Evaluation & Plan of Treatment and Treatment Encounter Notes dated 05/25/2026 - 06/03/2026 revealed the resident was assessed for functional abilities with eating and the resident did not need adaptive utensils and the resident currently used regular utensils but reported difficulty with food control. They did not reveal OT assessed or made recommendations for the resident's ability to safely consume hot liquids. A record review of Resident 1's Speech Therapy (SLP) Evaluation & Plan of Treatment and Treatment Encounter Notes dated 05/28/2026 - 06/03/2026 revealed the resident was assessed for good safety awareness, safe swallow precautions, and food and fluid intake texture needs, but did not reveal SLP assessed or made recommendations for the resident's ability to safely consume hot liquids. An observation on 06/09/2026 at 1:20 PM revealed that Resident 1 had dark red skin damage to the upper right chest, right abdomen, and right upper thigh with 1 open blister on the right upper chest and 2 on the right abdomen that were being treated with Xeroform. In an interview on 06/09/2026 at 2:42 PM, RN-A confirmed RN-A was the nurse on that evening. RN-A was behind the desk and heard Resident 1 say hot a couple of times. RN-A went to the resident and took the resident's shirt and fanned it to cool it down. RN-A took the resident to the resident's room and noticed a red area and blisters, first upper chest and abdomen and then slowly developed into blisters. The thigh never developed a blister, just red. When removing the resident's shirt, the resident said it hurt. The resident complained of pain at the time, but after the 1st day never complained of pain. The nurse's station had a cart that had coffee on it and RN-A assumed the resident got their coffee from there. That cart was no longer there. RN-A has not assessed anyone for hot liquid safety. Before the event, there was no system in place to keep any resident from getting their own coffee. It was a push carafe with coffee in it and the carafe was not monitored by the nursing staff. The night of Resident 1's burn, they came and checked the temps and took everything. RN-A confirmed Resident 1 was confused, they thought the resident had dementia, and the resident was self-mobile in a wheelchair. In an interview on 06/09/2026 at 3:19 PM, Medication Tech (MT)-G confirmed MT-G did not see Resident 1 spill the coffee on self but heard the resident yell out. When MT-G looked, the resident had split coffee on self and was very shaky. The resident was shaking and yelling out at the same time. The hot coffee did cause the resident pain, and the resident was very confused. The resident got the coffee from the coffee pots that were siting in front of the nurse's station. There was not a process in place before the burn incident to keep the residents from getting hot coffee themselves. There was not a list of residents that MT-G was aware of that needed lids on their cups, the only thing they knew was which residents needed assistance with meals. In an interview on 06/09/2026 at 3:33 PM, Nursing Assistant (NA)-F confirmed NA-F was on break at the time of the incident but did assist Resident 1 in removing the resident's clothes after the coffee was spilled. Resident 1 was complaining of pain at that time. NA-F confirmed the coffee was out in the open at the nurse's station, and anyone had access to it. There was nothing in place to stop any resident from getting a cup of coffee themselves. In an interview on 06/09/2026 at 1:47 PM, Occupational Therapist (OT)-D confirmed there was not a regular assessment Therapy was doing to assess a resident for hot liquid safety. The Therapy staff would just observe the residents and make recommendations if they had concerns with a resident's fine motor skills. In an interview on 06/09/2026 at 1:47 PM, OT-E confirmed OT-E has made recommendations for a lidded cup if OT-E observed a resident had concerns with fine motor skills or positioning that would indicate the resident needed a lid. OT-E stated they did make that recommendation on Resident 1. In an interview on 06/09/2026 at 4:14 PM, the Administrator confirmed the facility did not have an accident prevention or hot liquid safety policy. In an interview on 06/09/2026 at 1:44 PM, the Administrator confirmed the facility did not do hot liquid safety assessments on the residents other than what Therapy staff did. In an interview on 06/10/2026 at 2:04 PM, the Administrator confirmed there were no assessments completed on residents for hot liquid safety until after Resident 1's incident, all they had was what Therapy was doing from a functional standpoint. The Administrator confirmed there was not a process in place prior to the burn incident on 06/03/2026 to prevent a resident from getting a cup of coffee, and getting burnt. The Administrator confirmed Resident 1 did receive a burn and blisters and should not have. B.A record review of Resident 2's Resident Census dated 06/10/2026 revealed the resident was admitted on [DATE]. A record review of Resident 2's Continuity of Care Document dated 06/10/2026 revealed the resident had diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting the dominant side (paralysis on the dominant side of the body after a stroke), aphasia following a cerebral infarction (language disorder following a stroke), dysphagia following a cerebral infarction swallowing disorder following a stroke), Bipolar Disorder (extreme highs and lows of mood), Presbyopia (far sighted), depression, and anxiety. A record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS score of 13 which indicated the resident was cognitively aware (able to think and comprehend). The resident required setup or clean-up assistance with eating, required substantial/maximal assistance with oral hygiene, and was dependent on staff for toileting, dressing, bathing, footwear, and personal hygiene. The resident was partial/ moderate assistance with rolling in bed and required substantial/maximal assistance with all other mobility and transfer needs. A record review of Resident 2's Care Plan with a last care conference date of 04/22/2026 revealed the resident had Problem areas of cognitive loss / dementia, Impaired vision related to cataracts and presbyopia, mood state, psychotropic drug use, falls, and pain. The resident had a Problem area of Nutritional Status and an intervention with an approach start date of 06/09/2026 that was edited on 06/09/2026 included resident to use cup with lid when drinking hot liquids and Resident 2's dietary preferences included enjoyed coffee all hours of the day. A record review of Resident 2's Search Progress Notes dated 05/01/2025 - 06/10/2026 did not reveal any safety assessments for the resident's ability to safely drink hot liquids that was completed prior to the coffee spill burn incident on 06/03/2026. A record review of Resident 2's Most Recent Observations list dated 05/19/2026 - 06/09/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids. A record review of Resident 2's Functional Abilities Assessments dated 05/19/2026 and 05/21/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids. A record review of Resident 2's Risk Assessments dated 05/24/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids. A record review of Resident 2's Electronic Medical Record dated 05/19/2026 - 06/09/2026 did not reveal a safety assessment for the resident's ability to safely drink hot liquids prior to the coffee burn incident on 06/03/2026. A record review of Resident 2's Physical Therapy Discharge Summary dated 12/04/2024 - 12/20/2024 revealed the resident had not been assessed by PT since 12/20/2024. It did not reveal PT assessed or made recommendations for the resident's ability to safely consume hot liquids. A record review of Resident 2's Occupational Therapy (OT) Evaluation & Plan of Treatment and Treatment Encounter Notes dated 06/09/2026 - 07/08/2026 revealed the resident was assessed for functional abilities with eating and the resident did not have concerns with self-feeding. On 06/09/2026 reports mild spillage with eating. It did not reveal OT assessed or made recommendations for the resident's ability to safely consume hot liquids. A record review of Resident 2's Speech Therapy (SLP) Evaluation & Plan of Treatment and Treatment Encounter Notes dated 12/04/2024 - 12/20/2024 revealed the resident had not been assessed by SLP since 12/20/2024. An observation on 06/10/2026 at 7:16 AM revealed that Resident 2 was seated in a wheelchair at Station 2's nurse's station with an overbed table in front of the resident and a cup of coffee without a lid on the overbed table. The resident was holding the cup of coffee by the handle with the resident's right hand. An observation on 06/10/2026 at 7:51 AM revealed that Resident 2 was seated in a wheelchair at Station 2's nurse's station with an overbed table in front of the resident and a 3/4 full cup of coffee without a lid on the overbed table. The resident was asleep until the nurse walked by and woke the resident up. The resident then grabbed the cup and slowly took 2 sips from the cup and sat it back down An observation on 06/10/2026 at 10:54 AM revealed that Resident 2 was seated in a wheelchair at Station 2's nurse's station with an overbed table in front of the resident and a 3/4 full cup of coffee without a lid on the overbed table. The resident had a gown on over the resident's clothing and there were large brown stains on the front of the gown where the resident had spilled the coffee. In an interview on 06/09/2026 at 2:42 PM, RN-A confirmed before 06/03/2026, there was no system in place to keep any resident from getting their own coffee. It was a push carafe with coffee in it and carafe was not monitored by the nursing staff. In an interview on 06/09/2026 at 3:19 PM, Medication Tech (MT)-G confirmed there was not a process in place before 06/03/2026 to keep the residents from getting hot coffee themselves. There was not a list of residents that MT-G was aware of that needed lids on their cups, the only thing they knew was which residents needed assistance with meals. In an interview on 06/09/2026 at 3:33 PM, Nursing Assistant (NA)-F confirmed prior to 06/03/2026 the coffee was out in the open at the nurse's station, and anyone had access to it. There was nothing in place to stop any resident from getting a cup of coffee themselves. In an interview on 06/09/2026 at 1:47 PM, Occupational Therapist (OT)-D confirmed there was not a regular assessment Therapy was doing to assess a resident for hot liquid safety. The Therapy staff would just observe the residents and make recommendations if they had concerns with a resident's fine motor skills. In an interview on 06/09/2026 at 1:47 PM, OT-E confirmed OT-E has made recommendations for a lidded cup if OT-E observed a resident had concerns with fine motor skills or positioning that would indicate the resident needed a lid. In an interview on 06/09/2026 at 4:14 PM, the Administrator confirmed the facility did not have an accident prevention or hot liquid safety policy. In an interview on 06/09/2026 at 1:44 PM, the Administrator confirmed the facility did not do hot liquid safety assessments on the residents other than what Therapy staff did. In an interview on 06/10/2026 at 2:04 PM, the Administrator confirmed there were no assessments completed on residents for hot liquid safety until after the incident, all they had was what Therapy was doing from a functional standpoint. The Administrator confirmed there was not a process in place prior to 06/03/2026 to prevent a resident from getting a cup of coffee, and getting burnt. In an interview on 06/10/2026 at 2:04 PM, Administrator confirmed the Administrator observed Resident 2 had a cup of coffee in front of the resident and there was not a lid on it. The Administrator confirmed the resident had coffee stains down the front of the resident. The Administrator confirmed the resident's care plan revealed included resident to use cup with a lid when drinking hot liquids. The Administrator checked the cup and said the coffee in the cup was not hot. In an interview on 06/10/2026 at 11:01 AM, LPN-H confirmed Resident 2 did have hot coffee in the cup at 7:15 AM, and the cup did not have a lid on it.

Licensure Reference Number 175 NAC 12-006.07(C) Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. The facility census was 148. Findings are:A record of the facility's Quality Assessment and Assurance (QAA) policy with a revised date of 7/21 revealed the purpose of the policy was to assist in improving quality of care and quality of life to each of the facility's residents. To identify and respond to quality deficiencies and develop positive outcomes that are sustainable (maintained) over time. During the recent survey with an exit date of 01/08/2026 the following deficiencies and repeat deficiencies were identified: F580 - The facility failed to notify the resident's representative and medical practitioner of a change in AIMS scale score for Resident 7 F628 - The facility failed to communicate with the hospital at transfer with the resident's current needs for Resident 154 and ensure transfer discharge documentation was completed for Resident 6 that was sent to the emergency department for evaluation and treatment. F644 - The facility failed to ensure a new PASARR referral had been completed after a diagnosis of a mental disorder was identified for Resident 10. F677 - The facility failed to assist or offer oral hygiene for Resident 17. F684 - (Repeat deficiency) - The facility failed to follow up on requested lab work related to Resident 47's recurrent UTIs, complete neurological assessments after an unwitnessed fall on resident 71, ensure fluid intakes and daily weights were monitored according to practitioner orders for Resident 128, failed to ensure an air mattress was functioning to promote healing of diabetic wounds for Resident 16, and failed to ensure weekly weights were completed for Resident 2. F686 - The facility failed to ensure air mattress was functioning to prevent the potential for pressure ulcer development for Resident 123. F689 - (Repeat deficiency) - The facility failed to complete quarterly bed assist devices assessments on Resident 5. F695 - The facility failed to set Resident 47's oxygen flowrate to the prescribed settings. F699 - The facility failed to assess and identify situational stressors and triggers related to post-traumatic stress disorder on resident 39. F756 - The facility failed to identify irregularities related to antipsychotic medication and adverse symptom monitoring for Resident 7 and ensure that a physician provided a rationale for the use of multiple medications for hypertension for Resident 6. F801 - The facility failed to ensure the Dietary Manager was qualified. F804 - The facility failed to ensure food was maintained at a palatable temperature for food delivered to resident's rooms. This had the potential to affect 40 residents who receive room trays F812 - The facility staff failed to perform hand hygiene between Residents 43, 107, 145, 149, 2, 97, 70, 163, 82, 110, 66, 143, 37, 30, 142, and 87 while assisting with eating in a manor to prevent cross contamination. F880 - (Repeat deficiency) - The facility failed to perform hand hygiene between glove changes in a manor to prevent cross contamination during peri care on Resident 1,17, and 47 and clean the nebulizer mask and nebulizer medication chamber between uses to prevent potential contamination on resident 160. State tag: 12-006.06A - The facility failed to ensure that the process for the resolution of grievances was displayed in a prominent location in the facility. This had the potential to affect all residents that resided in the facility. A record review of the facility's last standard survey results from the 08/22/2024 survey revealed the facility was cited for:F689 (Free of Accident Hazards/Supervision/Devices) - RepeatF690 (Bowel/Bladder Incontinence, Catheter, UTI)F803 (Menus Meet Resident Needs/Prep in Adv/Followed)F761 (Label/Store Drugs and Biologicals)F887 (COVID-19 Immunization)F880 (Infection Prevention & Control) - RepeatF757 (Drug Regimen is Free from Unnecessary Drugs) - RepeatF684 (Quality of Care) - RepeatF583 (Personal Privacy/Confidentiality of Records) In an interview on 01/08/2026 at 11:53 AM, Nursing Assistant (NA)-W confirmed NA-W had no idea what the quality assurance (QA) was or what the committee was working on. In an interview on 01/08/2026 at 11:53 AM, NA-X confirmed NA-X had no idea what the quality assurance (QA) was or what the committee was working on. In an interview on 01/08/2026 at 12:01 PM, Medication Aide (MA)-V confirmed MA-V knew the word QAPI but did not know anything else about it. MA-V confirmed MA-V had no idea what was being worked on or when the committee met. In an interview on 01/08/2026 at 11:55 AM, the facility's Administrator confirmed the Administrator was not sure why the above cited areas were not identified prior to the start of the survey. The facility does work on items from the previous survey but once audits show the area improved it falls off, and the facility failed to maintain the correction. The Administrator confirmed the only reason the Administrator could think of was because the facility had a lot of new staff, a new pharmacy, and the Medical Director's office has had staff turnover.

Licensure Reference Number 175 NAC 12-006.09(H) & 12-006.09(H)(iii)(3). Based on observation, interview and record review the facility failed to ensure fluid intakes and daily weights were monitored according to practitioner orders for Resident 128, failed to ensure an air mattress was functioning to promote healing of diabetic wounds for Resident 16, failed to follow up on requested lab work for recurrent urinary tract infections for Resident 47, failed to ensure weekly weights were completed for Resident 2 and failed to complete neurological assessments after an unwitnessed fall for Resident 71. The facility census was 148. The findings are:Licensure Reference Number 175 NAC 12-006.09 (H) & 12-006.09 (H)(iii)(3). Based on observation, interview and record review the facility failed to ensure fluid intakes and daily weights were monitored for Resident 128, failed to ensure an air mattress was properly functioning to promote healing of diabetic wounds for Resident 16, failed to follow up on requested lab work related to recurrent urinary tract infections for Resident 47, failed to monitor weekly weights for Resident 2 and failed to complete neurological assessments after an unwitnessed fall for Resident 2. The facility census was 148. The findings are: A. Record review of Resident 128's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-04-2025 revealed the facility staff assessed the following about the resident: -admit date was 08-01-2025 -had a diagnosis of heart failure -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required limited assistance with bathing and shower transfers. -required supervision with dressing. Record review of Resident 128's After Visit Summary (AVS) dated 08-01-2025 revealed Resident 128 had been in the hospital for heart failure and had orders for a 2000 milliliter (ml) fluid restriction and daily weights. Record review of Resident 128's Electronic Health Record (EHR) revealed no weights were listed from 11-19-2025 to 11-24-2025, 11-24-2025 to 12-5-2025 and from 12-08-2025 to 12-17-2025. An interview conducted on 01-08-2026 at 8:50 AM with the Assistant Director of Nursing (ADON) confirmed daily weights were not done and should have been. B. Record review of Resident 128's EHR revealed the absence of daily fluid intake monitoring. An interview conducted on 01-06-2026 at 11:18 AM with Nursing Assistant (NA) Y revealed the fluid intake for Resident 128 was not recorded or restricted. An interview conducted on 01-07-2026 at 1:30 PM with Licensed Practical Nurse (LPN) N revealed Resident 128 was on a 2000 ml fluid restriction and was to receive 480 ml of fluids with each meal and 240 ml on the day shift, 200 ml for the evening shift and 120 ml for night shift. The interview also revealed that the amount of fluids Resident 128 consumed in a 24-hour period was not tracked or recorded. An interview on 01-08-2026 at 8:50 AM with the ADON confirmed the amount of fluid Resident 128 consumed in a 24-hour period was not monitored to ensure the 2000 ml fluid restriction was followed. C. Record review of Resident 16's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -had a diagnosis of Diabetes Mellitus -BIMS was scored as a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required limited assistance with bed mobility. -required total assistance with dressing, toileting, bathing and transfers. -had a diabetic foot wound. Record review of Resident 16's Comprehensive Care Plan (CCP) revealed Resident 16 was at risk for skin tears, bruises and pressure injuries related to weakness and diabetes and had a diabetic foot ulcer to the right heel. The goal was for Resident 16's skin to remain intact. The interventions were: -air mattress to bed. -antibiotics as ordered. -apply lotion to resident's arms. -apply lotion to areas of concern. -monitor skin with bathing and clothes changes. -cover arms and legs with protective clothing as resident will allow. -transfer with fragile skin in mind. An observation on 01-05-2026 at 1:30 PM revealed Resident 16 had an air mattress on the bed and the low-pressure light was on. An observation on 01-06-2026 at 9:05 AM revealed Resident 16's air mattress had a low-pressure light on. An observation on 01-06-2026 at 12:35 PM revealed Resident 16's air mattress had a low-pressure light on. An observation on 01-07-2026 at 11:00 AM revealed Resident 16's air mattress had a low-pressure light on. An interview with the Wound Nurse (WN) I on 01-07-2026 at 12:45 PM confirmed the low-pressure light was on to Resident 16's air mattress and revealed (gender) would refer to the owner's manual to find out what the low-pressure light meant. An interview with the Assistant Director of Nursing (ADON) on 01-07-2026 at 2:30 PM confirmed Resident 16's air mattress was being replaced and provided the manufacturer's information which revealed if the low-pressure light remains on for longer than 30 minutes to call and have the mattress serviced. D. A record review of the facility's Antibiotic Stewardship policy with a revision date of 2/2024 revealed the test results for a culture and sensitivity (a lab test that indicates the bacteria and the antibiotic that would treat it) should be treated as high priority and communicated to the provider as soon as possible. A record review of Resident 47's Resident Census dated 01/07/2026 revealed the resident was admitted on [DATE]. A record review of Resident 47's Face Sheet dated 01/07/2026 revealed the resident had diagnoses of Urinary Tract Infection (UTI), Other specified bacterial agents as the cause of diseases classified elsewhere (History Of) Note: Citrobacter Freundii (a bacteria) UTI, Other Escherichia coli (E. coli)(a bacteria) as the cause of diseases classified elsewhere, Extended spectrum beta lactamase (ESBL)(a very hard to treat bacteria) resistance, and 11/17/2025 - Sepsis, unspecified organism (History Of). A record review of Resident 47's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 10/24/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was dependent on staff for all activities of daily living and mobility except the resident required set-up or clean-up assistance with eating and oral hygiene (cleaning). A record review of Resident 47's Care Plan with a last care conference date of 10/22/2025 revealed a problem area of the resident was at risk for infection related to incontinence (lack of control) of bowel and bladder, history of UTIs, chronic respiratory failure, recent influenza, Chronic Obstructive Pulmonary Disease, and recent pneumonia (lung infection). 01/17/2025 the resident was on an antibiotic for pneumonia, on 10/02/2025 the resident was on an antibiotic for a UTI, on 10/21/2025 the resident was on an antibiotic for a UTI, on 12/10/2025 a Microgen urinalysis (UA) had a UTI. The goal for the resident with a target date of 02/28/2026 was the resident would remain infection free through next review. The Care Plan had an Approach start date: 01/07/2026 for Macrobid ordered to treat UTI noted from Microgen UA. Created: 01/07/2026. A record review of Resident 47's Family Medicine 60-day review dated 12/3/2025 revealed the last UA and culture was on 11/21/2025. The resident had at least 3 UTIs in the past 2 months and the resident's urine had not been sent for special testing in order to properly treat the resident. A record review of Resident 47's Progress Notes dated 12/07/2024 – 01/06/2026 revealed on 12/02/2025 LPN-G documented the resident completed the antibiotic on 12/01/2025 and a urine specimen was collected for a Microgen UA and sent out, awaiting results. On 12/03/2025 the resident's physician documented that per the nursing staff, the resident had urinary symptoms, and staff was to monitor closely and await further culture and sensitivity for UTI. A record review of Resident 47's Order History dated 01/06/2026 revealed the resident's provider ordered a Deoxyribonucleic Acid (DNA)/Microgen UA after the resident completed the antibiotic on 12/02/2025. A record review of Resident 47's Resident Documents dated 01/06/2025 revealed the last urinalysis and urine culture results were from 11/21/2025. A record review of Resident 47's MicroGenDX Summary of Final Results with a reported date of 12/11/2025 revealed the UA was collected 12/08/2025, received 12/10/2025, and reported 12/11/2025, and the resident was positive for a UTI. In an interview on 01/05/2026 at 10:53 AM, Resident 47 confirmed the resident thought the resident currently had a UTI. The resident confirmed the resident had been on 2 antibiotics that did not work and the facility had recently retested the resident for a UTI, but the resident had not heard of anything further since the test. In an interview on 01/07/2026 at 6:19 AM, Resident 47 confirmed the resident had off and on burning when the resident urinates, and it was hard for the resident to urinate. In an interview on 01/06/2026 at 3:10 PM, the Director of Nursing (DON) confirmed that Resident 47's Microgen UA test results that were ordered on 12/02/2025 were sent to the Assistant Director of Nursing's (ADON) old email address. The facility was unaware the results were in the ADON's old email until they were requested on 01/06/2026. The provider was not notified of the results until 01/06/2025 and then the provider ordered a new antibiotic to treat the resident's UTI. E. A record review of the facility's Physician Orders, Following policy dated June 29, 2021 revealed all physician orders would be followed as prescribed and if not, the reason would be recorded in the medical record. A record review of Resident 2's Resident Census dated 01/07/2026 revealed the resident was admitted on [DATE]. A record review of Resident 2's Face Sheet dated 01/07/2026 revealed the resident had diagnoses of Chronic Diastolic (Congestive) Heart Failure (CHF) and Abnormal Weight Loss. A record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS of 12 which indicated the resident was moderately cognitively impaired. The resident was dependent on staff for all activities of daily living and mobility except the resident required substantial/maximal assistance with oral hygiene and to roll in bed, and the resident needed supervision or touching assistance with eating. The resident did have weight loss, but the MDS did not indicate the resident had a weight gain. A record review of Resident 2's Care Plan with a last care conference date of 12/24/2025 revealed a problem area of the resident was at risk for dehydration related to the resident on diuretic medication (medication used to remove excess fluid in the body) and a problem area of nutritional status with a goal of the resident would not have any significant weight changes. An intervention for the weight changes was to monitor the resident's weights and notify the MD of changes. A record review of Resident 2's Orders dated 01/06/2026 revealed the provider ordered weekly weights with a start date of 02/25/2022 and the resident was on Spironolactone (a diuretic) and Torsemide (a diuretic). A record review of Resident 2's Progress Note dated 12/30/2025 revealed the Registered Dietician (RD) documented the resident had weight fluctuations and Lasix (a diuretic) was ordered for 5 days due to increased edema (swelling from excess fluid in arms and/or legs) to bilateral lower extremities (both lower legs). Continue to follow resident status and notify RD of significant changes or concerns. A record review of Resident 2's Weight dated 06/01/2025 to 01/06/2026 revealed that the resident was not weighed: - 12/12/2025 - 01/06/2025 - 11/28/2025 - 12/10/2025 -10/22/2025 - 11/05/2025 -08/21/2025 - 09/03/2025 -08/08/2025 - 07/24/2025 An observation on 01/05/2026 at 10:05 AM revealed the resident had edema on both legs and feet. An observation on 01/07/2026 at 7:40 AM revealed Resident 2 was sitting in the wheelchair with a shoe on the right foot and edemawear and a pressure-reducing boot on the left foot. Both legs and feet appeared very swollen. In an interview on 01/06/2026 at 7:39 AM, Licensed Practical Nurse (LPN)-G confirmed Resident 2 had a lot of edema in the legs and Cardiology was following the resident and adjusting the resident's medications. In an interview on 01/06/2026 at 3:10 PM, the DON confirmed the weights were not being completed weekly and should have been. F. A record review of the facility's Post fall Assessment with a revision date of 10/2025 revealed the following: -Neurological assessment should be initiated with all falls: Initiate Neurological assessment form DGE 047 for falls. -Nurses will assess the resident's condition following the fall and document every shift for 72 hours after the fall. A record review of Resident 71's Face Sheet revealed diagnoses of delusional disorders, chronic pain, epilepsy, fall on same level, syncope and collapse. A record review of Resident 71's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed Resident 71 was admitted on [DATE]. A Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) was not conducted as Resident 71 is rarely/never understood. A record review of the facility's Post Fall Huddle dated 10/2/25 revealed that resident 71 rolled out of bed. Facility staff walked by resident 71's room and noticed resident 71 sitting on the floor in front of the wheelchair. The facility staff then notified the nurse. A record review of Resident 71's electronic medical record, which included progress notes, observations, and scanned documents, revealed that neurological checks for Resident 71's unwitnessed fall on 10/2/2025 were not completed. In an interview on 1/6/2026 at 11:59 AM the Director of Nursing confirmed that no neurological checks were found in Resident 71's electronic medical record.

Based on observation and interview, the facility failed to ensure food was maintained at a palatable temperature for food delivered to residents rooms. This had the potential to affect 40 residents who receive room trays. The facility staff identified a census of 148.Findings are:Interview on 1/06/2026 at 10:30 AM with Resident 15 revealed food was cold and not warm enough. Resident 15 confirmed they ate meals in the residents room.Observation on 1/6/26 at 12:33 PM of a test tray taken to hall 900 by the Dietary Manager (DM).Using the facility thermometer, the DM obtained the following temperatures;-tomato soup was 108.3 degrees-philly steak sandwich was 107 degrees-tater tots were 119 degrees-peaches were 43 degrees Interview with the DM on 1/6/25 at 12:35 PM confirmed the temperature for the tomato soup, philly steak sandwich and tater tots should have been above 135 degrees and the temperature for the peaches should have been below 41 degrees. The DM confirmed the facility did not have plate warmers or insulated plate covers. Interview on 01/07/2026 at 10:00 AM Resident 106 revealed food was not hot enough. Resident 106 confirmed they ate meals in the residents room.

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility staff failed to perform hand hygiene between residents while assisting 16 (Residents 43, 107, 145, 149, 2, 97, 70, 163, 82, 110, 66, 143, 37, 30, 142, and 87) of 27 sampled residents with eating in a manor to prevent cross contamination. The facility census was 148. Findings are: A record review of the facility's Feeding a Resident policy with a reviewed date of 6/21 revealed staff should wash hands before and after assisting the residents with meals. A. An observation on 01/06/2026 at 8:16 AM revealed that Nursing Assistant (NA)-P was assisting Residents 163 and 82 and NA-Q was assisting Residents 97 and 70 with eating their meals going back and forth between residents with the same hand and touching the residents and the resident's silverware without performing hand hygiene (cleaning) between residents. An observation on 01/06/2026 at 8:29 AM revealed NA-D was assisting Residents 66 and 110 with their meal while touching the Resident's clothing, plate, and the resident's silverware with NA-D's right hand and going back and forth between assisting residents with no hand hygiene between residents. An observation on 01/06/2026 at 8:33 AM revealed Registered Nurse (RN)-L assisted Residents 37 and 142 with their meals using RN-L's right hand going back and forth between assisting the residents with no hand hygiene. Licensed Practical Nurse (LPN)-R assisted Residents 30 and 143 with their meals using LPN-R's left hand going back and forth using the resident's silverware without hand hygiene. An observation on 01/06/2026 at 11:49 AM revealed NA-P assisted Residents 2 and 75 with their meals using their right hand for both residents without hand hygiene between the residents. NA-P used NA-P's right hand to wipe soup from Resident 75's clothing and face, then turned and gave Resident 2 a bite of food without hand hygiene between residents. NA-S assisted Residents 97 and 70 with their meals while NA-S was touching the resident's silverware without hand hygiene between the residents. An observation on 01/07/2026 at 8:00 AM with the Director of Nursing (DON) revealed NA-U assisted Residents 110 and 87 with eating their meals using each resident's silverware with no hand hygiene between residents. NA-U assisted Resident 110 wiped the resident's mouth and adjusted the resident's clothing, then assisted Resident 87 with the same right hand. No hand hygiene was performed between residents. In an interview on 01/07/2026 at 8:00 AM, the DON confirmed that staff should not go back and forth assisting residents with meals without performing hand hygiene between residents. B. Observation on 01/06/2026 at 12:01 PM revealed LPN E set up food for Resident 145 and then started feeding Resident 149 without performing hand hygiene between resident contact. Resident 145 was assisted throughout the meal at times and handed them items while feeding Resident 149. Observation on 01/06/2026 at 12:02 PM revealed LPN F assisted Residents 103 and 107 to eat with no hand hygiene performed between resident contact. Observation on 01/07/2026 at 7:30 AM revealed NA C assisted Resident 103 and Resident 145 to eat with no hand hygiene between resident contact. Interview with DON on 1/7/26 at 8:00 AM revealed staff were not completing hand hygiene between residents and should be. Interview with DON on 1/8/26 at 8:20 AM revealed there were 27 residents in the main dining area that were assisted with dining Record Review of the facility's Feeding a Resident policy with a reviewed date of 6/21 revealed staff should wash hands before and after assisting the resident.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to inform the physician and resident representative of a change in Abnormal Involuntary Movements Scale (AIMS) score for 1 (Resident 7) of 5 sampled residents. The facility census was 148. The findings are:Record review of the facility policy titled Abnormal Involuntary Movements Scale (AIMS) dated 02-2021 revealed the AIMS is a rating scale designed to measure involuntary movements known as Tardive Dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment of antipsychotic medications. A score of 2 or higher on the AIMS scale is evidence of TD. If the patient has mild TD in two areas, or moderate movements in one area, then he or she should be considered for a diagnosis of TD and the results discussed with their physician. If a resident's score on the AIMS suggests the diagnosis of TD, the clinician must consider whether the resident still needs to be on an antipsychotic medication. The question should be discussed with the resident, their family and their physician. Record review of Resident 7's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 10-13-2025 revealed the facility staff assessed the following about the resident:-date of admission [DATE]-was rarely able to make (gender) self understood.-had diagnosis of anxiety disorder, bipolar disorder, and schizophrenia. -was taking an antipsychotic medication.-required total assistance with eating, dressing, hygiene, toileting, bathing, bed mobility and transfers. Record review of Resident 7's AIMS tests revealed the facility conducted an AIMS on Resident 7 on 09-17-2025 and the score was a zero. Record review of Resident 7's Medication Administration Record (MAR) revealed Resident 7 was receiving Seroquel (an antipsychotic medication) 25 milligrams (mg) daily and on 10-02-2025 an additional dose of Seroquel 100 mg was added at bedtime. The MAR also revealed on 10-09-2025 an additional dose of Seroquel 25mg was added at noon resulting in Resident 7 receiving Seroquel 25 mg in the morning and at noon and 100 mg at bedtime. Record review of Resident 7's AIMS tests revealed the facility conducted an AIMS on Resident 7 on 11-04-2025 and the score was 4. An interview conducted on 01-08-2026 with the Director of Nursing (DON) at 8:45 AM confirmed Resident 7 had an increase in the AIMS score and the facility did not update Resident 7's representative or the physician of the increase and should have.

Based on record review and interview, the facility failed to communicate with the hospital and failed to provide transfer documentation during a hospital transfer for 2 (Residents 6 and 154) of 4 sampled residents. The facility staff identified a census of 148.The findings are: A. A record review of a facility policy entitled Transfer Resident to Hospital dated Revised 1/2021 revealed: -Purpose: To provide prompt and safe transfer of resident from the facility and to ensure continuity of care through provision of pertinent resident information. -9. INTERACT Nursing Home to Hospital Transfer Form Observation. -10. Nurse will contact emergency department nurse to give report to include Resident's COVID-19 status. -11. Document in the Resident's Progress Notes the basis for the transfer, conversations with the physician/nurse practitioner, family and hospital nurse. -13. Nurse will complete documentation in HER to include but no limited to: -a. Physician Discharge Order in Resident Orders -b. Progress Notes -c. Disposal/returned medications (if applicable) -d. Diagnosis at time of transfer -e. Location resident was transferred to -f. Who transported resident i.e., ambulance, family, etc. -g. Add census line to indicate hospital leave. Record review of Resident 154's Face Sheet printed 01/06/2026 revealed the facility admitted Resident 154 on 08/29/2025. Further review of the face sheet identified Resident 154 had conditions that included stage four chronic kidney disease (severe kidney damage where the kidneys struggle to filter waste), type 2 diabetes mellitus with complications (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), and obstructive sleep apnea (when breathing repeatedly stops and starts while asleep which causes throat muscles to relax, blocking the airway). Record review of Resident 154's progress notes dated 10/15/2025 showed Resident 154 was discharged to the hospital for pneumonia and respiratory failure. Further review of the progress note showed Resident 154's Power of Attorney was notified of the hospital transfer. Record review of Resident 154's electronic medical record (EMR) which included progress notes, observations, and scanned documents lacked evidence that a transfer form or communication with the hospital was completed at the time of transfer. An interview on 01/07/2026 at 7:43 AM with the Director of Nursing (DON) confirmed there was no evidence to support the transfer form and hospital communication was completed. The DON further confirmed the transfer form and hospital communication should have been completed. B. A record review of Resident 6's Continuous Care Summary revealed Resident 6 had the following diagnoses: Vascular Dementia (a significant decline in mental abilities), Hypertension (high blood pressure), Congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs), Bradycardia (slow heart rate), Transient Cerebral Ischemic Attack (temporary blockage of blood flow to the brain), Cerebral infarction (the death of brain tissue due to a severe lack of blood flow) A record review of Resident 6's Minimum Data Set (MDS – a federally mandated assessment tool used for all residents in Medicare or Medicaid certified nursing homes) revealed Resident 6 had a Brief Interview for Mental Status (BIMS – a federally mandated assessment tool used to assess the cognitive (ability to acquire knowledge and understanding through thought, experience and the senses) status of residents in nursing homes) of 3 which indicated they were severely cognitively impaired. A record review of Resident 6's Nursing Progress note dated 12/13/2025 by Licensed Practical Nurse K (LPN) revealed Resident 6 had fallen and was sent to the Emergency Department for evaluation. A record review of Resident 6's electronic medical record (EMR) which included progress notes, observations and scanned documents lacked evidence that a transfer form was completed at the time of the transfer. An interview on 1/8/2025 at 10:40AM with the Assistant Director of Nursing (ADON) confirmed there was no evidence to support the transfer form had been completed and that it should have been completed.

Based on record review and interview, the facility failed to ensure a new PASARR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) referral had been completed after a diagnosis of a mental disorder was identified for 1 (Resident 10) of 1 reviewed for PASRR. The facility census was 148.Findings are:Record review of a facility policy entitled Preadmission Screening and Resident Review (PASRR) Program dated August 2023 revealed the following information: The facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under the state approved Medicaid program. Coordination includes:b. Referring all level 2 residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level 2 resident review upon a significant change in status assessment. 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident with a mental illness or intellectual disability for resident review. Record review of Resident 10's admission Face Sheet dated 5/24/24 revealed an admission date of 5/24/24. Diagnoses listed included: Adjustment Disorder with depressed Mood 5/24/24, Depression 5/24/24 and PTSD [Post Traumatic Stress Disorder, a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event and may result in repeated, involuntary memories, distressing dreams or flashbacks of the traumatic event] 8/27/24. Record review of Resident 10's PASRR Level 1 screen completed on 5/14/24 at the time of admission revealed that a Level 2 PASRR evaluation and determination was not required at that time and no diagnoses or suspicion of serious mental illness or intellectual disability or related condition was indicated. Record review of Resident 10's quarterly Minimum Data Set [MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems] dated 10/1/24 revealed a diagnoses of PTSD. The MDS identified that Resident 10 had severe cognitive impairment, rejected care 1-3 days per week and required maximal assistance with activities of daily living. Record review of Resident 10's significant change MDS dated [DATE] revealed moderate cognitive impairment, a diagnosis of PTSD, adjustment disorder with depressed mood and depression. The MDS identified that the resident was not currently considered to have a serious mental illness or intellectual disability or related condition. Interview on 01/07/2026 at 7:49 AM with the facility Administrator confirmed that no recommendation had been made to the PASRR agency for a review of Resident 10's mental health condition after a significant change MDS had been completed on 1/13/25 for Resident 10. The Administrator confirmed this should have been done after the diagnoses of PTSD was identified on 8/27/24.

Based on observation, interview, and record review, the facility failed to assist with or offer oral hygiene during the morning routine for 1 (Resident 17) of 3 sampled residents. The facility staff identified a census of 148.The findings are:Record review of a facility policy entitled Oral Hygiene reviewed 5/2021 revealed the following: - Purpose: To ensure cleanliness; to prevent odor; to improve appetite; to prevent cavities, tartar buildup and gum disease; to stimulate circulation of blood in the gums. - Frequency: Every morning and bedtime.A record review of Resident 17's Face Sheet showed the facility admitted Resident 17 on 12/30/2024. Further review of the face sheet revealed Resident 17 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing), and dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]).A record review of Resident 17's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 01/05/2026 revealed Resident 17 was rarely or never understood and Resident 17 rejected care on one to three days during the assessment period. Further review of the MDS showed Resident 17 was dependent upon staff for wheelchair mobility and required supervision to complete oral hygiene.A record review of Resident 17's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) identified an intervention for assistance of one staff for dressing and hygiene dated 12/31/2024.A record review of Resident 17's Orders revealed a nursing order dated 07/09/2025 that read assist with brushing teeth every morning and every night. Document refusals in progress notes.A record review of Resident 17's Progress Notes dated 10/01/2025 through 01/05/2026 revealed the resident refused oral care on 10/14/2025 and 10/16/2025.A record review of Resident 17's Dental Visit Note dated 10/23/2025 revealed: -Oral hygiene - very poor today with heavy amounts of plaque and food debris, with moderate tartar accumulation. -The special needs of this patient render them incapable of maintaining adequate oral health care without daily assistance. -Encourage staff to assist patient with tooth brushing.An observation on 01/06/2025 at 10:33 AM revealed Resident 17 in [gender] bedroom watching television. Resident 17 had food debris in their mouth.A continuous observation on 01/07/2025 from 6:47 AM through 7:05 AM revealed Nursing Assistant (NA)-M assisted Resident 17 out of bed, to get dressed for the day, styled Resident 17's hair and assisted the resident with cleaning and donning eyeglasses. NA-M did not offer Resident 17 assistance to brush [gender] teeth.During an interview on 01/07/2025 at 7:06 AM, NA-M confirmed oral hygiene was not performed or offered and should have been as part of Resident 17's morning cares.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1). Based on observation, interview and record review the facility failed to ensure the proper functioning of an air mattress for 1 (Resident 123) of 1 residents sampled. The facility census was 148. The findings are: Record review of Resident 123's Minimum Data Set, dated [DATE] (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-had a diagnosis of malnutrition, and Inclusion Body Myositis (IBM: a slow-progressing inflammatory, muscle disease that causes the gradual weakening of the muscles).-Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with eating, dressing, hygiene, toileting, bathing, transfers and bed mobility.-was always incontinent of bowel and bladder.-had a recent weight loss-current body weight was 93 pounds.-was at risk of developing a pressure ulcer. Record review of Resident 123's care plan printed on 01-06-2026 revealed Resident 123 was at risk of developing a pressure ulcer related to weakness and reduced mobility. The goal was for Resident 123's skin to remain intact through the review date. Approaches to reach the goal were:-air pressure mattress-refer to the Medication Administration Record (MAR) for current treatment.-complete a pressure ulcer risk assessment quarterly and as needed.-apply treatments per physician's orders.-Bunny boots (pressure-relieving boots) on feet at all times.-apply lotion frequently to areas of concern.-assess skin with during daily cares as needed for bruises and skin tears.-complete bath/skin reports with showers-transfer with fragile skin in mind. An observation conducted on 01-05-2026 at 11:06 AM revealed Resident 123 was lying in bed and the air mattress pump was not on. An observation conducted on 01-05-2026 at 12:00 AM revealed Resident 123 was lying in bed and the air mattress pump was on and the low-pressure light on the pump was on.An observation 01-06-2026 at 7:35 AM revealed Resident 123 was lying in bed and the air mattress was on and the low-pressure light on the pump was on.An observation on 01-07-2026 at 5:35 AM revealed Resident 123 lying in bed and the air mattress was not on.An observation on 01-07-2026 at 6:35 AM revealed Resident 123 was lying in bed and air mattress was not on.An observation on 01-07-2026 at 7:35 AM revealed Resident 123 was lying in bed and the air mattress was off.An interview conducted on 01-07-2026 at 7:40 AM with Medication Aide (MA) J confirmed the air mattress was not on and should have been. An observation conducted on 01-07-2026 at 12:30 PM revealed Resident 123 was lying in bed and the air mattress was on and the low-pressure light on the pump was on.An interview with the Wound Nurse (WN) I on 01-07-2026 at 12:45 PM confirmed the low-pressure light was on to Resident 123's air mattress and revealed (gender) would refer to the owner's manual to find out what the low-pressure light meant.An interview with the Assistant Director of Nursing (ADON) on 01-07-2026 confirmed Resident 123's air mattress was being replaced and provided the manufacturer's information which revealed if the low-pressure light remains on for longer than 30 minutes to call and have the mattress serviced.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to complete quarterly bed assist devices assessments and regular preventive maintenance checks on 1 (Resident 5) of 1 sampled resident's bed assist device. The facility census was 148. Findings are:A record review of the facility's Bed Mobility Assist Devices policy dated February 2021 revealed A Bed Mobility Device Evaluation should be completed upon assessed need and reviewed quarterly, annually, and with significant change thereafter. Environmental staff would install and inspect for safety prior to use and preventative maintenance would be done bi-monthly and as needed. A record review of Resident 5's Resident Census dated 01/08/2026 revealed the resident was admitted on [DATE]. A record review of Resident 5's Face Sheet dated 01/07/2026 revealed the resident had diagnoses of Epilepsy (a brain disorder causing recurring seizures), Unspecified Dementia (confusion of unknown cause), Schizoaffective Disorder (serious mental illness), Morbid Obesity (very overweight), Panic Disorder, Major Depression, Obstructive Sleep Apnea, and Sepsis (severe infection). A record review of Resident 5's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/11/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was required setup or clean-up assistance with oral hygiene (cleaning), dressing, and footwear, supervision or touch assistance with personal hygiene and toileting, and partial/moderate assistance with bathing. The resident was independent with bed positioning and sit to stand, required setup or cleanup assistance with chair to bed transfer, supervision or touching assistance with toilet transfers, and partial/moderate assistance with tub or shower transfers. A record review of Resident 47's Care Plan with a last care conference date of 12/11/2025 revealed a problem area of the resident was at risk for injury related to having an assist rail in place to aid in bed mobility. The approaches were that an order was obtained from the resident's physician for the ongoing assist rail, monitor for signs or injury related to the assist rails, and resident had assist rails for self-positioning on both sides of the bed. The problem start date and approach dates were all 12/04/2025. A record review of Resident 5's Orders dated 01/07/2026 revealed an order dated 12/04/2025 for okay for bilateral (both sides) assist rails for self-positioning in bed and transfers. A record review of Resident 5's Observation History list dated 06/01/2023 - 01/07/2026 revealed the only Bed Assist Device Evaluation completed For Resident 5 was dated 06/13/2025. A record review of the facility's Daily Report of Maintenance dated 12/05/2025 - 01/06/2026 revealed the only entry for Resident 5's Bed Assist rails was on 01/07/2025 when Licensed Practical Nurse (LPN)-N entered Resident 5's right assist rails was loose and needed tightened. An observation on 01/05/2026 at 9:49 AM revealed that there was a washer and nut on the bedside table as you entered Resident 5's room. The resident's one quarter length bed rail on the right-hand side of the bed was very loose, and the top was bowed away from the bed. An observation on 01/06/2026 at 7:52 AM revealed that there was a washer and nut on the bedside table as you entered Resident 5's room. The resident's one quarter length bed rail on the right-hand side of the bed was very loose, and the top was bowed away from the bed. An observation on 01/06/2026 at 2:08 PM revealed that there was a washer and nut on the bedside table as you entered Resident 5's room. The resident was sleeping on bed with the resident's legs hanging off the right side of the bed. The bed rail on the right-hand side of the bed was very loose, and the top was bowed away from the bed. An observation on 01/07/2026 at 6:30 AM revealed that there was a washer and nut on the bedside table as you entered Resident 5's room. The resident's one quarter length bed rail on the right-hand side of the bed was very loose, and the top was sticking out away from the bed. An observation on 01/07/2026 at 7:28 AM revealed LPN-O exited Resident 5's room and go to the nurse's station to document that Resident 5's bed rail was loose and needed tighten on the Daily Report of Maintenance clipboard. In an interview on 01/05/2026 at 9:49 AM, Resident 5 confirmed the resident did not know what the washer and nut on the bedside table was from and the resident did not know there was a problem with the bed rail. In an interview on 01/07/2026 at 6:30 AM, Resident 5 confirmed the resident got in and out of bed by self daily and used the bed rail to assist with getting in and out of bed and into the wheelchair. In an interview on 01/07/2026 at 6:48 AM, Nursing Assistant (NA)-O confirmed NA-O works with Resident 5 Monday through Friday. The resident usually got up on their own, the bed rail was always in the upright position, and NA-O was not aware of any problems with the bed rail. In an interview on 01/07/2026 at 7:13 AM, LPN-N confirmed that LPN-N worked with the resident on the day shift since 01/05/2026. LPN-N confirmed that Resident 5 used the bed rail to assist with transfers and with naps. LPN-O confirmed that LPN-O was not aware of any problems with the resident's bed rail. In an interview on 01/07/2026 at 9:51 AM, the Minimum Data Set Coordinator (MDSC) confirmed the resident has had bed assist rails for a long time. The original order was in 2021. At some point the order fell off the system and a new order was received. MDSC confirmed the last bed assist device assessment that was completed was 06/13/2023 and they should have been done quarterly but were not. MDSC confirmed if there was a problem with loose bed rails, it would have been caught when they done the quarterly assessment. A new assessment was not completed when they got the new order for the bed assist rails and should have been. In an interview on 01/07/2026 at 1:19 PM, LPN-N confirmed the bed assist rail on Resident 5's bed was loose and should not have been. In an interview on 01/07/2026 at 1:02 PM, the Director of Nursing (DON) confirmed the bed assist device assessment should have been completed quarterly and annually and was not. In an interview on 01/08/2026 at 11:30 AM, the DON confirmed there were no preventive maintenance logs completed for Resident 5's bed assist devices.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to set 1 (Resident 47) of 3 sampled resident's oxygen flowrate to the prescribed settings. The facility census was 148. Findings are:A record review of the facility's Oxygen Administration policy with a revised date of 5/21 revealed the facility must have a physician's order to apply oxygen and the flow should be adjusted to the ordered rate. A record review of the facility's Physician Orders, Following policy dated June 29, 2021 revealed all physician orders would be followed as prescribed and if not, the reason would be recorded in the medical record. A record review of Resident 47's Resident Census dated 01/07/2026 revealed the resident was admitted on [DATE]. A record review of Resident 47's Face Sheet dated 01/07/2026 revealed the resident had diagnoses of Dependence on Supplemental Oxygen, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, and Chronic Diastolic (Congestive) Heart Failure (CHF). A record review of Resident 47's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 10/24/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15, which indicated the resident was cognitively aware (able to think and comprehend). The resident was dependent on staff for all activities of daily living and mobility except the resident required set-up or clean-up assistance with eating and oral hygiene (cleaning). The resident was on oxygen. A record review of Resident 47's Care Plan with a last care conference date of 10/22/2025 revealed a problem area of the resident was at risk for respiratory complications due to need for oxygen therapy. A goal of keeping the resident's oxygen saturations greater than 90 percent (%), and interventions of administer medications per doctor of medicine's (MD) orders and administer oxygen continuously to keep saturations greater than 90%. A record review of Resident 47's Order History dated 01/06/2026 revealed the resident had an order for oxygen per nasal cannula (a tube that goes on the nose to deliver oxygen) at 2 liter per minute (l/m) during day, 4 l/m at rest and while sleeping with Average Volume-Assured Pressure Support (AVAPS)(a machine used to treat Respiratory Failure). An observation on 01/06/2026 at 7:48 AM revealed Resident 47 was sitting up in the wheelchair with a nasal cannula in the resident's nose and the oxygen concentrator (a machine used to purify oxygen from the room) was set at 3.5 l/m. An observation on 01/07/2026 at 6:19 AM revealed Resident 47 was sitting up in the wheelchair with a nasal cannula in the resident's nose and the oxygen concentrator was set at 3.5 l/m. An observation on 01/07/2026 at 1:40 PM with Licensed Practical Nurse (LPN)-G revealed Resident 47 was sitting up in the wheelchair with a nasal cannula in the resident's nose and the oxygen concentrator was set at 4 l/m and LPN-G decreased it to 2 l/m. In an interview on 01/07/2026 at 1:40 PM. LPN-G confirmed Resident 47 was sitting in the wheelchair with oxygen on and the oxygen concentrator was set at 4 l/m and should been set at 2 l/m.

Licensure Reference Number 175 NAC 12-006.09(B)(ii) Based on observation, record review, and interview, the facility failed to assess and identify situational stressors and triggers related to post-traumatic stress disorder on 1 (Resident 39) of 4 sampled residents. The facility census was 148. Findings are:A record review of the facility's Trauma Informed Care and Behavioral Health Management policy with a revision date of 9/2022 revealed the following: -Posttraumatic Stress Disorder (PTSD) a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event and may result in repeated, involuntary memories, distressing dreams or flashbacks of the traumatic event. -2. If a diagnosis is confirmed or the resident answers yes to the above question, the Life Event Checklist will be completed as part of the admission Social History Observation. If the resident voices suicidal or homicidal ideation, ensure their safety as well as safety of others in the community and referral should be made to psychiatry. -7. Residents admitted with a diagnosis of history of trauma or PTSD will receive care and services to address the problem/illness. -8. Resident and/or resident representative are active participants in identifying triggers for behaviors and developing coping interventions. A record review of Resident 39's Face Sheet revealed diagnoses of post traumatic stress disorder, schizoaffective disorder, major depressive disorder, anxiety disorder, and bipolar disorder. A record review of Resident 39's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed Resident 39 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. A score of 15 indicated the resident was cognitively intact. Further review of the MDS revealed that the resident had a diagnosis of post traumatic stress disorder. A record review of Resident 39's electronic medical record, which included progress notes and observations, revealed that a trauma informed care assessment was not completed. In an interview on 01/06/2026 at 11:13 AM Resident 39 confirmed a history of childhood trauma. In an interview on 01/08/2026 at 11:36 AM the Social Service Director confirmed that a trauma informed care assessment was not completed for Resident 39.

Licensure Reference Number 175 NAC 12-006.12(A)(vi). Based on record review and interview, the facility failed to identify drug irregularities related to antipsychotic medication and adverse symptom monitoring for Resident 7 and failed to ensure the physician provided rationale for the use of multiple hypertensive (high blood pressure) medications for Resident 6 of 6 residents sampled. The facility census was 148. The findings are: Record review of the facility policy titled Abnormal Involuntary Movements Scale (AIMS) dated 02-2021 revealed the AIMS is a rating scale designed to measure involuntary movements known as Tardive Dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment of antipsychotic medications. A score of 2 or higher on the AIMS scale is evidence of TD. If the patient has mild TD in two areas, or moderate movements in one area, then he or she should be considered for a diagnosis of TD and the results discussed with their physician. If a resident's score on the AIMS suggests the diagnosis of TD, the clinician must consider whether the resident still needs to be on an antipsychotic medication. The question should be discussed with the resident, their family and their physician Record review of the facility policy titled Pharmacist Consultant Duties and Responsibilities dated 05-2021 revealed the consultant pharmacist reviews the medications for each resident for any irregularities and to: verify appropriateness of the medications involved; evaluate disease state management; ensure appropriate medication monitoring to maximize safety and efficacy and to prioritize patient goals, safety and quality of life. The policy also revealed the consultant pharmacist reviews each resident chart to identify any irregularities: -medication use without indications -untreated indications -improper medication selection -sub-therapeutic dosage -over-dosage -adverse drug reactions -drug interactions -failure to receive medications -potentially inappropriate medications in the elderly -gradual dose reductions -psychotropic medications -medication duration -medication monitoring -medication cost -medication errors -regulatory issues -other pertinent issues as needed. A. Record review of Resident 7's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 10-13-2025 revealed the facility staff assessed the following about the resident: -date of admission [DATE] -was rarely able to make (gender) self understood. -had diagnosis of anxiety disorder, bipolar disorder, and schizophrenia. -was taking an antipsychotic medication. -required total assistance with eating, dressing, hygiene, toileting, bathing, bed mobility and transfers. Record review of Resident 7's Abnormal Involuntary Movement Scale (AIMS) tests revealed the facility conducted an AIMS on Resident 7 on 09-17-2025 and the score was zero. Record review of Resident 7's Medication Administration Record (MAR) revealed Resident 7 was receiving Seroquel (an antipsychotic medication) 25 milligrams (mg) daily and on 10-02-2025 an additional dose of Seroquel 100 mg was added at bedtime. The MAR also revealed on 10-09-2025 an additional dose of Seroquel 25mg was added at noon resulting in Resident 7 receiving Seroquel 25 mg in the morning and at noon and 100 mg at bedtime. Record review of Resident 7's AIMS tests revealed the facility conducted an AIMS on Resident 7 on 11-04-2025 and the score was 4. An interview conducted with the Consultant Pharmacist (CP) on 01-08-2025 at 8:35 AM revealed the increase in AIMS score was not noted on the November 2025 Drug Regimen Review (DRR) or the December 2025 DRR therefore a recommendation to update the physician was not submitted. An interview conducted on 01-08-2026 with the Director of Nursing (DON) at 8:45 AM confirmed Resident 7 had an increase in the AIMS score and the facility did not act on the results. B. A record review of Resident 6's Continuous Care Summary revealed Resident 6 had the following diagnoses: Dementia (a significant decline in mental abilities), Hypertension (high blood pressure), Congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs), Bradycardia (slow heart rate), Transient Cerebral Ischemic Attack (temporary blockage of blood flow to the brain), Cerebral infarction (the death of brain tissue due to a severe lack of blood flow) A record review of Resident 6's Minimum Data Set (MDS – a federally mandated assessment tool used for all residents in Medicare or Medicaid certified nursing homes) revealed Resident 6 had a Brief Interview for Mental Status (BIMS – a federally mandated assessment tool used to assess the cognitive (ability to acquire knowledge and understanding through thought, experience and the senses) status of residents in nursing homes) of 3 which indicated they were severely cognitively impaired. A record review of Resident 6's Medication Administration Record (MAR) for 12/7/2025 to 1/5/2026 revealed Resident 6 received the following anti-hypertensive (medications used to treat high blood pressure) medications: Amlodipine 10mg tablet daily. Doxazosin 1mg tablet at bedtime daily. Hydralazine 100mg tablet every 8 hours. Lisinopril 10mg daily. A record review of a Pharmacy admission Medication Regimen Review (MRR) reviewed on 5/15/2025 by Registered Nurse L (RN) and signed by the provider on 06/04/2025 revealed a review request for the provider for the medications Amlodipine, Hydralazine, Doxazosin and Lisinopril for duplicate therapy (multiple medications from the same drug class for the same disease without a clear reason). No rationale was given for the duplicate therapy. A record review of a Pharmacy admission Medication Regimen Review (MRR) reviewed on 07/30/2025 by an RN and signed by the provider on 08/06/2025 revealed a review request for the provider for the medications Amlodipine, Hydralazine, Doxazosin and Lisinopril for duplicate therapy (multiple medications from the same drug class for the same disease without a clear reason). No rationale was given for the duplicate therapy. A record review of a Pharmacy admission Medication Regimen Review (MRR) reviewed on 12/18/2025 by an RN and signed by the provider on 12/31/2025 revealed a review request for the provider for the medications Amlodipine, Hydralazine, Doxazosin and Lisinopril for duplicate therapy (multiple medications from the same drug class for the same disease without a clear reason). No rationale was given for the duplicate therapy. A record review of the facility nursing policy dated November 2017 and reviewed on 5/21 titled Drug Regimen Review (DRR) revealed the following: The consultant pharmacist reviews the medications for each resident for any irregularities and verify appropriateness of the medications involved; evaluate disease state management, ensure appropriate medication monitoring to maximize safety and efficacy; and prioritize patient goals, safety, and quality of life. The consultant pharmacist reviews each resident chart to identify and address any irregularities: 5. Regulatory issues (I.E., specific documentation in the chart; CMS requirements) CMS requirements: F756 (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. An interview on 1/8/2025 at 11:00AM with the Assistant Director of Nursing (ADON) confirmed a rationale for duplicate therapy was not present.

Based on record review and interview the facility failed to ensure there was a qualified Dietary Manager (DM) or qualified nutrition professional full-time, part-time, or on a consultant basis. This had the potential to affect all residents in the building. The facility staff identified a census of 148. Findings are:Record review of employee files revealed the Dietary Manager was not certified. An Interview with the Administrator on 1/7/26 at 6:50 AM confirmed the DM had not completed the test to become certified and the facility did not have a full time dietician.

Licensure Reference Number 175 NAC 12-006.18BBased on observation, interview and record review the facility failed to perform hand hygiene between glove changes in a manor to prevent cross contamination during perineal care (the cleansing of the perineum-the area between the anus and genitals-to maintain hygiene, prevent infection, reduce odor, and promote skin health) on Resident 1, 17, and 47 and failed to clean the nebulizer mask and nebulizer medication chamber (a machine used to deliver aerosolized medications to the lungs) between uses to prevent potential contamination for Resident 160. A total sample of 3 residents were observed for perineal care and 4 residents were observed for nebulizer equipment. The facility staff identified a census of 148.Findings are:A. Record review of a Policy Titled Perineal Care dated 3/2021 revealed Purpose: To establish routine practices for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection, and prevent odors. All residents will receive perineal care, as needed, in the morning before breakfast, every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. 2. Identify yourself and explain procedure to resident. 3. Wash hands 7. Put on Gloves. Remove brief. Remove gloves, wash hands and apply new gloves. 10. Wash peri area thoroughly 14. Remove gloves, wash hands and apply clean gloves. 15. Apply protective barrier ointment to front peri area. 16. Remove gloves, wash hands and apply clean gloves. 17. Turn resident on side away from you. 18. Lather wash cloth and wash rectal area and buttocks if using soap and water, otherwise use disposable peri-wipes. 19. Rinse all cleansed areas where soap and water were used and dry thoroughly. 20. Remove gloves and wash hands 21. Put on clean gloves. 22. Apply lotion, or moisture barrier to buttocks and rectal area if indicated. 23. Position resident for comfort. 24 Remove gloves and wash hands. B. Record Review of Residents 1's Quarterly MDS (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 12/29/25 revealed Resident 1's cognition was severely impaired and was dependent on staff for toileting hygiene, personal hygiene and dressing. An Observation on 1/7/25 at 7:26 AM revealed Nursing Assistant (NA)-A and NA-B were in Resident 1's room at the bedside with gloves on, a trash bag and container of wipes had been placed on the foot of the bed. NA-A explained the procedure to Resident 1. NA-A removed Resident 1's brief and noted that the resident had a bowel movement (BM). NA-A used the brief to remove some of the BM and folded the brief down between the residents legs. Using the same soiled gloves, NA-A removed clean wipes out of the package and wiped outside of labia. Using the same soiled gloves NA-A removed more wipes out of package, wiped labia again and discarded the soiled wipes. Using the same soiled gloves, NA-A pulled more wipes out of the package. Using the same soiled gloves. NA-A turned resident on left side, used brief to remove some of the BM. NA-A folded up brief and pulled out from under resident and got BM on the bottom sheet. Using the same soiled gloves NA-A pulled more wipes out of the package with multiple wipes coming out of the package. NA-A wiped rectal area multiple times with one wipe before throwing away and using another. Using same soiled gloves, NA-A put left over wipes back in package and placed the package on the bedside table. Using the same soiled gloves, NA-A placed the top sheet on top of the BM that was on the bottom sheet and put the clean brief on Resident 1. Using the same soiled gloves NA-A put sweat pants on and rolled Resident 1 with NA-B to get the pants on. Using the same soiled gloves NA-A removed the resident's gown, picked a shirt up off the floor and proceeded to place it on the resident. NA-A removed their gloves and went to the hall to obtain the residents wheelchair (w/c), pushed w/c into room and donned (put on) new gloves without performing hand hygiene. NA-A and NA-B assisted resident with transfer into the wheelchair. Interview with NA-A on 1/7/26 at 7:47 AM confirmed that the gloves were soiled after cleaning up the BM and the wipes had been contaminated by the soiled gloves. NA-A confirmed hand hygiene and glove changes should have been performed. NA-A also confirmed the wipes should have been thrown away if not used and not put back in the package. C. Record Review of Resident 47's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIM's, used to measure cognitive impairment in nursing home residents categorized as 0-7 as severely impaired, 8-12 as moderately impaired and 13-25 as cognitively intact) of 15 and was dependent on staff for toileting hygiene, personal hygiene and dressing. An observation on 1/7/26 at 1:42 PM revealed NA-B and NA-D assisted Resident 47 with toileting and exited the room. An observation on 1/7/26 at 1:58 PM NA-D reentered Resident 47's room donned gloves after performing hand hygiene and assisted resident with perineal care. NA-D removed the soiled gloves and applied new gloves without performing hand hygiene. NA-D placed a barrier ointment on the right glove and placed the ointment on the resident's bilateral buttocks. NA-D removed the soiled gloves and put on new gloves without performing hand hygiene. NA-D placed a clean brief under Resident 47. NA-D took trash into the bathroom in a bag, removed gloves and performed hand hygiene. Interview with NA-D on 1/7/26 at 2:01 PM confirmed NA-B and NA-D had not washed their hands when changing gloves and should have. D. A record review of Resident 17's Face Sheet showed the facility admitted Resident 17 on 12/30/2024. Further review of the face sheet revealed Resident 17 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing), and dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]). A record review of Resident 17's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 01/05/2026 revealed Resident 17 was rarely or never understood and Resident 17 rejected care on one to three days during the assessment period. Further review of the MDS showed Resident 17 required substantial assistance with toileting hygiene. A record review of Resident 17's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) identified an intervention dated 12/31/2024 to cleanse the peri-area after each incontinent episode. A continuous observation on 01/07/2025 from 6:47 AM through 7:05 AM revealed NA-M performed hand hygiene, donned (applied) a gown and gloves, removed Resident 17's brief and cleaned the resident. NA-M doffed (removed) gloves. Without the benefit of hand hygiene, NA-M donned new gloves and applied a clean brief. NA-M assisted Resident 17 to don clothing and come to a sitting position on the edge of the bed. NA-M assisted Resident 17 into the wheelchair. NA-M doffed gloves and assisted Resident 17 to put on a button-down shirt. Without the benefit of hand hygiene, NA-M donned new gloves and finished Resident 17's morning routine. When completed, NA-M bagged dirty linens for transport, doffed gloves and gown, and exited the room. An interview on 01/07/2025 at 7:06 AM with NA-M confirmed hand hygiene was not performed between glove changes and should have been. E. A record review of the facility's Nebulizer Cleaning policy with a revision date of 5/2021 revealed the following: -1. Check equipment (nebulizer medication chamber and mask) prior to treatment to assure that it is clean and dry. -2. After pulmonary treatment, cleanse the medication chamber and mask with running water. Place chamber and mask on clean paper towel to air dry. Store tubing in unzipped zip lock bag or breathable bag. A record review of Resident 160's Face Sheet revealed diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, dependence on supplemental oxygen, and centrilobular emphysema. A record review of Resident 160's Physician Orders dated 1/6/26 revealed a medication order for albuterol sulfate solution for nebulization; 2.5 mg /3 mL (0.083%); amt: 3 ml; inhalation to ne administered as needed. An observation on 01/05/2026 at 7:50 AM revealed Resident 160's nebulizer mask and nebulizer chamber were laying on top of a stand with no barrier underneath the mask and condensation in the medication chamber. An observation on 01/05/2026 at 12:48 PM revealed Resident 160's nebulizer mask and nebulizer chamber were laying on top of a stand with no barrier underneath the mask and condensation in the medication chamber. An observation on 01/06/2026 at 9:13 AM revealed Resident 160's nebulizer mask and nebulizer chamber were laying on top of a stand with no barrier underneath the mask and condensation in the medication chamber. In an interview on 01/06/2026 at 11:03 AM Registered Nurse (RN)-H confirmed that the nebulizer medication chamber and nebulizer mask were not cleaned and on a barrier and should have been.

Based on record review and interview, the facility failed to report allegations of potential abuse within 2 hours involving 2 [Residents 2 and 3] of 7 sampled residents in accordance with federal requirements. The facility had a total census of 150 residents.Findings are: A. A review of undated facility investigation revealed on 6/27/25 at 5 PM Resident 3 was being redirected from the dining room by Nurse Aide A. Licensed Practical Nurse B approached Resident 3 to assist Resident 3in a attempted to guide Resident 3 to another area and took a hold of Resident 3's right hand/wrist. Resident 3 became upset with Licensed Practical Nurse B and stomped on Licensed Practical Nurse B's foot. Licensed Practical Nurse B's hand made contact with Resident 3's forearm and said stop it while trying to get Resident 3 off Licensed Practical Nurse B's foot. Nurse Aide A positioned self between Licensed Practical Nurse B and Resident 3. Licensed Practical Nurse B was sent home pending investigation. Further review of undated facility investigation revealed APS was notified at 9 AM on 6/28/25.In an interview on 7/21/25 at 11:21 AM and 1:53 PM, the Administrator confirmed that the report had not been called into APS within the required 2-hour timeframe. The Administrator reported that staff education on reporting had been assigned to be completed by 7/7/25. B. A review of undated facility investigation revealed that during a chart review conducted on 6/30/25 at 4:30 PM revealed a progress note dated 6/29/25 that stated Resident 3 had been combative with another resident. The facility completed interviews with staff members that had been working at the time. According to the facility investigation, Nurse Aide C reported Resident 3 had approached Resident 2 in the dining room and made open handed contact with Resident 2's arm. Resident 2 had swung out and made open hand contact to Resident 3's arm with Nurse Aide C getting between the residents. Further review of the undated facility investigation revealed APS had been notified of the potential abuse on 6/30/25 at 5 PM. In interviews on 7/21/25 at 11:21 AM and 1:53 PM, the Administrator confirmed that the report was not called in within the 2-hour timeframe as the facility was not aware of it. The Administrator reported that staff education on reporting had been assigned to be completed by 7/7/25. C. A review of facility policy titled Freedom From Abuse, Neglect and Exploitation revised 9/22 revealed the following: The administrator or designed will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately, not later than 2 hours after the allegation is made, to other officials in accordance with state law including to the state survey and certification agency.

Licensure reference: 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview, the facility failed to ensure a check of the APS/CPS [Adult Protective Service/Child Protective Service] registry had been completed for 1 [Nurse Aide D] of 5 sampled direct care staff. The facility had a total census of 150 residents. Findings are:A review of undated staffing list revealed Nurse Aide D was hired on 6/24/25.A review of preemployment checks for Nurse Aide D did not reveal a completed APS/CPS registry check.In interviews on 7/21/25 at 12:26 PM and 1:53 PM, the Administrator confirmed that Nurse Aide D did not have a completed APS/CPS registry check. The Administrator confirmed that Nurse Aide D had been working independently at the facility. The Administrator reported Nurse Aide D had been pulled off the schedule due to finding out the APS/CPS registry check had not been completed. The Administrator confirmed that APS/CPS registry checks are to be completed on new hires.A review of facility policy titled Freedom From Abuse, Neglect and Exploitation revised 9/22 revealed the following: All potential employees shall have a criminal background check. The facility must not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review the facility staff failed to ensure Enhanced Barrier Precautions (EBP - an infection control strategy that focuses on prevention the spread of multidrug-resistant organisms (MDRO) were followed when wound care was provided to 1 (Resident 2) of 3 residents sampled. The facility staff identified a census of 145. Findings are: Record review of Resident 2's undated Face Sheet revealed Resident 2 admitted to the facility on [DATE]. Record review of a General Order sheet revealed Resident 2's practitioner order a treatment to Resident 2's wound on the left heel dated 6-10-2025. An observation on 7/7/2025 at 9:55 AM of wound care to Resident 2's left heel by Licensed Practical Nurse A (LPN) revealed LPN A entered Resident 2 room and informed Resident 2 of need to complete wound care. LPN A carried a basin containing 3 plastic bags and a clean towel. LPN A placed the clean towel over Resident 2's bed side table and wash hand and donned gloves and did not don a gown. LPN A after setting up the supplies needed for wound care removed the soiled dressing from Resident 2's left heel. LPN A remove their soiled gloves,completed hand hygiene and donned a clean pair of gloves. LPN A with out donning a gown cleans the wound area, removed the soiled gloves completed hand hygiene and don a clean pair of gloves. LPN A completed the treatment as ordered to Resident 2's left heel,removed the soiled gloves and completed hand hygiene. An interview with LPN A was conducted on 7-7-2025 at 9:50 AM. During the interview LPN A confirmed LPN A should have been wearing a gown. A record review of the facility's Enhanced Barrier Precautions Policy dated July 2022 and revised 3/2024 revealed EBP are indicated for residents with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -Procedure: -3. Personal Protective Equipment (PPE) including gowns and gloves, will be available immediately out side of the residents room. -4. PPE should be worn with during high contact resident activities: -Dressing, bathing/showering, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care.

LICENSE REFERENCE NUMBER NAC 12.006.09(I) Based on record review and interview; the facility staff failed to transfer 1 (Resident 9) of 1 residents in a manner to prevent injury. The facility staff identified a census 159. Findings are: Record review of Resident 9's Electronic Health Record (EHR) titled Census Sheet revealed Resident 9 was admitted to the facility on [DATE]. Record review of Resident 9's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6-06-2024 revealed the following: -Resident 9 had short term and long-term memory problem. -Dependent for eating, bed mobility, transfers, and toileting. -Has a diagnosis of Alzheimer's and dementia with behavioral disturbance. Record review of Resident 9's Comprehensive Care Plan (CCP) with a last conference date of 6-05-2024 revealed Resident 9 required extensive to total assistance with Activities of Daily living (ADL's). According to Resident 9's CCP dated 7-06-2016 revealed 2 staff were to transfer Resident 9 using a full body sling. Further review of Resident 9's CCP revealed Resident 9's CCP did not identify the size of body sling that staff were to use when transferring Resident 9. Record review of Resident 9's Resident Profile (a sheet that identifies care needs of the resident including transfer status that nursing assistant use in the provision of care) sheet printed on 8-22-2024 revealed Resident 9's Profile sheet did not identify the size of the sling staff were to use for a Hoyer left transfer. Record review of an undated Final report for self-report of a major injury sheet revealed Nursing Assistant (NA) Q and NA R were transferring Resident 9 from the bed to the resident's wheelchair using a Hoyer (mechanical lift). Further review of the Final report revealed during the transfer Resident 9's bottom started to slide down through the opening of the Hoyer sling. NA R stopped pushing the Hoyer and NA Q cradled Resident 9, one arm under the legs and 1 arm behind the residents back in order to prevent the resident from sliding any further out of the sling. According to the final report, Resident 9 was assisted back into bed. The Final report identified Resident 9 stated my leg, my leg. The Final report sheet indicated NA Q went and found a full body sling versus the one NA Q and NA R were using, which was identified as a divided leg Hoyer sling. Record review of Resident 9's Progress Notes (PN) dated 7-16-2024 timed at 4:43 PM revealed Resident 9 had extreme pain while being transferred using the Hoyer left and after contacting the practitioner, Resident 9 was sent to the emergency room . Record review of Resident 9's PN dated 7-16-2024 with a time of 9:15 PM revealed the facility staff were notified Resident 9 had a tibial fracture (a fracture that occurred when the shinbone breaks near the knee) and anterior displaced fibula (a fracture of the calf bone) fracture. Record review of Resident 9's Emergency Department dated 7-16-2024 revealed the following information: -Resident 9 had an acute displaced and angulated fractures to of the proximal tibia and proximal fibula metaphysis. On 8-22-2024 at 9:35 AM an interview was conducted with NA Q. During the interview NA Q reported they were using a sling in which the legs of the sling were crossed. NA Q reported thinking the sling was too big for Resident 9. NA Q reported when NA Q and NA R started to move Resident in the Hoyer, Resident 9 began to slide out of the sling. NA Q reported not having knowledge of what size of sling residents needed when using the Hoyer lift. Record review of NA Q's Certified Nursing Assistant (CNA) Care Guidelines Orientation Checklist dated 6-25-2024 revealed there was no indications on how staff were to determine the sling size when using the Hoyer Lift. Record review of NA R Certified Nursing Assistant Care Guidelines Orientation Checklist dated 4-30-2024 revealed there were no indications on how staff were to determine the sling size when using the Hoyer Lift. On 8-22-2024 at 10:43 AM an interview was conducted with Licensed Practical Nurse (LPN) N. During the interview LPN N reported not knowing how to determine which slings are to be used with Hoyer Lifts for resident. On 8-22-2024 at 10:45 AM an interview was completed with the MDS Coordinator C. During the interview MDSC reported sling sizes are not identified in the resident's medical record. On 8-22-2024 at 10:43 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 9 sustained a fracture and was a major injury for Resident 9. Record Review of the Nursing Policy and Procedure Manual (dated 5/2021) Titled: Lift, Mechanical Full Body: -Purpose: To ensure that all nursing staff are using proper transfer techniques to minimize the risk of injury to resident and staff, while using full body lift. -Procedure: 1. Secure the assistance of another NA or other qualified employee. 2. Adjust bed to the same height as the surface transferring to. Lock brakes of bed and chair. 3. Position of transferring surfaces should be in close proximity to minimize transport area allowing enough room to move base from bed to chair or chair to bed. 4. Position lift sling under resident by rolling resident side to side while rolling sling underneath the resident if sling is not under resident. 5. Wheel the lift into place over the resident with the base beneath the bed or around the chair. 6. Attach the lift sling to the lift. 7. Widen the base/legs of the lift prior to moving the lift. The lift is more stable when the legs are widened. 8. Unlock the wheels of the lift when actually lifting the resident on an electric lift. This allows the lift to adjust for the change in weight. 9. Resident's arms should be inside the sling. 10. Begin lifting the resident, using the control panel on the lift. 11. Prior to moving resident, check to ensure the sling is securely attached to the mechanical lift after slightly raising resident. 12. Lift the resident only high enough to clear both the surface they are on, and the surface they are moving to. The higher a resident is lifted in the air, the less stable the transfer. 13. The second staff member monitors the resident's body position, making sure the resident' extremities or head does not bump or swing into any object (including the mast on the lift). 14. As the first staff member moves the lift toward the chair/bed with the resident suspended in the sling, the second staff member is guiding the resident's legs to prevent injury. 15. Bring the lift into position so that the resident is over the seat of the chair or centered over the bed. CAUTION: Do not close the support legs while transporting residents. 16. Lower the sling so that the resident is seated in the chair or centered on the bed. 17. Remove the sling from the hooks on the lift. 18. Carefully move the lift away from the resident; watching to make sure the resident is not bumped with the lift. There were no instructions on how staff were to determine the sling size when using the Hoyer Lift in the Mechanical Full Body Lift Policy and Procedure.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].02(8) Based on interviews, record review, and facility document and policy review, the facility failed to protect the residents' right to be free from sexual abuse by a resident. Specifically, the facility failed to ensure 2 (Resident #141 and Resident #142) of 4 residents reviewed for abuse who resided on the memory care unit (MCU) and were cognitively impaired were free from sexual abuse. The facility census was 147. Findings are: Review of a facility policy titled, Abuse, Neglect and Exploitation, Freedom From, last revised in ,d+[DATE], indicated, It is the policy of [the facility] to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment involuntary seclusion and misappropriation of property. The policy indicated sexual abuse is non-consensual sexual contact of any type with a resident which includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual contact is considered nonconsensual when the resident appears to want the contact but does not have the cognitive ability to consent, the resident does not want the contact, and the resident is sedated or unconscious. The resident has the right to choose sexual contact/preference in the community setting. The resident and/or representative will make the decisions regarding sexual contact/preference in the community setting. The sexual contact choice/preference will be care planned and reviewed by the interdisciplinary Review Team during care plan meetings quarterly and with significant change in resident condition to ensure resident rights and safety needs are met. When a resident makes a choice of a sexual contact or preference, the Interdisciplinary Team will meet with the resident and/or responsible party to ensure the sexual activity balances considerations of safety, resident's rights, resident's understanding of actions and ability to consent to the sexual activity. The documentation will be recorded on the resident's care plan. The sexual contact choice or preference will be care planned and reviewed by the Interdisciplinary Team during Care Plan meetings quarterly and with a significant change in resident condition to ensure resident rights and safety needs are monitored and re-evaluated periodically, as needed based on resident physical, mental and psycho-social needs. Every effort will be made to preserve the resident's dignity, privacy and self-determination or freedom of choice. A review of Resident #142's Admission Record revealed the facility admitted Resident #142 on [DATE]. The resident had diagnoses which included dementia with other behavioral disturbance and insomnia. The quarterly Minimum Data Set (MDS, a federally mandated assessment tool used for care planning), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #142 had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severely impaired cognition. The resident had behaviors of rejecting care and wandering one to three days during the assessment period. The MDS revealed the resident was independent with bed mobility, transfers, walking in the room, on the corridor, and on and off the unit. The resident required staff supervision for dressing, toileting, and personal hygiene. The MDS indicated Resident #142 received antipsychotic medication on an as needed basis. A review of Resident #142's Care Plan, initiated on [DATE], revealed the resident displayed behaviors of refusing medications and activities of daily living, pulled the fire alarm, screamed/yelled/verbal behaviors, pacing, and delusions related to deceased parents. The Care Plan indicated the resident had a diagnosis of dementia, was new to the facility, and was working on adjustment. The facility developed care plan interventions that directed staff to administer medication as prescribed; educate staff as needed on approaches that work best for the resident; remove the resident from the situation if/when the resident's behaviors become disruptive to others; engage family and friends in an effort to reduce behaviors; educate family on dementia/poor cognition and behavioral symptoms; prepare and organize supplies before care, do not argue with resident about deceased parents; provide distractions from behavior by offering snacks, changing environments, engaging in activities of interest, and avoiding over stimulation and excessive noise; and provide supportive words and validate feelings as appropriate. A review of Resident #142's Care Plan, initiated on [DATE], revealed the resident had difficulty understanding others and could not always process conversations/information. The facility developed interventions that directed staff to ask simple yes or no questions and questions requiring one-to-two-word answers, rephrase if necessary for the resident to understand, and attend to non-verbal behaviors. A review of Resident #142's Care Plan, revised on [DATE], revealed the resident was at risk for wandering/elopement related to dementia. The Care Plan indicated the resident paced the halls. The facility developed an intervention, dated [DATE], that directed staff to monitor Resident #142's whereabouts when wandering and redirect the resident if they wandered into other residents' rooms; remove the resident from unsafe situations and intervene as appropriate. A review of a Face Sheet indicated the facility admitted Resident #141 on [DATE]. The resident had diagnoses which included dementia with agitation, depression, and Alzheimer's disease. The quarterly MDS, with an ARD of [DATE], revealed Resident #141 had moderately impaired cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS). The MDS revealed the resident had continuous behaviors of inattention and disorganized thinking. The resident was independent with transfers and ambulation in the room and on and off the unit. The MDS also indicated the resident received antipsychotic medication in the seven days prior to ARD. A review of Resident #141's Care Plan, initiated on [DATE], revealed the resident had cognitive deficits related to dementia. Interventions directed staff to anticipate the resident's needs, provide verbal reminders, and redirect as needed. A review of Resident #141's Care Plan, initiated on [DATE], revealed the resident had difficulty understanding others and trouble communicating needs related to dementia. Interventions directed staff to ask simple yes or no questions, repeat phrases as needed, and attend to non-verbal behaviors. A review of Resident #142's progress notes revealed the resident exhibited the following behaviors toward a peer of the opposite gender: - On [DATE] at 5:59 PM, Resident #142 was attempting to kiss a peer of the opposite gender. - On [DATE] at 9:48 PM, Resident #142 made statements that themselves, and another resident were going to get married and wanted to leave. - On [DATE] at 11:10 PM, Resident #142 and their peer of the opposite gender were at the front entrance and the fire alarm was pulled. - On [DATE] at 8:30 PM, Resident #142 continued on behavior monitoring, needing redirection several times while attempting to kiss a peer of the opposite gender. - On [DATE] at 9:13 PM, Resident #142 continued on behavior monitoring, needing redirection several times related to exit seeking and attempting to kiss a peer of the opposite gender. - On [DATE] at 6:02 PM, Resident #142 continued on behavior monitoring, needing redirection several times related to exit seeking and attempting to kiss a peer. - On [DATE] at 11:36 AM, Resident #142 attacked the nurse when they attempted to remove Resident #141 from rummaging in a room. - On [DATE] at 10:01 PM, Resident #142 had been possessive of peer, not allowing them to wander off on their own. - On [DATE] at 9:32 PM, the peer of the opposite gender was lying in their bed, trying to sleep. Resident #142 entered the room and woke up the peer. Staff were attempting to keep the resident in the dining room in sight. - On [DATE] at 1:54 PM, Resident #142 was noted to be very controlling of a peer of the opposite gender, not letting them walk around alone. Resident #142 and the peer attempted to go into rooms and got upset and physically aggressive with staff when separation was attempted. - On [DATE] at 9:00 PM, Resident #142's obsessive behavior with a peer of the opposite gender continued, continuing to not let the peer go off alone. Resident #142 insisted on being with their peer, even if incontinence care was needed. Resident #142 told staff members the peer did not need staffs' assistance and insisted on accompanying their peer. If the peer was in bed, Resident #142 would enter their room, wake them, and bring them out to the common area to be with them. New orders for liquid Depakote were obtained from an Advanced Practice Registered Nurse (APRN). - On [DATE] at 11:09 AM, Resident #142 was still presenting with obsessive behavior of a peer of opposite gender, wishing to take care of the peer's routines. Resident #142 changed the peer's drink and tried to be in bed together. The residents were re-directable but were angry. - On [DATE] at 11:36 AM, Resident #142 continued with obsessive behavior with a peer of opposite gender, making sure they were within sight and diverting the peer away from any other residents who attempted to talk with the peer. - On [DATE] at 8:59 PM, Resident #142 continued to be possessive of a peer of opposite gender, rousing the peer from lying in bed. - On [DATE] at 3:19 PM, Resident #142 was on behavior monitoring for beginning Depakote. The resident was ambulating the hallways looking for Resident #141 and was redirected without difficulty. - On [DATE] at 12:37 PM, Resident #142 was awake early looking for their peer of the opposite gender. The resident spent the day pacing the unit with the peer of the opposite gender. - On [DATE] at 6:37 PM, Resident #142 was pacing and refusing medications. The resident was being possessive of a peer of the opposite gender, jumping up when the peer got up to walk, especially if any other residents of Resident #142's gender were around. - On [DATE] at 1:00 PM, Resident #142's obsession with a peer of the opposite gender was present and were observed to kiss each other one time and were redirected. - On [DATE] at 9:44 PM, Resident #142 continued to keep a peer of the opposite gender at their side. - On [DATE] at 1:16 PM, Resident #142 was controlling of a peer of the opposite gender and their whereabouts. - On [DATE] 12:50 PM, Resident #142 was close with a peer of the opposite gender. - On [DATE] at 1:14 PM, Resident #142 had no behaviors noted but the resident was still very closely attached to a peer of the opposite gender, sitting by each other frequently. - On [DATE] at 1:15 PM, Resident #142 was exhibiting obsession with a peer of the opposite gender. Further review of Resident #142's Care Plan revealed no documented evidence the facility developed interventions to address the resident's behaviors of attempting to kiss another resident nor being obsessive/possessive with the peer. A review of Resident #141's progress notes revealed the resident exhibited the following behaviors toward peers of the opposite gender: - On [DATE] at 12:28 PM, Resident #141 thought one of the other residents of the opposite gender was their ex-spouse. Resident #141 was hanging around with the other resident and telling them what to do. - On [DATE] at 12:57 PM, Resident #141 paced the hallway and was very friendly with residents of the opposite gender. Staff had to intervene a few times as Resident #141 kissed Resident #142. Both residents were easily redirected. - On [DATE] at 2:15 PM, Resident #141 was friendly with a member of the opposite gender who inappropriately physically touched the resident and verbally stated, I love you. Resident #141 responded by saying, What is this for? in a raised voice. Resident #141 continued to wander with this same resident and visited with other residents of the opposite gender. - On [DATE] at 12:21 PM, Resident #141 visited the rooms of other residents of the opposite gender. Staff were able to redirect the resident with additional effort. A review of Resident #141's Care Plan revealed no documented evidence the facility developed interventions to address kissing another resident nor inappropriate physical touching by another resident. A review of Resident #142's [DATE] Medication Administration Record [MAR] revealed that beginning on [DATE] staff were required to monitor the resident's obsessiveness with other resident. The MAR indicated staff were required to document how often the behavior occurred, the intensity, and how the resident responded to redirection (easily altered or difficult to redirect). The MAR indicated the behavior occurred continuously on [DATE] and was difficult to redirect. A review of Resident #142's [DATE] Medication Administration Record revealed the resident exhibited obsessiveness with other resident on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], ,d+[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of Resident #142's [DATE] Medication Administration Record revealed the resident exhibited obsessiveness with other resident on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of Resident #141 and Resident #142's progress note, dated [DATE] at 3:30 PM, revealed Certified Medication Assistant (CMA) A looked through a window into a lounge area of the MCU and observed Resident #141 providing oral sex to Resident #142. Both residents looked up at CMA A and stopped what they were doing. As CMA A entered the MCU to separate the residents, Resident #141 and Resident #142 walked in separate directions. CMA A notified the charge nurse, who assessed the residents with no injuries noted. A review of a progress note for Resident #141 and Resident #142, dated [DATE] at 3:45 PM, revealed the facility notified Adult Protective Services of the reportable incident. A review of an Event Report revealed on [DATE], CMA A looked through a window into the MCU and observed Resident #141 providing oral sex to Resident #142. Both residents looked up at CMA A and stopped what they were doing. The report revealed no injuries were noted. The report indicated Resident #141 was to have a chaperone when in a private location with a resident of the opposite gender. An observation on [DATE] at 8:45 AM with the Assistant Director of Nursing (ADON) revealed Resident #141 was standing next to Resident #142, who was seated in a chair. Resident #142 had their hand and was patting on Resident #141's lower back. Resident #141 had their arm around Resident #142's shoulder. Resident #141 went to untie the string on Resident #142's pants and a Nursing Assistant (NA) came and assisted Resident #141 down the hallway. An interview was attempted with Resident #142 on [DATE] at 3:10 PM. During the interview, the resident responded nonsensically. Even though the resident responded with a smile when asked about Resident #141, no specific information was provided, and the resident claimed no memory of events on [DATE]. During a telephone interview on [DATE] at 10:43 AM, CMA A stated the CMA saw through a window to the MCU, Resident #141 bending over performing oral sex on Resident #142, who was rubbing Resident #141's back. The CMA went into the common area room on the MCU, but the residents had already separated from each other. CMA A reported what was witnessed to the charge nurse, who forwarded the information to the DON. CMA A stated they provided a written statement to the DON. Review of an untitled facility witness statement from CMA A, dated [DATE], revealed the CMA was passing medication around 3:30 PM and was pushing a medication cart down 600 hall. CMA A looked into the dementia unit (MCU) window and observed Resident #141 bent over with their mouth on Resident #142's genitalia. Resident #142 was rubbing Resident #141's back at the time. Both residents looked up and immediately stopped. CMA A went into the dementia unit and both residents went their separate ways. CMA A immediately reported the incident to charge nurse, Licensed Practical Nurse (LPN) GG. During a telephone interview on [DATE] at 2:25 PM, LPN GG stated they were the assigned LPN for the MCU on [DATE] but was off the unit at the time of the incident between Resident #141 and Resident #142. LPN GG stated CMA A reported the incident and LPN GG passed the concern onto the DON who made phone calls to the physician and families. LPN GG stated they had witnessed Resident #141 and Resident #142 walking the halls together, holding hands, and kissing each other but would not have expected them to perform oral sex. LPN GG had found the two residents alone in a room together, but they would be rummaging through drawers. LPN GG stated they knew of no interventions for either resident regarding their relationship. Review of an untitled facility witness statement from LPN C, dated [DATE], revealed they had witnessed Resident #141 and Resident #142 holding hands, kissing on the cheek, and rubbing backs. On [DATE] at 7:56 PM, a telephone interview with LPN C revealed that in [DATE], Resident #141 thought Resident #142 was an ex-spouse. LPN C stated Resident #141 called Resident #142 by ex-spouse's name. LPN C stated Resident #141 and Resident #142's started out just talking at first. Resident #142 then became attracted to and liked Resident #141 and started holding hands. LPN C stated Resident #142 gave Resident #141 attention and their relationship escalated. LPN C stated Resident #142 thought Resident #141 was their parent. LPN C stated Resident #141 and Resident #142's would both kiss each other on the hand, and they would rub each other on the back. LPN C stated they did not think their behavior was anything but comfort and attention for each other. LPN C said they did not feel like their behavior was sexual. LPN C stated when they found them touching, kissing, or together, the staff would just redirect them. On [DATE] at 9:52 AM, a telephone interview with LPN P revealed that the LPN thought Residents #141 and Resident #142 had the capacity to consent for sexual activity, even though they had a low BIMS score (indicative of cognitive impairments) and dementia. LPN P stated that using the reasonable person concept, they thought that kissing and touching would not happen if Resident #141 and Resident #142 did not have dementia and lived outside of the facility. LPN P stated they documented inappropriate physical touch on [DATE] but did not think it was sexual or abuse. LPN P stated Resident #141 and Resident #142 had a close relationship and staff tried to separate them, but it did not work in the beginning. LPN P stated that Resident #141 and Resident #142 did not have a care plan about their sexual behaviors nor relationship. An interview with LPN S on [DATE] at 10:57 AM revealed the LPN did not think Resident #141 and Resident #142 had the cognitive ability to consent to sexual behavior. During an interview on [DATE] at 11:12 AM, the Social Services Associate (SSA) stated the DON notified them of the incident between the residents the evening of [DATE] and asked the SSA to conduct a BIMS assessment of the residents. The SSA stated neither resident was aware nor remembered the incident when SSA interviewed them on [DATE]. Both residents had severe cognitive impairment. The SSA stated they knew of Resident #142 and Resident #141 holding hands while walking down the hallway and attempting to kiss each other multiple times. The SSA stated the residents were admitted the same day and gravitated toward each other. When the residents were separated, they became aggressive. The SSA stated no behavior like what was observed on [DATE] had been observed in the past. They stated Resident #141 believed Resident #142 was their ex-spouse, and the interaction between the residents seemed consensual. The SSA stated the families of the residents were aware of the relationship, had met the other resident, and had given their verbal approval for the relationship. SSA stated they were not sure what assessments would be used to determine the residents' ability to consent. During a telephone interview on [DATE] at 10:31 AM, Resident #142's Responsible Party (RP) stated the facility had called them on [DATE] to inform them of the sexual act witnessed on [DATE]. The RP was surprised and shocked. They stated the facility had notified them that the resident had a friend of the opposite gender that the resident spent time with. However, Resident #142's RP stated they had no knowledge and the facility had not notified them of anything physical, like kissing, occurring between Resident #142 and Resident #141. The RP stated Resident #142 had always been single and never married. During a telephone interview on [DATE] at 1:22 PM, the RP of Resident #141 stated the facility had notified them of the incident between Resident #141 and Resident #142 on [DATE]. The RP stated the facility had notified them of the relationship between the residents shortly after it started in [DATE]. The RP stated they had met Resident #142 and had been all right with the relationship up until yesterday. Resident #141's RP stated their knowledge of the relationship before [DATE] consisted of holding hands, a smooch, and puppy love. They stated Resident #141 believed Resident #142 was their ex-spouse, who they had remained close with and who had cared for the resident after they separated. They stated having no knowledge of the residents being found alone together. The facility stated during the call on [DATE], the facility staff were doing their best to keep the residents separated. They stated the incident was concerning to the family, and they were concerned it could happen again. During an interview on [DATE] at 8:36 AM, the MDS Coordinator (MDSC) stated they were a part of the care plan team and responsible for implementing and revising care plans. The MDSC stated Resident #141 and Resident #142's care plan should have been updated to include sexual behaviors, and their relationship; however, the MDSC was not aware of these behaviors, and it was missed. The MDSC stated that the staff in the dementia unit did not think Resident #141 and Resident #142 had a relationship. The MDSC stated after they reviewed Resident #141 and Resident #142's progress notes, it revealed a relationship that should be investigated, and care plan interventions implemented. The MDSC stated that Resident #141 and Resident #142 did not have capacity to consent to sexual activity. The MDSC stated that sexual abuse included unwanted touching and unwanted kissing. The MDSC stated she did not know whether the incident would have occurred if interventions had been put in place. During an interview on [DATE] at 11:20 AM, the ADON stated before the incident on [DATE], Resident #141 and Resident #142 had no interventions or monitoring for their relationship, behaviors, or sexual interactions. The ADON stated she had mixed feelings on their capacity to consent because Resident #141 and Resident #142 lacked capacity to make good judgement due to their cognition and were not able to recall each other's name, but they were familiar with each other. The ADON stated she never thought it would lead up to the sexual event that happened on [DATE]. The ADON stated that it was possible if Resident #141 and Resident #142 had care plan interventions in place to protect both residents, the sexual abuse would not have happened. During an interview with the DON on [DATE] at 12:27 PM, the DON stated Resident #141 gravitated to Resident #142, even introducing them as their ex-spouse. They stated when Resident #141 and Resident #142 were admitted they would exit seek together and pull the fire alarms. According to the DON, the friend referred to in Resident #142's nursing notes was referring to Resident #141. They stated Resident #142 had not gravitated toward any other female residents while on the unit. The DON stated the dynamic of the unit changed when the residents were admitted and they made sure there was always three CNAs on the MCU; one would watch the doors, the second was in the common area, and the third was a one-to-one staff for another resident. The DON stated breaks were always covered so there were always three CNAs on the MCU. During an interview on [DATE] at 12:19 PM, the DON stated the facility had no specific process to determine a resident's capacity to consent to sexual activity. The DON stated neither Resident #141 nor Resident #142 had been assessed to determine capacity to consent to sexual activity. The DON stated no behavior monitoring nor interventions were implemented following a documented kiss that took place on [DATE]. The DON further stated nothing was implemented to protect the residents following the documented inappropriate physical touch that occurred between another resident and Resident #141 on [DATE], either. The DON stated it should have absolutely been care planned. During an interview on [DATE] at 11:43 AM, the DON stated that there was nothing in the care plans of Resident #141 and Resident #142 about their relationship, kissing, touching, nor holding hands. The DON stated Resident #141 and Resident #142's togetherness and holding hands was a comfort thing, but beyond that, they lacked the capacity to consent. The DON stated Resident #141 and Resident #142 were obsessed with each other. The DON stated since the beginning of Resident #141 and Resident 142's relationship when they admitted , care plan interventions should have been implemented. They expected care plans to be implemented and revised with new behaviors or concerns. During an interview on [DATE] at 12:54 PM, Physician G, the primary care provider for Resident #141 and Resident #142, stated they were aware of the residents' cognitive status and had been made aware of the sexual activity between the residents that had occurred the evening of [DATE]. Physician G stated they believed the residents had the capacity to consent to sexual activity because the residents had a history of holding hands and had an attachment. Physician G stated they had observed the residents holding hands, hugging, sitting together, and had not seen the residents with any other resident except each other. Physician G stated, in this case, they believed the residents did not have the capacity to consent to medical decisions, but the residents had been agreeable and attracted to each other in the past. Physician G stated this, in their mind, made the residents' behavior consensual. Physician G stated they did not think the fact the residents had dementia meant the residents did not have the desire to have sexual relations with one another. The physician stated they believed Resident #141 and Resident #142 had an attraction to one another since admission and that was the equivalent of giving consent. During an interview on [DATE] at 3:44 PM, geriatric psychiatric Nurse Practitioner (NP) H stated they were familiar with Resident #141 and Resident #142 and the residents' cognitive status. NP H stated they had been notified about the sexual incident between the residents the evening of [DATE]. NP H stated a resident's capacity to consent to sexual activity would be based on their diagnoses and BIMS score. NP H stated Resident #141 had no BIMS and Resident #142 had a BIMS of 4 and, with the residents' diagnoses, NP H did not believe either resident had the capacity to consent to sexual activity. NP H stated no one at the facility had asked them for recommendations for approaches to address the sexual attraction of Resident #141 and Resident #142. During an interview on [DATE] at 3:44 PM, the Administrator stated they were not aware of the behaviors of sexual attraction of any residents in the memory care unit until [DATE]. The Administrator stated they had seen handholding during their rounds in the unit but was not aware of inappropriate touching. The Administrator stated staff had not reported any inappropriate touching or kissing to them and the Administrator had not witnessed residents kissing or inappropriate touching. The Administrator stated they did not make it a practice to review nurses' progress notes. The Administrator stated they did not know how they felt about the determination of a resident's capacity to consent to sexual activity but felt it was important to have a discussion with the family members to make them aware of what was going on. The Administrator stated they did not consider kissing to be sexual abuse and did not know how they felt about residents' sexual behaviors beyond that. The Administrator stated touching that made either resident uncomfortable was inappropriate. The Administrator stated any type of sexual behavior that was new to the facility staff should be reported if the staff knew the residents did not have full consenting capacity. The Administrator stated the facility staff had not seen anything they thought met the definition of sexual abuse. They stated staffing had been increased, and the Administrator had asked staff to increase the number of activities to keep the residents busy, but that had not worked. The Administrator stated the Quality Assessment and Assurance/Quality Assessment Performance Improvement (QAA/QAPI) committee had not discussed the residents' sexual attraction. During an interview on [DATE] at 3:00 PM, the Administrator stated there was no care plan in place related to Resident #141 and Resident #142's relationship prior to [DATE]. Per the Administrator, there were multiple documented incidents in the progress notes that should have been care planned but were not identified. The Administrator then stated they expected their staff to understand the facility's policy before working the floor. If staff witnessed any incidents between residents, staff were expected to identify these incidents and report them to a charge nurse or supervisor so that further action could be taken to protect the residents. The Administrator stated it was not acceptable to just document these incidents in the progress notes. The care plan team also needed to be involved so that appropriate interventions could be implemented. Per the Administrator, the facility's training on the abuse policy included the seven required components, and staff were expected to adhere to this policy. The Administrator then stated staff assumed it was acceptable for two people to have a sexual relationship regardless of cognition because the documented incidents were not reported, and no interventions were implemented. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. To abate the immediacy of the situation the facility provided the following plan as follows: -Removal Plan: The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 6:23 PM and provided the IJ Template at 6:28 PM. The facility's Removal Plan included: 1. Upon learning of the incident on [DATE], the facility the Certified Medication Aide (CMA) immediately separated Resident #141 and Resident #142. A full body assessment was completed on both residents on [DATE] by the Licensed Practical Nurse (LPN) without any negative findings. The[TRUNCATED]

Licensure Reference Number 175 NAC 12-006.09D4 Based on observation, record review and interview; the facility failed to ensure devices were utilized to prevent contractures [a permanent tightening of muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff. This prevents movement of the joints or body part] and to decrease risk of skin breakdown secondary to contractures for 1 (Resident 37) of 1 resident reviewed for Range of Motion. The facility census was 154. Findings are: Record review of Resident 37's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/3/21 revealed that Resident 37 had severely cognitive impaired decision making, required extensive assistance of staff with bed mobility, total assistance with transfers and required assistance with eating. The MDS identified that Resident 37 had no impairment in range of motion of the upper extremities. Record review of the most recent MDS dated [DATE] revealed that Resident 37 had severely cognitive impaired decision making, required extensive assistance of staff with bed mobility, total assistance with transfers and required assistance with eating. The MDS identified that Resident 37 had no impairment in range of motion of the upper extremities. Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a significant change MDS dated [DATE] revealed that Resident 37 was on Hospice and had no impairment in range of motion of the upper extremities. Record review of Resident 37's Comprehensive Care Plan dated 1/4/22 revealed that Resident 37 was at risk for discomfort due to end of life changes and recieved Hospice services. Interventions included: - Offer non pharmacological means of pain relief : Repositioning, Range of Motion etc. - Monitor for skin breakdown, provide preventative skin care as needed. Record review of a Hospice Care Interdisciplinary Note [IN] dated 3/28/22 revealed that an Occupational Therapy [OT] evaluation had been completed for increased right hand contracture. The note indicated the following: - Patient would not allow OT to touch right hand due to increased pain and stiffness, unable to complete passive range of motion. A soft hand splint was provided to the patient, who was able to place it into the palm with a demonstration from OT. Soft hand splint utilized to decrease risk of skin breakdown secondary to contractures. Recommend wearing the soft hand splint as tolerated, recommendations conveyed to primary Registered Nurse Case Manager [ from the Hospice company] and facility staff. Record review of Resident 37's facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 37's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The verbal order was taken by the Hospice RN on 3/28/22. The faxed on date and by whom was left blank on the order. Observations on 6/8/22 at 10:21 AM, 12:05 PM and 1:23 PM revealed Resident 37 laying in bed. Resident 37's right hand was contracted into a tight fist and the resident could not open the hand on request. Observation revealed that no splint device was in use and there was nothing in the hand to prevent skin breakdown secondary to the contracture. Observations on 6/9/22 at 08:47 AM and 1:14 PM revealed Resident 37 laying in bed. Observation revealed that no splint devices were in use and there was nothing in the right hand to protect the skin from breakdown secondary to the contracture. Interview on 06/9/22 at 10:29 AM with Nursing Assistant [NA] D and NA E confirmed that Resident 37's right hand was contracted into a tight fist and there was nothing present inside the hand. Both NA D and NA E confirmed they had not seen a splint in use for Resident 37 at any time. Observations on 6/13/22 at 6:37 AM, and 9:10 AM of Resident 37 revealed that no splint device was in use and there was nothing present in the hand. Observation on 6/13/22 at 9:15 AM with Licensed Practical Nurse [ LPN] F confirmed that Resident 37's right hand was contracted into a tight fist and there was nothing in the hand and no splint in place. LPN F confirmed that the right hand could not be opened. Observation on 6/13/22 at 9:15 AM revealed that Resident 37 pulled the hand away and cried out in pain when the LPN tried to look at the right hand. Resident 37 stated it bad. Interview on 6/13/22 at 9:15 AM revealed that LPN F confirmed that the right hand could not be opened and that the resident pulled away in pain and stated it Bad. Interview on 06/14/22 at 09:48 AM with the Assistant Director of Nursing [ADON] confirmed that the facility was unaware of the order for the splint use for Resident 37 and a soft splint had never been utilized for Resident 37. The ADON confirmed that they were unable to find documentation that a splint had ever been utilized or the facility informed of the recommendations. The ADON confirmed the presence of a statement on the Hospice IN note that indicated that facility staff had been informed and a soft splint had been provided. The ADON confirmed that, according to the Hospice OT documetation on 3/28/22, the resident had been able to open the right hand enough to put the splint on at the time of the OT assessment. Interview on 06/14/22 at 10:34 AM with the Director of Nursing confirmed that a soft splint had never been utilized for Resident 37. Interview on 06/14/22 at 10:45 AM with the DON and the ADON confirmed that a soft splint had been located in the residents room but had never been used.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to provide assistance with eating for 1 (Resident 50) of 5 sampled residents who then experienced weight loss. The facility identified a census of 154. The findings are: Review of the Minimum Data Set (MDS a federally mandated comprehensive assessment tool used for care planning) dated 3/24/22 revealed Resident 50 required supervision and 1 person assist for eating. Record review of Point of Care History for Resident 50 with dates of 6/8/2022-6/11/2022 revealed documentation for staff support provided for eating was 1 person physical assist. Record review of Resident 50's weight revealed a documented weight of 132 pounds on 5/7/2022. Weight provided by LPN F (Licensed Practical Nurse) on 6/13/2022 revealed the resident's weight was 121 pounds which revealed an 8.33% significant weight loss in 1 month. An observation of dining on 06/08/22 from 11:30 AM to 12 Noon revealed Resident 50 at the dining table with lunch plate that was untouched. At no time during the observation did a staff member assist Resident 50 with eating. An observation of dining on 06/09/22 from 08:00 AM to 08:30 AM revealed Resident 50 at the dining room table with a breakfast plate that was untouched. At no time during the observation did a staff member assist Resident 50 with eating. An observation on 06/13/2022 at 09:03 AM revealed Resident 50 was lying in bed and the breakfast tray was on the over bed table uncovered and untouched. Observation on 06/13/2022 at 09:43 AM revealed Resident 50 continued to be in bed and the breakfast tray remained on the over bed table untouched. An interview was conducted with LPN F and the Assistant Director of Nursing on 06/13/2022 at 12:39 PM which revealed that Resident 50 has had a decline in Activities of Daily Living since returning from the hospital and should have assistance with eating and staff should be offering assistance at meals. An interview with NA I (Nurse Aide) on 06/14/2022 at 10:46 AM revealed that Resident 50 required assist of 1 staff with eating. An interview with the Director of Nursing (DON) on 06/14/2022 at 10:59 AM confirmed that resident 50 has had a decline and required assistance with eating.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to implement and evaluate the effectiveness of the pain management program for 1 (Resident 156), and failed to evaluate the effectiveness of as needed pain medications for 1 (Resident 256) of 5 sampled residents. The facility staff identified a census of 170. Findings are: A. Record review of a Face Sheet dated 1-24-18 revealed Resident 156 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 156's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 2-07-2018 revealed the facility staff assessed the following about Resident 156: -Brief Interview of Mental Status (BIM'S) was a 15. According to the MDS Manuel, a score of 13 to 15 indicate intact cognition. -Required Limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene. - No pain issues were identified for Resident 156. Record review of Resident 156's Comprehensive Care Plan (CCP) dated 1-27-2018 Resident 156 had a problem area of pain. The goal identified for Resident 156 was to be able to verbalize or demonstrate minimal pain or discomfort. Interventions to manage Resident 156's pain included administering pain medication and evaluating the effectiveness, assess for non verbal signs of pain such as guarding, moaning and grimacing. Assessing pain characteristics, asking the resident to be specific regarding the duration, location and the quality of the pain. Medicate and offer to medicate for pain prior to physical activities such as Activities of Daily Living (ADL's) or Therapy. Offer non-pharmaceutical means of relief, such as, repositioning, elevation of extremities on pillows, relaxation-quite music, and 1 to 1's. Record review of Nursing Assessment and Re-Admission sheet dated 1-15-2018 revealed Resident 156 had pain to a leg, foot, Shoulder, hip and back pain described as stabbing and shooting pain. The relieving factor was the administration of pain medication. Record review of NAAR dated 1-30-2018 revealed Resident 156 had leg and foot pain with the relieving factor was the administration of pain medication. Record review of Resident 156's Nurse's Notes (NN) dated 1-31-2018 with a time of 9:00 PM revealed Resident 156 refused to get out of bed, c/o (complained of) Pain). According to the NN dated 1-31-2018, pain medication was given. Record review of Resident 156's medical record revealed there was no evidence the facility staff had evaluated the effectiveness of the pain medication. Record review of Resident 156's NN dated 2-1-2018 with a time of 5:30 AM revealed Resident 156 was crying and expressing frustration c/o severe pain to bilat ( both) LE's ( lower extremities) with pain medication being administered. Record review of Resident 156's record that included the Medication Administration Record [REDACTED]. Record review of Resident 156's NN dated 2-2-2018 with the time identified as 8:00 AM revealed Resident 156 continues to cry loudly and to refuse cares. Record review of Resident 156's MAR for 2-2-2018 revealed at 9:50 AM pain medication and an anti-anxiety medication was administered to Resident 156. Further review of the MAR indicated [REDACTED]. Record review of Resident 156's NN dated 2-3-2018 with a time identified as 5:00 AM revealed Resident 156 was difficult to reposition in bed and change an adult brief related to Resident 156 yelling out in pain. Further review of Resident 156's NN dated 2-3-2018 at 5:00 AM revealed Resident 156 yelled out pain description, I hurt all over, its sharp pain. The NN dated 2-3-2018 at 5:00 AM revealed Resident 156 continued to cry and yell out with all cares with Resident 156 stating just let me die. Observation on 2-07-2018 at 8:45 AM revealed Resident 156 needed to use the bathroom. Registered Nurse (RN) C and Nursing Assistant (NA) D came into Resident 156's room and Resident 156 reported the need to use the bathroom. Resident 156 chose to use a bed pan instead of using the bathroom due to increased anxiety for the use of a mechanical lift. NA D with the assistants of another NA started to roll resident to the side. Resident 156 was observed to have facial grimacing reporting (gender) knee hurt and reported a pain level of an 8 to 9 on a scale of 0 to 10 with 10 being the worst pain. RN C asked Resident 156 if Resident 156 wanted pain medication with Resident 156 stating, yes. RN C obtained Resident 156's pain medication and administered to Resident 156. Observation with RN C on 2-07-2018 at 9:35 AM revealed NA D with another NA prepared to transfer Resident 156 using a mechanical lift. NA D placed the sling for the transfer under Resident 156 requiring Resident 156 to roll side to side. Resident 156 yelled out, oh that hurts my back. NA D explained the task of the transfer to Resident 156. NA A attached the sling to the mechanical lift and started to lift Resident 156 up. Resident 156 started to yell Oh my back, my back and started to cry. Resident 156 reported it feels like my back is broke. NA D started to raise Resident 156 up with Resident 156 yelling oh that hurts, stop. let me rest. Resident 156 stated put a sock in my mouth so I don't scream. On 2-07-2018 at 9:54 AM an interview was conducted with NA D. During the interview, NA D reported Resident 156 is always painful. NA D reported Resident 156 pain has been getting worse and this had been reported to the nurses. NA D reported Resident 156 is more painful when moved and that Resident 156's pain seems to be getting worse. On 2-07-2018 at 11:15 Am an interview was conducted with the Medical Records Manager (MRM). During the interview the MRM reported Resident 156 did not have a pain management flow sheet started for Resident 156. On 2-07-2018 at 1:25 PM an interview was conducted with RN C. During the interview when asked if Resident 156 had been pre-medicated prior to the ADL's being completed. RN C stated no, further reported Resident 156 should have been pre-medicated. When asked what Resident 156's acceptable pain level was, RN reported not knowing what was acceptable to Resident 156. On 2-08-2018 at 7:56 AM an interview was conducted with Resident 156 related to Resident 156's pain management. During the interview Resident 156 reported the goal for acceptable pain level was a 5 based on a scale of 0 to 10 with the 10 being the worst pain. Resident 156 reported (gender) pain level are between and 8 and 9 with movement. On 2-08-2018 at 10:45 AM an interview was conducted with Licensed Practical Nurse (LPN) G. During the interview LPN G reported that all pain medication should be evaluated for the effectiveness. Record review of an undated Policy and Procedure for Pain Assessment and management revealed the following information. -Purpose: All Residents will be assessed for pain and identified by nursing staff. Residents with pain will receive individual interventions aimed at reducing chronic and/or acute discomfort utilizing current standards of practice for pain control. -Procedure: -2. develop an individualized care plan for pain management. -3. Pain Management Flow Sheet will be placed in each residents medication record for assessment and documentation of intermittent and breakthrough pain. -4. Pain assessment will be done using the 0 to 10 pain scale based on the residents cognitive status. -6. Interventions to treat residents pain will be implemented to manage pain effectively. -7. Evaluate effectiveness of PRN (as needed) [MEDICATION NAME] within an hour of time administered and document effectiveness on the back of the MAR indicated [REDACTED]. B. Resident 256 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 2/7/18 at 2:21 PM, Resident 256 reported having pain at a level 10 (pain rating scale of 1-10) and reported having received a pain pill an hour ago. Resident 256 reported not getting relief from pain. A review of Resident 256's 2/2018 Medication Administration Record [REDACTED]. A review of Narcotic count record for Resident 256 revealed Resident 256 received [MEDICATION NAME] 5 mg 19 times between 2/1/18 and 2/7/18. A review of 2/2018 Resident 256 Medication Administration Record [REDACTED]. A review of the back side of the Medication Administration Record [REDACTED]. A review of Resident 256 PRN Pain Management Flow Sheet revealed documentation of [MEDICATION NAME] given 4 times as follows: 1 time on 2/4/18, twice on 2/5/18 and once on 2/7/18. The flow sheet identifies pain location, pain level, [MEDICATION NAME] given, and if [MEDICATION NAME] is effective. In an interview on 2/8/18 at 10:41 AM, Licensed Practical Nurse M reported pain flow sheet is to be completed when a resident asks for a pain medication. In an interview on 2/8/18 at 12:10 PM, Staff Development Registered Nurse reported no other PRN Pain Management Flow Sheet could be located for Resident 256. A review of undated policy titled Pain Assessment and Management revealed the following: -the Pain Management Flow sheet will be used for assessment and documentation of intermittent and breakthrough pain. -The effectiveness of PRN [MEDICATION NAME] will be evaluated within an hour of administration and documented on back of Medication Administration Record [REDACTED]

Licensure Reference: 175 NAC 12-006.09D7b Based on observation, interview, and record review the facility failed to implement interventions to prevent falls for one resident (Resident 15). The facility had a total census of 167. Findings are: Resident 15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 4/14/16 at 2:01 PM revealed Resident 15 was seated in a chair in the hallway. Resident 15 denied falling recently. Observations on 4/13/16 at 2:52 PM, on 4/14/16 at 4:21 PM, on 4/14/16 at 7:09 AM, on 4/14/16 at 9:46 AM, on 4/14/16 at 11:17 AM, on 4/14/16 at 2:56 PM, 4/18/16 at 8:26 AM, and 4/18/16 at 10:04 AM revealed Resident 15 asleep in bed. A review of a Post Fall assessment dated [DATE] revealed Resident 15 was found on the floor of the sunroom at 7:55 PM. Resident 15 sustained a 1 cm skin tear on left elbow. A review of a Post Fall assessment dated [DATE] at 6:20 PM revealed Resident 15 was walking from the dining room past the courtyard. Resident 15 fell and hit their head on the left side on the window pane. Resident 15 sustained a 2 x 2 rug burn to the left knee. Resident 15 was encouraged to take frequent rest periods. A review of a Post Fall assessment dated [DATE] at 10:05 PM revealed Resident 15 was found lying on their right side on the floor in the resident's room. Resident 15 was transferred to the emergency room . A review of a Post Fall assessment dated [DATE] at 8:15 PM revealed Resident 15 was found in the outside smoking area face down and bleeding through the nose. A review of the facility investigation revealed Resident 15 sustained a fracture to the nasal sputum. Facility investigation revealed the following follow up actions: a referral was made to therapy for evaluation, a request was made for labs. Also a review and communication with the attending physician and/or pharmacist to promote that proper orders and plan of care were in place for healing, pain management and prevention of further incident. A scheduling of an interdisciplinary care plan meeting with family and/or guardian to update on the plan of care and review this incident. A review of Resident 15's Plan of Care revealed a problem related to falls dated 7/15/15. The following interventions were listed: administer medications per doctor order; ambulate and transfer independently, remind to change positions slowly, labs per doctor orders, fall assessment quarterly and as needed, keep pathways clear, monitor for adverse effects of medications, non-slip sole footwear, notify doctor as needed, observe for any vision problems and report to physician as needed, and pharmacists to review medications monthly. A review on Resident 15's Continuation of Care Plan for Falls revealed the following up dates: 8/6/13 medication changes and therapy to screen; 3/11/14 directed not to assist other residents; 5/12/15 toileting program; 8/12/15 walk with resident when observed; 12/1/15 contact family for smaller sized clothing; 2/16/16 refer to Social Services for new shoes; 3/22/16 offer seat if unsteady gait and urinalysis; 3/29/16 therapy screen; and 4/12/16 hospice evaluation, labs, and therapy screen. A review of Resident 15's 3/28/16 fall risk assessment revealed Resident 15 was at high risk for falls. Resident 15's Activity of Daily Living Care Guide, a guidance for nurse aides, dated 7/18/15 did not identify Resident 15 as a fall risk. The Daily Activity of Daily Living Care Guide did not include any interventions for prevention of falls. In an interview on 4/14/16 at 2:05 PM, Nurse Aide A reported that Nurse Aide A did not believe Resident 15 was a fall risk as Resident 15 did not have a fall matt. In an interview on 4/18/16 at 3:25 PM, Nurse Aide B reported Resident 15 walks around independently and Nurse Aide B encouraged Resident 15 to use handrail. Nurse Aide B was not aware of Resident 15 being a fall risk. Nurse Aide B identified that a magnet in Resident 15's room stated Resident 15 required no assist. In an interview on 4/18/16 at 3:54 PM, the Director of Nursing reported Resident 15 was referred to therapy but this was discontinued as Resident 15 was admitted to hospice. The Director of Nursing confirmed that Resident 15 should be identified as a fall risk on the Care Guide and fall interventions should be included on the Care Guide so the nurse aides would be aware Resident 15 was at risk for falls. According to the Director of Nursing, magnets that identify a resident as a fall risk were used on residents' walker or wheelchairs but if a resident did not have a walker or wheelchair there was no magnet used to identify the resident as a fall risk.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to implement assessed interventions, evaluate casual factors for the development of pressure ulcers, and failed to evaluate nutritional requirements for pressure ulcer healing for 1 resident (Resident 16). Findings are: A. Record review of a Physician Order Report sheet for June 01,2014 through June 30, 2014 revealed Resident 16 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 16's Braden Scale (tool used for predicting pressure ulcer risk) revealed Resident 16 scored a 16 on 10-30-2013, 1-27-2014 and 4-23-2014. According to the information, a score of 16 placed the resident at mild risk for the development of a pressure ulcer. Record review of Resident 16's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4-25-2014 revealed the facility staff assessed the following about the resident; -BIMS (Brief Interview for Mental Status), score 6. According to the MDS manual, a score of 0 to 7 indicates severe cognitive impairment. -Required limited assistance with personal hygiene. -Required extensive assistance with transfers, dressing and toilet use. -Occasionally incontinent of bowel and had an indwelling catheter. Record review of Resident 16's Comprehensive Care Plan (CCP) dated 10-30-2013 revealed it did not contain evidence that Resident 16 was at risk for the development of a pressure ulcer or interventions to prevent the development of a pressure ulcer. B. Record review of Resident 16's Nurse's Notes dated 4-23-2014 revealed Resident 16 "...has a 3 cm (centimeter) by 1 cm open area to the R (right) buttocks". Record review of Resident 16's medical record revealed it did not contain an evaluation of the casual factors for the open area to the right buttocks. Record review of a Weekly Wound Assessment (WWA) dated 5-21-2014 revealed Resident 16 was evaluated with a stage 2( Partial thickness loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater).that measured 1.5 cm by 1.5 cm to the right buttocks. Record review a WWA dated 6-04-2014 revealed the pressure ulcer to the right buttocks/ischium area remained a stage 2 that measured 1.5 cm by 1.5 cm by 0.3 cm. C. Record review of Resident 16's Nurse's Notes dated 5-06-2014 revealed Resident 16 had a stage 2 pressure ulcer to the left ischium that measured 3 (cm) by 2 (cm). Record review of Resident 16's WWA dated 5-07-2014 revealed the left ischium pressure ulcer measured 3 cm by 2 cm by 0.2 cm deep and was a stage 2 pressure ulcer. Record review of Resident 16's WWA dated 5-14-2014 revealed the pressure ulcer to the left ischium measured 12.5 cm by 2 cm by 0.5 cm. Record review of Resident 16's WWA dated 5-21-2014 revealed the pressure ulcer measured 3 cm by 3 cm and 0.5 cm deep. Resident 16's physician was notified and the treatment changed. Record review of Resident 16's WWA dated 6-04-2014 revealed the pressure ulcer to the left ischium measured 3 cm by 3 cm and 3 cm deep and was a stage 3 ( stage 3, full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater wound or without undermining of adjacent tissue). Record review of Resident 16's Nutritional Notes revealed no nutritional evaluation of the pressure ulcers for healing had been completed until 6-03-2014. Record review of a Progress Notes sheet dated 6-04-2014 revealed the facility requested the Medical director to evaluate Resident 16. According to the Medical Director's documentation Resident 16 "...progressive decline is consistent with advancing dementia. (gender) recent pressure ulcer of (the) left ischium has likely worsened due to (gender) function decline, along with decline in nutritional status...". Record review of Resident CCP dated 10-30-2014 revealed a hand written entry dated 5-06-2014 that Resident 16 was to have a Roho cushion (a type of special pressure reliving cushion for wheelchairs). Observations on 6-04-2014 of Resident 16's wound treatment with Licensed Practical Nurse (LPN) J and LPN L revealed the left ischium pressure ulcer did not have an odor. The surrounding edges of the wound tissue was pale red and whitish. When asked the measurements of the pressure ulcer, LPN L stated 3 cm by 3 cm by 3 cm's. LPN J completed the treatment to the left ischium. LPN J removed the dressing to the right ischium. According to LPN J, the measurements of the right ischium pressure ulcer was 1.5 cm by 1.5 cm by 0.3 cm deep. Observations of the wound revealed raised tissue with an open area in the center. The tissue was whitish and did not have an odor. LPN L completed the treatment to the pressure ulcer. Observation on 6-04-2014 at 12:20 PM revealed Resident 16 was in the dining room for lunch, seated in a wheelchair. Observation of the cushion revealed it was not a Roho type. Further observation of the wheelchair revealed the wheelchair had the name of another resident on it. An interview with Registered Nurse (RN) N was conducted on 6-04-2014 at 12:21 PM. During the interview, the wheelchair that Resident 16 was sitting was reviewed with RN N. RN N confirmed the wheelchair that Resident 16 was seated in did not have the Roho type of cushion and that the wheelchair was not Resident 16's. An interview was conducted with LPN L on 6-04-2014 at 1:30 PM. During the interview, LPN L reported that (gender) does the weekly skin evaluations and is considered the wound nurse. When asked why Resident 16 had developed pressure ulcers, LPN L stated " I am not sure". LPN L clarified the right buttocks and the right ischium pressure ulcers were the same pressure ulcer. When asked why Resident 16 had developed a second pressure ulcer, LPN L reported that Resident 16 had been up too long in the wheelchair. On 6-5-2014 at 10:39 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 16's nutritional notes were reviewed with the DON. When asked if a nutritional assessment had been completed, the DON stated " I am not sure". The DON reported that (gender) would need to follow up with dietary. A follow up interview was conducted with the DON on 6-05-2014 at 12:10 PM. During the interview, the DON stated "no" when asked if a nutritional evaluation had been completed when Resident 16 had developed the pressure ulcers. When asked if there should have been, the DON stated "yes". Record review of the facility Policy and Procedure for Pressure Ulcer Care and Documentation dated 12-2006 revealed the following: -Causes: -Inadequate nutrition. -Moisture from perspiration, urine, feces. -Prevention: -Frequent turning and/or repositioning no less than every two hours. -Keep clean and dry. -Encourage adequate food and fluid intake.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D8 Based on record review, observations, and interviews; the facility failed to provide the ordered amount of tube feeding formula for Resident 89 that resulted in a significant weight loss and failed to re-evaluate the interventions implemented for weight loss for Resident 156. The facility census was 165. Findings are: A) Review of Resident 8's Physician order [REDACTED]. of 4-24-14. A review of Resident 89's weights were: 4-9-14: 98 lbs (pounds) 4-15-14: 102 lbs 4-22-14: 101 lbs 5-2-14: 104 lbs 5-6-14: 101 lbs 6-2-14: 97 lbs Review of Resident 89 's Treatment Sheet (TAR) for May 2014 revealed the resident was to get [MEDICATION NAME] 1.5 via [DEVICE] at 60cc/hour for 14 hours 7pm to 9am Review of a Dietician note dated 4-24-14 revealed recommendations of Resident 89's tube feeding be changed to 60cc/hour over 14 hours to provide a total of 840cc/day of tube feeding. This would meet 100% of needs. Review of formula intakes on the TAR for May 2014 revealed that from May 13th to May 31st, 2014, Resident 89 received less than 840cc/day of daily tube feeding 17 out of 19 days, with documented daily formula intakes of: 5-13-14: 626 cc 5-14-13: 788 cc 5-15-14: 547 cc 5-16-14: 426 cc 5-17-14: 709 cc 5-18-14: 865 cc 5-19-14: 797 cc 5-20-14: 607 cc 5-21-14: 532 cc 5-22-14: 335 cc 5-23-14: 710 cc 5-24-14: 751 cc 5-25-14: 687 cc 5-26-14: 492 cc 5-27-14: 670 cc 5-28-14: 825 cc 5-29-14: 698 cc 5-30-14: 903 cc 5-31-14: 736 cc On 6-4-14 at 8:50 am, Resident 89 was observed by the nurse's station without the tube feeding connected. On 6-5-14 at 7:01 am, Resident 89 was observed by the nurse's station without the tube feeding connected. An interview on 6-5-14 at 7:45 am, with Registered Nurse (RN) H confirmed that the resident was disconnected from the tube feeding early, before 9am. RN H further stated that Resident 89 was getting restless in room, and when that happens Resident 89 gets disconnected from the tube feeding and brought out to the nurse's station for monitoring. An interview with the Director of Nursing on 6-5-14 at 1130 am revealed that Resident 89 should not have been disconnected from the tube feeding prior to 9 am, which was the physicians order. An interview with the Registered Dietician (RD) on 6-5-14 at 9:20 am confirmed that the resident has had a significant weight loss over the last 30 days of 6.2% and revealed that Resident 89's nutritional needs were calculated at the resident receiving tube feeding for 14 hours. The RD confirmed that if Resident 89 was not getting the tube feeding as ordered for the 14 hours this could be causing the residents weight loss. B. Record review of the Resident Admission Record for Resident 156 indicated Resident 156 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 156's Nutrition assessment dated [DATE] indicated the following: -Weight of 139 lbs. -Meal intake of 50-100%. -Acceptance of supplements/snack 50-100%. -Ideal body weight was 126-154. -Diet order of no added salt and low potassium foods. -Interventions included monitor intake of food and fluids, offer substitutes for uneaten food, and monitor weight Review of Resident 156's Physician order [REDACTED]. Review of a Physician order [REDACTED]. Review of Resident 156's Care Plan dated 10/16/13 revealed the facility staff identified Resident 156 had a "nutritional status" related to [DIAGNOSES REDACTED]. The goal identified on the care plan was Resident 156's diet texture would be a safe texture and consistency, resident would eat greater than 75%, and maintain wt within usual body weight range. Interventions included: -Fluid restriction : 750 cc for dietary; 250 cc for nursing. -House supplement three times daily. -Evening snack. -Monitor intake of foods and fluids. -Monitor weight. -Offer substitutes for uneaten foods. Review of Resident 156's Nutritional Progress Notes dated 3/21/14 and signed by the Dietician indicated: Returned to facility (3/10) current body weight 134.6 pounds. Within normal range for (gender). Noted new order for [MEDICATION NAME] secondary to nausea on 3/16/14, no further emesis noted. Staff reports appetite was within normal for resident. Will continue with plan of care and monitor. Further review of the Nutrional Progress Notes revealed no evidence of an evaluation of weight loss for Resident 156. Record review of Resident 156's weights revealed a weight of 139.1 pounds on 1/1/14, 133.1 pounds on 5/1/14, and 124.3 pounds on 6/2/14 which is 14.8 pound or 10.68% weight loss in six months and 8.8 pounds or 6.76% weight loss in 30 days. Review of Resident 156's Nutritional Intake Flowsheet for May 2014 revealed: -Two entries of documentation consumption of 120 cc of house supplement for supper meal for the month. June 2014 revealed: -Resident 156 consumed 120 cc of House supplement with breakfast for first five days in June and no documentation of intake of house supplement with supper meal. Observation on 6/4/14 at 12:27 PM revealed Resident 156 sitting at the dining room table eating Chicken Noodle soup and crackers. Resident 156's tablemate stated, "I had to stop someone to get (gender) something (gender) would eat because (gender) does not feel good today and wont eat whay they served (gender)." Observation on 6/5/14 at 7:30 AM revealed Resident 156 sitting at the dining room table with a full glass of house supplement and apple juice. Resident 156's tablemate stated, "(Gender) never drinks the pink stuff, (gender) says that (gender) can't have milk products due to diet and [MEDICAL TREATMENT]." Observation on 6/5/14 at 7:45 AM revealed Resident 156 leaving the dining room with a -full glass of pink house supplement and apple juice remaining at the table. Review of Resident 156's Nutritional Intake Flowsheet, dated 6/5/14, revealed resident consumed 120 cc of house supplement for breakfast meal. Interview with Resident 156 on 6/5/14, through Spanish speaking NA (Nursing Assistant), stated "this is the first time (gender) received the pink drink and milk is not part of my diet so I didn't drink it." Interview on 6/5/14 at 12:46 PM with the Dietary Manager (DM) and Registered Dietician (RD) revealed the RD confirmed a significant change of Resident 126's weight of 6.76% or 8.8 pound weight loss in 30 days and 10.63% or 14 pound weight loss in 180 days was correct and that Resident 156 was on the list to be reviewed. DM and RD also confirmed that the documentation for the meal intake for lunch was not correct because the resident takes a sack lunch on the days that [MEDICAL TREATMENT] occurs which is Tuesday, Thursday, and Saturday and there was no communication from [MEDICAL TREATMENT] on what the resident's meal intake was when the resident was at [MEDICAL TREATMENT]. The DM confirmed that (gender) was unsure of how long it took to review the weights for the month to determine significant weight loss of a resident. Interview on 6/5/14 at 12:50 PM with Dietary Aide (DA) G confirmed that DA G did document that the resident had consumed 120 cc of the house supplement for the breakfast meal on 6/5/14 and Resident 156 did not drink the house supplement for that meal. DA G also stated, "Resident 156 never drinks the supplement for breakfast and I'm not sure why I documented that the resident did drink it all." Interview on 6/5/14 at 1:50 PM with the Director of Nursing (DON) revealed that the facility does not have a tool or communication device with [MEDICAL TREATMENT] to communicate any concern for a resident. The DON also stated that if there was concerns with a resident then the [MEDICAL TREATMENT] Center picked up the phone and called the facility or the facility called the [MEDICAL TREATMENT] Center if there were any concerns to discuss with them. The DON also confirmed that the weight of 124 was completed on 6/2/14. The DON also stated that the dietary department was responsible for significant change in a resident's weight.

Licensure Reference Number: 175 NAC 12-006.07C Based on record review and interview, the facility failed to have an effective quality assurance program as evidenced by repeated citations (F 280, 323, 325, and 371) and additional citations (F 164, 241, 242, 279, 309, 311, 314, and 315). The facility had a total census of 165. Findings are: A. A review of the findings for the last annual survey conducted on 2/12/14 in comparison with findings from survey completed on 6/9/14 revealed the following repeated deficiencies: F280 review and revision of care plans, F323 interventions to prevent falls, F325 implementation of interventions to prevent weight loss, and F371 food service sanitation. B. In an interview on 6/9/14 at 8:39 AM, the Director of Nursing reported the facility did not have a formal quality assurance study related to weight loss or care plans at this time. Care plans are reviewed in relation to care issues. C. In an interview on 6/8/14 at 8:14 AM, the Administrator reported quality assurance studies were being completed on citation from previous surveys, reports to the state and complaints from family and residents. The Administrator reported each department is working on developing quality assurance projects based on individual department concerns.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(5) Based on record review and interview; the facility staff failed to implement and evaluate a bowel management program for 1 (Resident 1). The facility staff identified a census of 173. Findings are: A. Record review of an undated Resident Admission Record sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Physician's Order sheet dated 2-28-2014 revealed Resident 1's physician had ordered medications that included [MEDICATION NAME]/APAP ( Narcotic [MEDICATION NAME] medication) 5/325 mg every 4 hours as needed for pain. According to Wikipedia at Wikipedia, [MEDICATION NAME] adverse effects include constipation. Record review of a Physician Telephone Order's (PTO) dated 3-06-2014 revealed Resident 1's physician had ordered [MEDICATION NAME] 17 gm (grams) daily for constipation. and to use a suppository if no BM (bowel movement) daily while on pain medications. Record review of Resident 1's Activity of Daily Living (ADL's) sheet for March 2014 revealed Resident 1 did not have a BM on 16 of 24 days. Record review of Resident 1's Medication Administration Record [REDACTED]. Further review of Resident 1's MAR for March 2014 revealed Resident 1 had received a suppository on 3-09-2014 and 3-29-2014. Record review of a Laxative Protocol sheet revealed the resident had received a suppository on 3-15-2014, 3-20-2014 and 3-30-2014. Record review of Resident 1's medical record that included the MARs for March 2014, ADL sheets for March and the resident progress notes did not contain evidence that Resident 1 was given a suppository for 12 of the 16 days without a BM. Record review of Resident 1's Nurses's Notes (NN) dated 3-26-2014 revealed Resident 1 had complained of nausea and refused lunch. Record review of Resident 1's NN dated 3-27-2014 revealed Resident 1 had "...severe stomach pains and nausea after getting dressed". Record review of Resident 1's NN dated 3-29-2014 revealed Resident 1 had complained of "abdominal bloating. Bowel sounds hypoactive. [MEDICATION NAME] suppository given. Bowel vault has soft brown stool". Record review of Resident 1's NN dated 3-30-2014 revealed Resident 1 abdomen was distended and hard. Resident 1's bowel sounds were hypoactive. Resident 1's physician was contacted and order the resident be sent to the hospital for an evaluation and treatment. Record review of Resident 1's NN dated 3-30-2014 revealed a facility nurse " called and spoke to (a) nurse...". According to the documentation, Resident 1 was admitted to the hospital with [REDACTED]. Record review of a Resident Transfer Form dated 3-30-2014 revealed the following information: -[DIAGNOSES REDACTED]. Last BM 3-25 (2014). Record review of Admission evaluation dated 3-30-2014 revealed the hospital physician identified that Resident 1 was " found to have a fecal impaction on CT ( Computed Tomography) which is believed to be a contrast ball in the intestine". Record review of Resident 1's March 2014 ADL sheets revealed Resident 1 did not have a BM as follows: - 3-10-2014 to 3-15-2014 (4 day span). -3-26-2014 to 3-29-2014 (4 day span). Record review of the facility Policy and Procedure for Laxative List/Bowel Routine dated 10/2014 revealed the following: -Purpose: -To assure that residents are monitored for adequate bowel elimination. -Procedure: -1. The night Charge Nurse will review all residents for their assigned area to identify those resident that have not had a bowel movement for three or more consecutive days. -2. The Day Charge Nurse will assess the residents gastrointestinal status before initiating The Laxative Protocol. The residents physician shall be notified if no bowel sounds are auscultated, the abdomen is unusually distended, resident complains of severe abdominal pain or experiences nausea and vomiting. -3. The Day Charge Nurse shall initiate the following laxative protocol: -Day 3 or 9 shifts without BM-give MOM. -Day 4 or 12 shifts without BM-give a laxative suppository. -Day 5 or 15 shifts without BM-give a Fleets Enema, if no results notify the physician. -5. Residents that have frequent problems with constipation should be placed on a daily bowel regimen to prevent problems with constipation.` On 4-08-2014 at 10:28 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 1's March 2014 bowel records were reviewed with the DON. During the interview; the DON confirmed Resident 1 had gone longer than 3 days without a BM and that the bowel protocol had not been implemented for Resident 1. Review of Resident 1's admission orders [REDACTED]. The DON confirmed Resident 1 did not admit with MOM orders and that facility nurses should have followed up with the physician. Review of the admission documentation to the hospital dated 3-30-2014 was conducted with the DON. The DON confirmed the documentation had identified that Resident 1 had a large amount of high dense stool in the rectum possibly impacted or an anorectal stricture. When asked if Resident 1's bowel status should have been evaluated from the dates of 3-26-2014 through 3-29-2014, the DON reported that the "nurses should have completed an evaluation". On 4-9-2014 at 12:37 PM a follow up interview on the phone was conducted with the DON. Review of the telephone orders dated 3-06-2014 were reviewed with the DON. The DON confirmed that the physician orders for bowel care had not been followed for Resident 1.