Every finding on record at The Banyan at Montclair

Licensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews and interviews: the facility staff failed to utilize handwashing and gloving techniques for 4 (Residents 5, 15, 28, and 41), failed to implement Enhanced Barrier Precautions (EBP) on 2 residents (Residents 5 and 15), failed to store equipment to prevent potential cross contamination for 1 resident (Resident 5), failed to implement isolation procedures for 1 (Resident 102) and fails to provide personal care in a manor to prevent potential infection for 1 (Resident 28). The total sample size was 53 and the facility census was 111. Findings are:Record review of the facility's Hand Hygiene policy with a revision date of 10/23/2025 revealed the following: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Record review of the facility's undated Hand Hygiene Table revealed the following: Before applying and after removing personal protective equipment (PPE), including gloves. Before preparing or handling medications. Before performing resident care procedures. A. Record review of Resident 28's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 3/2/2026 revealed the facility staff assessed the following about the resident: -Had a diagnosis of retention of urine. -Frequently incontinent of bowel. -Brief Interview of Mental Status (BIMS) was scored as 15/15. According to the MDS Manual a score of 15 indicated cognitively intact -required total assistance with toileting, shower/bath, putting on or taking off footwear, sit to stand, chair/bed transfers and tub transfers. An observation on 5/11/2026 at 12:30 PM revealed Nursing Assistant (NA)-G completed hand hygiene, applied gown and gloves. NA-G removed Resident 28's brief, did not complete hand hygiene, did not change soiled gloves and obtained cleansing wipes. NA-G used one wipe to cleanse the furthest thigh, folded the wipe, cleansed the furthest thigh again and then discarded wipe. NA-G obtained a new wipe to cleanse the closets thigh, folded the wipe, cleansed closet thigh again and then discarded the wipe. NA-G did not remove the soiled gloves, did not complete hand hygiene, and obtained a new wipe to cleanse around the head of the penis, folded the wipe, cleansed the tubing away from the urinary meatus (a pathway leading into the body) and discarded the wipe. Resident 28 rolled to themself to the left side, NA-G obtained a new wipe and cleansed the anus wiping towards the front of the residents' body and discarded the wipe. NA-G obtained a new wipe, cleansed the anus wiping towards the legs, folded the wipe, wiped again and discarded the wipe. NA-G removed gloves, completed hand hygiene and put on new gloves. NA-G placed brief under Resident 28 and did not fasten the brief. NA-G removed gloves, did not complete hand hygiene and applied new gloves. NA-G fastened the brief and covered Resident 28 with a blanket. An interview on 5/11/2026 at 12:52 PM NA-G confirmed that hand hygiene was not completed between glove changes and should have been. An interview on 5/11/2026 at 12:52 PM NA-G confirmed that NA-G was wiping Resident 28 from back to front and should have been wiping from front to back. An interview on 05/12/2026 12:00 PM Licensed Practical Nurse (LPN)-B confirmed that staff should be completing perineal care by cleansing front to back. LPN-B confirmed that cleansing back to front introduces bacteria to the urinary tract. B. An observation during medication administration on 05/11/2026 at 1:00 PM Medication Aide (MA)-F gathered medications for Resident 41 and went into Resident 41s room. MA-F gave Resident 41 the medication in the medication cup. MA-F did not complete hand hygiene and put gloves on to administer muscle rub to Resident 41s bilateral knees. An interview on 5/11/2026 at 1:07 PM MA-F confirmed that hand hygiene was not completed prior to putting on gloves and should have been. C. A record review of Resident 5's Clinical Resident Profile (a sheet containing residents name, code status, primary diagnosis, admission date, personal contacts information and medical professionals contact information) revealed Resident 5 was admitted to the facility on [DATE]. A record review of Resident 5's Minimum Data set (MDS – a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status), dated 2/11/2026, revealed Resident 5 had a Brief Interview for Mental Status (BIMS – a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 15, indicating Resident 5 was cognitively intact. A record review of Resident 5's Care plan (CP – a personalized, actionable document that outlines a patient's health needs, goals, and specific interventions to manage their care) revealed the following diagnoses: Chronic obstructive pulmonary disease (COPD- a progressive, treatable and preventable lung disease characterized by chronic airflow obstruction, making it difficult to breathe), blindness in both eyes, personal history of malignant neoplasm of larynx (a previous diagnosis of laryngeal cancer that has been treated and is no longer present), unspecified severe protein-calorie malnutrition (a life-threatening condition resulting from inadequate intake of protein and calories, leading to severe weight loss, muscle wasting and immune system failure), Muscle wasting and atrophy (the loss of muscle tissue, resulting in smaller, weaker muscles caused by inactivity, aging, malnutrition, or nerve damage). A record review of Resident 5's Baseline Care Plan (BCP – a preliminary individualized care strategy developed in nursing homes within 48 hours of a resident's admission) revealed Resident 5 was admitted with a feeding tube in place. A record review of Resident 5's Order summary (a consolidated, authorized record of instructions from a licensed provider detailing a resident's care, treatment, medications, and services) revealed the following orders: -Order dated 09/10/2024 - Enteral Feed (a method of delivering nutrients directly into the gastrointestinal (GI) tract using a flexible tube) Order every shift Check g-tube (a soft, flexible, medically placed tube that delivers nutrition, fluids and medication directly into the stomach through a small opening in the abdomen) placement by introducing air and listening for air sounds on the stomach area as the air is introduced using a syringe. -Order dated 5/28/2025 - Enteral Feed: Cleanse enteral tube feeding site with Normal saline and apply dry dressing. Assess for abnormalities to insertion site. Report changes to PCP (primary care provider) every shift for monitoring. -Order dated 12/02/2025 - Enteral Feed Order two times a day related to unspecified severe protein-calorie malnutrition. Administer Jevity 1.5, (a high-protein, fiber-fortified and calorically dense liquid formula manufactured to provide complete, balanced nutrition for tube feeding) 300milliliters (ml – a unit of measurement for liquid) by gravity (a method that used gravity to deliver formula at a slow, controlled rate) through feeding tube. Prior to and post (after) feed, flush tube with 30ml of tap water for line patency (the state of the line or tube being open, unobstructed, and functioning properly) prior to and post feed. May substitute equivalent options of Isosource (liquid nutritional formula) 1.5 or osmolyte (liquid nutritional formula) 1.5. -Order dated 12/21/2025 - Enteral Feed Order four times a day related to unspecified severe protein calorie. Flush feeding tube with 110ml tap water four times daily by gravity. -Order dated 08/13/2025 - Enhanced Barrier Precautions due to percutaneous endoscopic gastrostomy (PEG) tube placement. Ensure appropriate PPE is used during resident care activities. every shift for infection prevention. An observation on 5/7/2026 at 9:40 AM of tube feeding provided by Licensed Practical Nurse (LPN) I revealed the following: LPN I entered Resident 5's room and placed 2 graduated cylinders and a 60ml syringe on the bedside table. LPN I placed a clean towel on Resident 5's abdomen and lap area. LPN I turned on the faucet and filled one cylinder with an unmeasured amount of water. LPN I then uncapped a box of Jevity 1.5 liquid formula feed and poured it into the second graduated cylinder. LPN I washed their hands and donned gloves but did not don a gown. LPN I approached Resident 5 and informed them of what they were about to do. LPN I verified placement of the g-tube by using the syringe to push 10cc of air through the g tube into the stomach while listening to the abdomen sounds with a stethoscope. LPN I placed the stethoscope around their neck and removed the syringe from the g-tube to remove the plunger part and reattach the syringe. LPN I poured 60ml of water into the syringe to flush the tube. The water did not flow in by gravity so LPN I pushed it through with the syringe plunger. LPN I removed the syringe and attached the tube section back to the g-tube after removing the plunger. LPN I poured the formula solution into the syringe. The feed did not flow through with gravity so LPN I added an unmeasured amount of water to thin it out. When it still did not flow through, LPN I attached the plunger and pushed the liquid formula through the tube into the stomach. LPN I removed the syringe, removed the plunger, reattached the syringe and poured an additional amount of formula into the syringe. This also did not respond to gravity so LPN I reattached the plunger and pushed the formula into the stomach. LPN I detached the plunger from the syringe and poured the last portion of the tube feed into the syringe and when it did not flow through, LPN I reattached the plunger and pushed it through. LPN I removed the plunger and poured 60ml of water into the g tube and this went through easily by gravity. LPN I detached the syringe and took the syringe and the cylinders into the bathroom and washed them. LPN I removed their gloves and washed their hands. LPN I removed the towel from Resident 5's lap and exited the room. LPN I informed Resident 5 they would return to clean around the g-tube site LPN I went to the treatment cart and gathered the cleaning supplies after reviewing the order. LPN I entered Resident 5's room after knocking and placed a bottle of wound cleanser, a package of 4 x 4 gauze and a clean towel on the bedside table. LPN I washed their hands and donned a gown and gloves. LPN I placed a towel on the residents lap. LPN I removed a small, uncounted amount of gauze pads from the package and sprayed them with the wound cleanser. LPN I wiped the gauze pad around the base of the g-tube side in a circular motion. LPN I removed their gloves and donned clean gloves without using hand sanitizer. LPN I placed a split sponge dressing (a precut absorbent pad designed to fit snugly around tubes) around the g-tube site. LPN I discarded their gloves and gown, picked up the towel, cleaner and package of gauze pads and exited the room without using hand sanitizer or washing their hands. An interview on 5/7/2026 at 10:05AM with LPN I confirmed the resident was on EBP precautions due to having a g-tube. LPN I confirmed they did not don a gown during the tube feeding and they should have. LPN I confirmed they did not use hand sanitizer or wash their hands between glove changes when providing g-tube site care and they should have. LPN I confirmed they did not wash their hands or use hand sanitizer when they exited the room after site care. LPN I confirmed Resident 5's order stated the tube feeding should have been delivered by gravity and confirmed they had pushed it through using the syringe plunger. LPN I confirmed they had exceeded the amount of water ordered for flush with tube feeding. A record review of the Facility Hand Hygiene policy dated 8/25/25 and reviewed 10/23/25 revealed the following: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The policy stated: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Hand hygiene is indicated and will be performed under the conditions listed in but not limited to, the attached hand hygiene table, which includes: After handling contaminated objects Before applying and after removing personal protective equipment (PPE) including gloves Before performing resident care procedures A record review of the Enhanced Barrier Precautions poster by Center for Disease Control revealed the following instructions: Providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. A record review of a document titled Tube feeding: Process at Montclair: dated 12/2025 revealed the following: Washed hands and donned appropriate personal protective equipment. Adhered to infection control principles throughout the procedure. Flushed feeding tube with prescribed amount of fluid. Administered gravity feeding appropriately, as ordered. A record review of a document titled Enteral Feeding: Administration by syringe bolus dated 8/1/2016 and revised 11/16/2017 revealed the following: 9. Verify tube placement. 12. Flush tube with at least 50ml of water and instill by gravity. 13. slowly pour formula directly into syringe and instill using gravity. 14. Avoid letting the syringe empty completely. Increase or decrease the solution's flow rate by raising or lowering the syringe. Keep flow rate slow enough to spread feeding time over at least 20 minutes. 15. when all of formula is finished, flush with at least 50ml of water and instill by gravity. D. A record review of Resident 5's order summary revealed the following provider order dated 05/05/2026: Change nebulizer mask and tubing weekly; date and place in dated plastic bag. Date tubing. Place in dated bag when not in use. every night shift every Sat. For Infection Control Place in dated bag when not in use. An observation on 5/6/2026 at 1:45 PM of Resident 5's nebulizer mask (a medical device used to deliver liquid medication in the form of a fine mist directly into the lungs through the nose and mouth) and tubing placed directly on top of a table in Resident 5's room. An observation on 5/12/2026 at 8:10 AM of Resident 5's nebulizer mask and tubing resting on Resident 5's bedside table. An interview on 5/6/2026 at 1:45 PM with RN J confirmed the nebulizer mash should have been stored inside a dated plastic bag and not on top of a bedside table. An interview on 5/12/2026 at 8:10 AM with Medication Aide (MA) F confirmed the nebulizer mask and tubing should have been stored in a dated plastic bag and not lying on Resident 5's bedside table. E. An observation on 5/6/2026 at 1:45 PM of a urinal (a portable handheld container designed for collecting human urine) full of urine on Resident 5's bedside table beside a graduated plastic cylinder (plastic containers designed for measuring liquid) holding a 60ml syringe used to introduce water and a nutritional formula into Resident 5's stomach via a flexible tube. An interview on 5/6/2026 at 1:45 PM with Registered Nurse (RN) J confirmed having the urinal full of urine beside the graduated cylinder and syringe used to deliver the liquid formula constituted an infection control issue. F. A record review of the facility's undated Enhanced Barrier Precautions (EBP) sign revealed providers and staff must wear gloves and a gown for high-contact resident care activities such as dressing, transferring, changing linens, providing hygiene (cleaning), changing briefs of assisting with toileting, and device care. A record review of Resident 15's Order Summary Report dated 05/07/2026 revealed the resident had orders to cleanse the right heel with wound cleanser, apply honey hydrogel sheet (a wound dressing) to the wound bed, and cover with a border dressing. It did not reveal orders for pressure wound prevention measures. An observation on 05/11/2026 at 7:56 AM revealed that Nursing Assistant (NA)-A was already in the room with a gown and gloves on and had changed the resident's brief. Licensed Practical Nurse (LPN)-K was in the room to observe MA-A and there was an EBP to the left of the door as you enter the room. NA-A removed NA-A's gloves and applied a new pair without performing hand hygiene between glove changes. NA-A drained the resident's colostomy (an opening on the abdominal wall that allowed the colon to divert waste into an external bag) bag. The colostomy was leaking, so NA-A called for the nurse to replace it. The colostomy had leaked onto the resident's shirt, so NA-A removed gloves, got the resident shirt, gloved, without hand hygiene, and wiped the colostomy site again and removed NA-A's gloves. The nurse entered and started to change the colostomy and NA-A lifted the resident's hands out of the way without gloves on, then applied gloves without performing hand hygiene. The nurse completed the colostomy change, and NA-F rolled the resident to the left and to the right as NA-F removed the reusable chux (absorbent pad), pulled the resident's pants over the resident's brief, removed NA-A's gloves, re-gloved without hand hygiene, assisted the resident to a seated position on the side of the bed, and removed gloves. NA-A done hand hygiene, re-gloved, finished dressing the resident, transferred the resident to the wheelchair, put contaminated clothing and linens in a trash bag and removed gloves. NA-A then brushed and combed the resident's hair, touched around NA-A's mouth, and applied water to Resident 15's brown all without hand hygiene or gloves on. NA-A gloved without performing hand hygiene, applied lotion to the resident's face, removed gloves and gown, and took the resident to the dining room after washing NA-A's hands. In an interview on 05/11/2026 at 9:00 AM, LPN-K confirmed NA-A changed gloves without performing hand hygiene in between and did not have gloves on when working with the resident and should have. G. A record review of Resident 15's Progress Notes dated 04/29/2026 revealed the nurse assessed the area on resident's right heel and it was open again. The nurse cleaned with wound cleanser, applied betadine, and secured with bordered dressing. An observation on 05/06/2026 at 1:00 PM did not reveal an EBP sign on Resident 15's door or in the resident's room. An observation on 05/07/2026 at 11:08 AM, 1:40 PM, and 2:26 PM did not reveal an EBP sign on Resident 15's door or in the resident's room. An observation on 05/11/2026 at 6:52 AM revealed there was an EBP sign posted to the left of the entry door to Resident 15's room. In an interview on 05/11/2026 at 10:15 AM, the facility's Infection Preventionist (IP)-E confirmed Resident 15's room did not have an EBP sign posted until IP-E was informed of the resident having a new wound and it was not posted until after 05/07/2026. H. A record review of the facility's undated Neutropenic Precautions sign revealed everyone must: clean hands before entering the room and when leaving the room, and Face mask required! An observation on 05/06/2026 at 8:14 AM – 8:25 AM revealed there was a Neutropenic Precautions sign to the left of the door to Resident 102's room. At 8:19 AM the facility's Maintenance Director (MD) entered Resident 102's room, exited the room and spoke to staff, and re-entered the room to check the water temperature without a face mask on or performing hand hygiene. In an interview on 05/12/2026 at 11:20 AM, the Infection Preventionist (IP)-E confirmed the MD should not have entered Resident 102's room without a face mask and doing hand hygiene.

Licensure Reference Number 175 NAC 12-006.5(G)Based on record review and interview the facility failed to ensure that a psychotropic medication had an adequate indication for use for Resident 5, and side effect monitoring was in place for residents 10 and 105 of 6 sampled residents. The facility identified a census of 111. Findings are: A. A record review of the facility's Medication Regimen Review policy, with an implementation date of 4/1/2023 and a revised date of 1/8/2026 revealed the following: Policy: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Policy Explanation and Compliance Guidelines: 1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 5. The pharmacist shall communicate any irregularities to the facility in the following ways: Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. 7. Timelines and responsibilities for Medication Regimen Review: The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. Facility staff shall act upon all communications according to procedures for addressing medication regimen review irregularities. B. A record review of Resident 5's Clinical Resident Profile (a sheet containing residents name, code status, primary diagnosis, admission date, personal contacts information and medical professionals contact information) revealed Resident 5 was admitted to the facility on [DATE]. A record review of Resident 5's Minimum Data set ((MDS – a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status), dated 2/11/2026, revealed Resident 5 had a Brief Interview for Mental Status (BIMS – a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 15, indicating Resident 15 was cognitively intact. A record review of Resident 5's Care Plan (CP – a personalized, actionable document that outlines a patient's health needs, goals and specific interventions to manage their care) revealed they had the following diagnosis: Insomnia (a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep or waking too early, despite having the opportunity to sleep). A record review of Resident 5's physicians order summary (a consolidated, authorized record of instructions from a licensed provider detailing a resident's care, treatment, medications and services) dated 5/11/2026, revealed Resident 5 had an order, dated 02/10/2026, for Seroquel (a prescription antipsychotic medication used to treat schizophrenia, bipolar disorder and major depressive disorder) 50mg tablet at bedtime related to Insomnia. A record review of Resident 5's Medication Administration Record (MAR) for April 2026 revealed Resident 5 received Seroquel 50mg every night except April 5th, 2026, and April 26th, 2026, and every night between May 1st, 2026, and May 10th, 2026. A record review of a Consultant Recommendation to Physician dated 2/18/2026 from the consultant pharmacist to a physician revealed Resident 5 lacked an allowable diagnosis for the use of Seroquel and requested a different diagnosis from the physician to support the continued use of the medication. A record review of Resident 5's order summary dated May 11, 2026, revealed there was no new diagnosis attached to the order for Seroquel 50mg tablet. An interview on 05/12/2026 at 11:30 AM with the Director of Nursing (DON) confirmed if a response is not received within 2 weeks of the recommendation being sent to the physician the Assistant Director of Nursing (ADON) or the DON would send a second request by fax to the provider. The DON confirmed that this process would continue until a response was received from the provider. The DON confirmed they were unable to provide documentation to show the request for an allowable diagnosis had been faxed to Resident 5's provider. C. Record review of Resident 105's admission Record dated May 11, 2026 revealed an admission date to the facility on [DATE] with diagnosis of Alzheimer's disease, dementia with anxiety and psychosis, and depression. Record review of Resident 105's May 2026 MAR revealed that Resident 105 had an order for Risperidone (a psychotropic medication) 0.5mg one tablet twice daily. Record review of Resident 105's EHR revealed there was no side effect monitoring for psychotropic medications for Resident 105. In an interview with the Director of Nursing (DON) on 5/12/26 at 8:25 A.M. it was confirmed that there was no side effect monitoring for residents 10 and 105 and should have been.

Based on record review and interview, the facility failed to investigate and report a fall with significant injury within the required time frame for 1(Resident 63) of 1. The facility reported a census of 111. Findings are: A record review of Resident 63's Clinical Resident Profile (a sheet containing residents name, code status, primary diagnosis, admission date, personal contacts information and medical professionals contact information) revealed Resident 63 was admitted to the facility on [DATE].A record review of Resident 63's Minimum data set (MDS - a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 4/5/2026 revealed Resident 63 had a Brief Interview for Mental Status (BIMS - a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 5 indicating Resident 63 was severely cognitively impaired.A record review of Resident 63's care plan (CP - a personalized, actionable document that outlines a patient's health needs, goals and specific interventions to manage their care) revealed Resident 63 had the following diagnoses: Vascular dementia - a decline in thinking, memory and behavior caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrition, essential hypertension - high blood pressure with no single identifiable medical cause, Chronic kidney disease, stage 3 - moderate kidney damage, where kidneys do not filter waste and fluids as efficiently as they should, Pain, Diabetes type 2 - a chronic condition where the body cannot properly use or make enough insulin, leading to high blood sugar levels, peripheral vascular disease - a slow progressive circulation disorder involving narrowing, blockage or spasms in blood vessels outside the heart and brain, obstructive sleep apnea - a serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax and block the airway during sleep, spinal stenosis - chronic narrowing of the spaces within the spinal canal causing pain, major depressive disorder - a serious mental health condition characterized by persistent severe low mood, sadness or a loss of interest in activities lasting at least 2 weeks, morbid obesity - a body mass index of 40 or higher or 35 or higher accompanied by a serious, obesity related health condition. Further review of Resident 63's CP revealed Resident 63 was considered to be at risk for falls related to Type 2 diabetes, Hypertension, spinal stenosis, weakness, and decreased mobility.A record review of Resident 63's progress note by RN L revealed Resident 63 had a fall on 5/2/2026 resulting in a laceration (a torn or jagged wound caused by the tearing or stretching of soft body tissues, often resulting from blunt trauma) to their left eyebrow requiring sutures (medical devices used to hold body tissues together and approximate (bring the edges together) tissues). The progress note revealed Resident 63 was found on the floor and did not reveal how the laceration occurred. Resident 63 was transferred to the emergency department where they received sutures in the laceration. An interview on 5/12/26 at 1:45PM with Director of Nursing (DON) confirmed the facility did not report the residents fall with significant on 5/2/2026 and did not perform an investigation.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview, and record review, the facility failed to implement interventions to prevent the potential for pressure injuries on 1 (Resident 15) of 5 sampled residents. The facility census was 111. Findings are:A record review of the facility's Use of Support Surfaces policy with a date reviewed/revised of 2/26 revealed a support surface was a specialized mattress, overlay, or chair cushion to manage pressure, shear, microclimate, or friction on tissue. Support surfaces would be utilized in accordance with manufacturer's recommendations. A record review of the facility's Turning and Repositioning policy with a date reviewed/revised date of 2/2026 revealed all residents at risk of or had existing pressure injuries would be turned and repositioned. The frequency of turning and repositioning would be documented in the resident's care plan. If the resident had a pressure redistribution support surface in use, turning and reposition was still required but may be less frequent. If the resident was in bed, the staff was to ensure heels were floated off the surface of the bed. If the resident was in a chair, staff was to ensure feet were properly supported on the footrests. A record review of the undated SpanAmerica's Geo-Mattress Pro Pressure Redistribution Foam Mattress information sheet revealed the mattress had a exclusive heel slope that had a subtle taper to redistribute load to pressure tolerant lower legs and reduce heel pressure by 27 percent (%) compared to a flat mattress. Patient indications were general patient population, with moderate to high risk for skin breakdown, had decreased mobility, and was repositioned frequently by self or a caregiver. A record review of Resident 15's Clinical Census dated 05/07/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 15's Medical Diagnosis dated 05/07/2026 revealed the resident had diagnoses of Unspecified Dementia, Stage III Chronic Kidney Disease, Polymyalgia Rheumatica (inflammatory disorder causing severe muscle pain and stiffness), and Osteoarthritis Of The Left Knee (cartilage breakdown resulting in pain, stiffness, and reduced mobility). A record review of Resident 15's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/10/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 00 which indicated the resident was severely cognitively impaired (confused). The resident required setup/clean-up assistance with eating, partial/moderate assistance with oral hygiene (cleaning), substantial/maximal assistance with footwear, dressing, and personal hygiene, and was dependent on staff for toileting hygiene and bathing. The resident required partial/moderate assistance with rolling left and right, and required substantial/maximal assistance with all other bed mobility and transfer needs. The resident was at risk of developing a pressure ulcer/injury and the resident did not have a pressure ulcer (wound) at the time of the assessment. A record review of Resident 15's Wound Assessment Report dated 04/30/2026 by the Nurse Practitioner revealed the resident had a new stage 3 pressure ulcer/injury to the right heel that measured 1.10 centimeters (cm) in length, .60 cm in width, and .10 cm in depth, and light exudate (wound drainage). The wound was acquired 04/28/2026 in house (at the facility). A record review of Resident 15's Progress Notes dated 03/31/2026 - 04/29/2026 revealed: - On 03/31/2026 the resident's provider seen the resident and no wounds were documented. - On 04/02/2026 the facility identified a 1.8 cm long by 1.2 cm wide area to the resident's right heel and orders were obtained for betadine 2 times per day. It appeared the skin alteration was possibly due to improper footwear (Crocs, with no socks) and the resident's family was to bring a different pair of shoes. - On 04/29/2026 the nurse assessed the area on resident's right heel was open again. The nurse cleaned with wound cleanser, applied betadine, and secured with bordered dressing. A record review of Resident 15's Progress Notes dated 04/30/2026 revealed the Nurse Practitioner (NP) evaluated the wound and changed the orders. The NP documented that previously the wound care nurse thought the right heel wound was healed out, but discovered the wound was reopened. The resident's wound was initially caused by Crocs and friction on the resident's heel and the resident had new shoes. The NP recommended avoiding pressure on any boney prominence (projecting outward) by adhering to turning protocols and floating heels (ensuring heels do not touch the mattress). The resident now had proper fitting footwear, Sketchers tennis shoes that properly fit and the Crocs were no longer in the room. A record review of Resident 15's Order Summary Report dated 05/07/2026 revealed orders to cleanse the right heel with wound cleanser, apply honey hydrogel sheet (a wound dressing) to the wound bed, and cover with a border dressing. It did not reveal orders for pressure wound prevention measures. A record review of the facility's Wound Tracker 2026 dated 04/10/2026 revealed Resident 15 was listed dated 04/02/2026 with a right superior (located above) heel abrasion and treatment was betadine twice a day. A record review of the facility's Wound Tracker 2026 dated 04/22/2026 revealed Resident 15 was listed dated 04/02/2026 with a right superior heel abrasion, treatment was betadine twice a day, and it was marked healed. A record review of Resident 15's Clinical Physician Orders dated 05/11/2026 that was filtered to show orders that were completed or discontinued did not reveal any orders for pressure wound prevention, and did not reveal wound care or betadine to the right heel until 04/30/2026. A record review of Resident 15's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated April 2026 did not reveal any orders for pressure wound prevention and did not reveal wound care or betadine to the right heel until 04/30/2026. A record review of Resident 15's MAR & TAR dated May 2026 did not reveal any orders for pressure wound prevention. A record review of Resident 15's Care Plan Report with an admission date of 08/26/2025 revealed a Focus area of Pressure Ulcer Risk and the resident had the potential to develop a pressure ulcer and had an open area to the right heel. The only intervention was weekly skin checks to monitor for redness, pressure sores, open areas, and skin integrity (overall health). A record review of Resident 15's Bed Mobility: Self Performance task dated 04/12/2026 - 05/11/2026 revealed the resident was extensive assistance to total dependence on staff for bed mobility all but 2 times in those 30 days and the resident was only assisted once or twice per day. An observation on 05/07/2026 at 1:40 PM revealed Licensed Practical Nurse (LPN)-C who was the wound care nurse completed wound care on Resident 15's right heel, put the sock on the resident, discarded all wound care supplies, removed LPN-C's gown and gloves, and put the resident's foot back flat on bed. The Nursing Assistant (NA) came into the room and took trash to hopper and asked the resident if they wanted to get in the wheelchair and the resident wanted to stay in bed. LPN-C and the NA left the room and the resident's heels were flat on the surface of the bed. An observation on 05/07/2026 at 2:26 PM revealed Resident 15 was in bed, feet flat on the mattress, knees bent up, and no pillow underneath the resident's lower legs. An observation on 05/11/2026 at 6:52 AM revealed Resident 15 was sleeping in bed and the resident's heels were flat on the mattress. An observation on 05/11/2026 at 2:27 PM with LPN-C, the wound care nurse, revealed the mattress on Resident 15's bed had tags that revealed it was a Span-America 54668 mattress that was a Geo-Mattress Pro that did have a heel slope, but the tag that said foot end was at the head of the bed and the heel slope was on the upper body portion of the bed. In an interview on 05/11/2026 at 2:00 PM, LPN-D, a wound care nurse, confirmed LPN-D was monitoring the wound after it was identified on 04/02/2026, but another nurse was doing the wound care. At the time, the resident had wandering (roaming) behaviors and Prevalon boots (padded heel protectors) were not a safe option for the resident. LPN-D confirmed LPN-D told the staff to float the resident's heels, but an order was not put in the system, and it was not on the care plan. LPN-D confirmed turning and repositioning should have been completed per standards of practice and the facility's protocol. In an interview on 05/11/2026 at 1:30 PM, LPN-C, the wound care nurse, revealed the resident had a wound on the right heel that was identified on 04/02/2026, was healed on 04/22/2026, and reopened on 04/28/2026. They think it was from Resident 15's shoes rubbing on the resident's heel, so they decided to have the resident wear nonskid socks with therapy. LPN-C confirmed the only intervention put in place between when the right heel wound was identified on 04/02/2026 and finding it reopened on 04/30/2026 was monitoring the right heel, changing the resident's shoes, nothing for when the resident was in bed. LPN-C confirmed the facility used pressure redistribution mattresses on all beds to assist on pressure reduction to the heels. In an interview on 05/11/2026 at 2:27 PM, LPN-C confirmed Resident 15 had a Span-America 54668 Pressure Redistribution Foam Mattress on the bed, but the tag on the mattress that said Foot End was by the bed's headboard and therefore the heel slope was on the wrong end of the bed. In an interview on 05/11/2026 at 3:40 PM, the facility's Maintenance Director (MD) confirmed the MD moved the resident to room [ROOM NUMBER] and put the mattress on the bed and did not pay attention to there being a specific direction that mattress needed to go. The MD confirmed the maintenance staff and NAs apply the mattresses to the beds. The MD confirmed the staff had not been educated on that mattress. In an interview on 05/12/2026 at 10:05 AM, the facility's Administrator confirmed the staff had not had a competency (education) on the placement of the SpanAmerica's Geo-Mattress Pro.

Licensure Reference Number 175 NAC 12-006.09(I)(1)(i)Based on record review and interview, the facility failed to implement a new fall intervention for Resident 63 following a fall on 05/02/2026. The facility reported a census of 111. Findings are:A record review of the facility Accidents and Supervision policy dated 4/1/24 and reviewed on 2/2026 revealed the following:Implementation of interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes:Communicating the interventions to all relevant staffProviding training as neededDocumenting the interventions (plans of action developed through the QAA Committee or care plans for the individual resident. A record review of Resident 63's Clinical Resident Profile (a sheet containing residents name, code status, primary diagnosis, admission date, personal contacts information and medical professionals contact information) revealed Resident 63 was admitted to the facility on [DATE].A record review of Resident 63's Minimum data set (MDS - a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 4/5/2026 revealed Resident 63 had a Brief Interview for Mental Status (BIMS - a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 5 indicating Resident 63 was severely cognitively intact.A record review of Resident 63's Care Plan (CP - a personalized, actionable document that outlines a patient's health needs, goals and specific interventions to manage their care) revealed Resident 63 had the following diagnoses: Vascular dementia - a decline in thinking, memory and behavior caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrition, essential hypertension - high blood pressure with no single identifiable medical cause, Chronic kidney disease, stage 3 - moderate kidney damage, where kidneys do not filter waste and fluids as efficiently as they should, Pain, Diabetes type 2 - a chronic condition where the body cannot properly use or make enough insulin, leading to high blood sugar levels, peripheral vascular disease - a slow progressive circulation disorder involving narrowing, blockage or spasms in blood vessels outside the heart and brain, obstructive sleep apnea - a serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax and block the airway during sleep, spinal stenosis - chronic narrowing of the spaces within the spinal canal causing pain, major depressive disorder - a serious mental health condition characterized by persistent severe low mood, sadness or a loss of interest in activities lasting at least 2 weeks, morbid obesity - a body mass index of 40 or higher or 35 or higher accompanied by a serious, obesity related health condition.A record review of Resident 63's CP revealed Resident was considered to be at risk for falls related to Type 2 diabetes, Hypertension, spinal stenosis, weakness, and decreased mobility.A record review of Resident 63's progress notes revealed Resident 63 had a fall on 5/2/2026 resulting in a laceration to their left eyebrow requiring sutures.A record review of Resident 63's CP did not reveal any new fall interventions for the fall on 5/2/2026.An interview on 5/12/2026 at 7:55 AM with Licensed Practical Nurse (LPN) I revealed the following steps nursing is required to take after a resident has fallen.Assess the resident.Notify the physician, Director of Nursing (DON), and family members.Begin neurochecks (serial, abbreviated neurological examinations performed by healthcare providers to quickly monitor for changes in a patients neurological status) if the fall is not witnessed.Complete a fall assessment and risk management paperwork which is to include a new fall intervention (an intentional action, step or interference taken to alter the course of a situation, improve a condition or prevent a negative outcome).An interview on 5/12/2026 at 7:55 AM with LPN I confirmed they were unable to find a new intervention related to the fall on 5/2/2026 on Resident 63's care plan.An interview on 5/12/2026 at 7:56 AM with Medication Aide (MA) F confirmed they were unable to find a new intervention related to Resident 63's fall on 5/2/2025 on the residents care plan.An interview on 5/12/2026 at 9:17 AM with LPN B confirmed they were unable to find a new intervention related to Resident 63's fall on 5/2/2025 on the residents care plan.An interview on 5/12/26 at 12:15pm with the MDS Director confirmed a new intervention had not been placed in the residents care plan for the fall on 5/2/26.

Licensure Reference Number 175 NAC 12-006.9(H)(iv) Based on record reviews and interviews the facility failed to ensure that a bowel protocol was followed for 1 resident (Resident 2) of 5 sampled residents. The facility identified a census at 111. Findings are:A.Record review of the facility's policy Constipation Prevention dated 8/1/2023 revealed the following:PRN Laxative will be offered during the 3rd day without a BM. The PRN Laxative will be offered and preferably administered by 2:00pm. Example: no BM on the 1st and 2nd, PRN laxative too be offered on the 3rd.A suppository will be offered the AM of the 4th day without a BM. Example: no BM on the 1st, 2nd and 3rd, a suppository will be offered the AM of the 4th.If a resident does not have a BM after PRN laxative and a suppository is provided, an assessment of the abdomen, bowel sounds, pain and appetite will be completed. The primary physician will be notified.When a resident is using PRN laxative/suppository on a regular basis, update the primary physician and request a routine stool softener/laxative. B.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 3/9/2026 revealed the facility staff assessed the following about the resident:-Had a diagnosis of non-Alzheimer dementia, Hemiplegia or hemiparesis, seizure disorder or epilepsy-Always incontinent of bowel-Brief Interview of Mental Status (BIMS) was scored as 12/15. According to the MDS Manual a score of 12 indicated moderate cognitive impairment. -Required total assistance with toileting, shower/bathing and transfers Record review of Resident 2's Bowel Movement (BM) tasks dated 5/12/2026 revealed Resident 2 had not had a documented BM since 5/1/2026, eleven days. An interview on 5/12/2026 at 12:50 PM Assistant Director of Nursing (ADON)-H confirmed that a BM had not been documented since 5/1/2026. ADON-H confirmed that it had been eleven days without a BM documented for Resident 2. An interview on 05/12/2026 2:57 PM ADON-H confirmed that Pro Re Nata (PRN) (as needed) medications were not provided to Resident 2. ADON-H confirmed that there was no assessment completed on Resident 2. ADON-H confirmed that there was not any progress notes completed regarding Resident 2 having a BM or that an assessment was completed.

Licensure Reference Number 175 NAC 12-006.12(A)(4)Based on record review and interview, the facility failed to ensure a medication irregularity was reported to the attending physician and failed to ensure the report was acted on for 1 (Resident 5) of 5 sampled residents.The facility reported a census of 111. Findings are: A record review of the facility's Medication Regimen Review policy, with an implementation date of 4/1/2023 and a revised date of 1/8/2026 revealed the following.Policy:The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart.Policy Explanation and Compliance Guidelines:1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes:Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.5. The pharmacist shall communicate any irregularities to the facility in the following ways:Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs.Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing.7. Timelines and responsibilities for Medication Regimen Review:The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review.Facility staff shall act upon all communications according to procedures for addressing medication regimen review irregularities. A record review of Resident 5's Clinical Resident Profile (a sheet containing residents name, code status, primary diagnosis, admission date, personal contacts information and medical professionals contact information) revealed Resident 5 was admitted to the facility on [DATE]. A record review of Resident 5's Minimum Data set ((MDS - a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status), dated 2/11/2026, revealed Resident 5 had a Brief Interview for Mental Status (BIMS - a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 15, indicating Resident 15 was cognitively intact.A record review of Resident 5's Care Plan (CP - a personalized, actionable document that outlines a patient's health needs, goals and specific interventions to manage their care) revealed they had the following diagnosis: Insomnia (a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep or waking too early, despite having the opportunity to sleep).A record review of Resident 5's physicians order summary (a consolidated, authorized record of instructions from a licensed provider detailing a resident's care, treatment, medications and services) dated 5/11/2026, revealed Resident 5 had an order, dated 02/10/2026, for Seroquel (a prescription antipsychotic medication used to treat schizophrenia, bipolar disorder and major depressive disorder) 50mg tablet at bedtime related to Insomnia.A record review of a Consultant Recommendation to Physician dated 2/18/2026 from the consultant pharmacist to a physician revealed Resident 5 lacked an allowable diagnosis for the use of Seroquel and requested a different diagnosis from the physician to support the continued use of the medication.A record review of Resident 5's order summary dated May 11, 2026, revealed there was no new diagnosis attached to the order for Seroquel 50mg tablet.An interview on 05/12/2026 at 11:30AM with the Director of Nursing (DON) confirmed the following procedure: a Consultant Recommendation to Physician is sent by the consultant pharmacist to the physician, the DON, and the Medical Director of the facility. The DON confirmed if a response is not received within 2 weeks of the recommendation being sent to the physician the Assistant Director of Nursing (ADON) or the DON would send a second request by fax to the provider. The DON confirmed that this process would continue until a response was received from the provider. The DON confirmed they were unable to provide documentation to show the request for an allowable diagnosis had been faxed to Resident 5's provider.

Licensure Reference Number 175 NAC 12-006.10(D) Based on interview and record review, the facility failed to ensure that 2 (Resident 5 and 15) of 5 sampled residents were free of significant medication errors. The facility census was 111. Findings are:A record review of the facility's Medication Errors policy with a date last reviewed/revised of 2/2026 revealed a significant medication error meant one which causes the resident discomfort or jeopardizes the resident's health and safety. The facility should ensure medications were administered according to physician's orders. A record review of the facility's Medication Administration policy with a date reviewed/revised of 02/2026 revealed medications would be administered by staff who are legally authorized to do so, as ordered by the physician, and in accordance with professional standards of practice. A. A record review of Resident 15's Clinical Census dated 05/07/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 15's Medical Diagnosis dated 05/07/2026 revealed the resident had diagnoses of Unspecified Dementia, Stage III Chronic Kidney Disease, Infrarenal Abdominal Aortic Aneurism (a dangerous bulge in the main blood vessel), Cardiac Murmur (unusual sound during a heartbeat), and Essential (Primary) Hypertension (high blood pressure). A record review of Resident 15's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/10/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 00 which indicated the resident was severely cognitively impaired (confused). The resident required setup/clean-up assistance with eating, partial/moderate assistance with oral hygiene (cleaning), substantial/maximal assistance with footwear, dressing, and personal hygiene, and was dependent on staff for toileting hygiene and bathing. The resident required partial/moderate assistance with rolling left and right, and required substantial/maximal assistance with all other bed mobility and transfer needs. A record review of Resident 15's Care Plan Report with an admission date of 08/26/2025 revealed a focus area of the resident had hypertension and an intervention of medication as ordered. A record review of Resident 15's Order Summary Report dated 05/07/2026 revealed the resident had a provider's order for Hydralazine Hydrochloride (HCL) oral tablet 25 milligram (MG). Give 1 tablet by mouth three times per day. HOLD FOR SPB (systolic blood pressure) LESS THAN (<) 115 millimeters of hemoglobin (mmHg). A record review of Resident 15's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2026 with Licensed Practical Nurse (LPN)-B revealed the resident's Hydralazine HCL was to be held if SBP < 115 mmHg and was administered with an SBP of < 115 mmHg on: - the 02/15/2026 2:00 PM dose the SBP was 113 mmHg - the 02/15/2026 PM dose the SBP was 109 mmHg - the 02/26/2026 AM dose the SBP was 114 mmHg - the 02/27/2026 AM dose the SBP was 112 mmHg A record review of Resident 15's MAR & TAR dated April 2026 with LPN-B revealed the resident's Hydralazine HCL was to be held if SBP was < 115 mmHg and it was administered with an SBP of < 115 on: - the 04/11/2026 AM dose the SBP was 113 mmHg - the 04/13/2026 AM dose the SBP was 104 mmHg - the 04/13/2026 2:00 PM dose the SBP was 112 mmHg A record review of Resident 15's MAR & TAR dated May 2026 with LPN_B revealed the resident's Hydralazine HCL was to be held if SBP < 115 mmHg and was administered with an SBP of less than 115 on: - the 05/07/2026 PM dose the SBP was 112 mmHg - the 05/08/2026 PM dose the SBP was 102 mmHg In an interview on 05/12/2026 at 10:13 AM, LPN-B confirmed that LPN-B reviewed the above values and confirmed Resident 15's Hydralazine HCL was administered on the above dates with and SBP of < 115 mmHg and should not have been. LPN-B confirmed that would be a medication error. A record review of Resident 5's Clinical Resident Profile (a sheet containing residents name, code status, primary diagnosis, admission date, personal contacts information and medical professionals contact information) revealed Resident 5 was admitted to the facility on [DATE]. A record review of Resident 5's Care plan (Care Plan – a personalized, actionable document that outlines a patient's health needs, goals, and specific interventions to manage their care) revealed the following diagnoses: Essential Hypertension (high blood pressure with no single, identifiable medical cause), Cardiomyopathy (a disease of the heart muscle, causing it to become enlarged, thick or rigid, making it harder for the heart to pump blood effectively to the rest of the body), Paroxysmal Atrial Fibrillation (a type of irregular, rapid heart rhythm that starts and stops suddenly, with episodes typically lasting less than 7 days, often resolving on their own) and Hypotension (abnormally low blood pressure, generally lower than 90/60 mmHg (mmHg – a standard unit used to measure blood pressure). A record review of Resident 5's Order Summary (a consolidated, authorized record of instructions from a licensed provider detailing a resident's care, treatment, medications, and services) dated 5/11/2026 revealed the following orders: -Daily BP (blood pressure – the force of blood pushing against the artery wall) and HR (heart rate – the number of times a heart beats in a minute); Call if HR>115, SBP (systolic blood pressure – the first number in a blood pressure reading, measuring the maximum pressure in your arteries when your heart beats and pumps blood out) <90 or SBP>180. every shift for BP & (heart rate) HR monitor. Date: 09/10/2024 -Midodrine HCl (a prescription medication used to treat a sudden drop in blood pressure upon standing which works by restricting blood vessels to increase blood pressure)Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet via PEG -Tube (Percutaneous Endoscopic Gastrostomy – a soft flexible feeding tube inserted through the abdomen directly into the stomach to deliver nutrition fluids, and medication) three times a day for hypotension (low blood pressure) Hold if SBP> 120 mmHg sitting; take at least 4 hours prior to bedtime. Dated: 12/20/2025 -Metoprolol Tartrate (a prescription medication used to treat high blood pressure by slowing the heart rate and reducing strain on the heart) Oral Tablet 25mg. Give 12.5 milligrams (mg) by mouth two times a day for HTN Hold if SBP <90 or HR <60 Dated: 02/02/2026. A record review of Resident 5's Medication Administration Record (MAR) revealed the following information: Residents 5's morning HR on 4/8/2026 was 58 beats per minute (bpm), on 4/10/2026 it was 58, on 4/17/2026 it was 58, on 4/20/2026 it was 43, and on 4/29/26 it was 56. Resident 5 received Metoprolol Tartrate 12.5mg on each of these days. The medication order the Metoprolol was to be held (not given) for HR of less than 60. Resident 5's morning BP was 72/40 on 4/5/2026. It was 81/29 on 4/12/2026, 78/56 on 4/14/2026 and 88/58 on 4/29/2026. Resident 5 received Metoprolol Tartrate 12.5mg on each of these days. The medication order stated Metoprolol Tartrate should be held for SBP of less than 90. Resident 5's BP was 131/81 on 4/1/2026 at 2:00PM, 128/60 on 4/2/2026 at 2:00PM, 125/85 on 4/9/2026 at 2:00PM, 133/84 on 4/10/2026 at 2:00PM, 125/81 on 4/16/2026 at 2:00PM, and 132/76 on 4/19/2026 at 2:00PM. Resident 5 received Midodrine HCL 5mg on these dates for the mid-afternoon medication pass. The medication order stated Midodrine HCL was to be held if the SBP was greater than 120. An interview on 5/11/2026 at 10:20 AM with RN J confirmed the Metoprolol should not have been given on 4/1/2026, 4/10/2026,4/17/2026, 4/20/2026, and 4/29/2026 due to Resident 5's heartrate was less than 60 on these dates. An interview on 5/11/2026 at 10:20 AM with RN J confirmed the Metoprolol should not have been given on 4/5/2026, 4/9/2026, 4/12/2026, 4/14/2026, and 4/29/2026 because Resident 5's SBP was less than 120 on these dates. An interview on 5/11/2026 at 10:20 Am with RN J confirmed the Midodrine should not have been given for Resident 5's 2:00 PM BP on 4/1/2026, 4/2/2026, 4/9/2026, 4/10/2026, 4/16/2026 and 4/19/2026. RN J confirmed the Midodrine was to be held if the SPB was greater than 120. RN J confirmed each instance was a medication error.

Licensure reference: 175 NAC 12-006.09(J)(i)(l) Based on record review and interview, the facility failed to monitor nutritional status after implementation of nutritional interventions for weight loss for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 111 residents. Findings are:A.A review of facility policy dated 4/1/24 titled Weight Monitoring revealed the following:- Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status.- A weight monitoring schedule will be developed upon admission for all residents: a. Weights should be recorded at the time obtained. Mathematical rounding should be utilized (i.e., if weight is X.5 pounds [lbs.] or more, round weight upward to the nearest whole pound. If weight is X.1 to X.4 [lbs.] round down to the nearest whole pound). b. Newly admitted residents-monitor weight weekly for 4 weeks c. Residents with weight loss-monitor weight weekly d. If clinically indicated-monitor weight daily e. All others-monitor weight monthly B.A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a Diagnosis of Alzheimer's disease with late onset and chronic kidney disease, stage 3 unspecified. Resident 3's admission Record identified family member as POA [Power of Attorney]. A review of Resident 3's quarterly MDS [Minimum Data Set: a comprehensive assessment used for care planning] dated 12/29/25 revealed the following:-Resident 3 scored a 12 on Brief Interview for Mental Status exam with a score of 8-12 identified as moderate impairment-Resident 3 is identified as independent with eating-Resident 3 was not identified as having a weight loss of 5% or more in last month or 10% or more in last 6 months A review of Resident 3's Care Plan revealed a focus area related to nutritional status which was initiated on 7/2/25 and updated on 1/15/26. Resident 3 was identified with significant weight loss and admitted to hospice care with loss being identified as unavoidable. Interventions identified for Resident 3 included the following:-Offer/assist Resident 3 as needed with meals initiated 1/27/26-provide and serve diet as ordered-mech soft revised on 10/8/25-Dietary Manager to discuss food preferences with resident or family upon admission and as needed initiated on 7/2/25 A review of dietary note dated 11/29/25 revealed Resident 3 had a current body weight of 137 lbs. which was identified as 3.5% loss in 30 days. Interventions for Resident 3 were listed as add med pass 60 cc three times per day, monitor weight, continue diet as ordered and offer snacks as requested. Registered Dietitian to monitor oral intake, diet status, weight trends and skin integrity. A review of dietary note dated 12/18/25 revealed Resident 3 had a current body weight of 134.8 lbs. which was identified as 8.9% weight loss in 90 days with a new intervention of prealbumin lab being ordered. The plan included review of prealbumin, continue diet as ordered and offer snacks as requested. The Registered Dietitian would monitor oral intake, diet status, weight trends and skin integrity. A review of provider orders for Resident 3 revealed an order dated 12/16/25 for a prealbumin lab [a lab to assess nutritional status] for Resident 3 due to unintended weight loss. A review of Resident 3 electronic medical record did not reveal any results for prealbumin order dated 12/16/26. In an interview on 1/29/26 at 4:50 PM, Regional Nurse Consultant C confirmed that no results could be located for prealbumin lab ordered on 12/16/26. A review of Resident 3's Weight and Vital Summary report revealed a weight on 12/2/25 of 134.8 lbs. and the next recorded weight on 1/7/26 of 121 with reflected a weight loss of 13.8 lbs. or 10.2% between 12/2/25 and 1/7/26. A review of Resident 3's order dated 1/8/26 revealed an order for prealbumin lab for weight loss and order for Mirtazapine 15 mg [an antidepressant] at night for dementia with depression and weight loss. A review of Resident 3's Weight and Vital Summary report revealed a weight on 1/14/16 of 114 lbs. which reflected a loss of 7 lbs. or 5.79% in one week. A review of Resident 3's prealbumin lab dated 1/14/26 revealed a level of 14 which could indicate malnutrition. A review of Social Service Note for Resident 3 dated 1/15/26 revealed Resident 3 was admitted to hospice. In interviews on 1/29/26 at 12:55 PM and 4:35 PM, Registered Dietitian A had confirmed that weekly weights were not started. Registered Dietitian A reported Resident 3 was started on med pass supplement and reviewed at weekly risk meeting weight loss.

Licensure reference: 175 NAC 12-006.04(F)(i)(5) Based on interview and record review, the facility failed to notify resident representative of changes in treatment and significant weight loss for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 111 residents. Findings are:A.A review of facility policy dated 2024 titled Notification of Changes revealed: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. The facility further identified the following circumstances that required notification:- 1. Accidents a. Resulting in injury. b. Potential to require physician intervention.- 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include: Life-threatening conditions, orClinical complications- 3. Circumstances that require a need to alter treatment.This may include:New treatment.Discontinuation of current treatment due to:Adverse consequencesAcute conditionExacerbation of a chronic condition.- 4. A transfer or discharge of the resident form the facility.- 5. A change of room or roommate assignment.- 6. A change in resident rights. B.A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset and chronic kidney disease, stage 3 unspecified. Resident 3's admission Record identified family member as POA [Power of Attorney]. In interviews on 1/27/26 at 10:47 AM and 1/28/26 at 8:40 AM, the POA reported being told Resident 3 was losing weight and would be starting on a supplement during a care conference that had occurred 3-4 months ago. The POA reported that the POA had heard nothing more about Resident 3's weight loss until 2 weeks prior when Resident 3 was put on hospice. A review of Social Service Note dated 10/22/25 revealed a care plan conference was held for Resident 3 with POA in attendance. Social Service Note did not identify weight loss as a concern. A review of Resident 3's Weight and Vital Summary report revealed the following weights for Resident 3:-7/1/25 152.5 lbs.-7/6/25 151.5 lbs.-8/21/25 147 lbs.-9/9/25 148 lbs.-9/30/35 145.8 lbs.-10/16/25 142 lbs.-11/20/25 137 lbs., -10% change [comparison weight 7/1/2025 152.5 lbs. -10.2%, -15.5 lbs.]-12/2/25 134.8 lbs., -10% change [Comparison Weight 7/1/2025, 152.5 lbs., -11.6%, -17.7 lbs.] -7.5% change [comparison weight 9/9/25, 148.0 lbs., -8.9%, -13.2 lbs.]-1/7/26 121 lbs., -10% change [comparison weight 8/21/2025, 147.0 lbs., -17.7%, -26.0 lbs.]-5% change [Comparison weight 12/2/2025, 134.8 lbs., -10.2%, -13.8 lbs.]-7.5% change [comparison weight 10/16/2025, 142.0 lbs., -14.8%, -21.0 lbs.]-1/14/26 114 lbs.-10.0% change [comparison weight 8/21/2025, 147.0 lbs., -22.4%, 33.0 lbs.] -5.0% change [comparison weight 1/7/2026, 121.0 lbs., -5.8%, -7.0 lbs.] -7.5% change [comparison weight 10/16/2025, 142.0 lbs., 19.7%, -28.0 lbs.] A review of Dietary Progress Note dated 11/29/25 revealed Resident 3 was started on med pass 60 cc [nutritional supplement], three times per day for slow weight loss. A review of Health Status Note dated 11/25/25 revealed new order to start Resident 3 on KCL [potassium chloride] 40 meq. once per day for hypokalemia [low potassium]. A review of Nurses Note dated 12/11/25 revealed new order was received to start Resident 3 on Metformin [a medication used to treat high blood sugars] 500 mg twice per day for prediabetes. A review of Health Status Note dated 1/8/26 revealed new order to start Resident 3 on Mirtazapine [an antidepressant] 15 mg every night for dementia with depression and weight loss. A review of physician order for Resident 3 dated 1/8/26 revealed an order for prealbumin [a lab test used to assess nutritional status] lab test due to weight loss. A review of provider orders for Resident 3 dated 1/8/26 revealed orders for weekly weights and renal ultrasound due to history of mass to significant weight. A handwritten note on order sheet identified that family declined ultrasound. A review of 1/14/26 Social Service Note revealed email was sent to Resident 3's POA regarding Resident 3 refusing meals, not eating, significant weight loss and sleeping a lot. The email suggested a discussion about hospice. A review of Resident 3's Progress Notes between 10/20/25 and 1/8/26 did not reveal any documentation of Resident 3's POA being notified of Resident 3's weight changes, orders for prealbumin lab, new orders for potassium chloride, metformin, and mirtazapine. A review of Medical Professional Progress Notes dated 10/15/25, 10/27/25, 11/18/25, 11/24/25, 12/12/25, 1/5/26, and 1/8/2026 did not reveal any documentation of Resident 3's POA being notified of Resident 3's weight changes, orders for prealbumin lab, new orders for potassium chloride, metformin, and mirtazapine. In an interview on 1/29/26 at 12:55 PM, Registered Dietitian A confirmed that Registered Dietitian A had not spoken with Resident 3's family regarding Resident 3's weight loss. In an interview on 1/29/26 at 3:09 PM and 4:18 PM, ADON B [Assistant Director of Nursing] confirmed that the nurses are to notify POA of changes in condition including weight loss and changes in medication. ADON B confirmed ADON B contacted Resident 3's POA about weight loss and kidney ultrasound on 1/8/26 and family declined. ADON B confirmed that no additional information could be located regarding notification of Resident 3's POA.

The facility failed to ensure all food stored in the facility's kitchen was labeled, sealed, and/or dated, ensure food was discarded that was past it's use-by date, and failed to ensure all kitchen equipment was clean and sanitized. This had the potential to affect all residents that consume food from the kitchen.A record review of the facility's Food Safety Requirements with a date reviewed/revised of 5/2025 revealed facility staff shall inspect all food, product, and beverages for proper storage to include labeling, dating, and monitoring food so it is used by its use by date. All equipment used shall be cleaned and sanitized. A.An observation on 12/10/2025 at 7:12 AM - 8:04 AM The True 2 door reach-in fridge contained a bag of a green leafy substance that was not labeled or dated. The true 2 door reach-in fridge by the double ovens had contained a plastic bag of brown patties that was not labeled and dated and 1 gallon container of Mayonnaise that had been opened with no open date. The walk-in refrigerator contained one personal can of Pepsi and one 5-pound container of low fat cottage cheese that had a best if used by date of 11/22/25. There were three 6.5-pound cans of [NAME] Country Style Gravy with a Best Buy date of September 14, 2025 on the can rack in the dry storage rack. The dry storage contained 1 large, opened bag of all-purpose flour sealed or dated. An observation on 12/10/2025 at 8:04 AM with the Dietary Manager (DM) revealed all of the above listed items were not labeled, dated, and/or sealed and there were items past their use-by date. In an interview on 12/10/2025 at 8:04 AM, the DM confirmed all of the above listed items were not labeled, dated, and/or sealed and should have been, or were past their use-by date and should have been discarded. B.An observation on 12/10/2025 at 7:12 AM - 8:04 AM revealed the bottoms of the [NAME] double oven contained a black crust. The True 2 door reach-in refrigerator's (fridge) by the back exit had vents on the bottom front that had food splatters throughout. The true 2 door reach-in fridge by the double ovens had vents on the bottom front that contained food splatters and debris. The large commercial mixer and stand had food debris and splatters on it. The walk-in refrigerator contained an internal thermometer that had a black slimy substance on it. The walk-in freezer floor had food debris and kernels of corn scatter throughout. Ther was a black cart by the walk-in freezer that contained food debris. The drawers on the prep table by the walk-in fridge and freezers contained food debris. The top and front of the milk cooler by the back door contained food splatters on the top and front. The ceiling vent by the back door and one in the dry storage area contained a thick gray fuzzy substance. There was 1 box of Grove Cranberry Juice Cocktail on the floor and 1 box of Marinara Sauce on the floor in the dry storage area. One opened large bag of all-purpose flour not labeled dated sealed. It was labeled. An observation on 12/10/2025 at 8:04 AM with the Dietary Manager (DM) revealed all of the above listed items were not clean. In an interview on 12/10/2025 at 8:04 AM, the DM confirmed all of the above listed items were not clean and should have been.

Licensure Reference Number 12-006.09(H)(vi)(3)g Based on observation, interview and record review the facility failed to ensure oxygen and BiPap orders were obtained and followed for 1 (Resident 73) of 4 residents sampled. The facility census was 113. The findings are:Record review of the facility policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) dated 05-20-2025 revealed it is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. BiPAP or bi-level positive airway pressure, is a respiratory therapy intervention that delivers an inhale pressure and an exhale pressure to provide a patent airway. It requires a machine that generates the separate pressures through a tube into a mask that fits over the nose or mouth. A personal BiPAP device may be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. Record review of Resident 73's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 10-30-2025 revealed the facility staff assessed the following about the resident:-had a diagnosis of morbid obesity with alveolar hypoventilation (a condition where excess weight impairs breathing and requires a treatment of positive airway pressure).-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicated a person is cognitively intact. -had a noninvasive mechanical ventilator.-had shortness of breath while lying flat.-required extensive assistance with bathing and lower body dressing.-required total assistance with toileting, bed mobility and transfers. Record review of Resident 73's After Visit Summary (AVS) dated 10-24-2025 revealed an order for BIPAP AUTO, use every night as directed. Settings 14/6 and back up rate 16. Record review of Resident 73's Comprehensive Care Plan (CCP: a document describing agreed goals of care, and outlining planned medical, nursing and allied health activities for the resident.) dated 10-24-2025 revealed Resident 73 had impaired respiratory status and was at risk of shortness of breath, respiratory distress, increased anxiety and hypoxia. Interventions the staff were to use included the BiPAP per order and to ensure settings and supplementary oxygen are correct each time the device is applied. An observation conducted on 12-10-2025 at 8:15 AM revealed Resident 73 had a BiPAP machine on the bedside table next to the bed. An interview conducted with Resident 73 on 12-16-2025 at 9:20 AM revealed the facility staff attach supplementary oxygen to the BiPAP when the machine is used. An interview conducted on 12-16-2025 with Registered Nurse (RN) F at 10:05 am revealed Resident 73's BiPAP machine was brought from home and the staff at the facility do not program or adjust the settings on BiPAP machines. The machine is either brought from home with the settings already programmed or the facility has their respiratory company come to the facility and set up the machine. An observation on 12-16-2025 at 10:10 am of RN F checking Resident 73's BiPap revealed the inability to verify BiPAP machines settings. An interview with the Regional Nurse Consultant (RNC) on 12-16-2025 confirmed Resident 73's BiPAP machine had not had the settings verified by facility's respiratory company and the facility had not obtained orders for supplementary oxygen to be used with the BiPAP. The RNC confirmed this should have been done and wasn't.

Licensure Reference Number 175 NAC 12.006.02(H) Based on observation, interview, and record review, the facility failed to ensure Adult Protective Services (APS) was notified within 2 hours of an allegation (a statement, made without giving proof, that someone has done something wrong) of potential abuse for 1 (Resident 51) of 3 sampled residents. The total facility census was 113. Findings are:A record review of the facility's Abuse, Neglect, and Exploitation policy with a Date Reviewed/Revised of 8/4/25 revealed an alleged violation is: A situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Reporting of all alleged violations to the Administrator, state agency, adult protective services would be done immediately, but no later than 2 hours after the allegation was made if the allegation involves abuse, or result in serious bodily injury. A record review of Resident 51's Comprehensive Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 11/28/2025 revealed the resident was admitted to the facility 04/04/2023. 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 required supervision or touching assistance with eating, oral and personal hygiene (cleaning), and was dependent on staff for all other activities of daily living and mobility. The resident did not have behaviors, and it was very important to the resident to choose their own bedtime. A record review of the facility's un-named investigation form dated 12/10/25 at 12:20 PM revealed that was the date and time that APS was contacted and the Notification to Administrator/Director of Nursing (DON) was at 9:00 AM. An observation on 12/10/2025 at 9:33 AM revealed Resident 51 was lying in bed and appeared upset. An observation on 12/10/2025 at 9:42 AM revealed Registered Nurse (RN)-D was on the phone with the administration and overheard the RN-D tell the administration that the resident reported a nursing assistant (NA) bumped Resident 51's head against the side rail of the bed during cares last night. An observation on 12/10/2025 at 11:13 AM revealed staff just got Resident 51 up into the wheelchair. The resident pointed to an area on the right side of the forehead where the resident's head was bumped against the bed rail, and the resident did have a dime size diameter (round) raised area on the right side of the forehead 1 inch in front of a dark mole. In an interview on 12/10/2025 at 9:33 AM Resident 51 confirmed the resident felt afraid or humiliated by the staff because a staff member was rough during a brief change early that morning and rolled the resident toward the window and the resident hit the resident's forehead on the bedrail. The resident confirmed the resident reported the staff member being rough and hitting the resident's head on the bed rail to the nurse that was on during the interview, but the resident confirmed the resident was just trying to be peaceful. In an interview on 12/10/2025 at 9:36 AM, RN-D confirmed Resident 51 did report a staff member last night was rough and bumped the resident's face into the bed rail. RN-D confirmed the resident told RN-D the resident was hit on the right upper forehead. RN-D confirmed the resident did not know the staff member's name and that RN-D had not reported the incident to anyone. In an interview on 12/10/2025 at 9:46 AM, RN-D confirmed RN-D was on the phone with the Director of Nursing (DON) and told the DON about the situation. RN-D confirmed Resident 51 told RN-D what happened with the staff member during RN-D's medication pass which was at about 8:46 AM. In an interview on 12/10/2025 at 11:13 AM, Resident 51 confirmed that staff had not been in to talk to the resident about the incident with the staff member during the morning brief change. The resident confirmed the staff member came in and woke the resident up to change the resident's brief and that is when the staff member came in acting all ugly. The resident was not afraid to be in the facility but would not let that staff member help the resident again. He confirmed it seemed like (gender) was in a rage. When the staff member got ready to change the resident diaper the staff member rolled the resident over, and the resident was trying to stop the staff member, but the staff member kept pushing. The resident confirmed he told the staff member to stop, the staff member was pushing the resident's head against the rail. The resident confirmed the resident still had a little knot on the resident's head. He confirmed the staff member was getting mad and the resident was getting mad, so told the staff member to stop. In an interview on 12/10/2025 at 11:37 AM, the DON confirmed the RN-D called the DON that morning and the DON thought RN-D told the DON that Resident 51 bumped the resident's hand on the bedside table and that RN-D did not see any injuries. RN-D was going to assess the resident and call the doctor. In an interview on 12/10/2025 at 11:48 AM, RN-D confirmed RN-D spoke to the DON on the phone that morning and told the DON that Resident 51 reported that the NA on the night shift bumped the resident's head on the siderail, on the upper forehead above the right eyebrow. The resident did not give RN-D a name or description of the NA. The resident said the NA turned the resident too far and hit the resident's head on the bedrail. In an interview with the facility's Administrator confirmed the Regional Director of Operations (RDO) was on the phone at the time of the interview and the RDO called APS about the allegation on 12/10/2025 at 12:20 PM. In an interview on 12/15/2025 at 2:35 PM, the DON confirmed that if there was an allegation of potential abuse, APS should be contacted within 2 hours of a person reporting it to a staff.

.Based on record review and interview, the facility failed to evaluate and identify situational triggers for post -traumatic stress disorder [PTSD, a psychological reaction occurring after experiencing a highly stressing event (such as wartime combat, physical violence, or a natural disaster) that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of reminders of the event] for 1 (Resident 12) of 2 residents reviewed. The facility census was 113. Findings are:Record review of a facility policy entitled Trauma Informed Care dated 3/25/25 revealed the following information: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and / or re-traumatization. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual wellbeing. Common sources of trauma may include but are not limited to: Natural and human caused disasters, accidents, rape, violent crime, physical, sexual, mental and /or emotional abuse past or present, war, history of imprisonment, history of homelessness, traumatic life events (death of a loved one. Personal illness etc). Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effect of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his/her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools, such as the RAI [Resident assessment instrument, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities], admission assessment, the history and physical, the social history / assessment and others. 4. The facility collaborates with resident trauma survivors, and as appropriate the family and physician and other health professionals such as mental health professionals to develop and implement individualized care plan interventions. 6. The facility will identify triggers which may re-traumatize residents with history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents' care plan. 7. Trauma specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression and anxiety. These interactions will also recognize the survivors need to be respected, informed, connected and hopeful regarding their own recovery. 8. The facility will evaluate whether the interventions have been able to mitigate or reduce the impact of identified triggers on the residents that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. 10. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Record review of Resident 12's Face Sheet dated 12/11/25 revealed an admission date of 9/30/16 with diagnoses that included PTSD chronic, unspecified Dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, Bipolar Disorder[mental illness characterized by mood changes], Schizoaffective Disorder [mental health condition that combines symptoms of schizophrenia such as hallucination with mood disorder symptoms like depression or mania [elevated or irritable mood], Major Depressive Disorder and Anxiety Disorder. Record review of Resident 12's most recent quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 10/30/25 identified that Resident 12 exhibited short- and long-term memory problems and modified independence with decision making with some difficulty in new situations only. The resident exhibited no mood concerns, and no behaviors were exhibited. Diagnoses identified on the MDS included PTSD, anxiety, Depression, Bipolar Disorder and Schizophrenia. The MDS identified that Resident 12 took antipsychotic [a class of medications used to manage psychosis in Schizophrenia], antidepressant and antianxiety medications daily. Record review of Resident 12's Electronic Medical Record [EMR], including progress notes, clinical assessments and the Comprehensive Care Plan {a document that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs] dated 10/27/25 revealed no evaluation for PTSD had been completed for Resident 12. The EMR and CCP did not identify situational triggers or specific interventions that would identify ways to decrease Resident 12's exposure to triggers which could re-traumatize the resident. Interview on 12/15/25 at 3:27 PM with the Regional Nurse Consultant [RNC] confirmed that Resident 12 had a diagnosis of PTSD. The RNC confirmed there was no history of trauma identified in the EMR and PTSD had not been evaluated and should have been. The RNC confirmed that Resident 12's CCP did not identify situational triggers or specific interventions that would identify ways to decrease Resident 12's exposure to triggers.

Licensure Reference Number 175 NAC 12-006. 09(H)Based on record review and interview, the facility failed to hold blood pressure medications according to prescribed blood pressure parameters for 2 (residents 1 and 3) of 5 sampled residents. The facility census was 113. Findings are: A. A record review of the facilities Medication Administration policy with a revision date of 10/15/25 revealed the following: Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A record review of the facilities Unnecessary Drugs-Without Adequate Indication for Use policy with a revision date of 11/4/24 revealed the following: Information gathered during the initial and ongoing evaluations will be incorporated into the resident's comprehensive care plan that reflects person-centered medication related goals and parameters for monitoring the residents condition, including the likely medication effects and potentials for adverse consequences. A record review of Resident 3'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 11/28/25 revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a BIMS score of 15 indicated that the residents had intact cognition. Further review of the MDS revealed a diagnosis of coronary artery disease, heart failure, and hypertension. A record review of Resident 3's Medication Administration Record (MAR) dated 11/2025 and 12/2025 revealed an order for Metoprolol Tartrate 25 milligram (mg) Give 0.5 tablet by mouth two times a day related to essential hypertension. Hold medication if pulse (p) is below 60 and/or Systolic Blood Pressure (SBP, the top number in a blood pressure reading) is below 110 and or Diastolic Blood Pressure (DBP, the bottom number in a blood pressure reading) is below 60. Further review of Resident 3's MAR revealed the following medication administration outside of parameters: -11/2/25 AM bp 106/63, p50, -11/4/25 PM bp 105/66, p84, -11/9/25 AM bp 101/59, p55, -11/9/25 PM bp 101/59, p55, -11/11/25 AM bp 109/71, p54, -11/17/25 PM bp 108/57, p50, -11/21/25 PM bp 111/62, p50, -12/1/25 PM bp 104/62, p66, -12/13/25 PM bp 95/80, p71. In an interview on 12/16/25 at 7:13 AM the Director of Nursing (DON) confirmed that the administration of Metoprolol on 11/2/25 AM, 11/4/25 PM, 11/9/25 AM & PM, 11/11/25 AM, 11/17/25 PM, 11/21/25 PM, 12/1/25 PM, and 12/13/25 was given outside of parameters and should not have been administered. B. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-20-2025 revealed the facility staff assessed the following about the resident: -Had a diagnosis of orthostatic hypotension (a sudden drop in blood pressure when moving from sitting to standing). -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicated a person was cognitively intact. -Required supervision with eating, bathing, toileting and transfers. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 08-07-2024 revealed Resident 1 had hypotension. The interventions the staff were to use included giving medications as ordered, monitor for side effects and effectiveness, and obtain vital signs (blood pressure, pulse, respiration rate, temperature) as ordered. Record review of Resident 1's Medication Administration Record (MAR) for November 2025 printed on 12-11-2025 revealed an order dated 03-24-2025 for hydralazine (a blood pressure medication) 25 milligram (mg) tablet, give 1 tablet 3 times a day for a Systolic Blood Pressure (SBP: the top number of a blood pressure reading) of greater than 160 or a Diastolic Blood Pressure (DBP: the bottom number of a blood pressure reading) greater than 90. Further review of the November 2025 MAR revealed on the following dates hydralazine was administered outside of the prescribed parameters: -11-03-2025 at 9 AM Blood Pressure (BP) was 125/83. -11-03-2025 at 9 PM BP was 112/66. -11-06-2025 at 9 PM BP was 119/86. -11-07-2025 at 9 PM BP was 132/76. -11-08-2025 at 9 AM BP was 125/78. -11-09-2025 at 9 AM BP was 98/53. -11-12-2025 at 2 PM BP was 128/87. -11-14-2025 at 9 PM BP was 105/65. -11-15-2025 at 9 PM BP was 130/79. -11-16-2025 at 9 PM BP was 125/79. -11-17-2025 at 9 AM BP was 120/62. -11-17-2025 at 2 PM BP was 120/62. -11-19-2025 at 9 PM BP was 82/48. Record review of Resident 1's November 2025 MAR revealed an order dated 11-25-2025 for Midodrine 5 mg tablet give 1 tablet 3 times a day for hypotension hold if SBP is greater than 120 while sitting. Further review of the November 2025 MAR revealed on the following dates Midodrine was administered outside of the prescribed parameters: -11-26-2025 at 8 PM BP was 134/96. -11-28-2025 at 8 PM BP was 145/89. -11-29-2025 at 2 PM BP was 145/82. An interview conducted with the Regional Nurse Consultant on 12-16-2025 at 10:55 AM confirmed the midodrine and the hydralazine medications were administered outside of the prescribed parameters, should have been held and wasn't.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications revealed 4 errors with a resulting error rate of 16%. The medication errors are related to 1 (Resident 100) of 4 sampled residents. The facility census was 113.Findings are:A record review of the facilities Medication Administration policy with a revision date of 10/15/25 revealed the following: Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation A record review of the facilities Medication Errors policy with a revision date of 8/16/25 revealed the following: The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. A record review of Resident 100's medication administration record (MAR) dated 12/2025 revealed the following:-Tylenol Extra Strength Oral Tablet 500 milligrams (mg) (Acetaminophen) Give 2 tablet via Percutaneous Endoscopic Gastrostomy (PEG)-Tube (a feeding tube in the stomach that can be accessed outside the body) three times a day for pain with scheduled administration times of 8:00 AM, 2:00 PM, and 10:00 PM.-Clonidine HCl Oral Tablet 0.2 mg (Clonidine HCl) Give 1 tablet via PEG-Tube two times a day for hypertension (HTN). Hold for Systolic Blood Pressure (SBP, the top number in a blood pressure reading) less than (<)100.-Amlodipine Besylate Oral Tablet 5 mg (Amlodipine Besylate) Give 1 tablet via PEG-Tube one time a day for HTN. Hold for SBP<130-Valproic Acid Oral Solution 250 mg/5 milliliter (ml) (Valproate Sodium) Give 5 ml via PEG-Tube two times a day related to adjustment disorder with depressed mood. An observation on 12/16/25 at 9:22 AM revealed Licensed Practical Nurse (LPN)-G dispensed two tablets of Tylenol, one tablet of clonidine, one tablet of amlodipine and placed each medication into a clear pouch. LPN-G crushed each medication and dumped the pouch into a medication cup. LPN-G grabbed a bottle of valproic acid with another resident's name on it and poured it into a medication cup. LPN-G entered the resident's room and mixed each medication cup with water and administered the medications through the PEG-tube. LPN-G did not obtain a blood pressure for the amlodipine or clonidine. LPN-G administered the Tylenol 1 hour and 22 minutes after the scheduled administration time. LPN-G administered the valproic acid to Resident 100 after LPN-G obtained the medication from another resident's pharmacy dispensed medication bottle.In an interview on 12/16/25 at 10:40 AM, LPN-G confirmed that valproic acid of another resident was administered to Resident 100. LPN-G confirmed that Tylenol was administered outside of the administration window. LPN-G further confirmed a blood pressure was not obtained with the Amlodipine and Clonidine and should have been.

Licensure reference: 175 NAC 006.11 Based on observation, interview and record review, the facility failed to ensure to physician's ordered diet was followed for 1 [Resident 122] of 1 sampled resident with orders for a renal diet. The facility had a total census of 113. Findings are:A review of Resident 122's admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dependence on renal dialysis and end stage renal disease [a stage of impairment that appears irreversible and permanent]. A review of Resident 122's order summary revealed an order dated 12/3/25 of a renal diet with regular texture and thin liquid consistency. A review of Resident 122's care plan revealed an intervention of providing and serving diet as ordered. Observations on 12/11/25 at 12:22 PM revealed Resident 122 with lunch tray. Resident 122's lunch included chicken, cornbread, macaroni and cheese, Brussel sprouts, and pumpkin pie. A review of facility menu for 12/11/25 and Resident 122's 12/11/25 tray ticket revealed residents on a renal diet were to be served buttered macaroni noodles in place of macaroni and cheese and butterscotch pudding in place of pumpkin pie. Observations on 12/15/25 at 8:37 AM revealed Resident 122 with breakfast tray. Resident 122's breakfast included French toast casserole, bacon, oatmeal, and chocolate milk. A review of facility menu for 12/15/25 and Resident 122's 12/15/25 tray ticket revealed residents on a renal diet were to be served 2 slices of French toast in place of French toast casserole and 1/4 cup scrambled eggs in place of the bacon. In an interview 12/15/25 at 2:11 PM, Registered Dietitian I reported that menu modifications from the regular diet automatically print out on the resident's tray ticket. In an interview on 12/15/25 at 2:31 PM, the Dietary Manager confirmed that Resident 122 should have received the menu items for the renal diet and the renal diet needed to be followed. A review of facility Diet and Nutrition Care Manual dated 2021 revealed the following regarding the Renal Dialysis Diet:- Individuals placed on this diet are often limited in the amount of sodium, fluid, potassium and phosphorus they can consume. Protein and calorie needs may be increased depending on the individual's health, weight, laboratory parameters and dialysis therapy.

Licensure Reference Number 175 NAC 12.006.18(B)Licensure Reference Number 175 NAC 12.006.19(A)(i) Based on observation, interview, and record review, the facility failed to ensure staff transported clean linen in a manner to prevent potential cross contamination, ensure clean sheets were utilized for Resident 70, and failed to ensure Resident 1's nebulizer (neb)(a machine used to deliver aerosolized medications to the lungs) administration kit was cleaned after each use. The facility census was 113. Findings are: A. An observation on 12/15/2025 at 7:29 AM revealed Medication Aide-A exited the laundry room and walked down the 100 hallway to Resident 11's room with unbagged, clean, bedding draped over MA-A's left arm and against MA-A's hand and clothing. An observation on 12/15/2025 at 2:55 PM revealed NA-B exited the dining room and walked to the South side of building into the resident care areas with unbagged, clean, linens being carried between NA-B's left arm and chest against NA-B's clothing. In an interview on 12/15/2025 at 2:56 AM, the facility's Regional Director of Operations (RDO) confirmed the staff should not have carried clean linens against the staff member's body or clothing. D. A record review of the facility's Nebulizer Therapy policy with a Date Reviewed/Revised of 8/24/25 revealed that the neb equipment should be cleaned after each use. When the medication delivery was complete, the staff should disassemble and rinse the neb kit with sterile or distilled water and allow it to air dry. Once it was completely dry, it should have been stored in a zip lock bag. A record review of Resident 1's Clinical Physician's Orders dated 12/11/2025 revealed Resident 1 had an order for Sodium Chloride Inhalation Nebulization Solution 3 percent (%) four times per day. A record review of Resident 1's Medication Administration Record (MAR) dated [DATE] revealed the Sodium Chloride Inhalation Nebulization Solution 3 percent (%) was administered four times per day on 12/09/2025 – 12/15/2025 during the morning (AM) medication pass, 2:00 PM, 4:00 PM, and HS (hours of sleep). An observation on 12/10/2025 at 2:07 PM revealed Resident 1 had a nebulizer on the table between the bed and recliner that had the neb kit draped over it and the kit had a residual (small, leftover) amount of medication in the kit, and the mask had facial oils on it. An observation on 12/11/2025 at 3:15 PM revealed Resident 1's neb kit was draped over the nebulizer on a table in front of the resident's window and it had a residual amount of medication in the kit, and the mask had facial oils on it. An observation on 12/15/2025 at 9:12 AM revealed Resident 1's neb kit was laying on the ledge below the window, and it had a residual amount of medication in the kit, and the mask had facial oils on it. In an interview on 12/15/2025 at 3:17 PM, Registered Nurse (RN)-F confirmed Resident 1's neb kit was supposed to be cleaned after each treatment and it had not been. C. Observation on 12/15/2025 at 9:08 AM with NA [Nurse Aide] E on the secured unit of the facility revealed NA-A carried a set of clean sheets and towels to room [ROOM NUMBER]. The clean sheets and towels were draped across NA-E's bare forearm. Interview on 12/15/25 at 9:15 AM with NA-E confirmed that clean linens should not be carried in contact with the staff member's arm. D. Record review of Resident 70's most recent quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/3/25 revealed an admission date of 4/18/24 with Diagnoses that included Non-Alzheimer's Dementia and Psychotic Disorder [severe mental illnesses characterized by disconnection from reality]. The MDS identified that Resident 70 was independent with transfers and ambulation and was occasionally incontinent of urine. Observation on 12/10/2025 at 8:02 AM revealed sheets on the bed in room [ROOM NUMBER]-B for Resident 70 were heavily soiled with a large, circular yellow brown substance that resembled a dry urine ring. Observation on 12/10/2025 at 12:25 PM revealed sheets on the bed in room [ROOM NUMBER]-B for Resident 70 were heavily soiled with a large, circular yellow brown substance that resembled a dry urine ring. Observation on 12/11/2025 at 2:36 PM revealed sheets on the bed in room [ROOM NUMBER]-B for Resident 70 were heavily soiled with a large, circular yellow brown substance that resembled a dry urine ring. Observation on 12/15/2025 at 7:05 AM revealed sheets on the bed in room [ROOM NUMBER]-B for Resident 70 were heavily soiled with a large, circular yellow brown substance that resembled a dry urine ring. Observation on 12/15/2025 at 9:08 AM with NA-E observed and confirmed that the sheets in Resident 70's were soiled with a large, dried urine ring and needed to be changed. NA-E confirmed that the sheet smelled of urine when the comforter was pulled back. Interview on 12/15/25 at 9:15 AM with NA-E confirmed that Resident 70's sheets were soiled with a large, dried urine ring and needed to be changed. NA-A confirmed the sheet smelled of urine when the comforter was pulled back.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interviews, the facility failed to maintain the carpets in clean condition to prevent urine odors in 13 resident rooms (Rooms 103, 105, 106, 109, 203, 205, 207, 208, 311, 317, 407, 409) of 45 occupied resident rooms on the north side of the building and the carpets throughout the 100, 200, 300 and 400 hallways of the north side of the facility. This had the potential to affect 17 residents that resided in those rooms. The facility had a total of 81 occupied resident rooms in the facility. The facility census was 110. Findings are: Observation during the environmental tour 6/25/25 between 8:00 AM and 9:50 AM, with the facility Maintenance Director [MD], Housekeeping Director [HD] and Administrator [ADM], revealed the following environmental concerns in resident use areas in the facility: - Carpets were stained in spots on the north side of the building on the 100, 200, 300 and 400 hallways. - A piece of carpet was pulled up and folded over itself beside the vending machine in the 400 hallway. - Carpets were stained in spots with a strong odor of urine present in resident rooms 103, 105, 106, 109, 203, 205, 207, 310, , 315, 317, 407, and 409. - Carpets were stained in spots in resident rooms 103, 105, 106, 109, 203, 208, and 311. - A strong odor of urine was present in the 100-unit hallway. - Handrails along the 100 hallway had a buildup of dust, dead bugs, food particles and trash in the space between the handrail and the wall. Interview on 06/25/25 at 09:50 AM with the facility HD confirmed that the carpets are stained in several of the rooms and several areas of the hallways on the 100, 200, 300 and 400 hallways. The HD confirmed that several of the rooms had a strong odor of urine present. The HD confirmed the build up of dust, dead bugs, food particles and trash in the space between the handrails and the walls on the 100 hall of the facility and that the carpet had not been placed under the leg of the vending machine as intended. Observation on 06/30/25 between 11:00 AM and 11:38 AM with the Housekeeping Director revealed the following environmental concerns in resident use areas in the facility: - Stained carpets in resident rooms 103, 105, 106, 109, 203, 208, and 311. - Stained carpets with strong odors of urine present in resident rooms 205, 207, 310, 315, 317, 407, and 409. - Carpets were stained in spots on the north side of the building on the 100, 200, 300 and 400 hallways. - Strong odor of urine present in the 100-unit hallway. Interview with the HD on 06/30/25 at 11:39 AM confirmed that the rooms observed had carpets that were very stained, the carpet fibers held odors of urine and urine odors were present in those rooms. The HS confirmed that housekeeping staff had tried to clean the carpets and that they would not come clean and needed to be replaced.

Licensure Reference Number 175 NAC 12-006.05 Based on record reviews and interviews, the facility failed to notify the resident and resident representative in writing of the reason for hospital transfer for 5 residents (Resident 45, 75, 70, 61 and 16) of 5 sampled resident. The facility staff identified a census of 110. The findings are: A. Record review of the facility policy Transfer and discharge date d 4/2024: 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a. obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis d. The original copies of the transfer form and Advance Directive accompany the resident. copies retained in the medical record. g. provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. A. A record review of Resident 45's admission Record revealed the facility admitted the Resident on 01/14/2024. Further review of Resident 45's admission Record identified diagnoses of Alzheimer's disease, unspecified, paroxysmal atrial fibrillation, unspecified combined systolic and diastolic heart failure. A record review of Resident 45's Significant Change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 05/22/2025 identified Resident 45 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 99. According to the MDS Manual, a score of 99 indicated that the Resident was unable to complete the interview. Record review of the Resident' 45's Progress Notes (PN) revealed Resident 45 was sent to the hospital on [DATE]. Record review of Resident 45's medical record that included PN's, faxes. practitioner orders care plan revealed there was no indications information of the reason for transfer and no indications a written notification of the transfer had been completed. In an interview on 06/25/2025 at 3:45 PM the Regional Nurse Consultant (RNC) confirmed there was no transfer form for the incident which sent the resident to the hospital on [DATE] and no written notification to the Resident's representative. B. A record review of Resident 75's admission Record revealed the facility admitted the Resident on 01/08/2024. Further review of Resident 75's admission Record identified diagnoses of hyperlipidemia, Type 1 diabetes mellitus with other specified complications. A record review of Resident 75's MDS dated [DATE] identified Resident 75 had a BIMS score of 15. According to the MDS Manual, a score of 15 indicated the Resident was cognitively intact. Record review of Resident 75's PN dated 04/04/2025 revealed an emergency discharge to the hospital. Record review of Resident 75's medical record that included PN's, faxes. practitioner orders care plan revealed there was no indications information of the reason for transfer and no indications a written notification of the transfer had been completed. In an interview on 06/25/2025 at 3:45 PM the RNC confirmed there was no transfer form for the incident and no written notification to the Resident's representative. C. A record review of Resident 70's admission Record revealed the facility admitted the Resident on 04/15/2024. Further review of Resident 70's admission Record identified diagnoses of history of falling, schizoaffective disorder, bipolar type, violent behavior and other chronic pain. A record review of Resident 70's MDS dated [DATE] identified Resident 70 had a BIMS score of 5. According to the MDS Manual, a score of 0-7 indicated the Resident had severe impairment. Record review of Resident 70's PN dated 03/11/2025 revealed Resident 70 was discharged to the hospital. Record review of Resident 70's medical record that included PN's, faxes. practitioner orders care plan revealed there was no indications information of the reason for transfer and no indications a written notification of the transfer had been completed. In an interview on 06/25/2025 at 3:45 PM the Regional Nurse Consultant (RNC) confirmed there was no transfer form for the incident which sent the resident to the hospital on [DATE] and no written notification to the Resident's representative. D. Record review of Resident 16's admission Record revealed that Resident 16 was admitted to the facility on [DATE] with diagnoses that included secondary Parkinsonism, and Alzheimer's Disease early onset. Record review of Resident 16's Clinical Census revealed that Resident 16 was discharged to the hospital on [DATE]. Record review of Resident 16's quarterly MDS dated [DATE] revealed that Resident 16 had a BIMS score of 15. The MDS manual identified that a score of 13-15 indicated the resident was cognitively intact. The MDS identified that Resident 16 had verbal behaviors exhibited toward others and rejection of care 1-3 days per week. The MDS identified that Resident 16 used a wheelchair for ambulation and required supervision with activities of daily living. Record review of a Health Status Note for Resident 16, dated 12/10/24, revealed the following information: - Note Text: Resident called 911 and stated [gender] couldn't breathe. However, resident was non-compliant with nursing staff, refused to be assessed by staff and told 911 [gender] just wanted to go to the hospital. Upon the ems's [Emergency Medical ] assignment, resident's spo2 [oxygen level] was 94%, [gender] was very aggressive and telling staff [gender] does not want them in his room. Resident took all [gender] meds this morning, and [gender] refused to sign any paperwork. [gender] was transported via stretcher and taken to [hospital]. Pa [physician assistant] [name] notified. Record review of Resident 16's Electronic Medical Record, including scanned documents, revealed no written transfer / discharge notice with the reason for transfer and the required information had been provided to Resident 16 at the time of discharge to the hospital on [DATE]. Interview on 06/26/25 at 10:58 AM with the RNC confirmed that no written transfer / discharge notice with the required information was provided to Resident 16 at the time of transfer to the hospital on [DATE]. E. Record review of Resident 61's admission Record revealed that Resident 61 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure and Type 2 Diabetes Mellitus. Record review of Resident 61's Clinical Census revealed that Resident 61 was discharged to the hospital on 4/27/25 and returned to the facility on 5/2/25. Resident 61 was discharged to the hospital again on 5/14/25 and returned to the facility on 5/29/25. Record review of Resident 61's 5 -day scheduled MDS assessment dated [DATE] revealed that Resident 61 had a BIMS score of 15. The MDS manual identified that a score of 13-15 indicated the resident was cognitively intact. The MDS identified that Resident 61 used a wheelchair for ambulation and required substantial to maximum assistance with activities of daily living. Record review of Resident 61's Health Status notes identified the following information: - 5/14/2025 10:19 Health Status Note Note Text: This ADON [assistant director of nursing] received a call back from resident's nurse at [Name] hospital who stated that resident is going to be transferred and admitted to [Name] hospital for hypotension and abnormal labs. - 5/14/2025 05:45 Health Status Note: Note Text: [Name] PA notified altered labs, B/P 84/42, unable to manage pain, TO [telephone order] send to ER, resident transferred 4:10 am per squad - 5/14/2025 10:19 Health Status Note Note Text: This ADON received a call back from resident's nurse at [name] hospital who stated that resident is going to be transferred and admitted to [name] hospital for hypotension and abnormal labs. - 4/27/2025 12:28 Health Status Note Note Text: Resident continues on Fluconazole daily for Tinea Cruris. Bilateral legs are very red, swollen, and warm to the touch. Resident complains of itching but denies any pain. Vitals: BP-106/64, P-90, R-18, T-98.4, O2-93% room air. Called Dr [Name] and [Gender] said go ahead and send [gender] to the hospital (non-emergent). Nurse called [name] for transportation. They transported resident from bed to stretcher and took resident to [hospital name] ER.[emergency room]. Record review of Resident 61's Electronic Medical Record, including scanned documents, revealed no written transfer / discharge notice with the reason for transfer and the required information had been provided to Resident 61 at the time of discharge to the hospital on 5/14/25 and 4/27/25. Interview on 06/26/25 at 10:58 AM with the RNC confirmed that no written transfer / discharge notice with the required information was provided to Resident 61 at the time of transfer to the hospital on 4/27/25 or 5/14/25.

Licensure reference: 175 NAC 12-007.04C1 Based on observation, interview, and record review, the facility failed to ensure temperatures in 59 of 76 occupied resident rooms and common areas were maintained at a safe and comfortable level. This has the potential to affect all 119 residents of the facility. The facility was notified on 2/18/25 at 8:23 PM of an Immediate Jeopardy (IJ) which began on 2/18/25. The IJ was removed on 2/19/25, as confirmed by surveyor onsite verification. Findings are: A. A review of undated, un-timed temperature log revealed the following temperatures of less than 71 degrees F [Fahrenheit]: memory care unit 67.3 F; room [ROOM NUMBER] 68.3 F; and Station 1 67 F. A notation on the log revealed the log temperatures were due to a tripped breaker and the breaker had been reset. The log also stated an electrician had been called to increase the breaker size to prevent a reoccurrence. In an interview on 2/18/25 at 5:53 PM, the DON [Director of Nursing] reported that the undated log had been completed on 2/18/25 at 3 PM and that the low temperatures were due to the breaker being tripped. Observations on 2/18/25 between 3:56 PM-4:09 PM revealed the portal heaters in hallways as follows: -500 hallway-4 portal heaters -600 hallway-3 portal heaters -700 hallway-2 portal heaters -400 hallway-1 portal heater -200 hallway-1 portal heater Observations of random resident rooms on 2/18/25 between 4:56 PM-5:30 PM revealed the following temperatures below 71 F measured by the Maintenance Director with a facility thermometer: -room [ROOM NUMBER]-69 F -room [ROOM NUMBER]-66 F -room [ROOM NUMBER]-68 F -room [ROOM NUMBER]-69.1 F -room [ROOM NUMBER]-63 F -200 hallway-64 F -room [ROOM NUMBER]-64 F -room [ROOM NUMBER]-58.6 F -room [ROOM NUMBER]-61 F -Hallway near North exit door in Memory Unit-51 F -Memory Care hallway-67 F -room [ROOM NUMBER]-61.7 F -room [ROOM NUMBER]-65.5 F -room [ROOM NUMBER]-69.6 F -800 hallway-70.5 F -room [ROOM NUMBER]-70.1 F -room [ROOM NUMBER]-70.2 F -500 hallway-66.9 F -room [ROOM NUMBER]-66.9 F -room [ROOM NUMBER]-69.6 F -room [ROOM NUMBER]-69.1 F -room [ROOM NUMBER]-67.3 F -600 hallway-64.9 F -room [ROOM NUMBER]- 68.4 F -room [ROOM NUMBER]-70.9 F -room [ROOM NUMBER]-68.9 F -room [ROOM NUMBER]-67.1 F -room [ROOM NUMBER]-69.4 F -room [ROOM NUMBER]-70 F In an interview on 2/18/25 between 4:56-5:30 PM, the Maintenance Director reported that having to many portal heaters running in the hallways will trip the breaker. In an interview on 2/18/25 between 5:53 PM-6:09 PM, the DON and RDO [Regional Director of Operations] identified the following interventions had been implemented to maintain temperatures and keep residents warm in the building: -Residents offered extra blankets -Windows covered with plastic -Facility has closed to admission for the week -Several rooms on the 700 hallway have been closed for the winter -An electrician has been hired to resolve the issues with the breakers Observations on 2/18/25 between 9:41 PM-10:23 PM of all occupied rooms revealed the following temperatures below 71 F in the building measured by the Maintenance Director with a facility thermometer: -room [ROOM NUMBER]-68.7 F -room [ROOM NUMBER]-65.5 F -room [ROOM NUMBER]-64.6 F -room [ROOM NUMBER]-63.1 F -room [ROOM NUMBER]-62.2 F -room [ROOM NUMBER]-66.2 F -room [ROOM NUMBER]-64.3 F -room [ROOM NUMBER]-68.5 F -room [ROOM NUMBER]-64.8 F -room [ROOM NUMBER]-64.9 F -room [ROOM NUMBER]-65.5 F -room [ROOM NUMBER]-59.2 F -room [ROOM NUMBER]-62.2 F -room [ROOM NUMBER]-61.9 F -room [ROOM NUMBER]-61.9 F -room [ROOM NUMBER]-61.9 F -room [ROOM NUMBER]-63.1 F -room [ROOM NUMBER]-65.6 F -room [ROOM NUMBER]-64.8 F -room [ROOM NUMBER]-62.2 F -room [ROOM NUMBER]-58.8 F -Memory Unit dining room-65.8 F -room [ROOM NUMBER]-58.8 F -room [ROOM NUMBER]-63.7 F -room [ROOM NUMBER]-61.5 F -room [ROOM NUMBER]-59.2 F -room [ROOM NUMBER]-58.1 F -room [ROOM NUMBER]-58.8 F -room [ROOM NUMBER]-65.3 F -room [ROOM NUMBER]-66.4 F -room [ROOM NUMBER]-59 F -room [ROOM NUMBER]-64.2 F -room [ROOM NUMBER]-64.8 F -room [ROOM NUMBER]-65.7 F -room [ROOM NUMBER]- 64.9 F -room [ROOM NUMBER]-61.3 F -room [ROOM NUMBER]-62.4 F -room [ROOM NUMBER]-69.8 F -room [ROOM NUMBER]-66 F -room [ROOM NUMBER]-65.1 F -room [ROOM NUMBER]-65.2 F -room [ROOM NUMBER]-63.5 F -room [ROOM NUMBER]-61.7 F -room [ROOM NUMBER]-61.9 F -room [ROOM NUMBER]-64.4 F -room [ROOM NUMBER]-63.3 F -room [ROOM NUMBER]-69.1 F -room [ROOM NUMBER]-64.4 F -room [ROOM NUMBER]-67.1 F -room [ROOM NUMBER]-62.6 F -room [ROOM NUMBER]-60.1 F -room [ROOM NUMBER]-61.5 F -room [ROOM NUMBER]-63.3 F -room [ROOM NUMBER]-69.6 F -room [ROOM NUMBER]-64.2 F -room [ROOM NUMBER]-64.2 F -room [ROOM NUMBER]-63.5 F -room [ROOM NUMBER]-67.1 F -room [ROOM NUMBER]-64.9 F -room [ROOM NUMBER]-63.5 F In an interview on 2/18/25 at 10:30 PM, the DON reported staff were checking to ensure all of the wall heaters were on in the rooms on the 700 hallway. A review of facility policy dated 8/23 titled Loss of Heating or Cooling revealed the following procedure for loss of heat: -a. Layer clothing. -b. Provide extra blankets. -c. Serve warm foods and liquids. -d. Monitor residents for signs of hypothermia. Notify physician as needed. -e. Consider partial or complete evacuation, depending on the circumstances and estimated time before heating will be restored. The Immediate Jeopardy situation was determined to have begun on 2/18/25. The facility was informed of the Immediate Jeopardy status on 2/18/25 at 8:23 PM. The facility abatement plan was implemented on 2/18/25. The specific requirements that were violated were F584 and 175 NAC 12-007.04C1. The facility implemented the following actions on 2/18/25 to remove the immediacy of situation and to protect the residents: -Every resident will have their temperature taken every two hours to assess for hypothermia. If the resident temperature drops, to the resident shows signs of hypothermia, appropriate medical treatment will be provided, beginning with moving the resident to a warmer environment. -Every occupied room temperature will be taken every hour to assure they maintain their temperature. -If the temperature drops or there are problems with the portable heaters, maintenance will be notified immediately. -If a resident is cold in their room, another room will be offered. If no other warmer rooms are available, residents will be moved to an area in the dining room for warmth. -Education will be provided to nursing staff of the temperature process and schedule. -Education will be provided to staff on the signs of the hypothermia. -A portable whole building heating unit was obtained from Nebraska Machinery. The heater will be operational by approximately midnight on 2/18/25. 21492 B. Record review of a temperature log sheet with columns identifed a resident room number, resident temp (temperature) and time. Further review of the sheet revealed the upper portion had the dates of 2-17 and 2-18 with out the year. The lower portion of the sheet had a staff name and identified resident room temperatures obtained at 11:00 PM, 1:00 AM and 2:00 AM revealing the following information: -11:00 PM: -room [ROOM NUMBER] was 63.0 degrees (D) F. -room [ROOM NUMBER] was 64.0 DF. -room [ROOM NUMBER] was 66.9 DF. -room [ROOM NUMBER] was 67.8 DF. -room [ROOM NUMBER] was 68.2 DF. -room [ROOM NUMBER] was 65.1 DF. -room [ROOM NUMBER] was 61.1 DF. -room [ROOM NUMBER] was 63.1 DF. -1:00 AM: -room [ROOM NUMBER] was 63.2 DF. -room [ROOM NUMBER] was 66.2 DF. -room [ROOM NUMBER] was 65.1 DF. -room [ROOM NUMBER] was 67.5 DF. -room [ROOM NUMBER] was 68.0 DF. -room [ROOM NUMBER] was 66.4 DF. -room [ROOM NUMBER] was 69.1 DF. -room [ROOM NUMBER] was 66.7 DF. -2:00 AM has 2 different entries for room temperature as follows: -room [ROOM NUMBER] had 57.0 DF and 55.0 DF. -room [ROOM NUMBER] had 56.0 DF and 55.0 DF. -room [ROOM NUMBER] had 55.0 DF and 55.0 DF. -room [ROOM NUMBER] had 56.0 DF and 56.0 DF. -room [ROOM NUMBER] had 67.0 DF and 56.0 DF. -room [ROOM NUMBER] had 69.0 DF and 60.0 DF. -room [ROOM NUMBER] had 70.0 DF and 58.0 DF. -room [ROOM NUMBER] had 70.0 DF and 60.0 DF. -room [ROOM NUMBER] had 70.0 DF and 61.0 DF. -room [ROOM NUMBER] entries were not legible. Record review of an undated temperature log sheet with a timed entry of 4:00 AM revealed the following information: -room [ROOM NUMBER] was 52.3 DF. -room [ROOM NUMBER] was 49.0 DF. -room [ROOM NUMBER] was 52.9 DF. -room [ROOM NUMBER] was 53.0 DF. -room [ROOM NUMBER] was 54.1 DF. -room [ROOM NUMBER] was 56.7 DF. -room [ROOM NUMBER] was 57.7 DF. -room [ROOM NUMBER] was 69.0 DF. Observation on 2-19-2025 at 5:24 AM revealed the windows in rooms 204, 205 and 206 had frost build up. Further observations revealed the residents in the 200 section of the building had 2 to 3 blankets covering them. On 2-19-2025 at 5:28 AM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A confirmed resident room temperatures were obtained every 2 hours and not hourly as directed in the facility abatement plan. LPN A further confirmed the resident rooms in the 200 had were cold. LPN A reported not being aware if the Maintenance Director (MD) had been notified of the continued cold resident room. LPN A confirmed LPN A had not followed up on the resident room temperatures. C. Observation on 2-19-2025 at 5:48 AM revealed upon entering the secured memory support unit revealed there were 2 portable heating units with one of the heating units tuned off. On 2-19-2025 at 5:48 AM Nursing Assistant (NA) C reported they were instructed to turn off the 1 heating unit as it was blowing out cold air. NA C further reported the secured unit was cold and they were trying to keep the residents covered with extra blankets. Observation on 2-19-2025 at 5:52 AM with Registered Nurse (RN) B revealed RN B using the facility thermometer gun from another unit, obtain the temperatures in the following rooms: -room [ROOM NUMBER] was 56.6 DF. -room [ROOM NUMBER] was 50.5 DF. -room [ROOM NUMBER] was 57.9 DF. -room [ROOM NUMBER] was 62.8 DF. -room [ROOM NUMBER] was 53.4 DF. On 2-19-2025 at 5:52 AM during the observation RN B confirmed the resident rooms were cold. RN B reported the thermometer gun staff had been using in the secured unit was not accurate. D. Record review of a Room Temps (temperature) sheet dated 2-19 and no year identified, with a time of 7:00 AM revealed the following information: -room [ROOM NUMBER] was 68.4 DF. -room [ROOM NUMBER] was 64.6 DF. -room [ROOM NUMBER] was 59.2 DF. -room [ROOM NUMBER] was 61.5 DF. -room [ROOM NUMBER] was 62.4 DF. -room [ROOM NUMBER] was 60.1 DF. -room [ROOM NUMBER] was 55.9 DF. -room [ROOM NUMBER] was 68.7 DF. -room [ROOM NUMBER] was 52.2 DF. -room [ROOM NUMBER] was 61.7 DF. -room [ROOM NUMBER] was 64.8 DF. -room [ROOM NUMBER] was 55.4 DF. E. Observation on 2-19-2025 at 5:40 AM revealed the portable heating unit by the 500 exit door was not on. Observation on 2-19-2025 at 6:35 AM revealed the portable heating unit by the 500 exit door was not on. Record review of a temperature sheet dated 2-18-2025 for the 500 hall revealed the following temperature information: -5:00 AM: -room [ROOM NUMBER] A was 65.7 DF. -room [ROOM NUMBER] A was 64.0 DF. -room [ROOM NUMBER] A was 69.3 DF. -room [ROOM NUMBER] A was 65.1 DF. -room [ROOM NUMBER] A was 67.5 DF. Record review of an undated temperature log revealed the temperature of resident room at 7:00 AM revealed the following: -room [ROOM NUMBER] was 63.1 DF. -room [ROOM NUMBER] was 64.6 DF. -room [ROOM NUMBER] was 66.7 DF. -room [ROOM NUMBER] was 65.0 DF. -room [ROOM NUMBER] A was 65.0 DF. -room [ROOM NUMBER] B was 64.0 DF. On 2-19-2025 at 7:02 AM an interview was conducted with the Maintenance Director (MD). During the interview the MD reported not being notified of the cold rooms or the portable heating unit being off on the 500 hall exit door area. On 2-19-2025 at 7:10 AM an interview was conducted with RN D. During the interview when asked how often were resident room temperatures and resident temperature were to be obtained, RN D reported every 2 hours. RN D further reported if the residents rooms were cold, the MD was to be called. On 2-19-2025 at 7:12 AM an interview was conducted with LPN E. During the interview when asked how often temperatures in residents room and residents were to be obtained, LPN E reported hourly. On 2-19-2025 at 9:40 AM an interview was conducted with the DON. During the interview review of the temperature logs on the 200 and temperatures obtained by RN B was completed. The DON confirmed the original abatement plan had not been followed and further confirmed the secured unit resident rooms were cold. The DON reported the MD should have been called to report the residents rooms were cold. According to Accucheck.com temperature on the morning of 2-19-2025 was 10 below zero. On 2-19-2026 at 11:02 AM the facility implemented a revised abatement plan to to remove the immediacy of situation and to protect the residents as follows: -On February 18.2025 the building temperatures were not maintained at a safe and comfortable levels, according to federal requirements. To protect the safety of the affected residents, the following steps were being taken: -Every resident will have their temperature taken every two hours to assess for hypothermia. If the resident temperature drops, to the resident shows signs of hypothermia, appropriate medical treatment will be provided, beginning with moving the resident to a warmer environment. -Every occupied room temperature will be taken every hour to assure they maintain their temperature. -If the room temperature falls by more than 1 degree or there are problems with the portable heaters, maintenance will be notified immediately. -If a resident is cold in their room, another room will be offered. If no other warmer rooms are available,the residents will be moved to the dining room. -Education will be provided to nursing staff of the temperature process and schedule. -Education will be provided to staff on the signs of the hypothermia. -A portable whole building heating unit was obtained from Nebraska Machinery. The heater will be operational by approximately midnight on 2/18/25. -staff were re-educated on 2/19/2025 on taking room temperatures every hour, residents temperatures every 2 hours, and when to call maintenance. Education will be provided every shift by DON or designee, until all staff have been educated and are able to verbalize understanding of the temperature process. -DON or designee will verify that temperature procedures are being followed, and all heating units are functioning properly every two hours. -The doors to the memory care unit will be opened to allow heat to flow through. A staff member will be stationed at each memory care unit entrance continuously to ensure no resident leave the unit unattended. Velcro door signs will be added to each unit doorway as a visual reminder for residents. We will re-evaluate temperatures in 24 hours to determine if this needs to continue. -Three additional large heating units have been obtained and en route to the building as of 1000. -Heating company called to check heating system to ensure current system is working properly. -Maintenance are working to patch large portable units into wall ventilation system so that we are not dependent on hallway heater. If maintenance unable to connect heating units to ventilation system, we will blow heat directly into the building through a door opening or window opening. Hourly monitoring to continue until comfortable temperatures are maintained. -staff will be educated the carbon monoxide detectors on each unit and what to do if they alarm. At the time of the survey, the violation was determined to be at the immediate jeopardy level L. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the F level.

Licensure Reference Number 175 NAC 12-006.10(D) Based on interview and record review the facility failed to ensure 1 (Resident 4) of 4 was free from significant medication errors. The facility staff identified a census of 131. Findings are: A record review of Resident 4's patient profile sheet dated 6/23/2024 revealed Resident 4 was [AGE] years old. A record review of the residents' electronic health record medical diagnosis sheet revealed Resident 4 had the following medical diagnoses: Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, Stage 4, Cirrhosis of Liver, Anemia, Type 2 Diabetes with Diabetic Polyneuropathy, Hypertension, Hypothyroidism, Vitamin D Deficiency, Constipation and Extended Spectrum Beta Lactamase Resistance (EBSL). A record review of Resident 4's quarterly Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 5/28/2024 revealed Resident 4 had a Brief Interview for Mental Status (BIMS - A federal mandated tool used to screen and identify the cognitive condition of residents in a long-term care facility) of 13 which indicated Resident was cognitively intact. A record review of Resident 4's hospital discharge paperwork dated 6/18/2024 revealed Resident 4 had been hospitalized from 6/10/2024 to 6/18/2024 for Acute Chronic Congestive Heart Failure (a condition that occurs when the heart tries to compensate for a loss of function that developed over time). A record review of page 6 of a 34 page hospital discharge document dated 6/18/2024 revealed Resident 4 was to start taking the following medications: levofloxacin (an antibiotic used to treat bacterial infection) 250 Milligrams (mg) tablet. Take 1 tablet (250 mg total) by mouth every other day for 1 dose starting on June 20, 2024. Metolazone (a medication used to treat fluid retention) 5 mg tablet, take 1 tablet (5 mg total) by mouth once a week for 30 days. Start June 24, 2024. Potassium chloride SA (a medication used to treat low potassium levels in patients) 20 milliequivalent (mEq - the number of grams of medication contained in a 1milliter solution) tablet. Take 2 tablets (40 mEq total) by mouth daily with breakfast for 30 days. Rifaximin (a medication used to treat hepatic encephalopathy - a condition that occurs when your liver does not work properly) 550 mg tablet. Take 1 tablet (550 mg total) by mouth 2 times a day for 30 days. Sevelamer carbonate (a medication used to lower the body's phosphorus levels in patient with chronic kidney disease) 800 mg tablet. Take I tablet (800 mg total) by mouth 3 times a day with meals for 30 days, torsemide 40 mg (a medication used to remove fluid buildup in the body). Take 40 mg by mouth 2 times daily for 30 days. Also on page 6 were the instructions to continue to take Acetaminophen (a mild pain medication) 500 mg tablet. Take 2 tablets (1,000 mg total) by mouth 3 times a day as needed for pain, Artificial tears, place 1 drop into both eyes once every 4 hours as needed for dry eyes. A record review of Resident 4's facility Order Summary sheet printed 7/8/2024 revealed the orders for levofloxacin ( a antibiotic medication), metolazone (a diuretic), potassium chloride SA, rifaximin(an antibiotic medication), sevelamer carbonate, acetaminophen, artificial tears and torsemide did not appear on the Order Summary sheet. A record review of Resident 4's progress note dated 6/23/2024 at 11:09 AM revealed Resident 4's physician was informed Resident 4 was more confused than usual, chewing on their medication and attempting to dump water on their eyes. The physician ordered Resident 4 to be sent to the emergency room to be evaluated. A record review of a progress note dated 6/23/2024 at 2:28 PM revealed Resident 4 had been admitted to the hospital for Hepatic Encephalopathy (a brain dysfunction due to liver dysfunction). A record review of a progress note dated 6/24/2024 at 4:26 PM revealed the Director of Nursing (DON) received a call to confirm the current medication list for Resident 4 and found the following medications had not been implemented: Levaquin, Metolazone, Potassium Chloride SA, Rifaximin and torsemide. A record review of a progress note dated 6/26/2024 at 5:00PM revealed the residents Power of Attorney (POA) called the facility to let them know Resident 4 had passed away. A record review of the Facility Verification of Investigation sheet titled Significant Medication Error-#1070010, submitted to the state on 7/1/2024 revealed a signed typewritten note dated 6/28/2024 which revealed the person who placed the discharge orders into Point Click Care (PCC - a healthcare computer software provider for long-term care and senior care industries) had printed out the discharge orders from an e-mail and took them home to enter into the software system. The individual had left out pages 6 and 7 which had the residents new orders and therefore they did not enter the new orders into PCC. An interview on 7/8/2024 at 2:45 PM with the Director of Nursing (DON) revealed the facility had investigated the incident and reported a corporate employee had taken the orders home to enter them into the facility system. The DON reported the facility investigation confirmed the employee had missed the page containing the new and revised orders for the medications resulting in Resident 4 not receiving the ordered medications.

Licensure Reference Number 175 NAC 12-006.09D2a Based on observation, record reviews and interview; the facility staff failed to implement interventions to prevent and treat pressure ulcer for 1 (Resident 87 ) of 5 sampled residents. The facility staff identified a census of 126. The findings are: A. Record review of Resident 87's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 2-08-2024 revealed Resident 87 admitted to the facility on [DATE] with the diagnoses of Anemia, Atrial fibrillation, Hypertension, Gastroesophageal reflux Disease (GERD), thyroid disorder, Cerebrovascular Accident (stroke), Malnutrition, Hemiplegia (paralysis on one side of the body). Further review of Resident 87's MDS dated [DATE] revealed Resident 87 required Substantial/Maximal assistance with toileting, shower/baths, upper body dressing, lower body dressing, rolling left and right and go from a sitting to lying position. Resident 87 was dependent on staff form sitting to standing and chair to bed transfer. The facility staff identified Resident 87 was frequently incontinent of bladder. Resident 87's MDS dated [DATE] identified the resident as at risk for developing pressure ulcers and did not currently have a pressure ulcer. Record review of a Skin Only Evaluation ([NAME]) sheet dated 2-05-2024 revealed the facility staff had identified Resident 87 did not have any skin issues. Record review of Resident 87's Comprehensive Care Plan (CCP) printed on 3-19-2024 revealed the facility staff identified Resident 87 was at risk for skin impairment related to decreased mobility, muscle weakness, malnutrition, cancer and anemia. The goal identified for Resident 87 was to be free from pressure ulcers revised on 3-08-2024. Intervention identified on Resident 87's CCP printed on 3-19-2024 was to have the resident wear edema wear, encourage good nutrition and hydration, encourage the resident to wear Pravalon boots (a type of heel protection boots that lift the heel to help prevent the development of heel pressure injuries), Braden scale (a nursing assessment used to accurately identify pressure injury risk) upon admission, re-admission, weekly, quarterly, annually, and as needed. In addition, staff was to complete weekly skin inspections. Record review of Resident 87's Comprehensive Skin Sheet Evaluation (CSE) sheet dated 2-12-2024 revealed the facility staff evaluated Resident 87 with no skin issues. Record review of Resident 87's CSE sheet dated 2-19-2024 revealed the facility staff evaluated Resident 87 with no sin issues. Record review of a Skin Observation-Shower sheet for Resident 87 dated 2-28-2024 revealed Resident 87 was identified as having red areas and open area to Resident 87's left buttocks. Record review of Resident 87's practitioner orders, CCP, Progress notes, faxes, assessments revealed there were no additional CSE weekly skin evaluations completed. In addition, there was no indications the facility staff had followed up on the Skin Observation-Shower sheet dated 2-28-2024 that had identified Resident 87 had red and open areas to the left buttocks. Record review of Resident 87's medical record revealed the a Braden scale completed was on 2-5-2024. An observation on 3-25-2024 at 3:10 PM of Resident 87's skin during a dressing change being performed by LPN (Licensed Practical Nurse) -O revealed a dressing was observed on Resident 87's right buttock. LPN-O removed the soiled dressing revealing a moderate amount of red and brown drainage on it. The wound to the right buttock was approximately 2.5 centimeters in length and 1.5 centimeters in width, with an approximate depth of 0.1-0.2 centimeters. The wound edges were pink in color and the wound bed was beefy red with a drop of blood noted in the center of the wound bed. Skin to left buttock was intact and free of the presence of a wound dressing. LPN-O irrigated the wound with wound wash and patted the wound dry with a clean dry gauze sponge. LPN-O then applied hydrogel gauze to the wound bed and covered the area with a bordered foam dressing. During this observation on 3-25-2024 at 3:10 PM the wound nurse LPN-I was present and confirmed the correct dressing was applied to the pressure ulcer on the right buttock and did not have a pressure ulcer on the left buttock. Record review of Resident 87's order summary printed on 3-19-2024 revealed the facility received an order for wound care plus service to evaluate and treat Resident 87 on 3-6-2024. In addition, orders for wound care was to right buttock as follows: -cleanse wound with wound wash -apply hydrogel gauze -cover with bordered foam dressing daily at bedtime and as needed if the dressing was soiled dated 3-12-2024. Record review of Wound Care Plus's progress notes dated 03-07-2024 indicated that Resident 87 had a pressure ulcer to the right buttock that was a stage 3 (a full thickness tissue loss through the epidermis and dermis). Wound care orders were written on 03-07-2024 to cleanse wound with wound cleanser of facility choice, apply hydrogel sheet/gauze preferred, cover with bordered gauze change daily and as needed for soiling, saturation, or unscheduled removal. An interview with the DON on 3-26-2024 at 11:45 AM revealed that no other skin checks were performed by the facility staff between 02-28-2024 and 03-07-2024 when the Wound Care Plus practitioner evaluated Resident 87. The DON confirmed there was no follow up by nursing staff for the Skin Observation-Shower Sheet completed on 2-28-2024 and the one Braden Scale evaluation had been completed for Resident 87 was done on admission on 02-05-2024. Record review of an undated policy Pressure Injury Prevention and Management revealed the facility shall establish and utilize a systematic approach for the pressure injury prevention and management including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions and modifying interventions as appropriate. Licensed nurses will conduct a pressure injury assessment using the Braden Scale on all residents upon admission/readmission, then weekly for 4 weeks, then quarterly or whenever the resident's condition changes significantly. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, record review, and interview, the facility failed to ensure that staff were trained to check the function of individual resident elopement prevention equipment to prevent an elopement (unsupervised wandering that leads to the resident leaving the facility without facility staff knowledge). The facility staff identified a total of 13 residents at risk for elopement. The facility had a census of 135. Findings are: A. Record review of Resident 1's Medical Diagnosis sheet, revealed Resident 1's medical diagnoses of: personal history of traumatic brain injury, paranoid schizophrenia and anxiety disorder. Record review of Resident 1's Minimum Data Set (MDS - a federally mandated assessment tool used for care planning) dated 2/15/2024 indicated the resident had a Brief Interview Mental Status, (BIMS - a federally mandated tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 15 out of 15 which indicated the resident was cognitively intact. A record review of the Resident 1's Clinical Resident Profile sheet, dated 11/08/2023 indicated Resident 1 had a guardian. A record review of Resident 1's physician's orders dated 11/8/2023 revealed the following: Wanderguard to left ankle check place and functioning every shift. Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 3/01/2024 revealed Resident 1 was an elopement risk/wander with an initiated date of 11/08/2023 and was revised on 2/24/2024. The CCP goal that was identified for Resident 1 revealed to not leave the facility unattended. The interventions identified on Resident 1's CCP revealed: - Apply a wander guard or wander alert and check the functioning as ordered. The wander guard was to be placed on the left ankle with an initiated date of 11/08/2023. - Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. - Monitor the resident's activity and whereabouts, initiated on 11/08/2023. - Provide Structured activities to occupy time and attention as needed, initiated on 11/08/2023. Record review of Resident 1's Progress Note (PN) dated 2/24/2024 at 7:10 AM revealed at approximately 5:00 AM to 5:15 AM Resident 1's nurse entered Resident 1's room to administer their morning medications and realized the resident was not present. The PN revealed Resident 1's nurse searched the dining room and discovered Resident 1 was not there. The nurse activated the elopement procedures and conducted a thorough search of all common areas, including the gardens, and all resident rooms on each floor. Then, at approximately 5:45 AM the hospital contacted the facility and informed the facility staff that Resident 1 was found at a gas station and was experiencing confusion and coldness and was admitted to the emergency room (ER). A record review of Resident 1's Elopement Evaluation dated 11/08/2023 revealed the following questions: Does the Resident have a history of elopement or an attempted elopement while at home? The response was marked yes. Does the resident have a history of elopement or attempted leaving the facility without informing staff? The response was marked yes. A record review of Resident 1's Elopement Evaluation dated 02/15/2024 revealed the following questions: Does the Resident have a history of elopement or an attempted elopement while at home? The response was marked no. Does the resident have a history of elopement or attempted leaving the facility without informing staff? The response was marked no. There was no information on the Elopement Evaluation sheet dated 2-15-2024 as to why the history of attempts at elopement had changed from the elopement sheet dated 11-08-2023. A record review of Resident 1's Elopement Risk dated 02/24/2024 and signed by the MDS Coordinator revealed the following conclusion: Resident 1 left the building without supervision and went to a gas station and identified Resident 1 as an elopement risk. A record review of the Facility Verification of Investigation form dated 3/1/24 revealed the following: -New interventions: -New elopement assessment completed determining Resident 1 was at risk for elopement. -WanderGuard placed to Resident 1's left ankle. -Resident 1's guardian notified and wishes to have the WanderGuard in place indefinitely. -Resident 1's practitioner notified. -Resident 1's Care Plan updated. Observation on 2/27/2024 at 5:00 PM revealed Registered Nurse (RN)-A was checking the function of Resident 1's WanderGuard with a WanderGuard scanner which revealed Resident 1's WanderGuard was not functioning. Interview on 2/27/2024 at 6:25 PM with RN-A revealed Resident 1's Wanderguard was checked and was not functioning. B. Record review of Resident 2's CCP initiated on 08/31/2023 revealed Resident 2's medical diagnoses of: Unspecified Dementia and Adjustment Disorder with mixed Anxiety and Depressed Mood. Record review of Resident 2's MDS dated [DATE], indicated the resident had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. Record review of Resident 2's CCP initiated on 8/31/2023 revealed Resident 2 was an elopement risk/wander with an initiated date of 11/08/2023 and revised on 2/24/24. The goal identified for Resident 2 was to not elope from the facility. The interventions identified on Resident 2's CCP revealed: - Check placement and functioning of WanderGuard per protocol, initiated on 01/10/2024 and revised on 02/28/2024. - Has a WanderGuard on right ankle, initiated on 10/19/2023 and revised on 11/08/2023 and - Identify events that increase anxiety and trigger resident to want to elope with an initiated date 08/31/2023. Record review of Resident 2's Elopement Risk dated 2/24/2024 revealed Resident had the ability to leave the facility, was at risk for elopement and was confused. Further review of the Elopement Risk dated 2/24/2024 identified the following interventions: - Personal safety Alarm device, - Utilization of a check in/out log, - Photo on potential elopement list, - Staff aware of residents on wander/elopement risk. Observation on 2/27/2024 at 5:00 PM revealed RN-A checked the function of Resident 2's WanderGuard utilizing a scanner which revealed the WanderGuard was not functioning. Interview on 2/27/2024 at 6:25 PM with RN-A revealed Resident 2's WanderGuard was checked it was not functioning. C. A record review of Resident 3's CCP initiated on 11/08/2023 revealed Resident 3's medical diagnoses of: Schizophrenia, Schizoaffective Disorder, Bipolar type, Personal History of other Mental and Behavioral Disorders, Bipolar Disorder, Generalized Anxiety Disorder. A record review of Resident 3's Clinical Resident Profile dated 11/08/2023 revealed Resident 3 had a guardian. A record review of Resident 3's CCP initiated on 11/08/2023 and revised on 02/24/2024 revealed Resident 3 was an elopement risk/wander. The goal identified for Resident 3 was to not elope from the facility. The interventions on the CCP revealed: - Identify events that increase anxiety and trigger resident to want to elope which was initiated on 2/24/2024, - Promote verbalization of feelings which was initiated: 02/24/2024, - Resident listed on Behavior log with wander guard noted which was initiated on 02/24/2024, - WanderGuard check every shift for placement and that it is working which was initiated on 02/24/2024. Record review of Resident 3's Elopement Risk dated 2/24/2024 revealed Resident had the ability to leave the facility, was at risk for elopement and was confused. The Elopement Risk identified the following interventions: - personal safety Alarm device, - photo on potential elopement list. Observation on 2/27/2024 at 6:15 PM Resident 3 was sitting at a table in the dining room and had a WanderGuard on their right ankle. Observation on 2/27/2024 at 5:00 PM revealed RN-A was checking the function of Resident 3's WanderGuard utilizing the scanner which revealed the WanderGuard was not functioning. Interview on 2/27/2024 at 6:25 PM with RN A revealed Resident 3's WanderGuard was checked and it was not functioning. D. Interview on 2/27/2024 at 11:30 AM with the Director of Nursing (DON) revealed if a resident failed the Elopement Risk Assessment a WanderGuard was to be placed onto the resident. Interview on 2/27/2024 at 5:15 PM with the DON revealed the process for an elopement was in a binder at the each nursing station. The DON confirmed the 13 residents identified at risk for elopement resided on the facility halls between nurse station 3 and 4. The DON confirmed the Elopement Book was kept at the receptionist desk located near the front door. Record review of the binder on nursing stations 1, 2, 3 and 4 on 3/04/2024 at 10:30 AM revealed the binders did not contain the names or pictures of the residents who were at risk of elopement. Record review of the binder revealed it contained the Wandering and Elopement policy effective date 07/01/2020 revealed the following: - The purpose of this policy is to provide a system for identification of residents at risk for unsafe wandering and elopement, provide a program of supervision and interventions to minimize risk of resident elopements, improve resident safety through timely investigations of elopements and elopement attempts, and provide staff education in effective wandering/elopement management through in-services and elopement drills. Record review of an undated sheet identified as Elopement, provided by the DON on 2/27/2024 at 5:20PM and describing the process to follow to for residents at risk for elopement, revealed the following information: 1. Elopement assessments are to be completed on Admission, Quarterly and as needed. 2. If a resident is at risk for elopement, ensure the resident has a WanderGuard on. If the resident does not have a WanderGuard on, notify the DON immediately. 3. When a resident is determined to be at risk for elopement, a WanderGuard must be placed on the resident, an order must be entered into PCC for WanderGuard placement, an order must be entered to check placement and function of WanderGuard q shift, the resident will need to be added to the elopement book, and the care plan must be updated. New WanderGuards will be kept in the treatment cart at each nurses' station. Notify PCP and responsible party anytime an initial WanderGuard is placed. 4. All residents determined to be at risk for elopement are added to the facility Elopement Book. The Elopement Book is located at the front desk. 5. All residents at risk for elopement must have their WanderGuard checked every shift to ensure it is present and functioning properly. If at any time a WanderGuard is not functioning, notify the DON immediately. A new WanderGuard will need to be placed immediately. 6. In the event an elopement occurs notify facility administrator and DON immediately. Interview on 2/27/2024 at 5:20 PM with Licensed Practical Nurse (LPN)-B revealed [gender] was unaware of how to check a WanderGuard for function and had not received training on how to operate a WanderGuard scanner. LPN-B confirmed they had not examined the binder for the residents at risk for elopement on any of the 4 nursing stations. Interview on 2/27/2024 at 5:25 PM with RN-C revealed [gender] was unaware of how to check a WanderGuard for function and had not received training on how to operate a WanderGuard scanner. RN-C confirmed they had not examined the binder on any of the 4 nursing stations for the residents at risk for elopement. Interview on 2/27/2024 at 6:20 PM the DON confirmed [gender] was not aware 3 of 13 WanderGuards were not functional. Interview on 2/28/2024 at 7:30 AM with RN-D revealed [gender] was unaware of how to check a WanderGuard for function and had not received training on how to operate a WanderGuard scanner. RN-D confirmed they had not examined the binder on any of the 4 nursing stations to identify the residents at risk for elopement. Interview on 2/28/2024 at 8:25 AM with RN-E revealed[gender] was unaware of how to check a WanderGuard for function and had not received training on how to operate a WanderGuard scanner. RN-E confirmed they had not examined the binder on any of the 4 nursing stations to identify the residents at risk for elopement. Interview on 2/28/2024 at 8:45 AM the DON revealed [gender] was unaware the nurses did not know how to check a WanderGuard for function. The DON revealed the nurses had been informed to check the binders on the nursing stations for instructions. The DON confirmed the facility did not complete competency training for staff regarding the WanderGuard system. Interview on 2/27/2024 at 12:15 PM with the facility Administrator confirmed a new door switch was installed at the receptionist desk on 2/26/2024. The Administrator confirmed that to enter the building by the front door requires someone needs to use the code or press the switch at the receptionist desk to open the front door. The Administrator confirmed several residents in the facility knew how to use the switch to open the front door. The new door switch is on the right side of the desk and is not easily visible to residents. The following is the Abatement Statement to remove the immediency received from the Facility Administrator dated 2/28/2024. Immediately: An audit of all residents was conducted to assess elopement risk, completed by DON, MDS, and LPN Supervisor on 2/24/2024. Any necessary wander guards were put into place. An audit of all residents with wanderguards in use was conducted to verify orders for checking placement and function Q shift is in place completed by DON, MDS and LPN Supervisor on 2/24/2024. An audit of care plans for residents at risk for elopement was completed by the DON, MDS, and LPN Supervisor on 2/24/2024 to validate current interventions and risk are reflected. An audit of front door for proper wanderguard system function was completed with no concerns identified by Maintenance Director on 2/24/2024. An audit of the elopement binder was completed to validate current identification sheets are in place as required, by Administrator and Social Services Director on 2/24/2024. Education initiated by DON and designees to licensed nurses on 2/28/2024 regarding checking wander guards for working order every shift and education related to how to use the device to check wander guards. The education will also include this abatement information. 3. Measure put in place/systematic changes to ensure the deficient practice does not recur. Education to be completed by DON and designees to licensed nurses prior to next shift worked regarding checking wander guards for working order every shift and education related to how to use the device to check wander guards. The education will also include this abatement information. New facility and agency staff will be educated on the facility elopement binder at the front desk, which will identify the residents at risk for elopement and the facility elopement process and the steps to check for proper function of wanderguard. Maintenance Director added a switch at the front desk to disable the front door release button when the desk is not being monitored by staff, and clinical staff were notified of new process on 2/27/2024. Staff will be further educated prior to next shift worked until all staff are educated. How-to-binder at each nurses station updated with summary of process for determining residents that are at risk and steps to take when a wanderguard is not functioning. All current wanderguards in place were checked for placement and function by facility leadership on 2/27/2024 and 2/28/2024. If wanderguard is identified as missing or not functioning, it will be replaced immediately. 4. Plans to monitor performance to ensure solutions are sustained. Audit of TAR during clinical stand up to ensure placement and function of the wanderguard has been documented as completed and in place and functioning, 5x/week x 4 weeks, 3x/week x 4 weeks, 1x/week x 4 weeks with results taken to QAPI x 3 months. Nurse manager to verify function and placement of all wanderguards weekly x 12 weeks with results taken to QAPI x 3 months. Maintenance Director and /or designee to check power of wanderguard screener 5xweek x 4 weeks, 3x/week x 4 weeks, 1x/week x 4 weeks with results taken to QAPI x 3 months. Maintenance Director and/or designee to audit front door for proper wanderguard system function 5x/week x 4 weeks, 3x/week x 4 weeks, 1x/week x 4 weeks with results taken to QAPI x 3 months. Administrator and/or designee will ensure facility has a supply of spare wanderguards weekly x 12 weeks with results taken to QAPI for 3 months.

Licensure Reference Number 175 NAC 12-006.02 Based on observation, record review and interviews, the facility failed to ensure the facility and corporate administration utilize resources in a manner to ensure resident safety and quality of care. The facility census was 107. Findings are: The facility was found to be out of regulatory compliance in multiple areas resulting in an extended survey related to substandard quality of care for accidents. Please refer to the Tag citations for specific detailed findings. -F584-Based on observation and interview, the facility failed to maintain the cleanliness and condition of ventilation systems, fixtures, base boards and walls in 12 (resident rooms 106, 110, 111, 112, 204, 307, 309, 315, 317, 402, 404 and 409) of 73 occupied resident rooms. -F623-Based on record review and interview the facility failed to ensure Resident 43 was given a letter explaining the reason for transfer to the hospital. -F661-Based on record review and interview, the facility failed to complete discharge summaries/ recapitulation for Resident 110. -F684- Based on observation, record review and interview, the facility failed to identify, obtain treatment orders and monitor a skin abrasion for 1 (Resident 60) of 1 sampled resident. -F689-Based on observation, record review and interview; the facility failed to ensure water temperatures in resident rooms and a bathing area were maintained at a safe temperature to prevent the potential for scald burns for rooms 111, 112, 202, 203, 204, 205, 208, 209, 300, 307, 309, 317, 409, 406, 401, and the North spa room. -F695-Based on observation, record review and interview; the facility failed to ensure nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) equipment was stored in a manner to prevent the potential for cross contamination and changed weekly for 2 (Resident 1 and 49) of 2 sampled residents. -F698-Based on Observation, record review and interviews the facility failed to ensure a dialysis access site was checked daily and failed to maintain a fluid restriction order for Resident 2. -F812-Based on observation and interview; the facility dietary staff failed to maintain the cleanliness and condition of ceiling tiles, stove back splash, shelf above the stove, floors in the walk-in cooler, plate warmer, light fixtures and ventilation covers in the facility kitchen to avoid the potential for food borne illness. This had the potential to affect 107 residents that ate food prepared in the facility kitchen. -F867- Based on observations, record reviews and interviews, the facility Quality Assurance Performance Improvement (QAPI) team failed to identify high water temperatures to avoid the potential for burns and failed to maintain compliance as evidenced by repeat deficient practice. -F880-Based on observation, interview and record review the facility, failed to ensure staff wore the designated PPE in rooms in precautions, failed to ensure staff followed the masking requirements, failed to ensure infection control procedures were followed during catheter care for 1 resident (Resident 15) and failed to disinfect blood glucose machines between 2 residents (Residents 71 and 74). -F923-Based on observation, record review and interview; the facility failed to ensure a working ventilation system in 17 resident bathrooms (rooms 106, 110, 111, 112, 202, 203, 204, 205, 208 209, 307, 309, 315, 317, 402, 404, 409) of 73 occupied resident rooms. -F940-Based on observation, record review and interview; the facility failed to provide education/orientation specific to maintenance job duties to the maintenance employees. Interview on 03/30/23 at 10:39 AM with Consultant Z revealed the Quality Assurance Performance Improvement (QAPI) committee has been primarily focusing on the plan of correction from the previous complaint survey deficient practice.

Licensure Reference Number 175 NAC 12-006.07 Based on observations, record reviews and interviews, the facility Quality Assurance Performance Improvement (QAPI) team failed to identify high water temperatures to avoid the potential for burns and failed to maintain compliance as evidenced by repeat deficient practice. The facility census was 107. Findings are: Review of the facility Quality Assessment and Assurance (QA&A) policy dated March 2023 revealed the following members: Administrator, Director of Nursing, Assistant Director of Nursing, Business office manager (BOM) and Assistant BOM, housekeeping supervisor, Social services director, Maintenance Director, Dietary manager, Activities director, Medical records, Staffing, Concierge. Review of the facility policy dated February 2022 titled Quality Assurance and Performance improvement (QAPI) Program revealed: -The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. -The objective of the QAPI program is to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. -The owner and/or governing board of our facility is ultimately responsible for the QAPI program. -The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and makes adjustments to the plan. Review of the facility [NAME] report revealed repeat tags during the past 3 annual surveys: -F584 Safe/clean/comfortable/homelike environment. -F623 Notice requirements before transfer/discharge. -F689 Free of Accident Hazards. -F695 Respiratory care. -F812 Kitchen cleanliness. -F867 Quality Assurance performance Improvement. -F880 Infection Control. Additional repeat tags from complaint surveys since last annual survey on 10/14/2021 include: -F880 Infection Control -F689 Free of Accident Hazards -F695 Respiratory care -F812 Kitchen cleanliness Interview on 03/30/23 at 10:39 AM with Consultant Z revealed the Quality Assurance Performance Improvement (QAPI) committee has been primarily focusing on the plan of correction from the previous complaint survey deficient practice.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E3, 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility failed to ensure water temperatures in resident rooms and a bathing area were maintained at a temperature to prevent the potential for scald burns for rooms 111, 112, 202, 203, 204, 205, 208, 209, 300, 307, 309, 317, 409, 406, 401, and the North spa room. The facility census was 107. Findings are: A. On 03/27/23 at 09:00 AM an observation of the water temperatures in room [ROOM NUMBER] was 129 degrees. room [ROOM NUMBER] had a water temperature of 126 degrees, room [ROOM NUMBER] had a water temperature of 127.1 degrees and room [ROOM NUMBER] had a water temperature of 123.9. Resident 1 resides in room [ROOM NUMBER] and has a BIMS (Brief Interview for Mental Status) of 5. According to the MDS Manuel a score of 5 indicates a resident is cognitively impaired. Resident 1 is mobile per wheelchair. Resident 54 resides in room [ROOM NUMBER] has a BIMS of 2 which indicates the resident is cognitively impaired. Resident 54 is ambulatory. Resident 67 and Resident 3 reside in room [ROOM NUMBER]. Resident 67 has a BIMS of 5 indicating cognitive impairment and Resident 3 has a BIMS of 3 indicating cognitive impairment. Resident 67 and Resident 3 are both mobile per wheelchair. 17285 B. Record review of Federal Tag F 689's Time and Temperature Relationship to Serious Burns identified that water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident and may put residents at increased risk for burns caused by scalding. Decreased cognition may put residents at risk for burns caused by scalding. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. The following information illustrates damage to skin in relation to the temperature of the water and the length of time of exposure: - Water at 140 degrees F could cause 3rd degree scald burns after 5 seconds of exposure. - Water at 133 degrees F could cause 3rd degree scald burns after 15 seconds of exposure. - Water at 127 degrees F could cause 3rd degree scald burns after 1 minute of exposure. - Water at 124 degrees F could cause 3rd degree scald burns after 3 seconds of exposure. Observation on 3/27/23 between 9:00 AM and 10:00 AM revealed that the following hot water temperatures in resident bathroom sinks on the 100 and 200 halls of the facility: - room [ROOM NUMBER]: 127.4 Degrees Fahrenheit [F] - room [ROOM NUMBER]: 127.5 F - room [ROOM NUMBER]: 126 F - room [ROOM NUMBER]: 126 F - room [ROOM NUMBER]: 126.8 F - room [ROOM NUMBER]: 127.1 F - room [ROOM NUMBER]: 128.8 - room [ROOM NUMBER]: 126.8 F Observation on 3/27/23 at 10:00 AM revealed that there was a total of 14 residents that resided in the rooms with hot water accessible. Interview on 03/27/23 at 10:10 AM with Nursing Assistant [NA] G confirmed the water was hot and stated, If the water is too hot, I turn on some cold to even it out and then report it immediately to maintenance. Interview on 03/27/23 at 10:15 AM with NA H confirmed the water was hot and stated, I turn on the cold water and then report it to maintenance right away. Interview on 3/27/23 at 3:00 PM with Director of Maintenance [DM] C revealed that the hot water is checked in one room on each hall weekly. DM C confirmed that they were not aware the water was too hot. DM C stated that the water temperatures were increased in January to keep the pipes from freezing. Interview on 04/03/23 at 09:50 AM with Licensed Practical Nurse [ LPN] J revealed that, of the 14 residents that resided in the rooms with hot water accessible, Resident 5 and Resident 34 were self-mobile once in their wheelchairs and were severely cognitively impaired. LPN J confirmed that Resident 5 and 34 would be able to wheel themselves into the bathroom and up to the hot water faucet to access the hot water. LPN J confirmed that Resident 5 and 34 had very poor safety awareness. LPN J confirmed that Residents 5 and 34 were most at risk for scald burns due to being self-mobile, severely cognitively impaired and had poor safety awareness. Record review of Resident 5's most recent Minimum Data Set [MDS] [a mandatory clinical comprehensive assessment used for care planning] dated 3/16/23 revealed a Diagnoses of Non - Alzheimer's Dementia and a Brief Inventory of Mental Status [BIMS] [a brief screening tool that aids in detecting cognitive impairment] score of 5 [severe cognitive impairment]. The MDS identified that Resident 5 required supervision with locomotion in the room and on the unit. Record review of Resident 34's most recent MDS 2/8/23 revealed a Diagnoses of Non - Alzheimer's Dementia and a [BIMS] score of 4 [severe cognitive impairment]. The MDS identified that Resident 5 required limited assistance with locomotion in the room and on the unit. 45614 C. The following water temperatures were observed on 03/27/23 at 1:18 PM revealed the following information: -The water temperature in the bathroom of room [ROOM NUMBER] was 127.7 degrees Fahrenheit. - The water temperature in the bathroom of room [ROOM NUMBER] was 125.7 degrees Fahrenheit. - The water temperature in the bathroom of room [ROOM NUMBER] was 125.3 degrees Fahrenheit. - The water temperature in the North spa (bathhouse) was 129.9 degrees Fahrenheit. An observation on 03/28/2023 at 10:16 AM revealed the resident in room [ROOM NUMBER] attempting to get to walk to the bathroom on their own. RN- T (Registered Nurse) intervened and assisted the resident to the bathroom. On 3-28-2023 at 10:16 AM a interview was conducted with Registered nurse (RN)-T During the interview RN T reported the resident had the physical ability to get to the bathroom and had a dementia diagnosis. This diagnosis also places the resident at risk for burns from excessively hot water. On 03/27/23 at 12:22 PM an interview with BA (Bath Aide) S. During the interview BA S reported maintenance staff check the temperature of the water everyday before showers are given. 28155 D. Review of a Daily Round sheet of water temperature for February 2023 revealed the following information: -2-10-2023: -100 hall, 135.4 degrees. -200 hall, 137.6 degrees. -300 hall, 138.2 degrees. -400 hall, 140.1 degrees. -500 hall, 124.7 degrees. -South Spa 121.8 degrees. -North Spa 136.4 degrees. -2-13-2023: -200 hall, 128.6 degrees. -300 hall, 133.3 degrees. -500 hall 126.1 degrees. -600 hall 123.6 degrees. -2-16-2023: -100 hall 123.3 degrees. -300 hall 134.2 degrees. -South spa 125.7 degrees. Record review of A daily Rounds sheet of water temperature for March 2023 revealed the following information: -3-2-2023: -100 hall was 126.8 degrees. -400 hall was 127.5 degrees. -500 hall was 127.5 degrees. -600 hall was 125.6 degrees. -South Spa was 122.9 degrees. -North Spa was 122.1 degrees. -3-8-2023: -South Spa 124.5 degrees. -North Spa 141.0 degrees. -3-10-2023: -200 hall was 126.6 degrees. -300 hall was 138.5 degrees. -400 hall was 135.0 degrees. -South Spa was 125.0 degrees. -North Spa was 135.0 degrees. -3-17-2023: -100 hall was 135.5 degrees. -300 hall was 132.0 degrees. -South Spa was 125.6 degrees. -North Spa was 133.5 degrees. Review of the policy revealed: -Test temperature in shower areas. Shower should be between 100 and 110. -Test temperature at the mixing valve. -Check resident rooms at the end of each wing on a rotating basis or by facility policy. Resident rooms in Nebraska should be between 110 and 120. -Record results in the water temperature log. -Note any discrepancies. -Adjust water heater settings as required. -Retest as necessary. Interview on 3/27/2023 at 10:00 AM with the Maintenance Director revealed information had been provided for maintenance to leave the water temperatures high so the pipes would not freeze during the winter. The TELS (a system for documenting and tracking maintenance activities) instructions are the policy for checking water temps. Interview on 3/27/2023 at 11:45 AM with Consultant Z revealed the mixing valve have been adjusted and they will be checking all sinks at 15 min intervals and readjusting as needed. Interview on 03/29/23 at 1:35 PM with Consultant Z revealed the water had been adjusted down and now is too cold and the facility has had to suspend bathing and has called in a plumber. As outlined by Consultant Z of the facility on 3/27/2023 at 12:30 PM the facility initiated the following plan to address the immediacy of the situation and abate the immediate jeopardy situation: 1. The facility immediately verified the main hot water heater/mixing valve is set at 100 degrees and began adjusting it according to room temperature readings. 2. The facility immediately initiated and are continuing to check water temps in resident rooms and shower areas. 3. Facility educated residents and staff to increase use of hand sanitizer while temps are being monitored. Additional staff sent to memory unit. 4. Facility immediately educated maintenance personnel to regulations and policies associated with Water temps, 110-120 degrees at sinks, and 100-110 in shower areas. and the practice of placing the results in TELS system going forward. 5. The facility immediately initiated facility wide education on Azria Water Temps, and regulations associated with water temps, 110-120 degrees at sink and 100 to 110 degrees in shower areas. Azria Water Temps states that if at any time the water feels excessive to touch they will report to the immediate supervisor. The education will take place before staff work their next shift. 6. The DON educated and competencies bath aides on ensuring water temps are between 100-110 degrees on daily basis before first shower/ bath of the day/ shift. The facility maintenance staff and /designees will continue to audit water temps facility wide and adjust the main water heater mixing valves as needed until temps reach regulatory requirement, 110-120 degrees at sinks, and 100-110 in shower areas. Those staff will alert administrator / designee of any temps outside of the regulatory requirements and further action / adjustments to the water heater/mixing valve will be completed. Facility maintenance staff/ designee will audit random water temps on each station and each bath house daily x 2 weeks, then 3x's a week x 6 weeks, and then return to periodically per policy. Staff will alert administrator / designee of any temps outside of the regulatory requirements and further action/ adjustments to the water heater/mixing valve will be taken. Results of all audits will be taken to QAPI for further review and analysis. With the above interventions initiated, the immediate jeopardy was abated and the scope and severity of the deficiency was lowered to an E

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to implement interventions to manage pain during wound care for 1 (Resident 2) of 3 sampled residents. The facility had a total census of 126 residents. The findings are: A review of the facility's Wound Report, last updated 10/20/22, revealed Resident 2 had a surgical site wound to their right hand due to post-op amputation of fingers. The wound was documented as measuring 5cm (centimeters) x 5cm with a depth of 0.2cm. A review of a Resident Grievance/Complaint Investigation Report Form dated 11/1/22 for Resident 2 and completed by the Wound Care Registered Nurse (RN-L) revealed the following recommendations/corrective actions were taken to resolve a concern voiced by Resident 2's family related to Resident 2's wound care: -[Resident 2] voices concerns, discussed plan of correction [Resident 2] agreeable. Education to staff - premedicate [with] pain medicine prior to all wound care. Complete wound [treatments] as ordered, ensure supplies stocked . An observation on 11/8/22 at 10:26 AM revealed LPN-K (Licensed Practical Nurse) provided wound care to an amputation site of the second digit on Resident 2's right hand. At the start of the wound care Resident 2 stated the wound, burned like hell. LPN-K rinsed the wound with 250 mL (milliliters) of sterile normal saline. Resident 2 was wincing and grimacing throughout the rinsing of the wound. LPN-K asked Resident 2 if they wanted to continue with the wound care and Resident 2 replied, keep going since we already started. Resident 2 fanned their right hand in the air to dry it while LPN-K washed their hands in the bathroom sink. While fanning their right hand, Resident 2 was in visible pain, wincing and covering their mouth. LPN-K dressed Resident 2's wound and cleaned up the supplies. At the end of the treatment, Resident 2 requested pain medication. When leaving the room at 10:40 AM, LPN-K told Resident 2 they would have the medication aide bring them some morphine (a narcotic medication used to treat moderate to severe pain). In an interview on 11/8/22 at 11:47 AM, Resident 2 reported they had just received their pain medication approximately 5 minutes ago. Resident 2 stated they had been in excruciating pain the whole time they had to wait for pain medication. An observation on 11/8/22 at 11:47 AM revealed Resident 2 was lying in bed in visible pain. Resident 2 was restless, wincing, and moaning. A review of Resident 2's November 2022 MAR (Medication Administration Record) revealed orders for the following medications for pain: -Acetaminophen (Tylenol) 500mg (milligrams) - take 2 tablets (1000mg) three times daily for pain - scheduled at 8:00 AM, 2:00 PM, and 8:00 PM -Morphine Sulfate 15mg ER (extended release) - take 1 tablet by mouth twice daily for pain - scheduled at 8:00 AM and 8:00 PM. -Morphine Solution 20mg/mL - take 0.25mL (5mg) by mouth every 1 hour as needed for pain -Oxycodone (a narcotic medication used to treat moderate to severe pain) 5mg - take 1 tablet by mouth every 1 hour as needed for pain/shortness of breath A review of Resident 2's November 2022 MAR revealed the following documentation for pain medications prior to Resident 2's wound care on 11/8/22: -Acetaminophen 500mg 2 tablets at 8:00 AM - documented as given -Morphine Sulfate 15mg ER - scheduled at 8:00 AM - documented as not given, no explanation documented -Oxycodone 5mg - as needed - documented as given at 7:42 AM for a pain level of '9' and follow up documentation that it was ineffective. A review of Resident 2's November 2022 MAR revealed the following documentation for pain medications following Resident 2's wound care on 11/8/22: -Morphine Solution 20mg/mL - take 0.25mL (5mg) every hour as needed - documented as given at 11:42 AM for a pain level of '10' and follow up documentation that it was ineffective. In an interview on 11/14/22 at 12:32 PM, the DON (Director of Nursing) confirmed Resident 2 was supposed to have pain medication administered prior to wound care. The DON reported the expectation was that staff offer pain medication to residents prior to wound care and if a resident requests pain medication it should be given as soon as possible after the request is made.

LICENSURE REFERENCE NUMBER 175 NAC 12- Based on observations, record review and interviews; the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents to ensure safety during a potential gas leak. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 138. Findings are: Record review of the facility Emergency Preparedness Plan Manuel revealed the emergency contact sheet contained numbers of agencies facility staff could call for emergency assistance. Further review of the emergency contact sheet revealed in bold black lettering that staff were to contact 911 in case of an emergency. Record review of an undated Policy and Procedure for Gas Leak found in the facility Emergency Preparedness Plan Manuel revealed the following information: -Purpose: -The purpose of a Gas Leak Policy and Procedure is to inform the facility's employees of the steps that should be taken in the event of a gas leak. The Administrator, or highest-ranking staff person on duty shall be responsible for declaring a situation a disaster and activate the facility disaster and evacuation policies and procedure. -Procedures: -1. In the event of a gas leak, the shift charge nurse shall immediately contact the Administrator, Maintenance Director and the Director of Nursing. -2. Call 9-1-1 to report the situation. Record review of a text message from Licensed Practical Nurse (LPN) F to the facility Administrator and Director of Nursing (DON) dated 12-28-2019 at 12:54 PM revealed LPN F notified the Administrator and DON that Registered Nurse (RN) A reported . lots of residents staff and therapy are complaining about headaches due to this gas smell . Record review of a text message to from the facility Activity Director (AD) to the facility Administrator dated 12-28-2019 at 1:39 PM revealed the AD reported resident and staff on station 2 of the facility were complaining of the smell, chest burning and eyes itching. Further review of the text message dated 12-28-2019 at 1:39 PM revealed the AD reported doing everything the AD could do to calm people and reported residents were opening their windows because the residents could not stand the smell. Record review of a text message from RN O to the Director of Facility Operation (DOFO) dated 12-28-2019 at 1:46 PM revealed the DOFO reported going to the facility due to gas issues and that residents were complaining of chest burning and eyes itching. On 1-01-2020 at 6:30 AM an interview was conducted with RN A. During the interview RN A reported on 12-28-2019 RN A had been notified the basement of the facility had flooding and it smelt like gas in the building. RN A reported being notified work had been completed on the heating/cooling system in the building and there would be some odor of the restarting of the heating system. RN A reported at approximately 9:30 AM the odor was getting stronger and the smell of gas remained. RN A reported making multiple reported to the Manager on duty and the nurse on call of the continued strong smell and not getting better. RN A reported on 12-28-2019 at 9:41 AM a resident was sent out of the facility and there were 7 people (3 residents and 4 visitors) who were complaining of eyes burning, light headed and being nauseated. On 1-02-2020 at 6:50 AM an interview was conducted with LPN C. During the interview LPN C reported when entering the north door to work immediately noticed a funny strong smell. LPN C reported being informed the heating system had been worked on. LPN C stated the smell was so bad I had to get a mask, it was that strong, it smelled like gas, not like natural gas. LPN C instructed staff to open windows and doors. LPN C reported the smell became stronger throughout the day. On 1-02-2020 at 8:00 AM an interview was conducted with the AD. During the interview the AD reported the facility had worked on the heating system in the building and there was an expected smell of restarting the heating system. The AD stated at 1:30 PM staff reported being dizzy , had [MEDICATION(S)] and their chest hurting. The AD further identified speaking with a resident and had noticed the resident had opened the window. According to the AD, the facility Administrator and the facility maintenance director were notified of the concerns. On 1-02-2020 at 8:44 AM an interview was conducted with RN D. RN D reported not noticing anything before lunch. According to RN D at 1:30 PM RN D had become very sleepy. RN D identified between 10:30 AM and 11:00 AM staff reported burning eyes, being nauseated and that something was happing in the building. On 1-02-2020 AT 9:07 am a interview was conducted with Nursing Assistant (NA) E. During the interview NA E had reported to work on 12-28-2019 and had noticed a strong odor and it smelled like gas. According to NA E, once residents were out of their rooms, windows were opened, NA E stated it defiantly was gas. On 1-02-2020 at 9:15 AM an interview was conducted with LPN F. During the interview LPN F reported being on call for the weekend. LPN F was informed on 12-28-2019 there was water issue in the building as well as a gas smell and the facility maintenance was notified. LPN F confirmed RN A had reported the continued gas smell and staff, residents and the therapist were complaining of headaches. During the interview LPN F reported the information LPN F was receiving was gas smell in the facility. LPN F reported 911 should have been called any time there is a gas smell. On 1-02-2020 at 9:40 AM an interview was conducted with NA G. NA G worked 6 AM to 6:30 PM on 12-28-2019. According to NA G when NA G walked into the building NA G noticed a gas like smell going into station 2 (south west side of building) . NA G reported around 10:00 AM had become nauseated and reported it to the charge nurse. On 1-02-2020 at 10:25 AM an interview was conducted with Resident 601. During the interview Resident 601 reported being extremely sleepy on 12-28-2019 and this was not normal for Resident 601. Resident 601 stated staff had to get me up to keep me awake. On 1-02-2020 at 10:30 AM an interview was conducted with Resident 606. During the interview Resident 606 reported on 12-28-2019 there was a strong smell in the building and that Resident 606 became nauseated, had a headache and could not seem to stay awake. On 1-02-2020 at 11:00 AM an interview was conducted with Occupational Therapist (OT) I. According to OT I, OT I worked on 12-28-2019 from 8 AM to 2 PM. OT I reported when entering the building OT I noticed a strong different type of smell. OT I stated eyes burned in 700 and 800 halls (station 2). OT I identified receiving reports from facility staff and residents of the odor and gas like smell. On 1-02-2020 at 11:25 AM an interview was conducted with OT J. According to OT J, OT J worked on 12-28-2019 from 8:45 AM to 1:45 PM. OT J entered the side door of the building through the therapy area to obtain the work load schedule. OT J stated a therapy assistant had reported a gasoline smell and later on in the morning had notified the DOT of the continued odor in the building. OT J reported later in the day it felt lake as if OT J was floating, it wasn't normal. On 1-02-2020 at 11:25 AM a interview was conducted with Speech Therapist (ST) K. During the interview ST K reported working on 12-28-2019 from 7:38 AM to 5 PM. ST K was informed on entering the building the facility staff were complaining of smelling natural gas. ST K stated another therapist had notified their supervisor. On 1-02-2020 at 11:45 a interview was conducted with OT L. During the interview OT L identified working on 12-28-2019 from 8 AM to 5 PM. During the interview OT L stated it smelled like gas. According to OT L on 12-28-2019 at 1:00 PM it was like the stuff hit you in the face. The odor was strong. That's when it really was bad. On 1-02-2020 at 12:10 PM an interview was conducted with NA M. During the interview NA M stated (gender) worked from 6:30 AM to 2:30 PM on 12-28-2019. NA M stated there was a gas smell when I came into the building, I reported that to my nurse. I told (gender) 911 should be called. On 1-02-2020 at 12:25 PM an interview was conducted with Resident 603. Resident 603 reported on 12-28-2019 around noon have family visitors. According to Resident 603 within 30 minutes of the visit Resident 603 family had developed headaches as did Resident 603. Resident 603 reported the concern to the facility staff on 12-28-2019 at 12:45 PM. On 1-02-2020 at 12:40 PM an interview was conducted with the facility Maintenance Director (MD). During the interview review of LPN F's text dated 12-28-2019 with a time of 12:54 PM was reviewed with the MD. The MD confirmed there was a change in atmosphere air around 12:54 PM and emergency services should have been called. On 1-02-2020 at 1:55 PM an interview was conducted with the Interim Administrator (IA). During the interview review of LPN F's text was completed. The IA confirmed emergency services should have been called at this time and was not. The IA confirmed the Policy and Procedure for Gas Leak that was currently in the Emergency Preparedness Plan was the correct policy. Record review of a Omaha Fire Department Incident Report dated 12-28-2019 revealed the facility requested assistance on 12-28-2019 at 2:09 PM. Record review of a Metropolitan Utilities District (MUD) Customer Warning Notice dated 12-28-2019 revealed there was a safety problem with gas. According the the Customer Warning Notice dated 12-28-2019, the specific item of concern was the furnace and that it was unsafe and improperly working. On 1-06-2020 at 6:30 AM an interview was conducted with LPN N. During the interview when asked if the facility administration was engaged in resolving the ongoing gas like issue and smell in the building , LPN N reported the administrator did not handle it properly. On 1-06-2020 at 11:45 AM a confidential interview was completed. During the interview the reporter stated the facility administrator had not made (gender) phone number available and reported the administrator was ineffective and unsupportive. On 1-06-2020 at 11:30 AM an interview was conducted with LPN B. When asked if facility management respond to the ongoing gas like smell in the building, LPN B stated staff had made multiple calls/text and not really much response. Record review of a MUD report dated 12-28-2019 at 5:20 PM revealed there was 200 parts per million (ppm) of carbon monoxide on the south section of the building and 50 ppm on the north section of the building. According to the www.NYAD.com the U.S standard for Carbon Monoxide is 35 ppm for a 1 hour exposure. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07 Based on record review and interview, the facility failed to have an effective quality assurance program to ensure compliance with F329 and F314 as evidenced by the re-citation of F329 and F314. The facility had a total census of 115. Findings are: A. A review of the survey report from the certification survey completed 4/23/13 revealed deficiencies were cited under F314 and F329. Deficiencies were cited at F314 and F329 during the certification survey completed on 3/27/14. During the revisit survey completed 5/29/14, deficiencies cited at F314 and F329 were not corrected. B. During the revisit survey completed 5/29/14, Residents 26 and 32 were cited at F314 for the facility's failure to evaluate casual factors and re-evaluate interventions to prevent pressure ulcer development and promote pressure ulcer healing. Resident 26 was identified as having a sacral decubitus ulcer in a physician's orders [REDACTED]. A review of the quality assurance audit report dated 5/23/14 did not list Resident 26 and 32 as having pressure ulcers. In an interview on 5/29/14 at 7:23 AM, Registered Nurse Assistant Director of Nursing A reported the last pressure sore audit was completed 5/23/14 and included all residents with pressure sores in the building. Registered Nurse Assistant Director of Nursing A reported 24 hour reports and telephone orders were reviewed to determine if residents had developed pressure sores. C. During the revisit survey completed 5/29/14, Resident 203, 32 and 68 were cited at F329 for failure to identify target behaviors on monthly behavior monitoring records. In an interview on 5/29/14 at 7:52 AM, Interim Administrator reported quality assurance audits did not identify that target behavior monitoring was not being completed and a review of behavior monitoring should have been a part of the audit.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07 Based on record review and interviews, the facility failed to provide an effective quality assurance (QA) program as evidenced by repeat deficiencies in: F157, F242, F253, F280, F309, F314, F315, F323, F329, F332, F364, F441, and F520. The facility census was 132. Findings are: An interview with the Administrator on 3-27-14 at 9am revealed an impromptu QA meeting was held on 3-23-13 and the committee developed action plans for the following issues: Restorative program, Nutrition and weights, Bowel and Bladder program, [MEDICAL TREATMENT], lab results avail, med administration, and Care plans. The administrator revealed that bathing or choices and catheter care were not being looked at and that the above action plans were not in place prior to the meeting on 3-23-14. Interview with the Administrator on 3-27-14 at 9:30am revealed the Quality Assurance committee did not identify issues relevant to F156, F279, F 311, F 312, F322, F325, F334, F353, F363, F425, and F514 and implement effective plans to correct the deficient practice as cited on the 3-27-14 survey. Review of the findings for the last annual survey conducted on 4-23-13 revealed the facility management did not assure repeated deficiencies at F157, F242, F253, F280, F309, F314, F315, F323, F329, F332, F364, F441, and F520, were corrected and the correction maintained. Interview with LPN S on 3-27-14 at 11:15am stated (gender) was unaware if the facility had a Quality Assurance committee. Interview with NA T on 3-27-14 at 11:20am stated (gender) was unaware if the facility had a Quality Assurance committee. Review of the facility QA Policy with a revision date of 3-7-14 stated Policy: The performance improvement Committee will meet monthly to review, recommend and act upon activities of the facility, performance action teams and/or departmental activities. The committee shall direct all activities including approving proposed monitoring, evaluating and review of services. The committee will assure QAPI activities have written indicators and standards/thresholds for evaluation, the appropriate actions are implemented, and that such correction has been evaluated by subsequent monitoring.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02 Based on record review and interviews, the facility failed to maintain an effective administration to ensure compliance with federal and state regulations related to bathing, care and treatment of [REDACTED]. The facility census was 132. Findings are: Interview with the Administrator on 3-27-14 at 9:30am revealed that the administrator was working at the facility temporarily with the Director of Nursing through a contract agency and the administrator will be done in another month and had been in the facility since the end of February 2014. Interview with the dietary manager on 3-17-14 revealed (gender) had been at the facility since Monday, March 14th, 2014. In an interview with the corporate MDS Coordinator on 3-26-14 at 9:30am revealed that both MDS coordinators had been working at the facility for one week. An interview on 3-27-14 at 9:47am with the Director of Nursing revealed (gender) had been there a few weeks and was supposed to have three unit managers and had 1 currently, and the nursing department was currently made up of an average of 42% agency staff. Record review and interviews revealed the facility management did not identify ongoing issues relevant to F156, F279, F 311, F 312, F322, F325, F334, F353, F363, F425, and F514 and implement effective plans to correct the deficient practice. The facility management did not ensure repeated deficiencies at F157, F242, F253, F280, F309, F314, F315, F323, F329, F332, F364, F441, and F520 were corrected and the correction sustained.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to obtain weight,re-evaluate and implement interventions to prevent significant weight loss for 1 (Resident 52). The facility staff identified a census of 132. Findings are: A. Record review of the facility Policy and Procedure revised on 01-01-2011 titled Clinical, Dietary revealed the following: -Policy: -PO (by mouth) intake is monitored on an ongoing basis to ensure the effectiveness and appropriateness of the care provided. -Procedure: -1. Nursing service monitors and documents the percent of the diet consumed buy each resident at each meal. -2. The acceptance or refusal of a supplement or planned snack is also documented on a daily basis. -3. Residents who eat less than 50% of a meal are offered a substitute and dietary is notified of the request. If substitute is refused, resident is offered additional substitutes. Record review of the facility Policy and Procedure for Weighing the Resident dated 1-06-2012 revealed the following: -Policy: -At a minimum, all residents of the facility shall be weighed upon admission, and monthly unless ordered otherwise by the physician or as directed by the weight committee, or if contraindicated by the residents condition. B. Record review of a face sheet dated 7-02-2012 revealed Resident 52 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 52's Comprehensive Care Plan (CCP) dated 10-08-2013 revealed Resident 52 had swallowing problems and had a history of [REDACTED]. The approaches that were identified on the CCP included to provide the diet as ordered, monitor weight and provide assistance with meals. Record review of Resident 52's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3-3-2014 revealed the facility staff assessed the following about the resident: -Resident 52 had short and long term memory problems. -Cognition was severely impaired. -Required Supervision with eating. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Weight loss or gain was identified as "no or unknown". Record review of Resident 52's weight record revealed the following weights: -09-2013, 144.4 pounds (lbs). -10/2013, 143.2 lbs. -11/2013, 146.1 lbs. -12-2013, 147.0 lbs. -01-2014, 145.2 lbs. -02-2014 no weights were recorded. -03/19/2014, 128.8 lbs,( a loss of 18.2 pounds or 12.38% from the weight dated 12-2013). Record review of Resident 52's Meal Intake Daily Report printed on 3-26-2014 revealed 18 of the 93 meal intakes were recorded for December 2013, 15 of the 93 meals for January 2014 were recorded, 13 of the 84 meals for February were recorded and 3 of 54 meals up to March 18,2014 were recorded. Record review of Resident 52's Weekly Nursing Progress Notes (WNPN) dated 1-31-2014 revealed the section titled Weight loss contained documentation that Resident 52 ate an average of 50 to 75 percent of meals. NO other information was documented for this section. According to the directions in the Nutrition section of the WNPN, staff were to summarize the average meal intake for the last 7 days, identify any nutritional interventions, ability to feed self, review laboratory work, and any special programs such as 6 meals per day, hi calorie supplements and restaurant foods. Record review of Resident 52's WNPN dated 2-07-2014, weight loss section revealed Resident 110 ate 50 to 75 percent of food. No other information was documented in the section. Record review of Resident 52's WNPN dated 2-14-2014, weight loss section, revealed Resident 52 was eating an average of "...25 to 50 percent". No other information was documented in this section for weight loss. Record review of a Nutritional Evaluation form dated 3-7-2014 revealed the facility Registered Dietician (RD) had made a recommendation of "med pass ( supplement) 2.0 at 90 cc (cubic centimeters) twice a day. The facility RD identified that Resident 52 was now on Hospice services. Record review of Resident 52's medical record did not contain evidence the supplement had been provided as recommened by the facility Rd on 3-07-2014. Record review of a Progress Note (PN) sheet dated 3-18-2014 revealed the facility RD identified that Resident 52 had lost 12 % of weight in the last 3 months and 10% for the last 6 months. According to the RD's documentation, the recommendation for 3-07-2014 had not been completed. Record review of Resident 52 PN dated 3-24-2014 revealed the facility RD recommended Medpass (supplement) 120 cc's three times a day between meals to increase calories/protein needs for weight management. Record review of Resident 52's Medication Administration Record [REDACTED]. An interview on 3-26-2014 at 1:16 PM was conducted with the facility Director of Nursing (DON). During the interview, Resident 52's meal intake records were reviewed with the DON. The DON confirmed that Resident meal intakes had not been completed for each meal. An interview on 3-26-2014 at 8:44 AM was conducted with Registered Nurse (RN) C. During the interview, Resident 52's weight record was reviewed. According to RN C weights are obtained from the first of the month through the fifth of the month and if a resident refused, staff were to keep trying. RN C confirmed February's weight had not been obtained. A follow up interview was conducted with RN C on 3-27-2014 at 7:53 AM. Review of Resident 52's MARs and TARs for March 2014 was conducted with RN C. RN C confirmed the Med Pass supplement had not been started for Resident 52. C. Observation of Resident 52's meal for lunch on 3-26-2014 at 1:16 PM revealed Resident 52 had eaten less than 10% of the meal. An interview on 3-26-2014 at 1:16 PM was conducted with RN C. During the interview; RN C reported that (gender) had been in the dinning room for the entire lunch meal. When asked if Resident 52 had been offered a substitution, RN C stated "no". D. Observation on 3-27-2014 at 7:30 AM revealed Resident 52 was in bed sleeping. Observation on 3-27-2014 at 8:59 AM revealed Resident 52 was in bed asleep. An interview with Licensed Practical Nurse (LPN) J was conducted on 3-27-2014 at 9:02 AM. According to LPN J, staff were to get Resident 52 up for breakfast. On 3-27-2014 at 9:19 AM an interview was conducted with RN C. When asked what time breakfast was, RN C reported from 8 AM to 9 AM. An interview with LPN J was conducted on 3-27-2014 at 9:24 AM. during the interview, LPN J reported that (gender) was not aware Resident 52 had not eaten breakfast.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2B Based on record review, observation and interview; the facility staff failed to implement assessed interventions, failed to evaluate casual factors and re-evaluate interventions to promote pressure ulcer healing for 3 (Resident 32, 137 and 26). The facility staff identified a census of 115. Findings are: A. Record review of a Face Sheet dated 5-22-2014 revealed Resident 32 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Pressure Ulcer Record sheet dated 5-21-2014 revealed Resident 32 had a stage 2 ( Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) to the right knee. Record review of a Weekly Wound Assessment Sheet dated 5-27-2014 revealed the order for the Pressure Ulcer treatment to the right knee was a [MEDICATION NAME] type of dressing. Record review of Resident 32's Comprehensive Care Plan (CCP) dated 4-22-2014 revealed Resident 32 had unstageable pressure ulcers to the left and right knees. The goal for Resident 32 was the pressure ulcers would display healing to the target date of 8-14-2014. Interventions listed on the CCP to meet the goal was to complete the treatment as ordered and to have a soft padding between the resident knees. On 5-28-2014 at 3:19 PM an observation with Registered Nurse (RN) B was conducted of Resident 32's knee's and placement of wound dressing to the right knee. During the observation, Resident 32 did not have a dressing to the right knee in place and did not have a soft padding between the knees. An interview with RN B was completed on 5-28-2014 at 3:19 PM. During the interview, RN B confirmed that Resident 32 did not have a dressing in place to the right knee and did not have soft padding in between the knees. Observation on 5-28-2014 at 4:14 PM an observation with RN D was conducted of Resident 32's knees. Resident 32 was observed not to have the soft padding or dressing in place to the right knee. An interview with RN D was conducted on 5-28-2014 at 4:14 PM. During the interview, RN D confirmed Resident 32 did not have padding between the knees and did not have a dressing to the right knee. B. Record review of a Face Sheet dated 5-22-2014 revealed Resident 137 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 137's CCP dated 4-22-2014 and updated on 5-20-2014 revealed Resident 137 had skin breakdown to the left and right buttocks. Interventions listed on Resident 137's CCP included barrier cream as indicated, and to encourage the resident to lay down. Further review of Resident 137's CCP did not contain any evidence that Resident 137 was non-compliant with any cares. Record review of a Weekly Wound Assessment sheet dated 5-27-2014 revealed Resident 137 had a stage 2 pressure ulcer to the left and right buttocks and Resident 137 was to have Prafo Boots on. Observation on 5-28-2014 at 1:37 PM with Licensed Practical Nurse (LPN) E revealed nursing staff were assisting Resident 137 with toileting. Observation of Resident 137's buttocks after toileting revealed Resident 137 had dark red area to the left and right buttock and a open area to the coccyx area. When asked what the measurements of the dark red areas were, LPN E reported approximately 4 cm (centimeters) by 6.5 cm and the open area was approximately 0.3 cm. LPN E applied a barrier cream to Resident 137 and nursing staff assisted the resident into bed. Nursing assistance did not apply prafo boots to Resident 134 feet. Observation on 5-28-2014 at 3:22 PM with RN B of Resident 137's feet revealed the resident did not have any prafo boots on. During the observation, when asked if Resident 137 was to have prafo boots on, RN B stated "yes". Observation on 5-29-2014 at 5:45 AM revealed Resident 137 was seated in a wheelchair and watching TV. Observation on 5-29-2014 at 7:54 AM revealed Resident 137 was in the Dinning Room for waiting for breakfast. When asked if staff had assisted (gender) with repositioning, Resident stated "not since they got me up this morning". On 5-29-2014 at 7:15 AM an interview was conducted with Resident 137's Advanced Registered Nurse Practitioner (ARNP). During the interview, discussion of Resident 137's pressure ulcers and prognosis for healing. According the ARNP, Resident 137's pressure ulcer is healable. According to Resident 137's ARNP, the facility needed to consider moisture issue and lay the resident down. According to the National Pressure Ulcer Advisory Panel (NPUAP) at www.npuap.org revealed Pressure ulcer prevention points included "Repositioning bed-bound persons at least every two hours and chair bound persons every hour consistent with overall goals of care". C. Review of Resident 26's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/17/14 revealed the following: - Alert and oriented with a BIMS score of 14. - No behaviors or rejections of cares. - Total assist of 2 with bed mobility, transfers, toileting, personal hygiene, and bathing. Review of Resident 26's Face Sheet dated 1/4/13 revealed the [DIAGNOSES REDACTED]. Review of a Methodist Physician Clinic Record dated 3/17/14 revealed Resident 26 had a [DIAGNOSES REDACTED]. Record review of Resident 26's Quarterly Data Collection form, Section B, Braden scale(a tool for predicting pressure ulcer risk) with completion date of 4/13/14 revealed a score of 14 (a score of 13-14 which indicates a resident at moderate risk for breakdown). Review of Resident 26's CCP revealed the facility identified that Resident 26 was at risk for skin impairment related to decrease mobility. The interventions identified on the care plan to prevent the skin breakdown included "Assess skin weekly by licensed nurse. Document changes in skin, color, turgor. Pressure reducing mattress. Assist with turning and repositioning as needed." Record review of a SBAR (Situation, Background, Assessment, and Response) form which identified Resident 26 to have a skin shear to right inner buttock on 5/15/14. Observation on 5/27/14 at 11:47 AM revealed Resident 26 was sitting in (gender) wheelchair (w/c) with a Hoyer sling (a device that lays under a resident to assist with lift transfers) underneath Resident 26. Observation on 5/27/14 at 12:23 PM revealed Resident 26 in the dining room eating. Resident 26 was seated in a w/c with a Hoyer sling under (gender). Observation on 5/27/14 at 2:03 PM revealed Resident 26 was seated in (gender) room, sitting in w/c with a Hoyer sling under Resident 26. Observation on 5/27/14 at 4:15 PM revealed Resident 26 lying in bed with Hoyer sling under Resident 26. Interview on 5/27/14 at 4:15 PM was conducted with Resident 26. During the interview, when asked how long Resident 26 had been laid down, Resident 26 stated, "I got laid down after lunch. I sit up from breakfast to after lunch. I'm use to it. That area to my bottom has been raw a long time and it's been a long time coming." Resident then stated, "I cant feel my bottom area and I used to be on an air mattress but they took it away and the sore came back after they took the air mattress away about a month ago." Resident 26 stated, "They don't turn or reposition me when I'm in my wheelchair for that long." Observation on 5/28/14 at 6:20 AM revealed Resident 26 was in a back lying position. Observation on 5/28/14 at 7:30 AM revealed Resident 26 sitting in room, upright in the wheelchair, with Hoyer sling under Resident 26. Observation on 5/28/14 at 9:40 AM revealed Resident 26 was sitting in wheelchair next to bed watching TV with Hoyer sling under Resident 26. Observation on 5/28/14 from 12:00 PM until 12:25 PM, revealed Resident 26 sitting in wheelchair in upright position at dining room table eating while Hoyer sling remained under the resident. Observation on 5/28/14 at 2:23 PM revealed Resident 26 in bed lying with Hoyer sling under the resident . Interview on 5/28/14 at 2:32 PM with Nursing Assistant (NA) F. During the interview, NA F stated Resident 26 "was laid down at 2:15 PM." NA F also stated, "I change (gender) every morning, lotion (gender) and change (gender) every afternoon when I lay (gender) down after meal when (gender) asks me to lay (gender) down and that is when (gender) was positioned today and (gender) didn't ask me until then." NA F repled, "no" when asked if Resident 26 was repositioned any time between 7:30 AM and 2:15 PM. Interview on 5/28/14 at 2:48 PM with LPN G stated, " Expectation is to reposition Resident 26 every 2 hours while sitting in wheelchair and if they refuse to lay down then expectation is notify CN (Charge Nurse) and the CN needs to explain to the resident that (gender) needs to lay down between meals, due to the sore, and if resident continues to refuse then document it. LPN G verified that no documentation for Resident 26's refusal for reposition or lying down had been documented for 5/28/14. LPN G also verified that Resident 26 was on a specialty mattress and the mattress was removed about a month or two ago. LPN G was unsure of the date of the specialty mattress removal. LPN G also stated, "Resident 26 was doing very well while on the air mattress and since it was removed (gender) skin broke down again." Observation on 5/28/14 at 3:44 PM of Resident 26 lying in bed with the Hoyer sling under (gender). LPN H removed the dressing from the resident's right ischial area to reveal an open area to the right ischium. LPN H cleaned the area with normal saline, dried the open area, and replaced the [MEDICATION NAME] to the area. When asked, LPN H agreed that the open area was not on the coccyx or buttock but was on the right ischium. Record review of TAR (Treatment Administration Record), dated May 2014, revealed an order to apply [MEDICATION NAME] dressing to the resident's right inner buttock daily and prn (as needed) and initiated on 5/17/14 with initials as administered from 5/17/14 to 5/27/14. Record review of physician's orders [REDACTED]. Record review of the Non-Pressure Skin Condition Record dated 5/15/14 revealed documentation of a skin tear/abrasion to the right inner buttock with a measurement of 4 cm x 3 cm X 0 cm with red drainage noted with wound edges bleeding and periwound area red. 5/19/14 entry of documentation with measurements 4 cm X 3 CM X 0 cm with red drainage and red periwound area. On 2/26/14 no measurements noted and the wound was described as "scaly coccyx area." 5/26/14 measured, "0.5 X 0.5 cm pink/red coccyx area". No other entries were noted. Record review of Resident 26's Pressure Ulcer Record dated 5/27/14 revealed "right inner buttock, Stage 2 with measurement of 0.5 X 0.8 x <0.1". Interview on 5/29/14 at 6:45 AM with Nurse Ambassador K verified that the open area was a pressure ulcer and was on the right ischium not the coccyx or right buttock. Nurse Ambassador K also stated they put the air mattress back on the resident's bed yesterday because Resident 26 requested the air mattress to be put back on the bed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review, and interviews; the facility failed to provide an ordered treatment to help in the healing of a coccyx pressure ulcer for Resident 168. The facility census was 132. Findings are: Review of Resident 168's face sheet revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Activities of Daily Living (ADLs) documentation for February and March 2014 revealed Resident 168 needed extensive assistance in bed, transferring, dressing and grooming. Weekly skin sheets stated Resident168 had a pressure ulcer on coccyx that was present on admission and the measurements in centimeters (cm) were: - 2cm x 2cm x <0.1cm on 2-3-14 - 8.5cm x4.5cm x<0.1cm on 2-26-14 - unstageable on 2/27/14 Progress Note for Resident 168 dated 2/27/14 showed an order for [REDACTED]. Observed Resident 168 on 3-25-14 at 10:40am in bed, with air overlay to mattress, however overlay was not running. Observed RN (Registered Nurse) C on 3-25-14 at11:50 am measured the wound to Resident 168's coccyx and revealed a pressure ulcer of 7cm x 2cm x 0.2cm, slough noted. Interview with RN C on 3-25-14 at 11:50am confirmed that the air overlay mattress was not turned on and then turned it on and it began filling with air. Review of February 2014 Treatment sheets revealed no documentation of treatments provided to the pressure ulcer on Resident 168's coccyx. Review of Resident 168's dietary assessment for skin condition dated 3-7-14, by Registered Dietician (RD), revealed recommendations of: -document amount of supplement consumed -check BMP (basic metabolic panel) and [MEDICATION NAME] (blood work to evaluate nutritional status) on next lab day -three day calorie count. Review of labs revealed no [MEDICATION NAME] or BMP checked as RD recommended Review of telephone orders revealed no orders for the RD recommendations on 3-7-14 Review of the facility policy on assessment and documentation of wounds with a revision date of 1-1-11 stated: residents with active Pressure sores: Every resident with active pressure sores will have Pressure Sore Progress documented weekly to determine any changes in potential risk factors, effectiveness/appropriateness of current interventions/appliances, recommendations to the physician for changes in the plan of treatment and complete documentation of current wound statistics as directed on page 2 of the form. Interview on 3-26-14 at 4:20 pm with RN Consultant E stated that the RD recommendations on 3-7-14 never were completed. Interview with RN C on 3-26-14 at 11:20am confirmed that there was no documentation between 2-3-14 and 2-26-14 of coccyx wound assessments and there was no documentation of wound care being done in February 2014.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility failed to have an effective Quality Assurance (QA) program to identify concerns related to pressure sores, pain management and accident prevention. The facility QA program failed to ensure that repeat deficiencies at 309, 314 and 323 were corrected and the correction maintained. The facility census was 145. Findings are: Review of the facility's Performance Improvement (QA) policy with a revision date of 9-1-11 revealed under Procedure: 5. the facility will identify areas for continuous quality monitoring and the monitoring tools to be used. These monitoring activities should focus on those processes that affect resident outcomes most significantly. This ongoing monitoring is used to establish the facilities baseline and the predictability of various outcomes. 8. Once an aspect of care has been selected the committee will: 2. Identify indicators of success. These indicators must be measurable and based on current knowledge and/or clinical experience. 14. The Performance Improvement Committee has the responsibility for designing and implementing corrective action plans as needed to resolve identified resident care/service problems. Review of the findings for the last annual survey conducted on 2-29-12 revealed deficiencies at: F309 (care for highest functioning), F314 (treatment of [REDACTED]. The annual survey conducted on 4-24-13 also cited deficiencies in these areas. An interview with the Director of Nursing (DON) on 6/12/13 at 9:28 AM revealed that the QA committee met monthly and utilized audits and roundtable discussion to identify problems and develop action plans. To evaluate if the plans were working, issues were discussed in daily stand up meeting or at next QA meeting. Auditing was also done. DON stated that QA monthly audits included information on pressure sores and accident prevention but did not include audits on pain management. The DON stated that no major issues had been identified during the QA audits related to pain, skin or accident prevention. Interview on 6/12/13 at 10:50 AM with the facility Administrator confirmed that the QA systems did not pick up on the issues that were identified on the revisit.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility failed to have an effective Quality Assurance (QA) program as evidenced by repeat deficiencies in: F157, F225, F280, F309, F314, F323, F329, F323, F333, F371, F520. The facility census was 144. Findings are: Review of the findings for the last annual survey conducted on 2-29-12 revealed deficiencies at: F157 (Informing of accidents and significant changes), F225 (Reporting abuse), F280 (Updating care plans), F309 (care for highest functioning), F314 (treatment of [REDACTED]. The annual survey conducted on 4-24-13 also cited deficiencies in these areas. An interview with the Director of Nursing (DON) on 4-24-13 at 8:00 am revealed that the QA committee met monthly and utilized audits and roundtable discussion to identify problems and develop action plans. To evaluate if the plans were working, issues were discussed in daily stand up meeting or at next QA meeting. Auditing was also done. DON stated that current issues the committee was working on were: survey readiness, customer service, falls, reducing hospitalization s and staffing. Skin was always discussed. A plan for skin care was now in place and was started when an unidentified pressure ulcer was found. Review of the facility's Performance Improvement (QA) policy with a revision date of 9-1-11 revealed under Procedure: 5. the facility will identify areas for continuous quality monitoring and the monitoring tools to be used. These monitoring activities should focus on those processes that affect resident outcomes most significantly. This ongoing monitoring is used to establish the facilities baseline and the predictability of various outcomes. 8. Once an aspect of care has been selected the committee will: 2. Identify indicators of success. These indicators must be measurable and based on current knowledge and/or clinical experience. 14. The Performance Improvement Committee has the responsibility for designing and implementing corrective action plans as needed to resolve identified resident care/service problems.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to evaluate, monitor provide treatment for [REDACTED]. The facility staff identified a census of 144. Findings are; A. Record review of a Face Sheet dated 4-01-2013 revealed Resident 61 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Admission-Data Collection Form (ADCF) dated 3-29-2013 revealed the facility staff evaluated Resident 61's risk for the development of a pressure ulcer. Resident 61 scored a 13 for risk factors for the development of pressure ulcers. According to the form, a score of 13 placed Resident 61 at moderate risk for the development of pressure ulcers. Further review of the ADCF dated 3-29-2013 revealed Resident 61 had been identified with multiple skin condition. Resident 61 was evaluated with a pressure ulcer to the left buttocks. No other pressure ulcers were identified for Resident 61. The Skin Condition section of the form had the skin condition identified as "warm" and no treatments were identified in the treatment section of the ADCF. Items to be identified in the treatment section included pressure reduction devices, turning program, ulcer sore care, and application of ointments/ medications. Record review of Resident 61's Care Plan dated 3-29-2013 revealed Resident 61's pressure ulcer to the left buttocks was listed on the care plan. Also listed on Resident 61's care plan was an entry that identified an area to Resident 61's right 4th toe as "UTS" ( unable to stage). Record review of Resident 61's medical record did not contain monitoring of the area to Resident 61's right 4th toe, any treatment or an evaluation of the right 4th toe. Observation on 4-22-2013 at 2:27 PM with Licensed Practical Nurse (LPN) D of Resident 61's buttocks and feet revealed Resident 61 had a dressing in placed on the right foot,between the 4th and 5th toes. LPN D removed the dressing revealing a dark/black area that was painful to touch. Once the dressing was removed, observation revealed Resident 61's toes would press together. Resident 61 reported (gender) was going to be seeing the podiatrist. An interview with LPN D was conducted on 4-22-2013 at 2:27 PM. LPN D reported that (gender) did not know about the area to Resident 61's right food and confirmed no monitoring of the area to the right foot, between 4th and 5th toes had been completed. A follow up interview with LPN D was conducted on 4-22-2013 at 2:46 PM. LPN D reported that Resident 61 was not on the list to be seen by the podiatrist. An interview was conducted with LPN E on 4-22-2013 at 2:46 PM. LPN E reported not being aware of the ulcer area between Resident 61's 4th and 5th digit. LPN E confirmed there was not a treatment for [REDACTED]. An interview on 4-22-2013 at 3:16 PM was conducted with LPN F. During the interview, LPN F reported there were no skin sheets for monitoring the area and should have been, no evaluation had been conducted for the casual factors for the skin breakdown or that Resident 61's physician had been informed of the ulcer areas. On 4-23-2013 at 10:30 AM The facility Assistant Director of Nursing (ADON) provided copies of the facility evaluation of Resident 61's skin condition to Resident 61's right foot. According to the Pressure Ulcer Record (PUR) sheet dated 4-22-2013 revealed Resident 61 was identified with a Stage II ( Partial thickness tissue loss of dermis presenting as a shallow open ulcer with red/pink wound bed without slough) to the right foot, 4th digit, that measured 0.4 cm (centimeter) by .03 cm by 0.1 cm. On 4-23-2013 The ADON provided a revised copy of a PUR dated 4-23-2013 that identified Resident 61 with a UTS to the right foot 4th digit. According to the definition on the PUR, A UTS is a wound bed that con not be seen due to a non-re-movable dressing/device, slough and/or eschar. Slough tissue is defined as necrotic/avascular tissue in the process of separating from the viable portions of the body. Eschar is defined as thick, leathery, frequently black or brown, necrotic or devitalized tissue that has lost its usually physical properties and biological activity. According to the PUR, Resident right 4th digit had "creamy drainage (and) eschar around the outer edge". Record review of a PUR sheet dated 4-23-2013 revealed Resident 61 was identified with a stage II to the right foot, 3rd digit. Record review of a PUR dated 4-23-2013, Resident 61 was identified with a stage II to the right foot, 5th digit. An interview was conducted with the Director of Nursing (DON) on 4-24-2013 at 10:44 AM. During the interview the DON confirmed the areas to Resident 61's right foot was pressure related, that an evaluation of the casual factors and monitoring of the ulcer areas had not been completed. B. Record review of a Face Sheet dated 3-21-2013 revealed Resident 159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a Skin Risk Assessment (Braden) revealed Resident 159 was scored at a 15. According to the information on the Braden sheet, Resident 159 was at risk for skin breakdown. Record review of a ADCF dated 3-19-2013 revealed was evaluated with a red bruise, discoloration and a surgical area. No pressure ulcers were identified. Record review of a Non-decubitis Skin Condition Record (NDSCR) dated 3-28-2013 revealed Resident 159 was identified as having a stage II to the right heel with a small amount of drainage. In information on the NDSCR revealed a "scabbed pulled (,) it came off R (right) heel open 31/2 x 21/2 cm. Record Review of an hand written entry revealed Resident 159's area to the right heel was identified as unstageable. An interview on 4-24-2013 at 11:04 AM was conducted with the DON. During the interview, the DON confirmed an evaluation of the casual factors related to Resident 159 ulcer to the heel had not been completed. Record review of the facility Policy and Procedure for Wound Care revised on 9-01-2011 revealed the following: -Implementation of appropriate treatment. -#3. If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure complete the PUR. -Wound Care Assessment and Documentation: -Accurate assessment and documentation of wounds and wound status is vitally important in management of wounds regardless of etiology. Record Review of Nurses Notes in the resident's chart dated 3/13/2013 revealed a phone call had been received from the resident's primary care physician's office following a Dr. visit. The call was an order for [REDACTED]. visit. A pressure ulcer identified as Stage II on the Left buttock was added to the care plan and dated 03/13/2013. A review was done at the weekly skin meeting with treatment to ulcer in place. The resident was offered and refused a gel overlay cushion for pressure relief on 04/17/2013. Record review revealed the treatment had not been charted as completed from 04/01/2013 thru 04/22/2013. An interview with Unit Manager I on 04/23/2013 at 11:10 AM verified that the treatment was not charted on the TARS as being completed from 04/01/2013 through 04/22/2013. Observation of dressing change to the pressure ulcer by LPN L on 04/23/2013 at 11:20 AM revealed the LPN followed treatment orders as directed by MD.

LICENSURE REFERENCE NUMBER 12-006.09 Based on observation, interview and record review, the facility failed to provide pain management for Resident 47. The facility had a total census of 145 residents. Findings are: Observation of Resident 47 on 06/11/13 at 3:15 PM revealed two medication cups sitting on the bedside stand with medications in them and two unopened cans of Ensure Plus. RN (Registered Nurse) Unit Manager F was called to Resident 47's room and removed the medication from the room. The Unit Manager was unable to identify the medications present in the medication cups. Interview with RN G on 06/11/13 at 3:25 PM revealed RN G had dispensed the medications to Resident 47 at the noon medication pass. RN G revealed the medications were [MEDICATION NAME] 100mg 1 capsule po (orally) TID (3 times daily), Calcium 600mg tab; 2.5 tabs (1500mg) po TID and [MEDICATION NAME] 5mg po q (every) 4hr (hours) for pain. RN G stated that in the past, the resident had always taken the medication. Interview with the DON (Director of Nursing) on 06/11/13 at 3:30 PM verified medications as medications that were to be dispensed at the noon medication pass. An interview was held with Resident 47 on 06/11/13 at 3:55 PM. The resident identified pain as "almost a 10" on a 1 -10 scale. Review of the policy and procedure on oral administration of medications done on 06/12/13 identified the policy was dated 01/01/2007 with a revision date of 09/01/11. The policy identified the following procedure to be followed: "Administer oral drug and remain with resident until medication is swallowed. Check resident's mouth if in doubt. DO NOT leave medication at the bedside." Review of the admission care plan dated 06/10/13 identified interventions to monitor pain, non-drug interventions, administer pain medications as ordered, eliminate or reduce causative factors, place on pain management, encourage rest periods, change room temperature, and written is "pain level is a 6 identified as tolerable."

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on observation, and interview; the facility staff failed to monitor and evaluate casual factors for a development of wound for 1 (Resident 61) of 54 sampled residents. The facility staff identified a census of 144. Findings are: Record review of a Face Sheet dated 4-01-2013 revealed Resident 61 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Admission-Data Collection Form (ADCF) dated 3-29-2013 revealed Resident 61 was identified as having a "scab" area to the outer aspect of the left foot. Record review of Resident 61's medical record did not contain evidence the facility staff evaluated the development of the "scab" area to Resident 61's left outer foot or that the area was being monitored for potential complications. Observation on 4-23-2013 at 7:20 AM of a treatment with Licensed Practical Nurse (LPN) D revealed Resident 61 reported the side of (gender) left foot was sore to LPN D. Observation of the left foot revealed a callused like area to the left outer area to the left foot. The edges around the wound was red and painful to touch. An interview with the Director of Nursing (DON) was conducted on 4-24-2013 at 10:44 AM. During the interview, the DON confirmed the area to Resident left foot had not been evaluated for the development of the wound or that monitoring had been completed.

Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews, the facility failed to ensure effective management of facility resources to maintain the high practical well being of residents and the facility as evidenced by failure to ensure the facility identified and developed plans of action to correct deficient practices and failure to maintain correction for previously cited areas of deficient practice and failed to provide Medical Director required docuemntation to fulfill Medical Directors duties. The survey sample was 26 residents with 4 non-sampled residents. The total facility census was 157 residents. Findings are: A. The facility was found to be deficient in multiple areas of regulatory compliance. The following is a list of F tags cited, please refer to the tag citation for specific detailed findings: -F157 Failed to notify resident's physician and/or family members of changes in condition -F221 Failed to evaluate a tilt and space wheelchair as a restraint -F225 Failed to report possible abuse or neglect immediately, investigate and submit investigation in accordance with federal requirements -F253 Failed to maintain equipment and furniture in clean condition and in good repair -F279 Failed to implement comprehensive care plan -F281 Failed to follow physician order [REDACTED]. -F309 Failed to evaluate skin breakdown and implement interventions -F311 Failed to provide restorative services -F323 Failed to evaluate causal factors, implement interventions and reevaluate interventions to prevent accidents -F325 Failed to weigh residents, evaluate weight changes and implement caloric count -F329 Failed to complete behavioral monitoring for aggressive behaviors -F332 Failed to ensure medication error rate of less than 5% with a medication error rate of 18.6% -F333 Failed to ensure residents were free from significant medication errors -F371 Failed to ensure dietary staff utilized hand washing techniques and install back flow prevention device -F467 Failed to maintain ventilation system in working order -F469 Failed to maintain an effective pest control program -F520 Failed to maintain an effective Quality Assurance Program B. The facility failed to maintain correction of the following tags cited during the previous annual survey completed 3/3/11: F157, F253, F280, F315, F323, and F329. C. The facility policy titled Physician Services revised on 11/11 listed the following duties for the Medical Director: - "Review and sign all incident reports, identify hazards to health and safety, and provide recommendations to the Facility's Administrator to promote a safe and sanitary environment for residents, guests, and personnel." - "Participate in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care including policies related to: i. admissions transfers, and discharges ii. infection control iii. use of restraints iv. physician privileges and practices v. responsibilities of non-physician health care workers (e.g., nursing, rehabilitation therapies, and dietary services in resident care, emergency care, and resident assessment and care planning). A review of 15 facility incident reports dated between 10/4/11 and 2/6/12 did not reveal signatures from either of the facility's Medical Directors. A review of the Administrative Manual of policies and procedures did not reveal a signature from either of the facility's Medical Directors indicating the manual had been reviewed and approved. The Administrative Manual of policies and procedures was approved by the Administrator on 4/27/11 and the Director of Nursing on 5/5/11. In an interview on 2/29/12 at 11:42 AM, Medical Director GG reported Medical Director GG had not recently been provided with incident reports to review and sign or the policy and procedure manual to approve. In an interview on 2/29/12 at 12:30 PM, Medical Director HH reported Medical Director HH had not been provided with incident reports to review and sign or the policy and procedure manual to approve.

Based on observations, record review, and interviews the facility failed to ensure effective management of facility resources to maintain compliance with federal regulations and the highest practical well being of residents. as evidenced by 1) failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice, and 2) failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice. Sample size was 15. Facility Census was 135. Findings are: The facility was found to be non-compliant in multiple areas of regulatory requirements after the tasks of the revisit survey were completed. Please refer to the Tag citations for specific detailed findings. ? F246 The facility failed to evaluate residents environment for functional mobility. ? F 280 The facility failed to review and revise care plans related to the development of pressure ulcers and toileting plan . ? F309 The facility failed to evaluate fluctuating blood pressures. ? F314 The facility failed to monitor , reevaluate and implement additional interventions related to skin breakdown. ? F315 The facility failed to evaluate catheter function. ? F323 The facility failed to evaluate the safety of transfers. ? F246 The facility failed to evaluate residents environment for functional mobility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 175 NAC 12-006.09D7a and 175 NAC 12-006.D7b Based on observation, record review and interview; the facility staff failed to evaluate casual factors, implement interventions and re-evaluate interventions to prevent accidents for 8 ( Resident 2, 8, 10, 11, 12, 17, 18 and 21) of 26 sampled and 4 non-sampled residents. The facility staff identified a census of 157. Findings are; A. Record review of a Face Sheet dated 11/28/2011 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 2's Minimum Data Set ( MDS, a Federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 11/21/2011 revealed the facility staff assessed the following about the resident: -Was usually understood and usually understands. -Long and short term memory problems. -No behaviors were identified. -Required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -Used a wheelchair for mobility. -Frequently incontinent of bladder and always incontinent of bowel. -No falls were listed since that last MDS. -Hospice resident. -Other [DIAGNOSES REDACTED]. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 8/11/2011 and updated on 11/13/2011 revealed Resident 2 required 2 people to assist with transfers. Record review of Resident 2's Progress Notes dated 1/25/2012 revealed the following entry" Pts (patient) roommate # reports to this nurse that pt was dropped to the floor last eve (evening) while being put to bed. found pt has swollen bruised Lt (left) knee. Painful to touch and unable to move Lt leg to propel w/c (wheelchair) as pt was able to do yesterday". According to the Progress Notes, Resident 2's Physician Assistant (PA) and the Hospice Nurse were informed of the incident. X-Rays were ordered for the left knee. The x-ray result did not reveal a fracture to the left knee. Record review of Resident 2's Progress Notes dated 1/26/2012 revealed a late entry for 1/25/2012 which stated the following " Interviewed CNA (Certified Nursing Assistant) taking care of res (resident) on 1/24/2012 evening shift. CNA states I was transferring (gender) by myself,(gender) started to lose (gender) balance and I was told never break a fall, so I assisted (gender) to the floor. I notified the nurse right away". Record review of a Change in Condition Evaluation (COCE) form dated 1/25/2012 for a late entry date for 1/24/2012 revealed Resident 2 was "... found on the floor in a sitting position in front of (gender) w/c. Legs were bent at the knees and feet to the left". Record review of Resident 2's Progress Notes dated 2/01/2012 revealed Resident 2's daughter reported to Resident PA that Resident 2 "...seems to be in more pain and requested further x-rays". An order was given for x-rays of both hips, pelvis and right knee. Record review of the X-ray results dated 2/01/2012 revealed Resident 2 had a "fixated right femur fracture". An interview with LPN (Licensed Practical Nurse) O was conducted on 2/08/2012 at 3:05 PM. During the interview, LPN O reported Hospice staff were sitting with Resident 2, 24/7. When asked why Hospice staff were staying with Resident 2, LPN O stated "since the fall (gender) has been very painful and we are trying to titrate (gender) pain medication". An interview with Resident 2's Daughter was conducted on 2/09/2012 at 8:30 AM. During the interview Resident 2's Daughter reported Resident 2 had been " very painful since the fall and is no longer getting up". Record review of a written statement dated 2/09/2012 by Nursing Assistant (NA) P revealed NA P documented (gender) had been informed that Resident 2 was a "1 assist and pivot" type of transfer. An interview with the Director of Nursing (DON) was conducted on 2/09/2012 at 1:50 PM. During the interview, Resident 2 incident with resulting fracture was discussed. The DON confirmed they were not aware Resident 2 had a fracture. When asked if all staff had been educated on care plans and the method of transfers for residents, the DON stated "no". The DON confirmed NA P had documented that (gender) had been informed by a staff member of Resident 2's incorrect transfer status. When asked what would prevent this from happing to someone else, the DON stated "I'm not sure". B. Record review of a Face Sheet dated 1/18/2012 revealed Resident 18 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 18's MDS dated and signed as completed on 1/30/2012 revealed the facility staff assessed the following about the resident; -A score of 15 on the BIMs ( a tool used as a brief screener that aids in detecting cognitive impairment). A score of 13-15 is identified as cognitively intact. -No behaviors were identified on the MDS. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Falls before and after admission and a history of a fracture. -Occasionally incontinent of bowel and bladder. No bowel or bladder program has been attempted. -Currently receiving Occupational and Physical therapy. Record review of Resident 18's medical record revealed Resident 18 had 15 found on floor or falls since admission. Record review of Resident 18's CCP dated 1/17/2012 revealed Resident 18 was at risk for falls. The goals identified for Resident 18 were to have no falls and no falls with injury. Interventions included tab alarm to chair and bed and pressure alarm to w/c and bed. Observation on 2/16/2012 at 6:50 AM revealed Resident 18 was in a low bed. No pressure or tabs alarms were in use. Observation on 2/22/2012 at 9:56 AM revealed Resident 18 was in the dining room seated in a wheelchair. Resident 18 had a tabs alarm and did not have a pressure alarm. Observation on 2/22/2012 at 12:10 PM revealed Resident 18 was in the dinning room. Resident 18 had a tab alarm on and did not have a pressure alarm. Interview with LPN Q was conducted on 2/22/2012 at 12:11 PM. During the interview, LPN was asked to observe Resident 18 for alarms. LPN Q reported Resident 18 had a tabs alarm and did not have a pressure alarm. When asked if Resident 18 required the pressure alarm. LPN Q stated "yes". C. Record review of COCE form revealed on 1/23/2012 Resident 18 " was done toileting-crawling to bed". Record review of a COCE form dated 1/26/2012 revealed Resident 18 was transferring (gender) to the toilet and lowered (gender) to the floor. Record review of a COCE form dated 2/15/2012 revealed Resident 18 had been trying to transfer (gender) from the toilet to the w/c and was found on the floor. Record review of a COCE form dated 2/18/2012 revealed Resident 18 was found on the floor. According to information on the COCE, Resident 18 had diarrhea. An interview with the DON was conducted on 2/22/2012 at 2:08 PM. During the interview the COCE dated 1/23/2012, 1/26/2012, 2/15/2012 and 2/18/2012 were reviewed. When asked if Resident 18's bowel and bladder function had been evaluated after the incidents, the DON stated "no". When asked if Resident 18 was on a bowel and bladder program, The DON stated "no". When asked if a toileting program should have been an intervention, the DON stated "yes, (gender) should have been on a toileting program" in an attempt to prevent falls or accidents. D. Record review of a COCE form dated 1/19/2012 revealed Resident 18 had a fall. The form did not identify potential casual factors related to Resident 18's fall. Record review of a COCE form dated 2/17/2012 revealed Resident 18 was found on the floor. According to the form, Resident 18 had reported sliding out of the w/c. The form contained documentation that Resident 18 had a red area to the mid lower back and complained of mild pain. Resident 18 medical record did not contain information of the cause of Resident 18 sliding to the floor. Record review of a COCE form dated 2/18/2012 revealed Resident 18 was found on the floor. Resident 18's record did not contain evidence of the casual factors relating to the fall. An interview with the DON was conducted on 2/22/2012 at 2:08 PM. During the interview, Resident 18's COCE forms dated 1/19/2012, 2/17,2012 and 2/18/2012 were reviewed. The DON confirmed during the interview that causal factors for the falls had not been completed. E. Record review of a Face Sheet dated 11/29/2011 revealed Resident 21 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 21's MDS dated and signed as completed on 2/07/2012 revealed the facility staff assessed the following about the resident: -Short and long term memory problems. -Decision making was moderately impaired-decisions poor. -Required extensive assistance with bed mobility, transfers,dressing and toilet use. -Required limited assistance when walking in the corridor. -Frequently incontinent of bowel and bladder with no bowel or bladder program identified. -Other [DIAGNOSES REDACTED]. Record review of Resident 21's CCP dated 1/25/2012 revealed Resident 21 was at risk for falls. The goals identified were Resident 21 would be free from falls and would not experience any injuries related to falls. Interventions identified on the CCP included referring Resident 21 for a restorative program, pressure alarm in the w/c, fall mats on both side of Resident 21's bed and a Tilt in space w/c. Observations on 2/21/2012 revealed with LPN R revealed Resident 21 had one fall mat next to the bed. LPN R confirmed Resident 21 had one fall mat next to the bed. Observation on 2/23/2012 revealed Resident 21 was in the T.V. viewing area in the tilt in space wheelchair. The pressure alarm was hanging down from the back of the w/c. LPN S was requested to observe the pressure alarm. LPN S confirmed the pressure alarm was not under Resident 21. Record review of a COCE form dated 12/05/2011 revealed Resident 21 was found on the floor by the bed. The form did not have information related to additional interventions to prevent further falls. Record review of a COCE form dated 12/08/2011 revealed Resident 21 was on the floor next to the bed. The form did not identify any new intervention to prevent further falls. Record review of Resident 21's CCP dated 2/02/2011 revealed no dated entry for interventions for the 12/08/2011 incident. Record review of a COCE form dated 12/15/2011 revealed Resident 21 was found on the floor. The form did not have evidence of any additional interventions that were implemented to prevent falls. Record review of Resident 21's Progress Notes dated 12/15/2011 did not identify any additional interventions to prevent further falls or being found on the floor. Record review of a COCE form dated 12/29/2011 revealed Resident 21 was found sitting on a floor mat next to the bed. Record review of Resident 21's CCP dated 2/02/2011 revealed a hand written update not to leave Resident 21 in (Gender) room unattended. Record review of a Fax sheet sent to Resident 21's physician revealed the following " Resident was sitting in wheelchair and slid out of chair onto floor upside down hanging from wc by pants". Record review of Resident 21's Progress Notes dated 1/04/2012 revealed the following entry;"Resident was found hanging upside down from wc by residents pants. Resident was yelling and alarms were going off. This nurse and CNA's went into res room and assessed resident and lifted resident into bed". Review of a COCE form dated 1/04/2012 revealed Resident 21 had fallen out of the wheelchair. Review of a Fall Action Team: Fall Review (FATFR) sheet revealed the intervention was to keep the arm rest on the wheelchair and to replace after a transfer. The form did not identify what action was taken to ensure the wheelchair was safe for Resident 21 who had been hanging upside down in the chair or why Resident 21 had been left alone in (gender) room. Record review of a COCE form dated 1/24/2012 revealed Resident 21 was found on the floor next to bed. Review of Resident 21's CCP dated 2/02/2011 revealed a hand written update for a medication review related to the fall on 1/24/2012. Record review of Resident 21's medical record revealed it did not contain an evaluation of medication review related to the fall potential for Resident 21 or if Resident 21 had been left unattended in the room. Record review of Resident 21's Progress Notes dated 2/16/2012 revealed Resident 21 was found on the floor by the bed. The Progress Notes did not evaluate if Resident 21 had been left alone. An interview with the DON was conducted on 2/22/2012 at 10:55 AM. During the interview the DON reported that a medication review had not been completed related to falls for Resident 21. Review of Resident 21's Progress Notes dated 1/04/2012 was conducted with the DON. When asked if the tilt in space w/c should have been re-evaluated for safety for Resident 21, the DON stated "yes, it should have been re-evaluated and was not". When asked if a restorative program had been evaluated as an intervention, the DON stated "that is one of the options we should have look at". The DON confirmed Resident 21 was to have 2 fall mats, one one each side of Resident 21's bed. An interview with Occupational Therapist (OT) T was conducted on 2/23/2012 at 8:45 AM. During the interview, review of Resident 21 found hanging upside down in the w/c dated 1/04/2012 was discussed. OT T stated "yes" when asked if the tilt in space w/c should have been re-evaluated for Resident 21's safety. F. Record review of a face sheet dated 1/27/2012 revealed Resident 17 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a physician's orders [REDACTED]. Record review of a COCE form dated 11/20/2011 revealed Resident 17 had a "Hot tea burns to inner thigh". Resident 17 medical practitioner was informed and a treatment order given for Resident 17. Record review of a Skin Sweep sheet dated 11/21/2011 revealed Resident 17 had an opened blister to the left inner thigh from the hot liquid burn. Record review of Resident 17's CCP dated 10/20/2011 revealed a hand written entry date 11/22/201 that Resident 17 was to have a safety cup for hot tea. Observation on 2/15/2012 at 11:52 AM revealed Resident 17 was in the dining room for lunch. Resident 17 was drinking tea from a regular cup without a lid. Observation on 2/16/2012 at 7:33 AM revealed Resident 17 was in the dining room unattended. Resident 17 had 2 cups of tea without lids or the safety cups. The Administrator was request to observe Resident 17 and the tea on 2/16/2012 at 7:33 AM. The Administrator confirmed the cups Resident 17 was using were not safety cups. The Administrator remove the hot liquid. The temperature of the 2 cups of hot liquid were 143.2 degrees and 133.0 degrees farenheit. The Administrator confirmed the temperatures. An interview with the DON was conducted on 2/21/2012 at 9:42 AM. During the interview, the DON reported the facility did not have a process to identify safety of hot liquids for residents in the facility. G. Record review of a Fall Risk Reduction and Management policy revised on 8/2010 revealed the following" -Overview: -The interdisciplinary team works with resident/patient and/or family/responsible party to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Post fall management includes appropriate resident/patient care, evaluation and revision of existing interventions, and investigation into potential factors to determine areas of improvement. -Components of the fall risk reduction program include, but not limited to, the following: -Implementation of individualized interventions to minimize risk factors for fall and injuries. -Evaluation of effectiveness of interventions in minimizing fall risk factors. -Procedure. -#4. Communicate risk factors and interventions to the care giving team. -#5. Identify resident/patient at high risk of falling by placing a "star" symbol in an identified area near the resident/patient. -#9. Revise the care plan to indicate changes in interventions as indicated. An interview on 2/22/2012 at 12:20 PM was conducted with RN (Registered Nurse) U. RN U stated "I'm not sure" when asked about the "star" procedure. A interview on 2/22/2012 at 12:22 PM was conducted with LPN S. When asked asked about the "star" procedure, LPN S stated " I'm not sure what that means". A interview with NA (Nursing Assistant) W was conducted on 2/22/2012 at 12:24 PM. During the interview, NA W stated " I'm not sure what that means" when asked about a "star" procedure. A interview with NA X was conducted on 2/22/2012 at 12:26 PM. During the interview, NA X stated "I'm not sure" when asked about the "star"on some residents door frames. H. Resident 10 was admitted to the facility on [DATE] according to the Face Sheet. Resident 10's 2/9/12 MDS listed active [DIAGNOSES REDACTED]. Observations on 2/21/12 at 1 PM revealed Resident 10 up in a manual wheelchair to be transported to physician appointment. Progress Note dated 2/21/12 at 4 PM reported Van Driver observed resident sliding out of wheelchair. Van Driver pulled over and 911 was called. Resident 10 was repositioned into a sitting position with the assistance of 5 firemen. Resident 10 was transported back to facility and assisted back to bed using bariatric hoyer. Observations on 2/22/12 at 8:41 AM revealed Resident 10 complaining of pain and inability to turn in bed. Progress Note dated 2/22/12 at 10:45 AM reported Resident 10 complained of pain in right leg with movement. Order was received for x-ray of right knee, right femur and right hip. Resident 10's Addendum Radiology Report dated 2/23/12 for x-ray taken 2/22/12 stated Resident had a fixated right knee fracture and a fixated right femur fracture. In an interview on 2/22/12 at 9:15 AM, LPN Q reported Resident 10 had been transported in a manual wheelchair owned by the facility to appointment on 2/21/12 as Resident 10's wheelchair did not work and would not fit in the facility van. LPN Q reported Resident was to be getting up in wheelchair on Tuesday and Thursday but always refused. In interviews at 9:34 AM and 10:35 AM on 2/22/12, OT Z (Occupational Therapist) confirmed there was only evidence that Resident 10 was gotten up in wheelchair for therapy only on 11/22/11 and on 1/13/12 for a bath. OT Z reported it would be questionable if Resident 10 would have the postural control to be up in a wheelchair for as long as it would take to attend an appointment after being in bed that long. OT Z stated the wheelchair needed to be evaluated to determine if Resident 10 needed a tilting wheelchair to keep from sliding. OT Z reported there was not as much support in a regular wheelchair. In an interview on 2/22/12 at 1:25 PM, the DON reported Resident 10 had not been evaluated to determine if Resident 10 could sit up. The DON stated Resident 10 could "obviously not" sit up. I. Resident 8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 8's 1/25/12 MDS revealed Resident 8 required extensive assistance of two people for transfer. A review of the nurse aide care plan revealed Resident 8 was to be transferred using a bariatric hoyer lift. In an interview on 2/9/12 at 11:20 AM, Resident 8 reported Resident 8 had ended up on the floor while being transferred from bed to wheelchair with Resident 8's neck being caught on wheelchair seat. Resident 8 reported neck was still hurting. OT Daily Treatment Note dated 1/13/12 stated the following: "Bed mobility with min.(minimum) assist of one. Able to get sling under resident to prepare for hoyer transfer. Two assist for transfer. Once resident over chair unable to get resident back far enough in chair. Plan was to lower resident into chair then tilt chair back to assist bottom back into chair. Once resident down in chair unable to get joystick in locked position. If joystick not locked in then chair will not operate. Resident slid down in chair and myself and CNA (Nurse Assistant) lowered resident to floor. Pulled lift and chair back so resident is lying flat on floor. Had resident roll side to side on floor to place sling. Hoyered back to bed." A review of Resident 8's Narrative Note for 1/13/12 did not reveal any documentation regarding transfer in which Resident 8 ended up on floor. Narrative Note for Resident 8 dated 1/4/12 at 10 AM (note was documented on page after notes from 1/13/12) stated Resident 8 was complaining of neck pain. Progress Note dated 1/25/12 at 1:30 PM stated Resident 8 was complaining of neck and leg pain. Progress Note dated 1/27/12 at 2:30 PM stated Resident 8 was requesting an x-ray of neck. Radiology Report from Resident 8's neck x-ray dated 1/28/12 stated the following: "This exam cannot reveal subtle neck tissue swelling or mass or asymmetry due to sever neck obesity." Radiology Report advised a Cat Scan to show any possible mass or infection. In an interview on 2/9/12 at 12:10 PM, COTA Rehabilitation Director AA (Certified Occupational Therapy Assistant) reported Resident 8 was up in lift and Resident 8's bottom was sliding. They could not get Resident 8's chair to recline. Resident 8 was placed on the floor with back up against chair. COTA Rehabilitation Director AA reported Resident 8's wheelchair was backed up and Resident 8 was laid on the floor and vitals were checked by the nurse before Resident 8 was placed back in bed. COTA Rehabilitation Director AA reported the DON had been told about the incident and DON stated an incident report did not need to be completed as Resident 8 was lowered to the floor and did not fall. COTA Rehabilitation Director AA reported a regular hoyer lift had been used to transfer Resident 8 instead of the bariatric hoyer lift due to the crampness of the room. COTA Rehabilitation Director AA confirmed Resident 8 started complaining of neck pain after the incident and an x-ray was requested. Observations of bariatric hoyer lift at 1 PM on 2/9/12 revealed bariatric hoyer had a much longer boom than regular hoyer lift. In an interview on 2/9/12 at 2:25 PM, LPN DD reported Resident 8 was on the floor when LPN DD entered the room. LPN DD reported assisting with getting Resident 8 into bed and assessing Resident 8 for injuries. LPN DD reported not completing an incident report as LPN DD was not in the room at the time the incident happened but offered to assist the COTA Rehabilitation Director with logging into the computer system to complete the incident report. LPN DD reported fall charting was not completed and Resident 8's physician was not called. LPN DD reported the therapist talked with DON and told LPN DD to monitor the resident. LPN DD reported Resident 8 began complaining of neck pain a couple of days after the incident. In interviews on 2/9/12 at 1:48 PM and on 2/22/12 at 2:55 PM, the DON denied knowledge of the incident involving Resident 8 and reported an incident report was not completed. The DON reported an assessment should have been completed and the physician called. The DON confirmed the nurse aide care plan should be followed when transferring a resident. J. Resident 11 was admitted to the facility on [DATE] according to Face Sheet. Resident 11's 12/26/11 MDS listed active [DIAGNOSES REDACTED]. A review of Resident 11's 12/26/11 MDS revealed Resident 11 utilized a wheelchair and required extensive assistance of 1 person to transfer. A review of Resident 11's Care Plan revealed a problem dated 7/5/11 of potential for falls. Approaches listed for this problem included use of a sit stand alarm. Observations on 2/15/12 at 11:15 AM and 12:15 PM and on 2/16/12 at 8:55 AM and 12:45 PM revealed Resident 11's sit stand alarm was not attached to Resident 11's clothing. In an interview on 2/22/12 at 2:45 PM, the DON confirmed Resident 11's sit stand alarm is to be on at all times. K. Resident 12 was admitted to the facility on [DATE] according to Face Sheet. Physician orders [REDACTED]. A review of Resident 12's MDS dated [DATE] revealed Resident 12 required limited assistance of one to transfer and utilized a wheelchair. A review of Resident 12's Care Plan revealed a problem dated 9/3/11 of potential for falls. Approaches for this problem included medication review dated 1/22/12 and have therapy write restorative program dated 2/7/12. A review of Change in Condition Evaluations for Resident 12 revealed the following: -2/1/12 at 4:30 AM resident stated resident had slipped out of wheelchair -1/22/12 at 2 AM resident slipped from wheelchair seat down to floor -1/4/12 at 5:15 AM fell in bathroom while transferring from toilet to wheelchair -12/16/11 at 5:15 AM fell while transferring from wheelchair to bed. A review of Fall Action Team: Fall Review dated 1/23/12 for fall on 1/22/12 stated a medication review would be completed as a response to fall. In an interview on 2/21/12 at 9:37 AM, the DON reported a medication review had not been done on Resident 12 at that time but one was completed on 2/21/12. Physician's telephone order dated 2/21/12 at 9:10 AM stated medication review complete with no new orders. A review of Fall Action Team: Fall Review dated 2/8/12 for fall on 2/7/12 listed restorative program started for Resident 12 in response to fall. In an interview on 2/16/12 at 9:24 AM, the DON reported Resident 12 had not yet been started on a restorative program. In an interview on 2/22/12 at 2:45 PM, the DON confirmed the interventions of a medication review and restorative program were not put in place prevent to falls.

Licensure Reference number 175 NAC: 175 NAC 12-006.09D7 175 NAC 12-006.09D7a 175 NAC 12-006.09D7b Based on observations, interview, and record review; the facility failed to evaluate causal factors and implement interventions to prevent accidents for 3 (Residents 39, 40 and 42) residents from 16 sampled and 3 non-sampled residents. The facility had a total census of 136. Findings are: A. Resident 39 was admitted to the facility on [DATE] according to Face Sheet. Resident 39's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 1-28-12 listed the following active Diagnoses: [REDACTED]. A review of Resident 39's Care Plan dated, 10-17-11 revealed Resident 39 was at risk for falls related to poor mobility, cancer with metasis to the brain, weakness, and use of antidepressants. Resident 39 was to experience no injuries related to falls through 7-17-12. Approaches listed for this problem dated 4-10-12 included scoop mattress and fall mat. Change of Condition Evaluation dated 4-10-12 for Resident 39 stated Resident 39 was found lying by bed on floor mat. A review of the Fall Investigation for Resident 39 dated 4-10-12 revealed a scoop mattress was to be implemented based on the fall committee recommendation. Observations on 4-17-12 at 1:30 PM and 3 PM revealed Resident 39 was lying in bed without fall mats in place on floor beside bed. Resident 39 did not have a scoop mattress on the bed. Observations on 4-18-12 at 9:10 AM revealed Resident 39 did not have a scoop mattress on Resident 39's bed. In an interview at 9:22 AM on 4-18-12, RN (Regisered Nurse) Unit Manager G confirmed Resident 39 did not have a scoop mattress on Resident's 39's bed. RN Unit Manager G confirmed a scoop mattress was an intervention implemented after Resident 39's last fall. In an interview at 11:15 AM on 4/18/12, RN Unit Manager G confirmed Resident 39 was to have a fall mat in place when Resident 39 was in bed. B. Resident 40 was admitted to the facility on [DATE] according to Face Sheet. Resident 40's MDS dated [DATE] listed active [DIAGNOSES REDACTED]. A review of Bruise Investigation form for Resident 40 dated 4-11-12 revealed Resident 40 sustained an 8cm (centimeter) in diameter left upper coccyx/buttock bruise and a 5 cm x 2 cm right inner thigh bruise. Both bruises where identified as dark purple. The Bruise Investigation form indicated Resident 40 was taking Coumadin (a blood thinner). According to Bruise Investigation form, it was determined Resident 40 toileted self at times and the bruise was in the area where Resident 40 could have sat down hard and hit back of toilet and toilet seat. Under Supervisor Report of Bruise Investigation form, it was documented that, in the DON (Director of Nursing) opinion, no abuse neglect or mistreatment occurred. There was no documentation of intervention implemented to prevent a reoccurrence. A review of Resident 30's 2-18-12 MDS revealed Resident 40 required extensive assistance of 1 to toilet. Resident 40's Care Plan revealed a problem dated 8-22-11 of Resident 40 being incontinent of urine with an approach of assisting Resident 40 to the bathroom or commode as needed. A review of nurse aide care plan revealed Resident 40 required one assist for toileting. In an interview on 4-17-12 at 2:50 PM, LPN (Licensed Practical Nurse)- K reported Resident 40 doesn't lower self to toilet but will drop down and Resident 40's bruise was located on back of leg where Resident 40 would sit on toilet. LPN K reported Resident 40 did not call for assist and was not on a toileting plan but if a staff member entered the room Resident 40 would point at the bathroom. In an interview on 4-18-12 at 9:15 AM, NA (Nursing Assistant) L reported Resident 40 didnt use the call and was not on a toileting schedule. NA L reported Resident 40 may come in to the hall and ask for assist or request assist when a staff member is in the room for something else. In an interview on 4/18/12 at 10 AM, RN Unit Coordinator G confirmed no plan was documented on the Bruise Investigation form to prevent reoccurrence. Unit Coordinator G was not aware of any interventions implement to prevent a reoccurrence. C. Record review of a Face sheet dated 10/27/2010 revealed Resident 42 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Transfer/Mobility Status Criteria dated 3/4/2012 revealed Resident 42 was assessed as requiring extensive assistance with 2 plus persons for transfers. According to the information on the form, Resident 42 as was able to bear weight for periods of time. The lift Aid to be used for the transfer was a gait belt (transfer belt) and 2 person assist. Observation of a transfer to bed revealed Resident 42 was seated in a tilt-n-space wheelchair. NA I and NA J positioned Resident 42 next to the bed and, without using a gait belt, transferred Resident 42 into bed. An interview with the Director of Nursing (DON) was conducted on 4/24/2012 at 2:10 PM. during the interview, the DON stated "yes" when asked if gait belts were to be used with transfers.

Based on observation, record reviews and interviews conducted during the revisit survey; the facility's Quality Assurance Committee (QA) failed to develop and implement plans of action to maintain compliance with the regulatory requirements. Facility census was 135. Sample size was 15. The facility was found to continue to be out of compliance in multiple areas of regulatory requirements after the tasks of the revisit survey were completed. The facility did not maintain correction for the regulations identified on the previous revisit and did not identify and develop action plans for prevent deficient practice in the areas identified as listed below. Please refer to the Tag citations for specific detailed findings. ? F246 The facility failed to evaluate residents environment for functional mobility. ? F 280 The facility failed to review and revise care plans related to the development of pressure ulcers and toileting plan . ? F309 The facility failed to evaluate fluctuating blood pressures. ? F314 The facility failed to monitor , reevaluate and implement additional interventions related to skin breakdown. ? F315 The facility failed to evaluate catheter function. ? F323 The facility failed to evaluate the safety of transfers.

Licensure Reference 175 NAC 12-006.D7b Based on observation, interview, and record review, the facility failed to evaluate the safety of transfer for 1 (Resident 21) of 16 sampled residents. The facility had a total census of 135 residents. Findings are: Resident 21 was admitted to the facility on [DATE] according to Face Sheet. Resident 21's 6/12 Medication Administration Record revealed a [DIAGNOSES REDACTED]. A review of Resident 21's Care Plan revealed a problem dated 5/23/12 which stated Resident 21 required assistance with activities of daily living. Resident 21's Care Plan and the aides care plan both stated Resident 21 required 2 assist to transfer. A review of Transfer/Mobility Status Criteria dated 3/7/12 for Resident 21 stated Resident 21 required sit-to-stand with sling or gait belt assist of 2. Observations on 6/12/12 at 3:23 PM revealed Nurse Aide A and Nurse Aide B transferring Resident 21 from wheelchair to bed. Nurse Aide A reported Resident 21's wheelchair pedals had been screwed on and could not be removed for the transfer. Observations revealed Nurse Aide A and Nurse Aide B attempting to place Resident 21's feet over the end of wheelchair pedal for the transfer. Resident 21's feet caught on the wheelchair pedals while Nurse Aide A and B were attempting to transfer Resident 21 and the wheelchair began to tip forward. Nurse Aide A and B then placed Resident 21's feet to the side of the wheelchair and lifted Resident 21 to standing position using a gait belt. Resident 21 was pivot transferred into bed. In an interview at 3:35 PM on 6/12/12 after watching the transfer of Resident 21, LPN (Licensed Practical Nurse) Unit Manager C confirmed the transfer of Resident 21 from wheelchair to bed was not safe. LPN Unit Manager C was not aware that Resident 21 wheelchair pedals could not be removed for the transfer. LPN Unit Manager C confirmed Resident 21 was to be transferred with 2 assist.

Based on observations, record review, and interviews, the facility failed to ensure effective management of facility resources to maintain the high practical well being of residents and the facility as evidenced by failure to ensure the facility identified and developed plans of action to correct deficient practices and failure to maintain correction for previously cited areas of deficient practice. The survey sample was 16 residents with 3 non-sampled residents. The total facility census was 136 residents. Findings are: A. The facility was found to be deficient in multiple areas of regulatory compliance. The following is a list of F tags cited, please refer to the tag citation for specific detailed findings: -F157 Failed to notify resident's physician and/or family members of exoriation and pressure ulcer -F221 Failed to evaluate a tilt and space wheelchair as a potential restraint -F279 Failed to develop a comprehensive care plan related to [MEDICAL TREATMENT] services -F309 Failed to monitor [MEDICAL TREATMENT] and failed to complete treatment for [REDACTED]. -F315 Failed to evaluate and implement a bowel and bladder toileting program and failed to provide incontinence care -F323 Failed to evaluate causal factors and implement interventions to prevent accidents -F329 Failed to evaluate and implement non-pharmacological interventions and provide pain medication prior to administration of an antipsychotic medication -F332 Failed to ensure medication error rate of less than 5% with a medication error rate of 7.5% -F520 Failed to maintain an effective Quality Assurance Program B. Tags cited during the revisit, in addition to the repeated citations included: -F280 Failed to review and revise comprehensive care plans related to [MEDICAL TREATMENT] sevices and falls -F314 Failed to reevaluate interventions to prevent the development of pressure ulcers C. The facility failed to maintain correction of the following tags cited during the previous annual survey completed 3/3/11: F157, F280, F315, F323, and F329.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility's Risk Management/Quality Improvement Program (RM/QIP) failed to assure staff were aware of quality improvement activities as evidenced by interviews with 6 staff meembers (Nursing Assistants I, N, and O, Licensed Practical Nurse H, and Central Supply Clerk P). The sample size of the survey consisted of 16 sampled and 3 non-sampled residents. The facility staff identified a census pf 136. Findings are: Record review of the facility policy and procedure for the RM/QIP revised on 03/2011 revealed the following: -The RM/QIP is directed by the Administrator. The program is focused on minimizing risk and improving resident/patient care by implementing a process for root cause analysis and the utilization of the Quality Improvement teams. -Procedure: -#6. Prepare a written agenda for each meeting to include the discussion of incidents, issues and concerns. -#7. Develop a action plan to improve the identified process or system. Action plan is to include goals, outcome indicators and a monitoring plan. -#8. Complete written minutes of the meeting to document items discussed and the proposed action item. -#9. Implement action plan. -#10. Collect, study and analyze the outcome data. -#11. Continue to monitor the completion and effectiveness of the action plan. Modify the action plan (if) results are not acceptable. -#12. Report results to RM/QIP committee. An interview on 4/18/2012 at 9:02 AM was conducted with Nursing Assistant (NA)-I . During the interview, NA-I stated (gender) was not aware of the RM/QIP committee or how the RM/QIP functioned, and was not able to verbalize any specific plans of action the RM/QIP was working on. An interview on 4/18/2012 at 10:00 AM was conducted with Licensed Practical Nurse (LPN)-H. During the interview, LPN-H reported (Gender) was not aware of the QI committee or how it functioned, nor any Committee Member names. An interview on 4/18/2012 at 10:05 AM was conducted with NA-N. During the interview NA-N stated (gender) was not aware of the RM/QIP or how the RM/QIP committee functioned. NA-N unable to verbalize any specific plans of actions described by the QI committee, however, thought they (the committee) might be working on customer service. In an interview on 4/18/2012 at 10:10AM, NA-O stated NA-O was not aware of the RM/QIP committee or how it functions. NA-O was not able to verbalize any QI committee member names. An interview on 4/18/12 at 10:12AM was conducted with Central Supply Clerk (CSC)-P. Upon interview, CSC-P stated that CSC-P was not aware of what the RM/QIP program was or who its committee members were. An interview with LPN-Q was conducted on 4/18/12 at 10:15AM. LPN-Q was not aware of what the RM/QIP program was or how it functioned, nor was LPN-Q aware of anything the committee was working on.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility's Risk Management/Quality Improvement Program (RM/QIP) failed to identify ongoing issues relevant to F157, F221, F225, F281, F309, F311, F315, F323, F325, F329, F332, F333, F431, F469, F490, F505 and F520 and implement effective plans of action to correct the deficient practice. The RM/QIP Committee failed to assure repeated deficiencies at F157, F253, F280, F315, F323 and F329 were corrected and the correction maintained. The sample size of the survey consisted of 26 sampled and 2 non-sampled residents. The facility staff identified a census pf 157. Findings are: Record review of the facility policy and procedure for the RM/QIP revised on 03/2011 revealed the following: -The RM/QIP is directed by the Administrator. The program is focused on minimizing risk and improving resident/patient care by implementing a process for root cause analysis ad the utilization of the Quality Improvement teams. -Procedure: -#6. Prepare a written agenda for each meeting to include the discussion of incidents, issues and concerns. -#7. Develop a action plan to improve the identified process or system. Action plan is to include goals, outcome indicators and a monitoring plan. -#8. Complete written minutes of the meeting to document items discussed and the proposed action item. -#9. Implement action plan. -#10. Collect, study and analyze the outcome data. -#11. Continue to monitor the completion and effectiveness of the action plan. Modify the action plan (if) results are not acceptable. -#12. Report results to RM/QIP committee. An interview on 2/23/2012 at 7:35 AM was conducted with Nursing Assistant (NA) C . During the interview, NA C stated (gender) was not aware of the RM/QIP committee or how the RM/QIP functioned. NA-C was not aware of what the QI (Quality Improvement) process was, did not know how to access the committee, and was not able to verbalize any specific plans of action the RM/QIP was working on. An interview on 2/23/2012 at 7:40 AM was conducted with NA-D. During the interview, NA-D reported (Gender) was not aware of the QI committee or how it functioned. NA-D was not aware what the QI process was, did not know how to access the committee, and was not able to verbalize any specific program or action plans the RM/QIP was working on. An interview on 2/23/2012 at 7:55 AM was conducted with NA-E. During the interview NA E stated (gender) was not aware of the RM/QIP or how the RM/QIP committee functioned. NA-E was not aware what the RM/QIP process was, did not know how to access the committee, and was not able to verbalize any specific plans of action described by the RM/QIP committee. In an interview on 2/23/2012 at 8:00AM, NA-F stated NA-F was not aware of the RM/QIP committee or how it functions. NA F was not able to verbalize any specific plans of action described by the QI committee. An interview with the Director of Nursing (DON) was conducted on 2/23/2012 at 9:30 AM. During the interview, the DON stated the facility RM/QIP committee was working on " routine things". When asked if the facility had identified any issues, other than routine items, The DON stated "no". When asked if any action plans were in place prior to the survey, the DON stated "no, just the routine things". An interview was conducted with the facility Administrator on 2/23/2012 at 9:45 AM. During the interview, the facility Administration was able to identify the RM/QIP process, how often the committee meets and what action plans were. When asked if the RM/QIP action plan would include, identifying the issue, implementing a plan and re-evaluation the intervention and monitoring, the Administrator stated "yes". When asked to describe an action plan the RM/QIP was currently working on, the Administrator identified resident falls was an action plan. The Administration was asked for evidence of the action plan. A follow up interview was conducted with the Administrator on 3/23/2012 at 10:25 AM. During the interview, the Administrator reported the information was not available as identified in the RM/QIP i.e. Develop an action plan, identify goals, outcome indicator, have a monitoring plan and re-evaluate your action plan as needed. The Administrator stated "we don't have it".

Licensure Reference: 175 NAC 12-006.09D1a Based on observations, interview and record review; the facility failed to evaluate and treat a decline in ability to transfer, ambulation, and bathe for 1 (Resident 5) of 12 sampled residents. The facility had a total census of 149 residents. Findings are: A. Resident 5 was admitted to the facility on [DATE] according to Face Sheet. physician progress notes [REDACTED]. Resident 5's Care Plan included a problem dated 4/24/10 of self care deficit and inability to complete self care task independently with a goal of Resident 5 maintaining or improving participation in ADL's (Activities of Daily Living) by next review. Interventions for Resident 5 included: "Supervise and assist with ADL's hygiene AM/PM and providing unaided assist to achieve increased independence or maintain current function," and "showers per schedule." A review of Resident 5's Care Plan did not reveal any information regarding Resident 5's ability to transfer, ambulate or bathe or Resident 5's refusal to get out of bed. A review of Occupational Therapy discharge summary dated 7/12/10 revealed Resident 5 was able to safely transfer from bed to wheelchair requiring supervision and verbal cueing but not physical assist. The Occupational Therapy discharge summary stated Resident 5 required assistance only with putting on and taking off wheelchair leg rests. A review of Physical Therapy discharge summary dated 7/9/10 revealed Resident 5 ambulated up to 80 feet with stand by assist and roller walker with forearms on walker. A review of Activities of Daily Living Care Record for 4/11, 5/11, and 6/11 revealed documentation of not applicable under transfer section for all except for 4/11/11 on 11 PM-7 AM shift and 6/24/11 on 7 AM-3 PM shift Resident 5 was listed one person assist. A review of Resident 5's 2011 Bath Flow Sheet revealed Resident 5's last recorded shower was on 2/11/11 and Resident 5 has received bed baths since that date. A review of undated nurse aide information record received on 6/28/11 revealed Resident 5 required the assistance of 2 staff members and a hoyer lift (mechanical lift) for transfer and Resident 5 used a wheelchair. The nurse aide information record did not indicate Resident 5 could ambulate. Observations and interview on 6/28/11 between 11:15-11:45 AM and on 6/29/11 at 10:05 AM revealed Resident 5 in bed. In an interview between 11:15-11:45 AM on 6/28/11, Resident 5 reported Resident 5 has not been out of bed for a while and doesn't have a comfortable wheelchair. Resident 5 reported Resident 5 has not had a full shower in a couple of months. Resident 5 reported Resident 5 used to get up for a standing appointment with the beautician but the beautician no longer works at the facility. In an interview on 6/29/11 at 10:05 AM, Resident 5 reported staff offered to get Resident 5 up that day but Resident 5 declined. In an interview on 6/28/11 at 1:50 PM, Nurse Aide A reported it has been at least a month or 2 since Resident 5 has gotten out of bed. Nurse Aide A reported Resident 5 stopped getting up related to back pain. Nurse Aide A reported being unable to recall the last time Nurse Aide A asked Resident 5 if Resident 5 would like to get out of bed. Nurse Aide A acknowledged Resident 5 used to be able to walk to Resident 5's wheelchair. In an interview on 6/28/11 at 1:50 PM, LPN (Licensed Practical Nurse) B reported it has been a couple of months since Resident 5 has gotten out of bed. LPN B reported Resident 5 used to get up when the facility had the other hair dresser. In an interview on 6/28/11 between 3:20-4 PM, the RN (Registered Nurse) Unit Manager C, who is new to the position, was not aware Resident 5 was not getting out of bed. The RN Unit Manager C reported wanting to be made aware if residents are not getting out of bed and are not receiving a bath or shower. The RN Unit Manager C acknowledged that Resident 5's Care Plan did not address Resident 5's refusal to bet out of bed. In a follow up interview on 6/29/11 at 9:05 AM, the RN Unit Manager C reported Resident 5 was changed to a hoyer lift transfer for safety reasons due to increased weakness from not being out of bed.