Every finding on record at The Lighthouse at Lakeside Village

Licensure reference: 175 NAC 006.04(A)(iii) Based on record review and interview, the facility failed to ensure criminal background checks were completed on 1 [Nurse Aide A] of 5 sampled staff members. The facility had a total census of 51 residents. Findings are: A review of background screening checks completed on 3/19/24 for Nurse Aide A did not reveal a completed criminal background check. A review of employee report dated 5/27/26 revealed Nurse Aide A had a hire date of 3/18/24. In interviews on 5/27/26 at 12:37 PM and 4:05 PM, Human Resource Business Partner confirmed a criminal background check had not been completed on Nurse Aide A due to Nurse Aide A being a minor. Human Resource Business Partner reported that an additional request would need to be made to the vendor in order to have a criminal background check completed on an employee who is a minor. A review of facility policy titled Abuse-Prevention and Reporting dated 4/7/26 revealed the following under the Pre-hire Screening section:- All applicants for employment in the facility shall, at a minimum, have the following screening checks conducted: a. Reference checks including the current and/or past employer(s) b. APS, Child Abuse Registry, and/or SING in Iowa to identify if applicant has been placed on the registry for substantiated abuse, neglect, or misuse of vulnerable person's property. c. Criminal background check, including Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE) and the Nebraska/Iowa Medicaid Excluded Providers List (Nebraska/Iowa List). d. Sex offender background check. e. Refer to Immanuel Administration policy 'Background Investigations for Employment Purposes'.

Based on interview and record review, the facility failed to ensure allegations of abuse and significant injury were reported to Adult Protective Services within 2 hours for 2 [Residents 1 and 2] of 3 sampled resident and failed to ensure an investigation report was submitted to the state agency within 5 working days for 3 [Residents 1, 2, and 3] of 3 sampled residents. The facility had a total census of 51 residents. Findings are:A.A review of facility Abuse/Neglect Report dated 5/7/26 revealed an incident of potential abuse involving Resident 2 occurred on 5/3/26 before dinner. The description of the incident in the report revealed that Nurse Aide A had observed Nurse Aide B was being rough with Resident 2 by grabbing Resident 2's wrists and pulling on them. Nurse Aide A reported the occurrence to Licensed Practical Nurse D who did an assessment of Resident 2. Nurse Aide B was sent home. According to the Abuse/Neglect report, the facility completed an investigation that included interviews with 2 other staff members that had entered Resident 2's room. Nurse Aide B's employment was terminated on 5/4/26. A further review of Abuse/Neglect report dated 5/7/26 that involved incident with Resident 2 revealed an online report was submitted to Adult Protective Services on 5/7/26 at 11:23 AM. The Abuse/Neglect report did not identify that the report was submitted to the state survey agency. In an interview on 5/27/26 at 1:13 PM, the Director of Nursing confirmed that the Abuse/Neglect report involving Resident 2 had only been submitted to Adult Protective Service and was not submitted to the state survey agency. The Director of Nursing further confirmed that the initial report regarding the incident involving Resident 2 was not made within 2 hours and in hindsight should have been reported within 2 hours of the occurrence. The Director of Nursing revealed the decision to file a report regarding the incident involving Resident 2 was made on 5/7/26 due to the evidence that was discovered during the investigation. B.A review of facility Abuse/neglect Report dated 12/1/25 revealed Resident 1 fell on [DATE] at 9:02 PM and was sent to the emergency department. Resident 1 returned to the facility with 3 sutures in a 1 cm laceration above Resident 1's right eye. A further review of Abuse/Neglect report dated 12/1/26 revealed the Adult Protective Service abuse/neglect hotline was called on 12/1/25 and the self-report was submitted online. The Abuse/Neglect report did not identify that the report involving Resident 2's fall with injury was submitted to the state survey agency. In interviews on 5/27/26 at 1:23 PM and 3:26 PM, the Director of Nursing confirmed that the report involving Resident 1 was not submitted to the state survey agency. The Director of Nursing also confirmed that the initial report of the fall with injury for Resident 1 was not reported within the 2-hour timeframe and needed to be. C.A review of Resident Concern Report completed 3/30/26 revealed Resident 3 reported on 3/26/26 that Resident 3 had been missing a blank check since July 2025 and that the check had been cashed for $450.00 on 3/2/26. According to the investigation, Resident 3 had not filled out the check or authorized the amount written. A further review of the Resident Concern Report completed 3/30/26 revealed a report was made to Adult Protective Services and the police regarding Resident 3's unauthorized check being cashed. The Resident Concern Report did not identify that an investigative report had been submitted to the state survey agency.In an interview on 5/27/26 at 2:20 PM, the Social Worker C confirmed that no investigative report was submitted to the state survey agency. D.A review of facility policy titled Abuse-Prevention and Reporting dated 4/7/26 revealed the following under the Reporting section:- The facility administrator designee, will notify the appropriate state agency (e.g. DIA or DHHS) and/or law enforcement (as applicable): a. Within 2 hours, if the alleged violation involves abuse or results in serious bodily injury. Or b. Not later than 24 hours, if the alleged violation involves neglect, exploitation, mistreatment, misappropriation of resident property, and does not result in serious bodily injury. Please refer to the above linked resources to determine when abuse should be reported. c. A written investigation will be submitted to the appropriate reporting agencies within 5 working days in either of the above situations. d. This does not have to be firsthand knowledge of the incident but rather a reasonable suspicion of abuse against a resident by another individual. e. Staff may utilize the forms provided in this policy to make a single report by multiple employees.

Licensure Reference Number 175NAC ,d+[DATE].11(E) Based on observation, interview, and record review; the facility failed to ensure expired food was discarded on or before the expiration date and failed to ensure opened food items were sealed and dated. The facility also failed to perform hand hygiene prior to and after touching soiled items while preparing food which had the potential for food borne illness. The facility also failed to measure items according to the recipe while preparing food. This had the potential to affect 30 out of 31 residents who consumed from the main kitchen in the facility. The facility census was 31. Findings are: A. An observation during the initial kitchen tour of the main kitchen on [DATE] at 12:22 PM revealed the dry storage area had two bags of corn flakes opened with no date, and a third bag opened with a date of ,d+[DATE]. One bag of premier white chips opened with no date, one small bin of white chips with no lid, one can of coconut pecan frosting with expiration date of [DATE]. One 25 pound bag of lentil beans opened with a date of [DATE] in a tub with no lid. One bag of cinnamon granola opened with no date, seven boxes of cheese sticks that expired on [DATE], one opened bag of jet puffed marshmallows with no date, a small spaghetti bag opened and wrapped with plastic wrap but not dated, a bag of rotini noodles opened with no date, a bag of small pasta shells opened with no date, a bag of elbow macaroni opened with no date, a large bag of spaghetti opened, wrapped with plastic wrap and no opened date, Crunchy dip bag opened with no date. Several gallon jugs of salad dressing with no expiration date to be found on containers. One package of an unidentified white substance with a date of ,d+[DATE] written on it, six boxes cream of wheat that expired [DATE]. An interview on [DATE] at 12:30 PM with the Sous Chef (SC-C) confirmed no manufacturer date could be found on the salad dressings and the above listed items were opened, expired foods and available for use in the dry storage area. SC further confirmed that the items listed above should be removed so that they are no longer available for use. An observation on [DATE] at 1:05 PM during the initial tour of the main kitchen of the small freezers that were available on the food preparation line revealed the following; one bag of breaded meat opened with no date, a bag of french fries opened with no date, a bag of tater tots opened with no date, a bag of hash brown patties opened with no date, a large bag of fish opened with no date, a bag of fajita blend veggies opened with no date, a small bag of curly fries opened with no date, a small bag of sweet potato fries opened with no date, a bag of onion rings opened with no date, a box of Quick steak opened with no date, a small steam pan with chicken fried steaks with no cover, one bag of corn opened and dated ,d+[DATE] and two additional bags of corn opened with no date, two bags of peas opened with no date, a bag of sunshine carrots opened with no date, one bag of chuckwagon corn opened with no date, one bag of chicken nuggets opened with no date, and a bag of opened cookie dough with no date. An interview on [DATE] at 12:22 PM with the Executive Chef (EC-D) confirmed the above listed foods were undated and opened in the freezers, and should be closed and dated. Record review of the facility policy titled Food Storage General Guidelines with a review date of [DATE] revealed under Procedure, General Guidelines: -All foods are labeled and dated. -Expiration dates of food products are checked when the stock is rotated. -Food is stored in clean, approved containers that are covered, labeled and dated. This includes foods stored in refrigerators, freezers, and pantries. Opened, dated perishable food is used or discarded following the guidelines provided in item 3) above. B. An observation on [DATE] at 9:00 AM of Lead [NAME] (LC-E) preparing scrambled eggs with ham and cheese for the noon meal using an 80 servings recipe. The LC-E completed hand hygiene and applied clean gloves. The LC-E obtained four 12x24x2 pans, sprayed pans with gloves on, and then poured an undetermined amount of ham cubes into each pan, with no amount measured. The recipe called for 2 pounds plus 3 ,d+[DATE] ounces of ham. LC-E removed gloves, completed hand hygiene and began cracking eggs into a bowl. Egg shells fell in the bowl, LC-E dumped bowl of eggs into trash, removed gloves, rinsed hands under water with no soap and applied new gloves. LC-E then retrieved new bowl and began to crack more eggs. After all the eggs were in the bowl the measurement was at approximately 5 liters, the recipe called for 1 ,d+[DATE] gallons plus 1 ,d+[DATE] cup of eggs. LC-E obtained milk and poured an undetermined amount into the bowl of eggs and mixed with electric blender stick. The recipe called for 1 quart plus 1 ,d+[DATE] cup of milk. LC-E then poured the mixture into four separate pans and determined more egg mixture was needed. Approximately 60 more eggs were cracked and blended without milk and poured into the first pan that needed more egg mixture. The pans were covered with tin foil and then placed in the oven. An observation on [DATE] at 10:06 AM revealed LC-E completed hand hygiene and applied clean gloves then obtained a bag of shredded cheese and dumped a portion into a visibly soiled bowl with food particals. LC-E removed the pans one at a time from the oven with the same gloves on, completed temperature checks and stirred each pan, then with the same soiled gloves on LC-E sprinkled an undetermined amount of cheese on top of all four pans, and returned pans to oven uncovered. The recipe called for 2 pounds plus 3 ,d+[DATE] ounces of cheese. An interview on [DATE] with EC-D at 10:35 AM confirmed that LC-E did not measure the ingredients per the recipe and stated, they have been using the recipe for quite some time and the cooks know the amounts for 80 servings for all recipes. The EC-D also confirmed the hand hygiene and gloving concerns when preparing food. Record review of the Facility Policy Sanitary Conditions effective date [DATE] revealed Policy Statement A: food is stored, prepared, distributed, and served in accordance with professional standards for food service safety. Record review of the Facility Policy Hand Washing Food Service effective date of [DATE] revealed Procedure: -After handling soiled equipment and utensils, -when changing tasks, -scrub for a minimum of 20 seconds. Record review of the Facility Policy Glove Use Food Service effective date of [DATE] revealed Procedure -after handling soiled equipment or utensils, -after any activity that contaminates the gloves.

Based on interview and record review; the facility failed to transmit a Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) record to the Centers for Medicare and Medicaid Services (CMS) within the prescribed time frames for 1 (Resident 6) of 1 sampled resident. The facility census was 31. Findings are: Record review of the Resident Assessment Instrument (RAI) manual revealed the facility is required to transmit the MDS within 14 days of completion. Record review of Resident 6's death tracking record with an assessment reference date (ARD) of 11/19/24, revealed the assessment was completed on 12/2/2024 but was not transmitted to CMS. An interview with the MDS Specialist (MDSS) on 03/10/2025 at 12:01 PM revealed that the MDS was marked as not to be transmitted to CMS. The MDSS confirmed the record should have been submitted to CMS. An interview with the Corporate Nurse Specialist (CNS) on 03/10/2025 at 3:46 PM confirmed the facility follows guidelines in the RAI manual for MDS transmission.

Licensure Reference Number 175 NAC ,d+[DATE].09(F)(iii) Based on record review and interview; the facility failed to update the Comprehensive Care Plan (CCP, a written interdisciplinary plan detailing how to provide quality care for a resident) to accurately reflect code status for 2 (Residents 5 and 12) of 2 sampled residents. The facility census was 31. Findings are: Record review of a facility policy entitled Care Plans-Comprehensive dated [DATE] revealed that the facility develops a comprehensive care plan for each resident which would include measurable objectives and timetables designed to meet the resident's medical, nursing, mental, and psychosocial needs through compassionate, trauma informed care, as identified in the comprehensive assessment. The policy identified that the care plan is periodically reviewed and revised by the interdisciplinary team after assessment. A. Record review of Resident 5's Census List dated [DATE] revealed the facility admitted the resident on [DATE]. Record review of Resident 5's Diagnosis List dated [DATE] revealed the resident had diagnoses of non-ST elevation myocardial infarction (heart attack), metabolic encephalopathy (a brain dysfunction caused by a problem with the body's chemical processes), and unspecified dementia with behavioral disturbance. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment used for care planning) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 02 which indicated a severe cognitive impairment. Record review of Resident 5's Resuscitation Authorization dated [DATE] revealed the resident wished to have cardiopulmonary resuscitation (CPR) attempted if needed. Record review of Resident 5's updated Resuscitation Authorization dated [DATE] revealed that the resident's code status was changed to Do Not Resuscitate (DNR). Record review of Resident 5's Order Summary Report dated [DATE], revealed an order dated [DATE] for DNR. Record review of Resident 5's CCP revealed an entry dated [DATE] that the resident admitted long-term care and the resident has personal choices. An intervention dated [DATE] identified the resident's code status as CPR/Full Code. An interview on [DATE] at 2:17 PM with the Social Services Designee (SSD) confirmed that Resident 5's updated code status was DNR and that the care plan was not updated and should have been. B. Record review of Resident 12's Census List dated [DATE] revealed that the facility admitted the resident on [DATE]. Record review of Resident 12's Diagnosis Report dated [DATE] revealed the resident had diagnoses that included chronic respiratory failure with hypoxia, dysphagia (difficulty swallowing), cerebral infarction (stroke), myocardial infarction (heart attack), pulmonary hypertension, malignant melanoma of scalp and neck (skin cancer), and congestive heart failure. Record review of Resident 12's MDS dated [DATE] revealed a BIMS score of 9 which indicated a moderate cognitive impairment. Record review of Resident 12's Resuscitation Authorization dated [DATE] revealed the resident wished to have cardiopulmonary resuscitation (CPR) attempted if needed. Record review of Resident 12's updated Resuscitation Authorization dated [DATE], revealed that the resident's code status was changed to Do Not Resuscitate (DNR). Record review of Resident 12's Order Summary Report dated [DATE], revealed an order dated [DATE] for DNR. Record review of Resident 12's CCP revealed an entry revised on [DATE] that the resident has personal choices. An intervention dated revised [DATE] identified the resident's code status as CPR. An interview on [DATE] at 2:17 PM with the SSD confirmed that Resident 12's updated code status was DNR and that the care plan was not updated and should have been.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review; the facility failed to implement interventions to prevent the potential for hot liquid burns for 1 (Resident 5) of 2 sampled residents. The facility census was 31. Findings are: A record review of the facility's policy entitled Hot Liquids Safety dated 2/16/22 revealed that the facility would have a process in place to assess risk of injury from hot liquids so appropriate interventions could be implemented to reduce the risk of burns. A record review of Resident 5's Census List dated 03/11/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 5's Diagnosis List dated 03/10/2025 revealed the resident had diagnoses of non-ST elevation myocardial infarction (heart attack), metabolic encephalopathy (a brain dysfunction caused by a problem with the body's chemical processes), need for assistance with personal care, visual hallucinations, psychotic disorder with delusions, unspecified dementia with behavioral disturbance, and chronic peripheral venous insufficiency. A record review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment used for care planning) dated 01/07/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 02 which indicated the resident had severe cognitive impairment. The resident required setup or cleanup assistance with eating and was dependent upon staff for wheelchair mobility. A record review of Resident 5's Hot Liquid Safety assessment dated [DATE] identified that Resident 5 would use a cup with lid and drink hot liquids while sitting at a table only. A record review of Resident 5's Comprehensive Care Plan (CCP, a written interdisciplinary plan detailing how to provide quality care for a resident) revised 05/03/2024 revealed that Resident 5 was at risk for injury related to hot liquid burns. The CCP interventions included that Resident 5 would only consume hot liquids while sitting at a table and hot liquids would have a lid. Continuous dining observation on 03/10/2025 at 8:11 AM to 8:59 AM revealed Resident 5 was served coffee in a paper cup with no lid. Resident 5 picked up the cup of coffee and turned the cup in a pouring motion, then sat the cup down on the table. There was no spillage from the cup. An observation on 03/10/2025 at 12:42 PM revealed Resident 5 received a paper cup of coffee with no lid. An interview on 03/10/2025 at 8:43 AM with Lead Server (LS)-F revealed kitchen staff does not serve hot liquids in resident rooms unless it is approved by nursing, residents sit at the table with hot liquids, and all residents who receive hot liquids receive a lid unless the resident requested the lid to be off. If a resident request the lid to be off the cup, the nursing department would be notified. An interview on 03/10/2025 at 1:58 PM with Registered Nurse (RN)-A revealed [gender] was not notified that Resident 5 was served coffee without a lid. An interview on 03/10/2025 at 2:00 PM with Nursing Assistant (NA)-G revealed [gender] was not notified that Resident 5 was served coffee without a lid. An interview on 03/10/2025 at 2:01 PM with Care Partner (CP)-I revealed [gender] was not notified that Resident 5 was served coffee without a lid. An interview on 03/10/2025 at 2:03 PM with CP-H revealed [gender] was not notified that Resident 5 was served coffee without a lid. An interview on 03/11/2025 at 1:32 PM with the Director of Nursing confirmed that Resident 5 was at-risk for hot liquid burns and that the care plan identified interventions of cups containing hot liquids to have lids, and hot liquids to be consumed at a table only. The DON confirmed the expectation is that if the resident is care planned to have lids on hot liquid cups, that the lids would be utilized.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure a medication error rate of 5% or less as evidenced by three errors out of 25 opportunities and resulted in a medication error rate of 12%. This affected two (Resident 1 and Resident 36) out of three residents sampled. The facility census was 31. The Findings are: A. A record review of an Admission Record indicated the facility admitted Resident 36 to the facility on [DATE] with a diagnosis of periprosthetic fracture around internal prosthetic right hip joint and age-related osteoporosis without current pathological fracture. An observation on 03/10/25 at 7:12 AM of medications for Resident 36 revealed Register Nurse (RN)-A administered the following: Acetaminophen 500 milligram (mg) take 2 tablets by mouth three times a day. Do not exceed 4 grams in one day. For pain control. Alendronate 70 mg take 1 tablet by mouth weekly with full glass of water on an empty stomach, sit up for 30 minutes, no food, medications, or beverages for 30 minutes. For age related osteoporosis without current pathological fracture. Aspirin low chew 81 mg take 1 tablet by mouth twice a day for 42 days for periprosthetic fracture around internal prosthetic right hip joint. Lidocaine Patch 4% - apply 1 patch at 8:00 AM daily for right hip pain. Oyster Shell/Vitamin D 500/200 tablet take 1 tablet by mouth daily as a calcium supplement. Tramadol HCL tablet 50 mg take 1 tablet by mouth three times a day for pain. Vitamin D3 2000Units (50 micrograms (MCG)) take 1 tablet by mouth daily for supplement. Record review of Resident 36's physician orders revealed the following: -Alendronate tab 70 milligram (mg), take one tablet by mouth weekly with a full glass of water on an empty stomach, sit up for 30 minutes, no food, medications or beverages for 30 minutes. Do not crush. Record Review of manufacturer's recommendation for Resident 36's Alendronate revealed: According to the manufacturer's package labeling for many bisphosphonates, absorption is decreased when Oyster Shell Calcium with vitamin D Oral Tablet 500-5 MG-MCG is co-administered. Clinical impact is not known. An interview with the Director of Nursing (DON) on 3/11/25 at 1:45 PM confirmed the Alendronate should have been given 30 minutes prior to any other medication or food. B. A record review of an Admission Record indicated the facility admitted Resident 1 to the facility on [DATE] with a diagnosis of aspiration pneumonitis and a diagnosis of Gastroesophageal reflux disease (GERD). An observation on 3/11/25 at 8:46 AM revealed Resident 1 finished eating prior to medication administration. RN-A began medication administration at 9:04 AM and administered: Omeprazole 40 mg take 1 capsule by mouth every morning, take 60 minutes before meals, do not crush/chew. For GERD. Record review of Resident 1's physician orders revealed the following: Omeprazole capsule 40 mg - take one capsule by mouth every morning, take 60 minutes before meals, do not crush/chew. An interview was conducted on 3/11/25 at 9:32 AM with RN-A who confirmed Resident 1 had already eaten breakfast. RN-A stated that some residents have requested to receive their medications all together for medications like omeprazole and thyroid replacements because they don't want to be woken up. That's why [gender] omeprazole is scheduled in the AM. An interview on 3/11/25 at 9:35 AM with the Asisstant Director of Nursing confirmed that at the time of medication administration, it would be the expectation to administer the omeprazole 60 minutes before meals. Record review of Resident 1's Omeprazole revealed: According to the manufacturer's guidance, swallow intact with a glass of water at least 1 hour prior to a meal. Do not use with any other liquid. Do not open capsules or mix the contents with food. Record Review on 3/11/25 of the Facility Medication Administration Policy effective 3/8/22 revealed the following: -Medications for individual residents will have pharmacy label with the resident name, drug, dose, directions and prescribing physician.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) was accurate and coded to reflect Hospice [End of Life] Services for Resident 1 and no intravenous (IV) fluid use for Resident 10. The sample size reviewed was 13. The facility census at the time of the survey was 31. Findings are: A. Record review of the Clinical Census Report revealed that Resident 1 was admitted to the facility on [DATE]. Resident 1 was admitted to Hospice services on 1/19/22 Record review of Resident 1's Comprehensive Care Plan [CCP, a interdisciplinary comprehensive plan that detailed care of the resident] dated 1/8/24 revealed that Resident 1 had an overall decline in health and had a terminal prognosis related to advanced Alzheimer's disease. Record review of Resident 1's MDS dated [DATE] revealed diagnoses that included Non Alzheimer's Dementia. The MDS revealed that Resident 1 was severely cognitively impaired with a Brief Interview for Mental Status [BIMS, a brief screener that aids in detecting cognitive impairment] score of 00 and was dependent on staff for all activity of daily living needs. Section Section O, K1 revealed that Hospice was not marked for Resident 1 on the MDS. Interview on 04/03/24 at 2:00 PM with the Director of Nursing [DON] confirmed that the Resident 1 had been on Hospice for a long time, since January of 2022, and that the MDS was coded incorrectly and Hospice should have been marked while a resident. B. Record review of Resident 10's Clinical Census Report revealed that Resident 10 was admitted to the facility on [DATE]. Record review of Resident 10's admission MDS dated [DATE] revealed that no BIMS score had been identified for Resident 10. The MDS revealed diagnoses that included Alzheimer's Disease and vascular dementia and that Resident 10 was dependent with all activities of daily living. Section K0520 of the MDS revealed that Resident 10 had received IV fluids as a resident and not as a resident, both of which were marked on the MDS. Interview on 04/03/24 at 10:06 AM with the Assistant Director of Nursing [ADON] confirmed that the MDS was coded incorrectly and that Resident 10 did not receive IV fluids while as a resident in the facility. The ADON stated that Resident 10 did receive IV fluids while in the hospital prior to admission but the fluids had been discontinued at the hospital.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure it was free of a medication error rate of 5% or greater. Observations were made of 25 medications administered which revealed 2 errors resulting in an error rate of 8%. The medication errors affect 2 (Resident 8 and 25) of 3 sampled residents. The facility staff identified a census of 31. Findings are: Record Review of Resident 8's Medication Summary printed on 04-03-2024 revealed an order for mucous relief 600 mg by mouth twice a day. Do not crush. An observation on 04-03-2024 at 7:40 AM of Care Partner (CP)-B administering medication for Resident 8 revealed CP-B prepared mucous relief 600 mg by placing the medication into a med pouch, crushing medication and then mixing the medication in applesauce. CP-B took the prepared medication and administered it to Resident 8. An interview with CP-B on 04-03-2024 at 7:55 AM confirmed that CP-B should not have crushed the mucous relief tablet. An interview with Registered Nurse (RN)-E on 04-03-2024 at 1:37 PM confirmed a medication error occurred because the mucous relief 600 mg medication should not have been crushed. Record Review of the facility Policy-Medication Administration dated 03-08-2024 under Crushing of Medication revealed the follow information: 1. Only medications approved by the manufacturer and pharmacy, and which have a provider order are crushed. 2. Each medication to be crushed should have this instruction on the Medication Administration Record. 3. If a medication cannot be crushed and the resident cannot take medication whole, alternatives include: -Pill can be administered in applesauce or food serving with similar consistency. -Pharmacy can dispense in liquid form. -Order can be requested from provider for different medication with the same class of drugs can be crushed or supplied in liquid form. B. Record Review of Resident 25's Medication Summary printed on 04-03-2024 revealed an order for Tylenol 500 mg take 2 tablets by mouth twice a day. An observation on 04-03-2024 at 8:00 AM of CP-B preparing medications for Resident 25 revealed CP-B began preparing medications to be administered and noted that Tylenol 500 mg take 2 tablets by mouth twice a day was unavailable. An interview with CP-B on 04-03-2024 at 12:41 PM revealed RN-E was notified of the Tylenol 500 mg tablets for Resident 25 was unavailable. An interview with the Director of Nursing (DON) on 04-03-2024 at 1:31 PM confirmed that a medication not given is an omission medication error. An interview with RN-A on 04-04-2024 at 11:02 AM confirmed that the facility had Tylenol 500 mg in stock and it was not given on 04-03-2024 at 8:00 AM to Resident 25. Record Review of the facility Policy-Medication Administration dated 03-08-2022 revealed Policy Statement: It is the Care Communities policy to store and administer medications and treatments in a safe and effective manner. The Procedure section revealed the following: Professional standards of medication administration are followed. -6 rights of medication administration-right resident, drug, dose, time, route, documentation. -Resident is observed swallowing oral medication. -Documentation is completed before setting up medication for the next resident.

175 NAC 12-006.17 Based on observation, record review and interview the facility failed to ensure linens were not exposed to cross contamination as evidenced by placing washcloths into the sink and failed to perform hand hygiene and glove changes during personal cares for 2 residents (Resident 2 and 20) of 7 sampled residents observed. The facility identified census was 31. Findings are: Record Review of the facility policy Hand Hygiene and Glove Usage dated 03-09-2021 revealed the following: -Policy Statement: It is the policy of the facility that hand hygiene for residents and staff will be performed to avoid the spread of pathogens. The use of gloves is to protect from potential exposure to blood, body fluids and/or other potentially infectious material with providing care. Gloves do not eliminate the need for hand hygiene. Hand Hygiene is required before putting on gloves and after removing gloves. -Under the section identified as Definitions revealed the following: -Hand Hygiene-Clean hands at appropriate times: -Before and after providing care to or handling resident belongings -After removing gloves. -After handling soiled linen or equipment. -Anytime you notice hands are soiled Glove Usage-Should be worn and changed at appropriate times: -Between Residents -When going from one contaminated area to another on a resident. -When going from a contaminated area/task to a clean area/task on a resident. -After completing a dirty task before going to a clean task. A. An observation on 04-03-2024 at 9:53 AM of Nursing Assistant (NA)-D providing a shower for Resident 20 revealed NA-D had 5 washcloths in the sink soaking in soap and water, NA-D performed hand hygiene with Alcohol Based Hand Rub (ABHR) and applied clean gloves. With gloved hands, NA-D took a washcloth from the sink and washed Resident 20's face, then tossed the washcloth in a plastic bag. NA-D took another washcloth from the sink and washed Resident 20's feet then discarded washcloth in plastic sack. NA-D using a mechanical lift raised Resident 20 in the mechanical lift to be transferred from the toilet to shower chair. NA-D took another washcloth and washed Resident 20's peri area and buttocks and discarded the washcloth in the plastic bag. NA-D with the same soiled gloved hands repositioned resident in shower chair and fastened a seat belt. NA-D with the same soiled gloves took another washcloth out of the sink basin and washed Resident 20's back, arms, chest and abdomen and discarded the wash cloth in a plastic bag. An interview with NA-D on 04-03-2024 at 10:30 AM revealed that NA-D did not remove gloves, perform hand hygiene and apply clean gloves after washing Resident 20's peri area and buttocks and before washing other areas of Resident 20's body. NA-D further confirmed washcloths were placed in the sink for use with Resident 20 An interview with RN-E on 04-04-2024 at 7:15 AM confirmed the placement of washcloths into the sink could cause cross contamination. B. An observation on 04-04-2024 at 7:40 AM of Care Partner (CP)-C providing care for Resident 2 revealed CP-C went to the bathroom with gloved hands, picked up Resident 2's denture cup and rinsed the dentures under running water. CP-C applied adhesive to the dentures, went to Resident 2's bedside and inserted the dentures into Resident 2's mouth. CP-C without changing the gloves lowered Resident 2's head of the bed and unfastened Resident 2's brief. CP-C went into the bathroom and obtained a bottle of bath soap and on the way back to the bedside CP-C used Alcohol Based Hand Rub (ABHR) on (gender) gloved hands and then continued to change Resident 2's brief. An interview with CP-C on 04-04-2024 at 8:04 AM confirmed that ABHR was used on gloved hands. An interview with RN-E at 8:10 AM on 04-04-2024 confirmed that ABHR should never be used on gloved hands, the gloves should have been removed and hand hygiene performed on bare hands.

175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) reflected the current status of the resident at the time of the assessmenht regarding falls for Resident 16 and discharge for Resident 32. This affected 2 of 14 residents sampled for MDS accuracy. The facility census was 33. Findings are: A. An initial interview with Resident 16 on 3/15/23 at 11:02 AM revealed that the resident had fallen at home prior to the hospitalization resulting in the nursing home admission. A review of the resident's hospital History and Physical dated 2/20/23 revealed that the reason for the emergency room visit was that the resident had a GLF (Ground Level Fall), on ground for 36 hours. A review of Resident 16's Medical Diagnosis page printed 3/16/23 at 9:21 AM revealed the resident was admitted to the facility on [DATE] with diagnoses of Unspecified Fall, Initial Encounter, and Fall on Same Level, Unspecified, Initial Encounter. A review of the resident's Admission MDS dated [DATE] revealed in Section J Health Conditions that question J1700 A Did the resident have a fall any time in the last month prior to admission/entry or reentry? was answered no and question J1700 B Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? was answered no. An interview with the MDS Coordinator (MDS) confirmed that the MDS should have been marked yes for question J1700 A, indicating a fall within the month prior to admission. 48271 B. Resident 32 admitted to the facility on [DATE] for rehab with a goal to return home. The resident's admitting diagnosis was closed fracture of left distal femur. Record review of Resident 32's MDS dated [DATE] revealed in Section A (2100)that the Resident was discharged to the hospital. Record review of Resident 32's progress notes dated 1/20/23 revealed that the resident was discharged to home. Record review of Resident 32's Discharge summary dated 1/20/23 revealed the resident was discharged to home. Record review of Resident 32's Physicians noted dated 1/17/23 revealed that the resident was discharged to home. An Interview with the MDS Coordinator on 3/20/23 at 1:42 PM, confirmed that the data entered in Section A (2100) question of discharge status was marked acute hospital and should of been marked discharged to the community.

Licensure Reference Number 175 NAC 12-006.09D3(5) Based on record review and interview; the facility failed to follow the facility's bowel protocol to prevent constipation for one (Resident 1) of one sampled resident. The facility census was 33. Findings are: In an interview on 3/15/23 at 1:44PM, Resident 1 revealed that Resident 1 had gone four days at times without a bowel movement. Record review of Resident 1's 30 Day Bowel Elimination Task, dated 2/19/23 to 3/20/23, revealed that Resident 1 went from 2/20/23-2/22/23, 2/27/23-3/1/23, 3/5/23-3/8/23, 3/10/23-3/12/23 and 3/14/23-3/16/23 without a bowel movement. Record review of Resident 1's current orders, dated 3/20/23, revealed orders for the following: -PEG3350 powder (a medication to prevent constipation) mix 17 grams (1 capful) in 4-8 ounces of liquid every day as needed (PRN). Indication for use: constipation -Milk of Magnesia suspension (a medication to treat constipation) 1200/15 milliliters (ml), take 30ml once daily PRN for constipation -Enema ready-[NAME]-TO-Use (a medication used to cleanse or stimulate the emptying of the bowel) use 1 enema per rectum once daily PRN for constipation if no bowel movement for three days -Bisacodyl suppository (a medication used to treat constipation) 10 milligrams, insert 1 suppository rectally once daily PRN for constipation -Docusate Sodium capsule (a medication used in the management and treatment of constipation) 100 milligrams twice daily PRN for constipation -Bowel protocol day 2 no bowel movement (BM): day shift as needed for constipation Give prune product as needed -Bowel protocol day 2 no BM: evening shift every 8 hours as needed for constipation Repeat prune product as needed; continue increased fluids -Bowel protocol day 3 no BM: day shift as needed for constipation Repeat prune product as needed; continue increased fluids -Bowel protocol day 3 no BM: evening shift every 8 hours as needed for constipation Digital check, assess bowel sounds, temperature (temp), give PRN medication as needed and sign off on medication administration record (MAR) -Bowel protocol day 4 no BM: day shift as needed for constipation If no results in 4 hours, then do digital check assess bowel sounds, temp, give PRN medication as needed -Bowel protocol day 4 no BM: night shift as needed for constipation If no results by AM, then do digital check, assess bowel sounds, temp, give PRN medication as needed Record review of Resident 1's MAR (Medication Administration Record) revealed that Resident 1 did not receive any PRN bowel medications and the bowel protocol was not followed. In an interview on 3/20/23 at 2:42PM, the Director of Nursing (DON) confirmed that on 2/20/23-2/22/23, 2/27/23-3/1/23, 3/5/23-3/8/23, 3/10/23-3/12/23 and 3/14/23-3/16/23 the bowel protocol was not followed for Resident 1 as ordered by the physician. Record review of the facility's Bowel and Bladder Management policy, dated 3/4/22, revealed the following: -Residents will be monitored as their condition requires for constipation and diarrhea. -Constipation- if a resident is showing signs or symptoms of constipation, bowel interventions will be started per physician orders.

Licensure Reference Number 175 NAC 12-006.09D4 Based on record review and interview; the facility failed to ensure a restorative nursing program per therapy recommendation was initiated for 1 (Resident 1) of 3 sampled residents. The facility census was 33. Findings are: In an interview on 3/15/23 at 1:43PM Resident 1 revealed that Resident 1 had not received restorative care. A review of Resident 1's Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 1/31/23, revealed that Resident 1 had an impairment to both of Resident 1's lower extremities and revealed no documentation that a restorative nursing program had been completed. A review of Resident 1's occupational therapy discharge summary, dated 10/31/22, revealed the recommendation for a restorative ROM (Range of Motion) program. The discharge summary further revealed that the information had been issued to the resident and to the restorative nursing staff with the recommended exercises and number of repetitions listed. A review of Resident 1's comprehensive care plan (written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed no mention that Resident 1 had been recommended for a restorative nursing program. A review of Resident 1's electronic medical record revealed no documentation of a restorative nursing program being completed for Resident 1. In an interview on 3/20/23 at 1:05PM, RA-A (Restorative Aide) revealed that Resident 1 was not receiving a restorative nursing program. In an interview on 3/20/23 at 2:40PM, the Director of Nursing (DON) confirmed that Resident 1 was not receiving a restorative program. A review of the facility's Restorative Program policy, dated 2/24/22, revealed the following: -documentation of the restorative plan with periodic progress notes are maintained in the resident's clinical record.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to maintain the cleanliness and condition of the stove and the stove hood in the main facility kitchen and failed to ensure that dishes were stored in a manner to prevent the potential for contamination of the eating surfaces in the satellite kitchen. This had the potential to affect all residents that ate foods prepared in the facility kitchen. The facility census was 32. Findings are: Observation on 11/15/21 between 7:11 AM to 7:30 AM in the facility main kitchen revealed a shelf above the stove was grease and dust covered, the caulking on the stove hood was loose and hung over the surface of the griddle and there was a black burned on substance on the back splash of the stove. Observation on 11/15/21 between 7:30 AM and 7:35 AM revealed that the plates and bowls located on a shelf in the satellite kitchen preparation and serving area were stored upright with the eating surface exposed. Interview with the Certified Dietary Manager [CDM] on 11/16/21 at 9:45 AM confirmed the condition of the shelf above the stove, caulking on the stove hood, the stove back splash and that the dishes were stored upright with the eating surface exposed. The CDM stated that those things were cleaned weekly but did not provide documentation of the date they were last cleaned. The CDM confirmed that dishes stored upright with the eating surface exposed could become contaminated by food or liquid splash and should be covered or turned up side down to protect the eating surface. The CDM confirmed that all residents that resided in the facility ate foods prepared in the facility main kitchen and the satellite kitchen.

Based on observation, interview, and record review, the facility failed to complete a Level II PASARR (Pre-Admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) after a new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Total census was 32 Findings are: A. Record review of the facility's Policy - Admission of a Resident, dated 03/11/2020, revealed the Care Community will coordinate assessments with the preadmission screening and review (PASRR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: 1. Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transition of care. 2. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Review of Resident 8's Admission PASRR was completed on 11/9/2015 as a Level 1. The Level 1 Screen conducted for this individual determined that there was no evidence to suggest the presence or known conditions of mental illness, intellectual disability, or a condition related to intellectual disability. As such, no further Level 1 screening was required unless the individual was later suspected or found to have a mental illness or intellectual disability condition. Interview with the Director of Nursing (DON) on 11/16/2021 at 3:56 PM revealed that Resident 8 fell and went to Lakeside Hospital for a [CONDITION(S)] in May 2019. Resident 8 returned to the facility 6/3/2019 with new orders from the hospital for [MEDICATION(S)] [an antipsychotic medication used for mood and behavior disturbances]. Record review of Resident 8's Mood and Behavior Review dated 7/25/2019 revealed that Resident 8 received antidepressant, antianxiety and antipsychotic (medications to manage [CONDITION(S)] such as [CONDITION(S)], [CONDITION(S)] disorder, and others disorders) medications for the following behaviors: - Agitation - Appears angry - Anxiety - Hallucinations - Paranoid - Repetitive behaviors - Sad expressions - Self-depreciation - Fear - Yelling out Record review of Resident 8's Minimum Data Set (MDS, a health status and screening tool used for all residents of long term nursing care facilities), dated 09/10/2019 and the Annual MDS dated [DATE] Section A, A1500 revealed that Resident 8 was not considered to have a serious mental illness. Section I, reveals Resident 8 had Anxiety Disorder, Major Depressive Disorder, Psychotic disorder with Delusions. The MDS section N0410 revealed that Resident 8 used Antipsychotic, Antidepressant and Antianxiety medications daily. Record review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/16/21 03:56 PM with the Director of Nursing confirmed that a new PASARR had not been completed, the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of Resident 2's Admission PASRR revealed the PASRR had been completed on 12/6/19 as a level 1 prior to admission to the facility. The PASRR level 1 screen for Resident 2 revealed the following information: - No mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - No medications were used for any mental health conditions. - Level 1 outcome: No Level 2 required, no serious mental illness or intellectual disability identified. - Rationale: The level 1 screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual disability or a serious behavioral health condition. If changes occur or new information refutes this findings, a new screen must be submitted. Record review of Resident 2's MDS dated [DATE] indicated that Resident 2 had a significant change after a return from an acute care hospital on 8/6/21. Section I of the MDS indicated that Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 also had a new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident 2's Electronic Medical Record revealed that no new PASRR had been requested since 10/11/18. On 11/17/21, after the start of the survey, a new Level 1 screen for PASRR was submitted to Ascend [the PASSR company] by the facility Social Worker for Resident 2. Interview on 11/17/21 at 8:54 AM with the facility Licensed Social Worker [LSW] confirmed that a new referral for a PASRR review had not been submitted after Resident 2 exhibited a change in behavioral status and received new serious mental illness diagnoses. The LSW stated that a PASSR batch had been created on 8/13/21 but had not been submitted until 11/17/21 after the start of the long term care survey. C. Review of Resident 31's PASARR dated 11/11/2020 revealed a Level one was completed and no level II was recommended. Review of the Pharmacy review and recommendations dated 11/17/2020 revealed a recommendation from the consultant pharmacist for the facility to add the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/17/2020 a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional information was sent to update level 1 PASSARR for Resident 31. Interview on 11/18/2021 at 2:30 PM with the administrator revealed a PASARR should have been done with the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observation, interview, and record review, the facility failed to ensure oxygen was provided at the prescribed liter flow and the facility failed to ensure respiratory equipment was available for use for 1 (Resident 8) of 3 residents identified with oxygen use. Total facility census is 32. Findings are: A. Review of the facility's Oxygen Administration Policy dated 06/03/2021revealed: Oxygen is considered a medication, so it requires a physician's/designee's order to initiate and discontinue including the following information. a. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] b. Oxygen flow rate c. Continuous or PRN (as needed) with parameters d. Mode of delivery (nasal cannula (tubing that runs to a person's nose to supply oxygen) or mask) Record review of Resident 8's Minimum Data Set (MDS, a health status and screening tool used for all residents of long term nursing care facilities), dated 09/10/2019 and the Annual MDS dated [DATE] revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 8's Treatment Administration Record (TAR) dated 10/4/21 and 11/15/21 revealed the use of O2 2.5L applied at HS marked every night. Observation of Resident 8 on 11/15/21 07:45 AM revealed an oxygen concentrator (a medical device that gives a person extra oxygen) was located on the right hand side of the bed and the machine was off. Observation on 11/16/21 at 06:40 AM revealed Resident 8 was lying in bed, but awake with the oxygen concentrator on and set at 2L (liters of oxygen delivered per minute) via nasal cannula. Record review of Resident 8's Admission assessment dated [DATE] revealed under the Equipment Section that Resident 8 was on Oxygen with a rate of 2L at Nocturnal (NOC, to be worn at night). Record review of Resident 8's Care Plan dated 9/7/2021 revealed Resident 8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/17/21 at 09:43 AM with LPN-A (Licensed Practical Nurse) revealed LPN-A turned on the oxygen concentrator and confirmed the oxygen concentrator was set at 2.0L. LPN-A reviewed Resident 8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/17/21 at 04:03 PM with the Director of Nursing confirmed the oxygen setting should be 2.5L and was not. B. Record review of Resident 8's Order Summary Report dated 11/16/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 8's Admission assessment dated [DATE] reveals under the Equipment Section that Resident 8 is on [CONDITION(S)] with setting: as ordered. Record review of Resident 8's Minimum Data Set (MDS, a health status and screening tool used for all residents of long term nursing care facilities), dated 09/10/2019 and the Annual MDS dated [DATE] Section O, O0100 F. Non-Invasive Ventilator ([CONDITION(S)]/[CONDITION(S)]) was marked yes for while a resident. Observation on 11/16/21 at 06:40 AM revealed Resident 8 was lying in bed, but awake with the oxygen concentrator on and set at 2L (liters of oxygen delivered per minute) via nasal cannula but there was not a [CONDITION(S)] in the room. Record review of Resident 8's Treatment Administration Record (TAR) dated November2021 revealed no documentation of [CONDITION(S)] usage. Interview on 11/17/21 at 09:43 AM with LPN- A confirmed the resident did not like the [CONDITION(S)]. LPN-A did confirm the [CONDITION(S)] was no longer in the facility and stated it should have been discontinued due to Resident 8 refusing to wear the machine. Interview on 11/17/21 at 04:03 PM with the DON confirmed the [CONDITION(S)] machine was not in the facility. The DON confirmed that the facility did not have a [CONDITION(S)] Policy.

Based on observation, record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the total number of hours worked per discipline. This had the potential to affect all residents that resided in the facility. The facility census was 32. Findings are: Observation on 11/15/21 at 03:07 PM revealed that the observation of the posted nursing staffing information for 11/15/ 21, 11/16/21 and 11/17/21 did not contain a total calculation of the hours worked per discipline. Interview on 11/18/21 at 10:06 AM with the Director of Nursing confirmed that the posted nurse staffing information did not contain the total number of hours worked per discipline and that those had not been calculated or documented on the posted nurse staffing information.

Based on record review and interview, the facility failed to provide documentation of reason for transfer to the hospital for 2 (Residents 15 and 25) of 2 sampled residents transferred to the hospital. The facility had a total census of 32. Findings are: [NAME] A review of Progress Notes for Resident 15 dated 8/25/19 revealed Resident 15 was transferred to the hospital on [DATE] following a fall at the facility. A review of Resident 15's medical record did not reveal any documentation that reason for transfer was provided to Resident 15 or responsible party in writing at time of transfer to the hospital. In an interview on 11/18/19 at 8:54 AM, the Director of Nursing confirmed documentation regarding reasons for transfer were not provided to Resident 15 in writing at time of transfer. B. A review of Progress Notes for Resident 25 dated 10/18/19 revealed Resident 25 was transferred to the hospital on [DATE]. A review of Resident 25's medical record did not reveal any documentation that reason for transfer was provided to Resident 25 or responsible party in writing at time of transfer to the hospital. In an interview on 11/18/19 at 8:54 AM, the Director of Nursing confirmed documentation regarding reasons for transfer were not provided to Resident 25 in writing at time of transfer.

Based on record review and interview, the facility failed to provide a copy of bed hold policy at time of transfer to the hospital for 1 (Resident 25) of 2 sampled residents transferred to the hospital. The facility had a total census of 32. Findings are: A review of Progress Notes for Resident 25 dated 10/18/19 revealed Resident 25 was transferred to the hospital on [DATE]. A review of Progress Notes dated 10/21/19 revealed Resident 25's family member was contacted on 10/21/19 regarding bed hold. In an interview on 11/13/19 at 3:30 PM, Social Worker B reported that a copy of the bed hold policy is provided on admission but not at time of transfer to the hospital. Social Service Designee B reported a resident's family is contacted after transfer to discuss and offer bed hold. In an interview on 11/18/19 at 1:52 PM, the Director of Nursing confirmed a copy of the bed hold policy is not provided to residents at time of transfer.

Licensure reference: 175 NAC 12-006.09C Based on record review and interview, the facility failed to develop a Comprehensive Care Plan related to recurrent urinary tract infections for 1 (Resident 22) of 12 sampled residents. The facility had a total census of 32 residents. Findings are: A review of Resident 22's 11/19 Medication Administration Record [REDACTED]. A review of 9/19/19 60 day long term care visit note identified Resident 22 as receiving daily [MEDICATION NAME] for being at risk of a urinary tract infection. A review of Resident 22's comprehensive care plan did not reveal any focus areas or interventions related to Resident 22's risk for urinary tract infections or order for daily [MEDICATION NAME]. In an interview on 11/18/19 at 2:05 PM, the Director of Nursing confirmed risk for urinary tract infections or daily [MEDICATION NAME] was not included on Resident 22's comprehensive care plan.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on record review and interview; the facility staff failed implement interventions to prevent falls and failed to evaluate a recliner for safety of use for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 33. Findings are: [NAME] Record review of a Admission Record sheet dated 8-30-2019 revealed Resident 1 was admitted to the facility 12-13-2018 and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 12-13-2018 revealed Resident 1 was at risk for falls. Record review of a Summary/ Conclusion Investigation Report (SCIR) sheet dated 6-08-2019 revealed Resident 1 was found sitting in front of Resident 1's recliner. Record review of Resident 1's Progress Notes (PN) dated 6-10-2019 revealed Resident 1 was observed trying to get out of a recliner with the leg rest extended. Record review of Resident 1's PN dated 7-19-2019 revealed Resident 1 was found on the floor between the recliner and medication cabinet. Record review of a SCIR sheet dated 7-31-2019 revealed on 7-26-2019 Resident 1 had been sent out to the hospital for an evaluation of let leg pain. Further review of the SCIR dated 7-31-2019 revealed the facility staff had been informed Resident 1 had sustained a non-displaced [MEDICAL CONDITION] sacral area. Record review of a Adult Abuse/Neglect Report for Licensed/Certified Facilities (ABNRLCF) dated 7-26-2019 revealed Resident 1 had been resting in a recliner. According to the information on the ABNRLCF sheet dated 7-26-2019, Resident 1 exited the recliner with the foot rest elevated and was found on the floor. Review of Resident 1's medical record revealed there was not evidence the facility staff had evaluated the safety of recliner for Resident 1's use. Record review of a Witness Statement (WS) sheet dated 8-25-2019 revealed a staff member seen Resident 1 laying on the floor. According to the WS sheet information, the staff member called for assistance and positioned Resident 1's head on a pillow. The information in the WS sheet dated 8-25-2019 identified Resident 1 was laying on (gender) side and the recliner was reclined. Record review of a ABNRLCF sheet dated 8-26-2019 revealed Resident 1 had sustained a right radius and alnar [MEDICAL CONDITION]. B. Review of the SCIR sheet signed and dated 7-31-2019 revealed Resident 1 was found laying on the right side between the recliner and medication cabinet. New interventions identified was to obtain orthostatic Blood Pressure (BP, measurement of BP, usually laying, sitting and standing, monitoring for hypotensive issues when standing) for 3 days. Record review of Weights and Vitals Summary sheet printed on 9-18-2019 revealed Resident 1's Orthostatic BP's results: -7-20-2019 at 9:25 AM, BP laying was 152/71 milligrams of mercury (mmHg), -7-20-2019 at 9:28 AM, BP sitting was 160/73. -7-20-2019 at 9:30 AM, BP standing was 138/72, a drop of 22 mmHg of the systolic reading ( the top number of a BP reading). -7-21-2019 at 8:48 AM , BP laying was 167/71 mmHg. -7-21-2019 at 9:48 AM, BP sitting was 153/73 mmHg. -7-21-2019 at 9:51 AM, BP standing was 145/73 mmHg. ( An hour and 3 minutes after the laying BP was obtained). -7-22-2019 at 9:35 AM, BP laying was 154/69 mmHg. -7-22-2019 at 10:03 AM, BP sitting was 164/77 mmHg. -7-22-2019 at 10:05 AM BP was 148/72 mmHg. Review of Resident 1's record revealed there was not evidence the facility staff had provided information of Orthostatic BP results to Resident 1's Practitioner. On 9-18-2019 at 9:38 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported Resident 1's recliner had not been evaluated for safety of use by Resident 1. Review of Resident 1's Orthostatic BP results was completed with the DON. The DON reported there was not a facility policy and procedure on how staff were to obtain orthostatic BP. The DON reported orthostatic BP should be completed laying, sitting and standing, one after the other. The DON confirmed the orthostatic BP's would not be accurate due to the length of time in between BP readings. The DON confirmed there were not other interventions implemented related to 7-19-2019 injury in an attempt to prevent further falls for Resident 1. Record review of a Assessment Measuring Orthostatic Blood Pressure by the CDC found at www.cdc.gov/steadi revealed the following information: -1. Have the patient lie down for 5 minutes. -2. Measure blood pressure and pulse rate. -3. Have the patient stand. -4. Repeat the blood pressure and pulse rate measurements after standing 1 and 3 minutes. A drop in BP greater than 20 mmHg systolic or 10 mmHg diastolic (bottom number of a BP reading), or experiencing lightheadedness or dizziness is considered abnormal. Record review of a SCIR signed and dated 8-30-2019 revealed Resident was observed in a recliner and later staff seen Resident 1 on the floor. Resident 1 complained of pain and was sent to the hospital for an evaluation. According to the SCIR sheet signed and dated 8-30-2019 the facility staff were notified Resident 1 had sustained a right arm radius and ulnar fracture.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b(1)(3)(4) Based on record review and interview; the facility staff failed to re-evaluate transfer ability and implement interventions to prevent injuries for 1 resident (Resident 1). The facility staff identified a census of 31. Findings are: Record review of an undated Face Sheet revealed Resident 1 was admitted to the facility on [DATE]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 5-14-2015 revealed the facility staff assessed the following about the resident: -Resident 1 had a score of 11 on the Brief Interview of Mental Status (BIMS). According to the MDS Manuel, a score of 8-12 indicate moderately impaired cognition. -Required extensive assistance and the physical assistance of 2 with bed mobility, transfers, dressing and toilet use. -No falls were identified for Resident 1. Record review of Resident 1's MDS dated [DATE] revealed the facility staff assessed the following about Resident 1; -Required extensive assistance and physical assistance of 2 with bed mobility, transfers, personal hygiene, and toilet use. -Resident 1 was identified as having falls since last assessment. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 8-29-2014 with a revision date of 9-02-2014 revealed Resident 1 was at risk for falls related to a history of falls and had poor balance. The goal for Resident 1 was to be free from major injury from falls. Interventions identified on the CCP were as follows: -Chair alarm. -Sign in bathroom reminding Resident 1 to call for assistance and not to get up out of the chair alone. -Do not leave Resident 1 alone in a wheelchair in (gender) room. -Transfer Resident 1 according to therapy's recommendation. -Resident 1's CCP did not identify how Resident 1 was to be transferred by the facility staff. Record review of a Situation Background Assessment Recommendation (SBAR) sheet dated 6-13-2015 revealed Resident 1 had developed a hematoma (blood filled space) and bruising to the right ankle area. Record review of Resident 1's Progress Note (PN) dated 6-13-2015 revealed Resident 1 was being assisted to the commode by 1 Nursing Assistant (NA) when Resident 1's right leg bumped the commode chair leg. According to the PN dated 6-13-2015, Resident 1 developed a bruise and hematoma began to form. Resident 1 complained of pain when the area was touched. An Ace Wrap was applied, the right leg was elevated and according to the PN dated 6-13-2015 Resident 1's entire lower leg is now bruised. No interventions to prevent further injuries with transfers was identified in the PN dated 6-13-2013. Record review of a SBAR sheet dated 7-02-2015 revealed Resident 1 obtained a skin tear on the lower right arm during a transfer to the bathroom. According to Resident 1's PN dated 7-02-2015, Resident 1 received the injury during a transfer with 1 person assisting the resident. Record review of a SBAR sheet dated 9-11-2015 revealed Resident 1 had sustained a bruise that measured 13.5 cm (centimeter) by 11 cm to the left lower leg. According to the SBAR dated 9-11-2015 the bruise was identified when assisting Resident 1 to the bathroom. Record review of SBAR dated 8-23-2015 revealed Resident 1 was identified with a new hematoma to the right shin that measured 5 cm by 5 cm. Record review of Resident 1's PN dated 8-23-15 revealed Resident 1 reported bumping the leg on something. Record review of Resident 1's record revealed there were no additional interventions in an attempt to prevent further injuries. Record review of a SBAR dated 9-13-2015 revealed Resident 1 sustained a skin tear to the right lower leg. According to the information on the SBAR sheet dated 9-13-2015, Resident 1 leg was bumped during a transfer. Record review of Resident 1 PN dated 9-13-2015 revealed a NA was assisting Resident 1 into bed when the skin tear was identified that measured 2 cm by 1 cm to the right lower leg. Resident 1's PN dated 9-13-2015 did not identify and new interventions to prevent further injuries. Record review of Resident 1's CCP dated 11-24-14 revealed there were no additional interventions to prevent further injuries identified on the CCP. Record review of Resident 1's PN dated 10-18-2015 revealed Resident 1 sustained a laceration that measures aprox (approximately) 7 cm by 5 cm not superficial. Moderate amount of bleeding. According the the PN, Resident 1 was sent to the emergency room (ER) for an evaluation of the laceration. Record review of a (ER) sheet dated 10-18-2015 revealed Resident 1 was [DIAGNOSES REDACTED]. Record review of a Summary/Conclusion Investigation Report dated 10-18-2015 revealed NA B had transferred Resident 1 without a second staff person to assist with transferring Resident 1 resulting in the avulsion to the left leg and fractured right toe. An interview was conducted on 10-22-2015 at 10:10 AM with NA A. During the interview when asked how Resident 1 transferred, NA A report Resident 1 was a 1 person transfer up until about 2 weeks ago. The nurse reported they think (gender) had a stroke. On 10-22-2015 at 11:15 AM an interview was conducted with the facility Director of Nursing (DON). During the interview, review of Resident 1 CCP, the SBARs for 6-13-2015, 7-02-2015, 8-23-2015, 9-11-2015, 9-13-2015 and MDS's dated 5-14-2015 and 8-13-2015 were reviewed with the DON. The DON confirmed Resident 1's CCP did not identify how Resident 1 was to be transferred. During the review of Resident 1's MDS dated [DATE] with the DON, the DON confirmed the MDS had identified Resident 1 required 2 people to physically assist with transfers and further confirmed Resident 1's transferring status had not be re-evaluated and should have been. The DON further confirmed no additional intervention were implemented related to the SBARS dated 6-13-2015,8-23-2015 and 9-13-2015. The DON confirmed there were no recommendations from therapy on how Resident 1 was to be transferred.