Every finding on record at Wauneta Care and Therapy Center

Licensure Reference Number 175 NAC 12-006.04(B)(ii)1 Based on record review and interview, the facility failed to ensure that Nurse Aides (NAs) are provided 12 hours of yearly education, and fails to follow their Facility Assessment that includes dementia management training for NAs. This affected 1 of 1 NAs sampled. The facility census was 27. Findings were: Record review of the Facility assessment dated [DATE] revealed that staff training, education, and competencies were required by in-service training for Nurse Aides and would be no less than 12 hours per year and include dementia management training among other subjects. Record review of the document Training Hours which documented ongoing yearly education for NA-A revealed that NA-A, whose date of hire was 6/11/2024, had only 10.15 hours of continuing education from 6/11/2025 to 6/11/2026 documented. No dementia management training was listed. Record review of the nursing services monthly meetings revealed that NA-A did not attend and had no further education through nurse staff meetings. Interview on 08/03/2026 at 11:05 AM with the Facility Administrator (FA) revealed that the FA reviewed all of the past nursing in-services and found that NA-A did not attend any staff in-services. The facility staff could not produce documentation of any more of the required continuing education hours except that which was shown on the education transcript for online learning. FA stated that NA-A is a student and it is hard to get the required continuing education hours for NA-A completed. FA confirmed that there was no dementia management training that was completed by NA-A in the past year. Interview on 08/03/2026 at 11:08 AM with the Director of Nursing confirmed that the total number of continuing education hours for NA-A were not equal to or greater than 12 hours for the past year and that there was no dementia management training noted on the training paperwork.

Licensure reference number 12-006.11(E)Based on observations, record reviews, and interviews, the facility to ensure that dietary personnel used hand hygiene as required in the kitchen, and the facility failed to ensure that foods in the kitchen were dated, labeled, and discarded to prevent food borne illnesses. Findings are: F812Licensure reference number 12-006.11(E)Based on observations, record reviews, and interviews, the facility to ensure that dietary personnel used hand hygiene as required in the kitchen, and the facility failed to ensure that foods in the kitchen were dated, labeled, and discarded when appropriate to prevent food borne illnesses. Observations made during the initial brief tour in the kitchen at 10:20 AM on 7/20/26 revealed the following:-2 boxes of gold metal muffin mix with a best buy date of 5/3/26-4 gallons of syrup with no best by or expiration date-4, 7 pound (lb) cans of chocolate pudding with no expiration or best by date-6, 7lb cans of butter scotch pudding with no best by or expiration dates.-5, 6.5lb cans of diced peaches with no best by or expiration dates.-3, 6.5lb cans of fruit cocktail with no best by or expiration dates.-5, 6.61lb cans mandarin oranges with no best by or expiration dates.-1, 11.3 oz container of fudge striped cookies was unsealed-1, 4.16lb can of tuna with a manufactured date of [DATE] with no best by or expiration dates.-10 bottles of 12 oz syrup with no best by or expiration dates.-11 Loaves of bread with no best by or expiration dates.-2, 64 oz containers of vanilla soft serve mix with a best by date of 7/16/26 in the standing fridge near the dry storage area. 1 large white lay down freezer in the back of the kitchen. Unable to sample all items in this freezer due to inability to access all foods but revealed the following: -2 packs of waffles with no best by or expiration dates.-2 packs of lemon squares with no best by or expiration dates.-1, 16oz pack of whipped topping with no best by or expiration dates.-5 bags of French fries with no best by or expiration dates.-2 bags of potato wedges with no best by or expiration dates.-1 bag of meatballs with no best by or expiration dates.-2 packs of red meat with no best by or expiration dates in the standing freezer in center of kitchen Record review of an undated and unlabeled document received from the Registered Dietician (RD) revealed the following statements:- Compare weekly order list against current stock in dry storage, walk-in coolers, and freezers to determine actual purchase quantities needed. - Stock Rotation: Transport items to designated storage areas immediately and restock using First-In, First-Out (FIFO) procedures-Placing newer stock behind existing stock to ensure proper rotationRecord review of an undated facility policy labeled Date Marking for Food Safety revealed information about staff being responsible for:-clearly marking food to indicate the date or day by which the food shall be consumed or discarded. -The individual opening or preparing food shall be responsible for date marking the food at the time the food is opened or prepared. -The marking system shall consist of a color-coded label, the day date of opening, and the day/date the item must be consumed or discarded-The discard date or day may not exceed the manufacturers use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1-The head Cook-I or designee shall spot check refrigerators weekly for compliance and document accordingly. Corrective action shall be taken as needed. -Prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. An interview at 11:05 AM on 7/20/26 with the RD confirmed all findings of expired foods, products without dates, and unsealed items as listed above. The RD confirmed they receive their food truck deliveries on Thursdays and they rotate and inventory all items. RD also confirmed that kitchen staff members are supposed to use stickers available for dating all foods in the kitchen. RD confirmed that staff mark the opening date of items only. Continuous observations of the evening meal service between 2:58 PM and 6:04 PM revealed the following:-Cook-I Donned (put on) gloves and began peeling onions. Cook-I confirmed they are preparing 30 servings of food. Stated they have 2lbs, 2oz of onions. There are 4 onions in total -Cook-I Weighed all 4 onions to total 2.5lbs and then began chopping/slicing the onions into strips. -Cook-I placed all sliced onions into a container and obtained a green lid to place on the container. Cook-I-I took a sticker and a pen from their shirt pocket and labeled the onions, then placed the onions in the fridge. -Cook-I then removed their gloves without performing hand hygiene and put away the food scale.-Cook-I took the cake out of the refrigerator and the whipped topping and then donned new gloves without performing hang hygiene, then added the whipped topping to the top of the cake. -Cook-I used their gloved hand to adjust glasses on their face, and then grabbed the cake pan and covered it with plastic wrap, placed the remainder of the whipped topping into a plastic container they grabbed with gloved hands, placed a lid on the green container, then removed gloves, labeled a sticker with a pen from their shirt pocket and placed on to the container of whipped topping. -Cook-I then put the whipped topping back into a refrigerator and then obtained a silver pan and placed it on the prep counter. Cook-I then stated there is no other prep work to be done because it is too early and stated they would begin again around 4:30. -Cook-I used the back side of their gloved hand to close the refrigerator door, and did not change their gloves.-Cook-I removed one glove, used the bare hand and grabbed a rag from the sink and wiped down their shirt, and then used the rag to wipe the lid of the blender cup, and then pureed the cake. Cook-I then removed the lid of the blender cup with their bare hand and used the same bare hand and spooned the pureed cake into 2 separate bowls. Cook-I did not perform hand hygiene during this time. -Cook-I then placed the blender cup in the sink and then took the sheet of cake servings and covered it with plastic wrap and placed it in the refrigerator.-Cook-I took the onions out of the refrigerator and grabbed a large skillet, while still wearing the same singular glove on one hand. Cook-I did not perform any hand hygiene.-Cook-I then took the remaining cake and covered it with plastic wrap and placed it in the refrigerator. -Cook-I removed their one glove and did not perform hand hygiene.-Cook-I used a rag to wipe down the prep counter with their bare hands and did not perform hand hygiene after.-Cook-I then added the onions to the pan on the stove. -Cook-I used the thermometer and poked it through the tinfoil covering the meat, to measure the temperature, then removed the meat from the oven and placed it on the prep counter and felt the tin foil with their bare hands, then placed it back in the oven.-Cook-I donned gloves at 4:49 PM without performing hand hygiene. -Cook-I is wearing gloves and has their hands crossed touching their shirt. -Cook-I transferred the hot skillet to the prep counter and began putting an unmeasured amount of meat an onion mixture into each hot dog bun using a pair on tongs. -Cook-I used their bare hand to place a piece of meat into the hot dog bun after it had fallen out of the tongs.-An observation at 5:19 PM revealed Cook-I used the same pair of tongs and added an unmeasured amount of cheese to each hot dog bun. -Cook-I removed a large jar of pickle spears from the fridge, and used gloved hands to open it, then added the pickles to the silver bowl that is sitting on top of the bowl of ice that was prepped at 4:41 PM-Cook-I used their gloved hands to grab the pen from their shirt and open the binder that is used to record temperatures, then recorded the temperature of the pureed meat and onion mixture.-The instant mashed potatoes are sitting in the pot uncovered on the prep counter. -The pickle spears are sitting in the silver bowl uncovered. -Cook-I used their gloved hands to adjust their glasses and then continued to plate foods. -Cook-I adjusted their glasses with their gloved hands again. -The skillet with the onion and meat mixture is sitting on the prep counter uncovered. -Cook-I has been using their gloved hand and a spatula 4 to grab the sandwiches and plate them for the entire meal service, wearing the same pair of gloves they wore when they touched their glasses-The staff member that is handing out trays mentioned to Cook-I that one resident would like some ketchup and so Cook-I then opened the fridge with their gloved hands and grabbed the ketchup bottle and added it to 2 out of 3 dressing cups and handed them to the staff member to pass out. Cook-I did not change their gloves or perform hand hygiene.Record review of a facility policy last revised on 6/1/26 labeled 'Hand Hygiene' revealed:- Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The hand hygiene table revealed that hand hygiene should be completed before applying and after removing personal protective equipment (PPE), including gloves.- Additional considerations: 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. An interview at 6:04 PM with Cook-I confirmed they did not realize they were touching things with their gloved hands, such as their glasses on their face.

Licensure Reference Number 175 NAC 12-006.11(D)Based on observation, record reviews and interviews, the facility failed to serve foods to the residents based on the serving sizes in the recipes to ensure all residents received the correct amounts of protein and other nutrients. This had the potential to affect all residents. The facility showed a census of 27.Findings are: Record review of a Recipe received from the facility for the evening meal on 8/3/26 revealed:'Steak, Onion and Cheese Submarine; Portion size 3 ounce (oz) / 1/2 oz/ 1 roll-Ingredients: Beef, Philly Steak meat, Frozen; 3 3/4 pounds (lbs) for 30 servings, 4lb 6 oz for 35 servings, and 5lbs for 40 servings. -Onion, Yellow fresh diced 1/4 or less; 2lbs 2oz for 30 servings, 2lbs, 7oz for 35 servings, and 2lbs 13 oz for 40 servings,-Cheese, Mozzarella, Shredded; 1lb for 30 servings, 1lb 2oz for 35 servings, and 1 1/4 lbs. for 40 servings.-Bun; Hot dog bun; 1 per serving. (30:30/35:35/40:40)Instructions: CCP (dietary staff) : vegetables must be washed or rinsed prior to use.CCP: Keep meat frozen until ready to use1.preheat griddle to 350F2. Grill frozen steak wafers; mix in onions gently as meat cooks. CCP: At completion of cooking, internal temperature must register 145F for 15 seconds.CCP: maintain minimum holding temperature of 135-140Assemble Sandwich: Cut rolls in half lengthwise.Place 3 oz meat/onion mixture and 1/2 oz cheese in each roll. Cut in half. Serve 1 sandwich per portion.Potato wedges:-Prepare per package instructions-Using a 4oz 'spoodle', serve 1/2 cup per portion. Discard leftovers Pickle Spear:-Drain spears-portion 1 spear per plateMaintain 41F or below Lemon-poke cake.-To serve, cut each 12x10x2 pan 4x4 for 16 servings. Each serving= 3x2 serve with a dollop of prepared whipped topping. Continuous observations between 2:58 PM and 6:00 PM revealed the following:-Cook-I Donned gloves and began peeling onions. Confirmed they are preparing 30 servings of food. Stated they have 2lbs, 2oz of onions. There are 4 onions in total - [NAME] -I weighed all 4 onions to total 2.5lbs and then began slicing the onions into strips. -Cook-I placed all sliced onions into a container and grabbed a green lid to place on the container. [NAME] them grabbed a sticker and a pen from their shirt pocket and labeled the onions, stating they would not saute the onions until they made everything together. Cook-I then placed the onions in the fridge. - Cook-I took the Lemon Poke cake out of the refrigerator and the whipped topping and then donned new gloves without performing hand hygiene and added the whipped topping to the top of the cake. -Cook- I then put the whipped topping back into a refrigerator, and then grabbed a silver pan, and placed it on the prep counter. Cook-I then stated there is no other prep work to be done because it is too early and stated they would begin again around 4:30. -There are 4 packs of 8 hot dog buns on the prep counter and one pack of 6 hot dog buns.-Cook-I removed the frozen meat from the plastic packaging and placed it on a large silver sheet pan and separated it using a spatula, with gloved hands. -Cook-I took a container off the prep counter and placed it in the sink, then grabbed tin foil and covered the frozen meat and then placed it in the oven which is set to 400F.-Cook-I removed the cake from the refrigerator, grabbed a container full of small bowls on the prep counter, then placed a few other white bowls on a silver pan and then donned gloves. - The cook then took the small clear white bowls and placed them on the silver sheet, filling the sheet. -Cook-I then sliced the cake into unmeasured servings and placed each serving into a plastic bowl. Each serving of cake is visibly different in size. -Cook-I added two different sized servings of cake to a blender cup.-Cook-I grabbed the blender cup that contained 2 slices of cake, opened the fridge door with his gloved hand to find milk, then asked the other available staff to add milk to the cup. The other staff member added an unmeasured amount of milk to the blender cup and then Cook-I placed a lid on the blender cup and pureed the cake.-Cook-I took the onions out of the refrigerator and obtained a large skillet and placed it on the stove then took the remaining cake and covered it with plastic wrap and placed it in the refrigerator. -Cook-I scooped an unmeasured amount of margarine into the skillet and then added the onions to the pan on the stove. -Cook-I removed a large bag of shredded mozzarella cheese from the fridge that has a date on the bag marked 7/29/26 and emptied 1quart of cheese from the bag into a container (roughly 2 lbs. of cheese)- Cook-I used a thermometer to record the temperature of the potato wedges in the oven, then left the wedges in the oven and closed it, then cleaned the thermometer. -There is a chart on the side of the refrigerator that contains different scoop colors and their respective capacities.-Cook-I removed the potato wedges from the oven and recorded their temperature, which was 198 Fahrenheit(F) with the thermometer and then cleaned the thermometer -The cook recorded a temperature of 208F for the meat and the onions. -Cook-I transferred the hot skillet to the prep counter and began putting an unmeasured amount of meat and onion mixture into each hot dog bun using a pair of tongs. -There is a visible difference in the amount of meat and onions going into each bun. -Cook-I then used the same pair of tongs and added an unmeasured amount of cheese to each hot dog bun. -Cook-I then added an unmeasured amount of meat, onion, and cheese to a blender cup and then added the liquid grease from the skillet to the blender cup and pureed the mixture.-Cook-I removed a large jar of pickle spears from the fridge then added the pickles to the silver bowl that is sitting on top of the bowl of ice that was prepped at 4:41 PM.-Cook-I added 3 pickle spears and some pickle juice to a blender cup and pureed it. -Cook-I scooped unmeasured amounts of the pureed meat and onion mixture on to the residents' trays.-The cook used a pair of tongs to add an unmeasured amount of cheese to the pureed meat and onion mixture-The dietary aid handing out food mentioned that one of the residents who requires pureed foods is not out at the dining hall. -Cook-I donned gloves and began grabbing plates and plating foods. -Cook-I put the bowl of ice and pickle spears on top of the hot steamtable. -Cook-I cut up 2 sandwiches into halves and served half a sandwich each on 4 plates with 1 pickle spear each and used a grey scoop with an unknown measurement amount of potato wedges for one plate, and a green scoop which is 4oz for the 3 other plates.-Cook-I then plated 1 full sandwich on 3 plates each with 1 pickle spear each and used the green scoop to plate potatoes. -Cook-I recorded the temperature of the remaining meat and onion mixture in the skillet (178F) and plated and unmeasured amount onto 2 plates for residents on soft and bite sized diets who cannot eat bread.-Cook-I then cut the pickles in half and plated half a pickle each for the remaining plates.-The cook cut another sandwich in half and plated half of it for one resident. -The cook removed 3 more pickle spears from the bowl and cut them in half, and then went back to plating foods. -Cook-I served one half sandwich and one full sandwich with half a pickle each and a 4 oz scoop of potato wedges onto room traysInterviews with Cook-I during the meal service from 4:00 PM to 6:00 PM confirmed there were 2 pureed diets, 1 chopped diet, and 1 bite sized diet. Cook-I also confirmed they did not have enough pickles for all residents, and that there were not extra available. At 6:00 PM one resident asked for an extra pickle and the cook stated they are out of pickles, or very close. At 6:04 PM Cook-I confirmed they did not measure the meat and onion mixture or the cheese, stating they 'eye balled' making the sandwiches with the tongs. Cook-I stated 'the spoons are inconsistent . thought the recipe said to use the tongs'.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview, the facility failed to ensure that the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) was updated with a change in orders for oxygen to reflect the current order for Resident 1; and failed to ensure Residents' 5 and 7's CCPs reflected their ability and desire to self administer medications. The sample size was 12 and the facility identified a census of 27. Findings Are: A. A record review of Resident 1's admission Record dated 7/21/2026 revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor). A record review of Resident 1's undated CCP revealed the resident suffered from altered respiratory status/difficulty breathing secondary to chronic obstructive pulmonary disease, chronic respiratory failure, as well as lung cancer. There was an intervention in place that stated the resident was to receive oxygen via nasal cannula at 3 liters per minute (LPM). The intervention had a start date of 10/23/2025. A record review conducted on 7/21/2026 of Resident 1's active Physician's Orders revealed an order for continuous oxygen via nasal cannula at 4L (liters)-5L. This order had a start date of 5/23/2026. An interview on 8/3/2026 at 9:35 AM with the Clinical Nurse Manager (CNM) confirmed that Resident 1's Care Plan had not been updated when their oxygen order was changed from 3 liters to 4-5 liters and should have been. B. A record review of Resident 7's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought, perception, and behavior, by a loss of emotional responsiveness and extreme apathy, and by noticeable deterioration in the level of functioning in everyday life). A record review of Resident 7's active Physician's Orders revealed the following medication orders: -Orajel (an over-the-counter topical medication used to temporarily numb and relieve severe toothaches, gum pain, and mouth sores) ointment every shift for pain. This order had a start date of 5/15/2026 and stated, patient may have at bedside. -Cough drops (throat lozenges), give 1 tablet by mouth as needed for cough. This order had a start date of 3/4/2026 and stated, unsupervised self-administration, may have at bedside. -Vicks VapoRub (a medicated topical ointment used to temporarily relieve coughs from colds and minor muscle or joint aches) apply topically as needed to chest for congestion. This order had a start date of 8/1/2024 and stated, may keep at bedside. -Saline Mist spray nasal solution 0.65%, 2 sprays in both nostrils every 6 hours as needed for dry nasal passages. This order had a start date of 8/5/2024 and stated, may keep at bedside). -Abreva (an over-the-counter cream containing 10% docosanol that treats cold sores and fever blisters by blocking the herpes virus from entering healthy skin cells) external cream, apply to affected area topically as needed for oral aphthae (small, painful, non-contagious ulcers that develop on the soft tissues inside the mouth). This order had a start date of 8/5/2024 and stated, may keep at bedside. An observation and interview on 7/20/2026 at 12:52 PM with Resident 7 in their room revealed a bag of cough drops on the resident's bedside table. The resident stated, I can keep those in my room, I have an order for that. A record review of Resident 7's CCP revealed no evidence of a focus, goal, or interventions related to their self-administration of medications. An interview on 8/3/2026 at 9:45 AM with CNM confirmed Resident 7's CCP did not contain information related to their self-administered medications. A record review of the facility policy Resident Self-Administration of Medication dated 2026 revealed that the care plan must reflect resident self-administration and storage arrangements for such medications. C. Record review of Resident 5's MDS, dated [DATE] revealed an admission date of 8/31/22. This MDS also revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Record review of Resident 5's Clinical Resident Profile dated 8/3/26 revealed a listed 'Responsible Party'. Record review of Resident 5's medical diagnoses revealed a diagnosis of unspecified Dementia, and Type 2 Diabetes Mellitus. Record review of Resident 5's order summary revealed an order for Insulin Lispro Injection 100 units/ milliliter (mL); Inject 4 units subcutaneously with meals related to Type 2 Diabetes Mellitus. There is no order for Resident 5 to self-administer medications. Record review of Resident 5's care plan revealed a focus of: I am at risk for complications secondary to my history of insulin dependent diabetes mellitus with a start date of 9/13/24, and no revision date. The intervention listed for this is: Administer medications as ordered with a start date of 9/13/2024 and no revision date. There is no information in the care plan about the resident self-administering medications. Record review of a facility policy with a revision date of 6/2/25 revealed no information regarding residents self-administering medications. An observation made at 11:47 AM on 8/3/26 revealed Licensed Practical Nurse (LPN)-C hand Resident 5 an alcohol wipe, which the Resident then used to clean their skin near their elbow, and then LPN_C handed the Resident a syringe with 4 units of insulin, which the Resident used to self-administer Insulin.

Licensure reference number 175 NAC 12-006.10(D)Based on record review, interview and observations, the facility failed to ensure that residents are free of significant medication errors for one resident (Resident 9). The facility showed a census of 27.Findings are: Record review of facility policy Medication Administration with a last revision date of 6/2/25 revealed that medications should be administered as ordered and in accordance with manufacturer's specifications. The policy stated to crush medications as ordered ad not to crush medications with do not crush instructions. The policy contained a list of 'Do Not Crush Medications' which included slow release and enteric coated medications. Record review of Resident 9's admission record revealed an original admission date of 4/7/20 with the following relevant diagnoses:-Chronic Diastolic Heart Failure (occurs when the main pumping chamber (left ventricle) of the heart becomes stiff and cannot relax normally between beats), and-Dysphagia (difficulty or pain when swallowing food, liquids, or even saliva ) following cerebral infarction (a medical emergency where a part of the brain dies because a blood clot or narrowed artery cuts off its blood and oxygen supply). Record review of Resident 9's Physician's Orders revealed an order for Potassium Chloride extended release (ER) tablet 20 Milliequivalents (mEq (units measuring the chemical activity and electrical charge of electrolytes in a solution, equal to one-thousandth of an equivalent)), give 1 tablet by mouth two times a day for supplement related to Heart Failure, DO NOT CRUSH. Further review of Resident 9's orders revealed no evidence of an order to crush their medications. Record review of Resident 9's undated Care Plan revealed: Special Instructions: Crush pills that can be crushed, and serve in chocolate pudding on the top of the care plan. During an interview at 8:36 AM on 7/21/26, Medication Aide (MA)-G confirmed they were going to crush all of Resident 9's morning medications except for their Pantoprazole. An observation made at 8:36 AM on 7/21/26 revealed the Medication Aide (MA)-G place the following medications into a medication cup and then crush them:-Clopidogrel (an antiplatelet medication)-Potassium Chloride ER (a vitamin supplement)-Sertraline (an antidepressant medication) -Torsemide (a diuretic medication)MA-G then added pudding to the crushed medications and fed the mixture to Resident 9. Record review of Davis's Drug Guide, 19th edition revealed that potassium chloride is a High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. It also revealed instructions stating, Do not chew or crush enteric-coated or extended-release tablets or capsules. Record review of the Food and Drug Administration website https://www.fda.gov/media/169646/download revealed in section 2.1: Recommended Dosage and Administration. Swallow tablets whole. Avoid splitting, crushing, or chewing the extended-release tablets because doing so may compromise the extended-release characteristics, effectiveness, or safety of DRUG-X.

Licensure reference number 175 NAC 12-006.10(A)(i)Based on observations, record reviews, and interviews, the facility failed to ensure residents who self-administer medications were competent to do so for one resident (Resident 5). The Facility showed a census of 27.Findings are:Record review of Resident 5's 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 6/16/26 revealed an admission date of 8/31/22. This MDS also revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment.Record review of Resident 5's Medical Diagnosis section of their electronic medical record (EMR) revealed the following relevant diagnoses:-Type 2 Diabetes Mellitus-Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Record review of Resident 5's clinical profile revealed a listed 'responsible party' with a phone number to contact them.Record review of Resident 5's care plan revealed a focus of: I am at risk for complications secondary to my history of insulin dependent diabetes mellitus; date initiated: 9/13/24. This focus has a listed intervention of: Administer medications as ordered; date initiated 9/13/24. There is no information in Resident 5's care plan revealing that they self-administer any medications.Record review of Resident 5's order summary dated 8/3/26 revealed there is no order for the resident to self-administer medications.Record review of a facility policy last revised on 6/2/25 labeled 'Medication Administration' revealed no information about residents' self-administration of medications.An observation made at 11:49 AM on 8/3/26 revealed the resident self-administer Insulin Lispro (a rapid-acting human-made insulin used to control high blood sugar, that is given as a shot under the skin). The Licensed Practical Nurse (LPN)-C verified the resident, med, route, dose, and time then removed the insulin vial from the medication cart, donned gloves without performing hand hygiene, then cleaned the vial with an alcohol wipe and drew up the ordered 4 units of Insulin into the required syringe. LPN-C then gave Resident 5 an alcohol wipe which the Resident used to clean their skin near their elbow. LPN-C then handed Resident 5 the insulin syringe, and Resident 5 injected the insulin into a spot near their elbow.An interview with the Director of Nursing at 6:21 PM on 8/3/26 confirmed there was no assessment completed to determine if Resident 5 was competent to self-administer medications.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview the facility failed to ensure that nurse aides received a minimum of 12 hours of continuing education per year as required for 1 of 5 sampled nurse aides. This had the potential to prevent residents from receiving competent care. The facility census was 30. Findings are: Record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides dated 3/12/24 revealed that it is the facility policy to comply with State and Federal regulations and requirements as they pertain to continuing education of nurse aides. The facility will provide at least 12 hours of in-service training annually, based on employment date and not on calendar year. Record review of the undated facility Employee List revealed that Nurse Aide (NA)-E had a hire date of 2/1/22. Record review of the facility Training Hours report dated 5/8/25 for NA-E for the date range of 2/1/24 through 2/1/25 (the annual period based on NA-E's employment date) revealed that NA-E completed a total of 2.85 hours of continuing education. Interview on 5/12/25 at 1:11 PM with the Facility Administrator (FA) confirmed that NA-E completed 2.85 hours of continuing education during the annual year based on the employment date of NA-E. The FA confirmed that NA-E did not complete 12 hours of continuing education as required.

Based on record reviews and interviews, the facility failed to ensure that residents were seen by a physician during the initial 30-day visit and at a minimum of every other visit. This affected 6 (Residents 10, 18, 25, 28, 31, and 32) of 12 sample residents reviewed. The facility census was 30. Findings are: Interview with the Director of Nursing (DON) on 05/08/2025 at 1:35 PM revealed that the DON believed that a physician assistant or nurse practitioner could perform all the 60-day certifications for nursing home residents after admission. At that time when asked about specific residents, the DON showed examples on the computer of the primary care physician for 2 residents was a Physician Assistant listed on the resident profile status. Another resident example revealed one resident's primary care physician was an Advanced Practice Registered Nurse. DON confirmed that the words primary care physician and primary care practitioner were used interchangeably but that they are not the same. DON confirmed a nurse practitioner and a physician assistant are not physicians. A. Record review of the Physician's Progress Notes for Resident 18 revealed that the Physician's Assistant (PA)-H (a licensed healthcare professional who works with physicians to provide medical care. An advanced practice non physician medical provider) had written notes during the 60 day on site recertification visits on the following dates: -06/11/2024 -08/20/2024 -10/15/2024 -12/23/2024 -02/03/2025 -02/28/2025 -04/15/2025 Record review of the office and clinic notes written on 06/11/2024 revealed Resident 18 was seen by PA-H for a 60-day recertification visit. This document revealed Resident 18 had a medical history of chronic bronchitis, chronic obstructive pulmonary disease, congestive heart disorder, diastolic heart failure, hypertension, edema, and osteoporosis. The diagnoses of chronic obstructive pulmonary disease, congestive heart failure, edema, and hypertension had been addressed during the visit. Record review of the office and clinic notes written on 10/15/2024 revealed Resident 18 was seen by PA-H for a 60-day recertification visit. The diagnoses of chronic obstructive pulmonary disease, congestive heart failure, hypertension, and osteoporosis had been addressed during the visit. Record review of the hospital discharge instructions dated 10/30/2024 for Resident 18 revealed the resident was seen by PA-H at the hospital. The diagnoses of chronic obstructive pulmonary disease, congestive heart failure, hypertension, and osteoporosis had been addressed during the visit. Record review of the office and clinic notes written on 12/18/2024 revealed Resident 18 was seen by PA-H for a 60-day recertification visit. Resident 18's congestive heart failure, edema, hypertension, osteoporosis, and hypoxemia had been addressed during the visit. Record review of the office and clinic notes written on 02/18/2025 revealed Resident 18 was seen by PA-H for a 60-day recertification visit. Resident 18's Congestive heart failure, edema, urinary incontinence, and hypertension were addressed as were the resident's medications during the visit. Record review of the Office and Clinic Notes from 04/15/2025 revealed Resident 18 was seen by PA-H for a 60-day recertification visit. Resident 18's Congestive heart failure, edema, hypothyroidism, and chronic obstructive pulmonary disease were addressed as were the resident's medications during the visit. Interview on 05/12/25 at 3:05 PM with the facility Director of Nursing (DON) confirmed that Resident 18 was not seen by a doctor on every other recertification visit. B. Record review of the Medical Diagnoses document for Resident 25 revealed an admitted [DATE] and had diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, chronic kidney disease stage 3B, hypothyroidism, hyperparathyroidism, dementia with behavioral, psychotic and mood disturbances, and anxiety. Record review of Resident 25's medical records revealed no evidence the resident had been evaluated by a physician during their stay in the facility. Record review of the emergency room physician notes for Resident 25 revealed the resident was seen by PA-H on 06/23/2024 for low back pain and a fall. Interview on 05/13/25 at 1:31 PM with the DON confirmed Resident 25 had not been evaluated by a physician during their stay at the facility. C. Record review of the 01/28/2025 quarterly Minimum Data Set (MDS - a standardized assessment tool used to collect data on the health and functional status of residents used to create care plans) revealed Resident 28 was admitted to the facility on [DATE]. Resident 28 had medically complex conditions which included coronary artery disease, congestive heart failure, hypertension, renal insufficiency, diabetes, Alzheimer's disease, pressure ulcers and other skin conditions. Resident 28's drug regimen included medications for anxiety, depression, anticoagulation (to reduce blood clots), diuretics for edema, opioid pain medications, and hypoglycemics for blood sugar control. Record review of the Physician Progress Notes revealed Resident 28's records had one entry for a 60-day recertification on 08/15/2024, when Resident 28 was seen by advanced practice registered nurse (APRN)-G (a registered nurse with advanced education and certification in a specific area of nursing practice. A non-physician care provider.) Record review of the Office and Clinic Notes for Resident 28 revealed the resident was seen on 08/15/2024 for a 60-day recertification visit. Resident 28's anxiety, depression, chronic systolic congestive heart failure, dementia, gastroesophageal reflux disease, hyperlipidemia, hypertension, kidney failure, sacral ulcer and diabetes were addressed during the visit as were the medications. Record review of the hospital transfer notes written and faxed to the facility on [DATE] revealed the resident was seen in the hospital by physicians. The patient was in the hospital from 10/14/2024 to 10/20/2024. The resident had been hospitalized for gallbladder removal. Record review of the Office and Clinic Notes dated 11/06/2024 revealed that Resident 28 was seen by APRN-G for a 60-day recert and addressed the following medical issues for Resident 28: osteoporosis, edema, acute chronic systolic heart failure, adjustment disorder, anxiety, atrial fibrillation, chronic pain, dementia, depression, gastroesophageal reflux, hyperlipidemia, insomnia, hypertension kidney failure, pulmonary hypertension and status post gallbladder removal as well as the medications at this visit. There were no records to review during the month of 1/2025 for Resident 28 in reference to a required recertification visit for the nursing home. Record review of the Office and Clinic Notes dated 02/21/2025 revealed that Resident 28 was seen by APRN-G for a 60-day recertification and addressed the following medical issues: Diabetes, Stage 3B kidney disease, sacral ulcer, diabetic ulcer of the left great toe, chronic pain, anemia, osteoarthritis, anxiety, adjustment disorder, depression, dementia, insomnia, pulmonary hypertension, Atrial fibrillation, and chronic systolic congestive heart failure as well as the medications at this visit. There were no records to review for recertification visits for Resident 28 during the month of March 2025. Record review of the Office and Clinic Notes dated 04/28/2025 revealed that Resident 28 was seen by APRN-G for a Medicare Nursing Home recertification, and addressed the following medical issues for Resident 28: pressure ulcer of the left leg, adjustment disorder, anxiety, atrial fibrillation, chronic pain, chronic systolic heart failure, constipation, coronary artery disease, dementia, depression , edema, gastroesophageal reflux, history of cardioversion, history of femur fracture, history of septic shock, hyperlipidemia, hypertension, insomnia, anemia, long term use of high risk medications, peripheral vascular disorder, pulmonary hypertension, diabetes, osteoarthritis, and gout secondary to renal impairment as well as the medications at this visit. Interview on 05/12/25 at 3:05 PM with the facility Director of Nursing (DON) confirmed Resident 28 had only been seen by the APRN for recertification and 60-day Nursing Home rounds. D. Record review of the discharge summary dated 12/18/2024 revealed Resident 32 was admitted to swing bed at the local hospital on 11/22/2024. Resident 32 was transferred to the local facility following a hip fracture and hip revision on 10/31/2024. Resident 32 was admitted for strengthening but physical therapy progressed slowly and the agreement was made between the facility and the local hospital to transfer Resident 32. Record review quarterly MDS dated [DATE] revealed Resident 32 was admitted to the facility on [DATE] and had medically complex conditions. Resident 32 had infection due to orthopedic joint prosthesis, a methicillin susceptible staphylococcus infection, long term use of antibiotics, acute clotting in the deep veins of the lower extremities, left sided foot drop, depression, malnutrition, and a surgical wound. Resident 32 took medications for depression, a long-term antibiotic, diuretics for fluid retention, and opioids for pain. Record review of the admission orders for Resident 32 revealed this resident was admitted for left hip replacement with complications, chronic right hip hardware, long term use of suppressive antibiotics, hypertension, allergic rhinitis, history of deep vein thrombosis, history of arterial embolism, anticoagulation, left sided foot drop, muscle weakness, anxiety and over active bladder. The attending Physician Assistant signed the admission orders. Interview with the DON on 05/12/2025 at 10:45 AM who confirmed there was no recertification visit found for Resident 32 during the month of January. Review of the office visit note from 02/04/2025 when Resident 32 was seen by a physician at the clinic. This was the initial visit since being admitted to the facility from the local hospital. The initial visit (30-day recertification visit) by the physician was due on 01/17/2025 and should have been completed on or before 01/27/2025. Record review of the office visit note completed on 03/12/2025 revealed Resident 32 was seen for complaints of hip pain, questions about pain medications, physical therapy progress, no feeling in the left foot, and dry mouth. Medications were review and a treatment plan put into place by PA-H. Record review of the 60-day recertification for Medicare for Resident 32 was done on 04/15/2025 and completed by PA-H. Interview on 5/12/25 at 3:05 PM with the facility Director of Nursing (DON) confirmed that a physician did not routinely see Resident 32. 41938 E. Record review of the Admission Record dated 5/8/25 for Resident 10 revealed that Resident 10 was admitted into the facility on [DATE]. Diagnoses included fracture of the lower spine, rectal cancer, and nutritional deficiency. Record review of the Emergency Department Provider Note dated 10/11/24 for Resident 10 revealed that the emergency physician (a Medical Doctor/MD) recommended admission to the facility for nursing home care. Record review of the Progress Note dated 10/23/24 at 4:02 PM for Resident 10 revealed that Advanced Practice Registered Nurse-F (APRN-F) (a registered nurse with advanced education and certification in a specific area of nursing practice. A non-physician care provider.) was in the facility for the 30-day nursing home recertification for Resident 10. (The 30-day visit was performed by a non-physician care provider). Record review of the History and Physical dated 11/1/24 for Resident 10 revealed that Resident 10 was evaluated by APRN-F. Record review of the Progress Note dated 1/2/25 at 1:01 PM for Resident 10 revealed that APRN-F was in the facility for the 60-day nursing home recertification for Resident 10. (The 60-day visit was performed by a non-physician care provider). Record review of the resident's profile page in the electronic health record for Resident 10 dated 5/12/25 revealed that APRN-F was listed as the resident's physician. F. Record review of the Admission Record dated 5/8/25 for Resident 31 revealed that Resident 31 was admitted into the facility on [DATE]. Diagnoses included fracture of the left leg, hypokalemia (a condition where the body has too little potassium. The condition can cause life-threatening complications including heart arrhythmias), and breast cancer. Record review of the Transition Orders and Information for the Continuation of Patient Care for Resident 31 dated 11/12/24 revealed that the physician ordered resident admission to the nursing facility for care. The document revealed a follow-up appointment was scheduled for 11/19/24 with Advanced Practice Registered Nurse-G (APRN-G). Record review of the Progress Note dated 12/19/24 at 8:35 AM for Resident 31 revealed that APRN-G was in the facility for the 30-day nursing home recertification for Resident 31. (The 30-day visit was performed by a non-physician care provider). Record review of the Progress Note dated 2/21/25 at 4:56 PM for Resident 31 revealed that APRN-G was in the facility for the 60-day nursing home recertification. (The 60-day visit was performed by a non-physician care provider). Record review of the resident's profile page in the electronic health record for Resident 31 dated 5/12/25 revealed that APRN-G was listed as the resident's physician. Interview on 5/12/25 at 3:04 PM with the facility Director of Nursing (DON) confirmed that a physician is an MD and that Advanced Practice Registered Nurse-G is not a physician.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, record reviews, and interviews, the facility failed to ensure that medication error rates were less than 5%. This was based on 31 medication administration opportunities and 2 medication errors resulting in an error rate of 6.5%. This affected 2 (Residents 27 and 18) of 4 sampled residents. The facility census was 30. Findings are: Record review of the undated facility policy The Five Rights of Medication Administration stated the safe provision of medication also includes observing a rule called the Five Rights. The Five Rights consist of several safety checks which help to prevent mistakes. While providing medications, give the right drug to the right resident, at the right amount at the right time, and by the right route. The five rights of medication administration are: -right drug -right resident -right amount -right time -right route Record review of the March 2010 policy Medication Errors - Defined revealed in paragraph 4 that medication errors can be made by not following accepted practice standards of medication provision. Examples included: -Giving a drug before a meal instead of after a meal when ordered -Given at the wrong time (anytime one hour prior to or one hour after the scheduled time) -Omitted or not given -Given by the wrong route -Wrong dose -Wrong drug -Wrong resident A. Record review of the May 2025 Electronic Medication Administration Record (EMAR) for Resident 27 revealed an order for acetaminophen extra strength 500 milligrams (mg), two tablets to be given four times a day at 9:00 AM, 12:00 PM, 5:00 PM, and at 9:00 PM for pain management. Observation on 05/08/2025 at 7:50 AM revealed Licensed Practical Nurse (LPN)-J administering medications to Resident 27, including the two tablets of acetaminophen 500mg, which was not due until 9:00 AM. Interview with LPN-J on 05/08/2025 at 7:50 AM revealed Resident 27 prefers their acetaminophen to be administered at this time rather than at the time it was ordered for. B. Record review of the May 2025 EMAR for Resident 18 revealed an order for acetaminophen 500 mg 4 times a day, with the first dose due at 7:00 AM. Observation on 05/08/2025 at 8:10 AM of LPN-J who gave medications, including the acetaminophen 500 mg, to Resident 18 at the dining room table. Interview on 05/08/2025 at 8:13 AM with LPN-J who confirmed that the acetaminophen was administered late to Resident 18. Interview on 05/08/2025 at 8:50 AM with the Director of Nursing (DON), who revealed that medications are in the medical records system with a specific administration time, and all are due in the time period of one hour before or one hour after the scheduled time. If the medications are given outside that time, then those medications were not given at the right time and that is a medication error.

Based on record reviews and interviews, the facility failed to ensure gradual dose reductions were completed for residents taking psychotropic medications. This affected 1 (Resident 23) of 5 sampled residents. The facility census was 30. Findings are: Record review of the 02/11/2025 quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool used to evaluate and document the health status of residents in Medicare and Medicaid certified nursing homes) revealed Resident 25 was unable to answer questions to perform a Brief Interview for Mental Status exam (BIMS), got annoyed eaily and was short tempered, had poor appetite, difficulty concentrating, had delusions, would verbally and physically act out towards others, rejected cares one to three days a week, wandered 4 to 6 days a week, was able to ambulate with their walker throughout the facility, and had urinary incontinence. Resident 25 was diagnosed with renal insufficiency, Alzheimer's dementia, anxiety disorder, adjustment disorder with mixed disturbances of emotions and conduct, and had orders for antipsychotics, antidepressants, and anti-anxiety medications. Record review of the physician orders revealed Resident 25 received buspirone (an anti-anxiety medication) for generalized anxiety disorder, mirtazapine (an antidepressant medication) for Alzheimer's disease, and sertraline (an antidepressant medication) for dementia with anxiety. Record review of Resident 25's medical records revealed no evidence of a gradual dose reduction being attempted for psychotropic medications for Resident 25 in the past year. There were also no orders with rationales by a physician that stated a gradual dose reduction was not to be completed. Interview on 05/13/2025 at 1:20 PM with Director of Nursing (DON) who stated Resident 25 had been seen by one mental health practitioner group and then the facility switched to a new group. DON was unable to find any GDR for Resident 25. Interview on 05/13/2025 at 3:30 PM with DON confirmed the staff had been unable to find a gradual dose reduction or any physician documentation related to a contraindication for doing a dose reduction for Resident 25.

Licensure Reference Number 175 NAC 12-006.08(A) Based on record reviews and interviews, the facility failed to ensure that all residents who were admitted to the facility had a written recommendation or had written orders from a physician. This affected 1 (Resident 32) of 12 residents sampled. The facility census was 30. Findings are: Record review of the admission orders for Resident 32 who was admitted to the facility on [DATE], revealed the orders had been written and signed on 12/18/2024 at 8:27 AM by Physician Assistant (PA)-H (a licensed healthcare professional who works with physicians to provide medical care - a non physician care provider). There was no co-signature of a physician (An MD or Medical Doctor) on these orders. According to the admission orders the resident had diagnoses for status post left hip replacement with complications, chronic right hip hardware infection, long term use of suppressive antibiotic use, hypertension, allergic rhinitis, history of deep vein thrombosis (blood lots), history of arterial embolism, anticoagulation (use of blood thinners to reduce the chances of blood clotting), left foot drop, muscle weakness, anxiety, and over active bladder. The resident was to see Physical Therapy and Occupational Therapy. Interview on 5/12/2025 at 3:05 PM with the Director of Nursing (DON) revealed that Resident 32's primary care provider was PA-H. DON confirmed the admission orders were signed by a physician assistant and not a physician. When asked about a physician caring for the resident, DON stated again that the primary care provider was PA-H. DON then stated that PA-H is a Physician Assistant and that Resident 32 was not followed by a physician, just the physician assistant. Interview on 5/13/2025 at 2:30 PM with DON who confirmed that after going through Resident 32's medical records, there was no information from a physician that recommended nursing home placement and a physician did not sign the admission orders.

Licensure Reference 175 NAC 12-006.09 Based on record review, observations, and interviews; the facility failed to identify and treat 1 (Resident 19) of 2 sampled resident's pain. The facility census was 32. The findings are: A record review of facility policy Pain Management with reviewed/revised date of 5/15/24 revealed the facility would observe for nonverbal indicators which may indicate the presence of pain and that the facility would use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The policy also revealed that the interventions for pain management would be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. A record review of facility policy Behavioral Assessment, Intervention and Monitoring with revised date of March 2019, revealed Behavioral or Psychological Symptoms of Dementia ([NAME]) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating underlying factors and those that cannot. A record review of Resident 19's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 4/9/24 revealed in Section C that the resident had short- and long-term memory loss, and moderately impaired cognitive skills for daily decision making. Section J revealed the resident did receive routine and PRN pain medications and did not receive any non-medication interventions for pain during the prior 5 days, and that the staff assessment for pain indicated the resident had non-verbal sounds of pain every day during the prior 5 days. A record review of Resident 19's paper Care Plan, dated 3/5/24 revealed a Problem Statement of Resident 19 has a history of dementia which has greatly increased this past quarter. An intervention in this section stated, Assess for pain when Resident 19 is yelling out, restless, anxious, tearful. The Care Plan did not have a section which specifically addressed Resident 19's potential for pain. A record review of Resident 19's active Physician's Orders revealed the following orders: - Observe for individualized behaviors such as pacing, statements of I'm sick, crying, pacing, general anxiety, yelling out, repeated questions, excessive worrying. This order had a start date of 11/7/23 and did not provide guidance on how to address any behaviors identified during observation. - Sertraline HCl (an antidepressant medication) 25 Milligram (MG) tablet, give one tablet by mouth daily for generalized anxiety disorder. This order was increased from 12.5 MG daily to 25 MG daily on 5/3/24. - Risperdal (an antipsychotic medication) 0.5 MG tablet, give one tablet by mouth twice a day (BID) at 8am and 8pm for unspecified dementia, unspecified severity with mood disturbances. This order had a start date of 4/16/24. - Buspirone HCl (an anxiolytic medication used to treat anxiety) 7.5 MG tablet, give one tablet by mouth three times a day (TID). The order stated to hold for sedation and listed potential side effects of dizziness, drowsiness, headache, nausea, nervousness, lightheadedness, restlessness, blurred vision, tiredness, and trouble sleeping. The order had a start date of 4/12/24 and did not have a diagnosis or indication listed on the order. - Divalproex Sodium Delayed Release (DR) (an anticonvulsant medication that can also be used to treat the manic phase of bipolar disorder) 125 MG, give one capsule TID for severe dementia. This order had a start date of 3/2/24. - Trazadone (an antidepressant medication often used to treat symptoms of insomnia, which causes difficulty sleeping) 50 MG tablet, give one half tab (25mg) by mouth at bedtime for insomnia. This order had a start date of 4/3/24. - Arthritis Pain Extended Release (ER) 650 MG, give one caplet BID. This order had a start date of 5/13/22 and did not have a diagnosis or indication listed on the order. - Ativan (an anxiolytic medication used to treat anxiety) 1 MG tablet, give every 6 hours as needed for anxiety. This order had a start date of 3/17/24. This medication was given to the resident 43 times in April 2024 and 19 times between May 1st and May 15th, 2024. - Hydroxyzine HCl (an antihistamine medication often used to treat symptoms of anxiety) 25 MG tablet, give every 6 hours as needed for anxiety. This order had a start date of 3/2/24. This medication was given to the resident 29 times in April 2024 and 9 times between May 1st and May 15th, 2024. - Ask resident every shift if having pain, if yes- refer to pain assessment sheet. This order had a start date of 1/9/22. According to the documentation on the order, the resident had no pain between April 1, 2024, and May 14, 2024. - Tylenol (an analgesic used to treat minor aches and pains) 325 MG, give two tablets every 4 hours as needed for pain. This order had a start date of 3/16/21. This medication was given to the resident two times in April 2024 and three times between May 1st and May 15th, 2024. An observation on 5/13/24 at 11:13 AM revealed Resident 19 sitting in their wheelchair in their room with Nurse Aide (NA)-C. The overhead light in the room was turned off, with dim natural lighting in the room coming from the window and there was soft music playing. Resident 19 was fidgeting with their hands and attempting to stand up repetitively. An interview on 5/13/24 at 11:13 AM with NA-C revealed Resident 19 had been agitated all morning and NA-C was sitting with the resident in their room providing a quieter environment and soft music for the resident to listen to in an attempt to decrease Resident 19's agitation. An observation on 5/14/24 at 7:15 AM revealed Resident 19 sitting in their wheelchair near the nurse's station and next to Medication Aide (MA)-B who was working at the medication cart. Resident 19 was attempting to stand up intermittently and had facial grimacing. Resident 19 was making repetitive distressed vocalizations. The Activities Supervisor (AS)-E approached Resident 19 and told the resident they would go to the dining room after they got their medication. AS-E held Resident 19's hand and attempted to make conversation with the resident but did not ask the resident what was wrong or if they were having any pain. An observation on 5/14/24 at 8:36 AM revealed NA-D pushed Resident 19 in their wheelchair from the dining room to the sitting area outside the nurse's station and parked the resident in their wheelchair. Resident 19 used their feet to wheel themselves to this surveyor and stated ma'am, ma'am I don't feel good. My head hurts. Resident 19 was observed to have facial grimacing at that time. The surveyor moved away from Resident 19 after assuring the resident that there would be staff nearby soon. An observation on 5/14/24 at 8:39 AM revealed NA-D approached Resident 19, moved the resident's foot pedals to the sides of the wheelchair, and then walked away from the resident. Resident 19 was holding their forehead with one hand. Resident 19 then attempted to self-propel their wheelchair with their feet, could not get chair moving, and stopped attempting. Resident 19 placed both hands on their forehead and had slight facial grimacing. An observation on 5/14/24 at 8:41 AM revealed Resident 19 stating ma'am, ma'am, ma'am numerous times each time someone walked past the resident. Resident 19 resumed attempting to wheel self, only making about 1 foot of progress. NA-D approached Resident 19 at 8:42 AM, turned their wheelchair and stated, are you okay? NA-D then walked away from Resident 19 without waiting for the resident to respond. An observation on 5/14/24 at 8:44 AM revealed the Director of Nursing (DON) approached Resident 19 and held the resident's hand while the resident used their feet to self-propel their wheelchair across the room. NA-D approached a few seconds later and Resident 19 grabbed NA-D's hand with their other hand. Resident 19 continued to propel their wheelchair with their feet while holding both staffs' hands. Resident 19 had facial grimacing, was intermittently stating ma'am, ma'am, and was softly moaning. The DON walked away at 8:46 AM and NA-D continued to hold Resident 19's hand. At 8:27 AM, Resident 19 started crying. NA-D asked the resident what was the matter and Resident 19 responded, stating I'm sick. NA-D asked the resident what was hurting. Before Resident 19 was able to respond, another staff walked up, stated where ya headed?, and then walked away. Resident 19 continued to repeat Ma'am, ma'am and had their hand on their forehead. NA-C walked up to Resident 19 at 8:49 AM and put the resident's feet on the wheelchair pedals and then NA-C and NA-D took Resident 19 into a community bathroom and closed the door. None of the staff identified that the resident was having pain to their head during this time period. An observation on 5/14/24 at 8:52 AM revealed Resident 19 being assisted out of the bathroom by NA-C in a Merry-Walker (a walker that a person can be secured into and that has a seat on it). NA-C remained at Resident 19's side and the resident continued to have facial grimacing and repetitive moaning. NA-C held Resident 19's hand and rubbed the resident's back with their fingers. At 8:55 AM, Resident 19 was wiping their eyes with a Kleenex and moaning, NA-C rubbed the resident's back again for a few seconds and then resumed holding the resident's hand. Resident 19 continued to have facial grimacing. At 8:56 AM, NA-C had still not asked Resident 19 what was wrong. An observation on 5/14/24 at 9:32 AM revealed Resident 19 had just received a bath and was sitting in their regular wheelchair at the nurse's station facing one of the staff, who was using a computer. Resident 19 did not have facial grimacing, was holding [gender] forehead with [gender] hand. An observation on 5/14/24 at 10:58 AM revealed Resident 19 sitting in their wheelchair outside the nurse's station holding their forehead with both hands. NA-F was standing next to the resident but did not acknowledge the resident. An observation on 5/14/24 at 1:38 PM revealed Resident 19 being pushed up the 200 hallway in [gender] wheelchair by NA-D and was fidgeting with [gender] hands. An observation on 5/15/24 at 1:45 PM revealed Resident 19 sitting in [gender] wheelchair in [gender] room, with [gender] child sitting on [gender] bed next to them and holding their hand. Resident 19 was rocking back and forth in the wheelchair and making repetitive moaning sounds. An interview on 5/15/24 at 10:29 AM with DON revealed the facility used the FACES pain scale or would ask the resident if they were having pain and document it using the 0-10 pain scale. The DON revealed the facility had no alternate scale to be used for residents who were not cognitively intact. The DON confirmed Resident 19 was taking five psychotropic medications on a routine basis, two PRN (as needed) psychotropic medications that were being utilized frequently, and a PRN pain medication that had been used minimally over the last two months. The DON confirmed that the resident continued to have behavioral symptoms despite the frequent use of PRN psychotropics and the routine psychotropics and that this could be due to the root cause of the resident's problem not being addressed. An interview on 5/15/24 at 11:22 AM with Licensed Practical Nurse (LPN)-G confirmed that Resident 19's pain assessment order stated to ask the resident if they were having pain and that the pain scale attached to the order was the 0-10 pain rating scale. LPN-G also revealed that with residents who were not able to verbalize their pain, the facility would usually utilize the FACES pain scale. LPN-G stated that it was hard to tell if Resident 19 was having pain and that their most frequent behaviors were repetitive statements of I'm sick or I hurt. A record review of website, wongbakerfaces.org revealed the Wong-Baker FACES Pain Rating Scale was a self-assessment tool that must be understood by the patient, so they would be able to choose the face that best illustrated the physical pain they were experiencing. The website also stated it was not a tool to be used by a third person, parents, healthcare professionals, or caregivers, to assess the patient's pain. A record review of the website geriatricpain.org revealed an assessment tool titled Pain Assessment in Advanced Dementia (PAINAD) Scale, which was a pain behavior tool used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain. Based on the observations of Resident 19 on 5/14/24, the resident's pain would have been rated at a 7 (on the PAINAD scale of 0-10), with positive responses in the negative vocalization, facial expression, body language, and consolability sections of the assessment tool.

Based on record review and interview; the facility failed to submit their Payroll Based Journal (PBJ) data for Quarter 1 of 2024 as required. This had the potential to affect all residents residing within the facility. The facility census was 32. The Findings Are: A record review of the PBJ report from CMS revealed no direct care nursing staff (Registered Nurses, License Practical Nurses, Medication Aides, and Nurse Aides) data was submitted for the first quarter of fiscal year 2024, from 10/1/2023 through 12/31/2023. An interview on 5/15/24 at 1:46 PM with the Administrative Assistant (AA) confirmed the AA was responsible for submitting the facility's PBJ Data and that they did not submit the data for 2024 Quarter 1. The AA stated they attempted to log onto the site the evening of the due date and entered an incorrect password too many times, causing themselves to get locked out of the system and therefore unable to submit the required data.

Licensure Reference 175 NAC 12-006.04B2a Based on record review and interview; the facility failed to ensure Nurse Aide (NA)-H completed 12 hours of ongoing training per year as required. This had the potential to affect all residents who resided within the facility. The facility census was 32. The Findings Are: A record review of a Relias (an online training program utilized by long term care facilities) Transcript for NA-H dated 5/14/24, revealed NA-H had completed two 0.5-hour training courses for a total of 1.0 hour of training in the prior 12 months. A record review of a Relias Transcript for NA-H dated 5/15/24, revealed NA-H had completed five training courses on 5/14/24 for a total of 1.85 hours of training. An interview on 5/15/24 at 9:19 AM with the Administrative Assistant (AA) confirmed that NA-H had completed only 2.85 hours of training on Relias and had not attended any of the in-person facility in-services over the last twelve months.

Licensure Reference 175 NAC 12-006.17B Licensure Reference 175 NAC 12-006.17D Based on record reviews, observations, and interviews; the facility failed to don (put on) the required personal protective equipment (PPE) of a gown for enhanced barrier precautions during catheters cares for 1 (Resident 4) of 1 sampled resident and failed to ensure hand hygiene was completed as required and medications were not contaminated during medication pass for 3 (Residents 16, 19, and 31) of 4 sampled residents. The facility census was 32. Findings are: A. A record review of the facility's policy Enhanced Barrier Precautions with a date implemented of 3/26/2024 revealed PPE of gowns and gloves is necessary when performing high-contact care activities, including urinary catheter care. A record review of a Face Sheet indicated the facility admitted Resident 4 on 4/18/2023 with diagnoses of left hip fracture and hydronephrosis (a condition that occurs when a kidney swells and can't get rid of urine like it should.) A record review of Resident 4's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), with an Assessment Reference Date of 3/26/2024 revealed Resident 4 required maximal assistance with toileting hygiene. The MDS also revealed Resident 4 had an indwelling urinary catheter. An observation on 5/15/2024 at 7:50 AM revealed Resident 4's door had a sign on the door alerting staff enhance barrier precautions were in effect and staff must gown and glove during high-contact care activities. An observation on 5/15/2024 at 7:55 AM Nurse Aide (NA)-J had donned gloves, but no gown then proceeded to provide catheter care for Resident 4. An interview on 5/15/2024 at 8:17 AM with NA-J confirmed [gender] was aware but did not follow guidelines of PPE for enhanced barrier precautions by donning a gown. B. A record review of the facility's policy Handwashing/Hand Hygiene last revised October 2023 revealed hand hygiene is indicated before and after touching a resident. An observation on 5/14/2024 at 7:10 AM revealed Medication Aide (MA)-B had completed a medication pass for Resident 28. MA-B did not perform hand hygiene prior to beginning a medication pass for Resident 31. An observation on 5/14/2024 at 7:20AM revealed MA-B had been preparing Resident 19's medication. MA-B had questions regarding a medication and had been awaiting the nurse for clarification. MA-B dug out the medication with MA-B's bare hand without the benefit of a glove. An observation on 5/14/2024 at 7:26 AM revealed MA-B had completed a medication pass for Resident 19. MA-B touched MA-B's hair then proceeded to begin a medication pass for Resident 31. MA-B did not perform hand hygiene after touching hair or beginning the medication pass. An interview on 5/14/2024 at 7:39 AM with MA-B confirmed hand hygiene should be performed between residents and when touching personal body. MA-B also confirmed MA-B should have donned a glove before touching Resident 19's medications.

Licensure Reference 175 NAC 12-006.09C Based on record review and interviews; the facility failed to develop and implement comprehensive care plans for 4 (Residents 19, 23, 26, and 32) of 12 sampled residents. The facility census was 32. The Findings Are: A record review of the facility policy Comprehensive Care Plans with a last revised date 5/15/2024 revealed the facility will develop a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental, and psychosocial needs based off the resident's needs as identified in the resident's comprehensive assessment. A. A record review of facility policy Pain Management with reviewed/revised date of 5/15/24 revealed the facility would observe for nonverbal indicators which may indicate the presence of pain and that the facility would use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The policy also revealed that the interventions for pain management would be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. A record review of Resident 19's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 4/9/24 revealed in Section C that the resident had short- and long-term memory loss, and moderately impaired cognitive skills for daily decision making. Section J revealed the resident did receive routine and PRN pain medications and did not receive any non-medication interventions for pain during the prior 5 days, and that the staff assessment for pain indicated the resident had non-verbal sounds of pain every day during the prior 5 days. A record review of Resident 19's active physician's orders revealed the following pain-related orders: - Arthritis Pain Extended Release (ER) 650 MG, give one caplet BID. This order had a start date of 5/13/22 and did not have a diagnosis or indication listed on the order. - Ask resident every shift if having pain, if yes- refer to pain assessment sheet. This order had a start date of 1/9/22. According to the documentation on the order, the resident had no pain between April 1, 2024, and May 14, 2024. - Tylenol (an analgesic used to treat minor aches and pains) 325 MG, give two tablets every 4 hours as needed for pain. This order had a start date of 3/16/21. This medication was given to the resident two times in April 2024 and three times between May 1st and May 15th, 2024. A record review of Resident 19's care plan, dated 3/5/24 revealed a Problem Statement of Resident 19 has a history of dementia which has greatly increased this past quarter. An intervention in this section stated, Assess for pain when Resident 19 is yelling out, restless, anxious, tearful. The care plan did not address Resident 19's potential for pain or interventions to utilize when the resident had symptoms of pain. An interview on 5/15/24 at 10:29 AM with Director of Nursing (DON) revealed the facility used the FACES pain scale or would ask the resident if they were having pain and document it using the 0-10 pain scale. The DON revealed the facility had no alternate scale to be used for residents who were not cognitively intact. The DON confirmed Resident 19 was taking five psychotropic medications on a routine basis, two PRN (as needed) psychotropic medications that were being utilized frequently, and a PRN pain medication that had been used minimally over the last two months. The DON confirmed that the resident continued to have behavioral symptoms despite the frequent use of PRN psychotropics and the routine psychotropics and that this could be due to the root cause of the resident's problem not being addressed. An interview on 5/15/24 at 11:22 AM with Licensed Practical Nurse (LPN)-G confirmed that Resident 19's pain assessment order stated to ask the resident if they were having pain and that the pain scale attached to the order was the 0-10 pain rating scale. LPN-G stated that it was hard to tell if Resident 19 was having pain and that their most frequent behaviors were repetitive statements of I'm sick or I hurt. 49766 B. A record review of a facility Face Sheet indicated the facility admitted Resident 23 on 1/15/2024 with diagnoses of heart failure, Chronic Obstructive Pulmonary Disease (COPD,) hypertension (high blood pressure,) and edema (swelling.) A record review of a quarterly MDS with an Assessment Reference Date of 4/9/2024 indicated that Resident 23 had a Brief Interview for Mental Status (BIMs) score of 11/15, which indicated Resident 23 had moderate cognitive impairment. The MDS also indicated Resident 23 had diagnoses of heart failure, hypertension, COPD and was currently taking an anticoagulant (blood thinner) and a diuretic (medication that reduces fluid buildup in the body.) A record review of Resident 23's Care Plan revealed no care focus for Resident 23's heart failure, COPD, or anticoagulant and diuretic use. An interview on 5/14/2024 at 11:24 AM with the MDS Nurse confirmed Resident 23's Care Plan was not comprehensive to address Resident 23's medical conditions. C. A record review of a facility Face Sheet indicated the facility admitted Resident 26 on 3/22/23 with diagnosis of Type 1 Diabetes. A record review of an annual MDS with an Assessment Reference Date of 2/13/2024 indicated Resident 26 had a BIMs score of 7/15, which indicated Resident 26 had severe cognitive impairment. The MDS also indicated Resident 26 had Diabetes Mellitus and was currently taking insulin. A record review of Resident 26's Care Plan revealed no care focus for Resident 26's Diabetes Mellitus and insulin use. An interview on 5/14/2024 at 3:07 PM with the MDS Nurse confirmed Resident 26's Care Plan was not comprehensive to address Resident 26's medical conditions. The MDS Nurse confirmed all care plans were not comprehensive and needed work. 50253 D. A record review of Resident 32's History and Physical dated 10/6/2023 sent to the facility from the discharge hospital confirms the presence of pressure ulcers and arterial stasis ulcers on both feet. A record review of Resident 32's Care Plan revealed no focus of care for Resident 32's arterial stasis ulcers or pressure ulcers from admission which were present upon admission. In an interview with MDS Nurse on 05/14/24 at 2:36 PM confirmed Resident 32's Care Plan was not comprehensive and did not address Resident 32's medical condition of pressure ulcers or arterial stasis ulcers. In an interview with DON on 05/14/24 at 2:38 PM. Confirms that the care plans do not include information regarding the pressure ulcers on both heels. Resident 32 entered the facility with pressure ulcers on his coccyx, both heels, the tip of one toe, and arterial stasis ulcers on both feet.

LISCENSURE Reference Number 175 NAC 12-006.09D Based on record reviews and interviews; the facility failed to ensure that all psychotropic medications (medications that are given for a variety of mental health disorders including psychosis, depression, anxiety, and sleep) given only when needed (PRN) are reviewed and reordered every 14 days for 1 (Resident 32) of 1 sampled resident. The facility census was 32. Findings are: In an interview with Resident 32 on 5/13/24 at 1:35 PM in Resident 32's room. Resident 32 revealed admission to this facility last year after being discharged from the hospital. Resident 32 confirms [gender] has meetings with some people by video (Telemedicine, the ability to visit a physician from home by using a television, computer, or other audio visual equipment) about every other week about how [gender] feels and about anxiety and depression. In an interview with Social Services Director (SSD) on 5/14/24 at 9:30 AM revealed Resident 32 is usually seen every one or two weeks with telemedicine for psychiatric care. In an interview with Minimum Data Set Nurse (MDS) on 5/14/2024 at 2:10 PM confirmed Resident 32 receives Mental Health Telemedicine every two weeks and has seen much improvement since the resident was admitted . In an interview with Infection Control Nurse (ICN)-A on 5/14/2024 at 2:15 PM confirmed that Resident 32 no longer receives Mental Health Telemedicine weekly as those appoints are now every two weeks. The facility staff have seen many changes and much improvement in the mental health of Resident 32. ICP-A further revealed staff receive the orders from the Telemedicine professionals. In an interview with the Director of Nurses (DON) on 5/15/24 at 1:45 PM confirmed Resident 32 is cared for by psychiatry using telemedicine. The resident was very sick and extremely depressed upon admission. Over the past few months (we) have watched Resident 32 come out of a shell and move mountains with all of the improvement. The ability to connect with psychiatric counsels and psychiatrists treat Resident 32's psychiatric behaviors and major depressive disorder has been incredible for everyone especially this resident. Telemedicine writes the orders for the psychiatric cares. A record review of the Mental Health Telemedicine document dated 1/9/2024 revealed an order change for the medication Clonazepam for Resident 32. New order reads Clonazepam 0.5 mg (milligrams) by mouth once daily as needed at bedtime for anxiety. The order did not reveal a stop date for Clonazepam. A record review of the Medication Administration Record dated February 2024 revealed that Resident 32 has an order for Clonazepam 0.5 mg (milligram) tablet daily at bedtime as needed for anxiety. The medication has an order date and a start date of 1/09/2024 with no stop date. Resident 32 received this medication on 2/3/24, 2/4/24, 2/8/24, 2/11/24, 2/12/24, 2/13/24, and 2/22/24. A record review of psychiatric telemedicine visit dated 2/1/2024 at 1:10 PM, revealed the chief complaint for the visit stated Resident 32 has been taking clonazepam less frequently - only once or twice a week. The document revealed that Resident 32 has an order for Clonazepam 0.5 mg tablet one tablet by mouth as needed at bedtime for anxiety. The medication list was reviewed by facility staff and psychiatric professionals during the telemedicine conference. The treatment plan revealed a new order for a different medication, continue monitoring psychiatric symptoms, continue to monitor therapeutic effects of psychiatric medications and for possible adverse effects. There is no 14-day renewal order for the clonazepam as needed order. A record review of Mental Health Telemedicine visit dated 2/7/2024 at 1:10 PM, revealed the chief complaint for the visit revealed Resident 32 has been taking clonazepam less frequently - only once or twice a week. The document revealed that Resident 32 has an order for Clonazepam (a medication) 0.5 mg tablet one tablet by mouth as needed at bedtime for anxiety. The medication list was reviewed by the staff hosting the telemedicine conference. There is no 14-day renewal order for the clonazepam PRN order. A record review of Mental Health Telemedicine visit dated 2/15/2024, documentation revealed Resident 32 has an order for Clonazepam (a medication) 0.5 mg tablet one tablet by mouth as needed at bedtime for anxiety. The medication list was reviewed by the staff hosting the telemedicine conference and this treatment plans states there are no medication changes at this visit. There is no specific 14-day renewal order for the PRN clonazepam. A record review of Mental Health Telemedicine visit dated 2/29/2024, documentation revealed Resident 32 has an order for Clonazepam (a medication) 0.5 mg tablet one tablet by mouth as needed at bedtime for anxiety. The medication list was reviewed by the staff hosting the telemedicine conference and this treatment plans states there are no medication changes at this visit. There is no specific 14-day renewal order for the PRN clonazepam. A record review of the Medication Administration Record dated March 2024 revealed that Resident 32 has an order for Clonazepam 0.5 mg (milligram) tablet daily at bedtime as needed for anxiety. The medication has an order date and a start date of 1/09/2024. Resident 32 received this medication on 3/6/24, 3/11/24, 3/20/24, 3/21/24, 3/25/24, and 3/26/24. A record review reveals there was no Mental Health Telemedicine review on 3/14/24 that addressed the as needed administration of clonazepam. A record review of psychiatric telemedicine visit dated 3/28/2024, documentation revealed Resident 32 has an order for clonazepam 0.5 mg tablet one tablet by mouth as needed at bedtime for anxiety. The medication list was reviewed by the staff hosting the telemedicine conference and this treatment plans states there are no medication changes at this visit. The chief complaint for the telemedicine visit reveals Resident 32 has been receiving clonazepam PRN three times weekly during the late-night hours for restless sleep. Orders reveal that facility staff are to continue to monitor psychiatric symptoms and the therapeutic effects of the medications. Clonazepam is not addressed in the orders or treatment plan and no specific 14-day renewal order for the PRN clonazepam. Record Review of the facility policy and procedure for Use of Psychotropic Medication dated 1/24/2024 states on paragraph 9 that for all psychotropic drugs the medications necessary to treat a diagnosed specific condition that is documented in the clinical record, and used only for a limited duration of 14 days, the prescribing practitioner will document the rationale for use in the medical record and indicate the duration for the PRN (as needed only) order.

Licensure Reference 175 NAC 12-006.10D Based on record reciews, observations, and interviews; the facility failed to ensure medications that could not be crushed were not crushed for 1 (Resident 16) of 4 sampled residents and failed to ensure the medication error rate was less than 5%. The medication error rate was 16.67%. The facility census was 32. Findings are: A record review of a facility policy Medication Administration with a last revised date of 9/13/2023 revealed the following: - Crush medications as ordered. Do not crush medications with do not crush instructions. - Do not crush slow release or enteric coated medications. A record review of a facility Face Sheet revealed the facility admitted Resident 16 on 5/7/2019 with diagnoses of atrial fibrillation, heart failure, hypertension, Gastro-esophageal reflux disease, iron deficiency, and overactive bladder. A record review of Resident 16's Physician Orders dated May 2024 revealed the following: - ferrous sulfate 325 milligrams (mg) - take 1 tablet daily - without instruction of do not crush. - pantoprazole 40 mg - take 1 capsule twice a day - without instruction of do not crush. - potassium 20 milliequivalents - take 1 tablet daily - without instruction of do not crush. - solifenacin 10 mg - take 1 tablet daily - without instruction of do not crush. - carvedilol 6.25 mg - take 1 tablet in the morning - without instruction of do not crush. An observation on 5/14/2024 at 7:26 AM revealed Medication Aide (MA)-B had crushed Resident 16's ferrous sulfate, pantoprazole, potassium chloride, solifenacin, and carvedilol. An interview on 5/14/2024 at 7:32 AM with MA-B confirmed MA-B had crushed Resident 16's medications. A follow-up interview on 5/14/2024 at 9:30 AM with MA-B confirmed Resident 16's crush order was not in the computer nor were there direction of which medications could not be crushed. MA-B was unaware of medications that could not be crushed. A record review of Institute for Safe Medication Practices document Oral Dosage Forms That Should Not Be Crushed revealed potassium chloride, ferrous sulfate, pantoprazole, solifenacin, carvedilol was included on the list to not be crushed.

Licensure Reference Number 175NAC 12-006.02(8) Based on record review and interview the facility failed to report potential abuse and neglect to the state agency in the required timeframe. This affected 1 resident (Resident 3) of 3 residents reviewed. The facility census was 31. Findings are: Record review of the facility policy titled Abuse, Neglect, and Exploitation dated 3/6/2 revealed that the resident has the right to be free from mistreatment, neglect and misappropriation of property. When abuse, neglect or exploitation is suspected, the Licensed Nurse should notify the Director of Nursing and Administrator and document the notification. Initiate an in investigation immediately. Contact the State Agency and the local Ombudsman office to report the alleged abuse. The administrator should follow up with government agencies and report the results of the investigation when final, as required by state agencies. Interview on 8/14/23 at 1:54 PM with Resident 3 revealed that Resident 3 had missing cash (misappropriation- a type of abuse and neglect) and that Resident 3 reported it to the Administrative Assistant. Resident 3 revealed that the Administrative Assistant and the head of housekeeping came into the resident's room and looked for the missing cash. Resident 3 stated that $500 in a small black pouch was taken along with the pouch. Resident 3 revealed that the resident kept the pouch in the pillow on their bed. Resident 3 revealed that in March the resident had $3000 to $4000 dollars go missing. Record review of the progress note dated 6/28/23 at 11:13 AM revealed that on 6/27/23 Resident 3 asked the charge nurse to talk to the Business Office Manager as the resident needed cash for supplies. Resident 3 stated that someone had stolen thousands of dollars from the resident. The Business Office Manager cashed out money from Resident 3's trust fund and counted it out with the facility Administrative Assistant as a witness. Record review of the progress note dated 7/12/23 at 3:16 PM revealed that the progress note was documented by the facility Administrative Assistant (AA). The progress note revealed that the AA visited with Resident 3 because Resident 3 reported to a Nurse Aide that someone stole $3000 from Resident 3. Resident 3 stated that someone stole the wallet from their pillow on Sunday that had $500 in it. Record review of the progress note dated 7/14/23 at 3:01 PM revealed that the facility AA spoke with Adult Protective Services (APS) to report misappropriation of funds from Resident 3. The AA documented that the facility would submit documentation for the required 5-day investigation report to the state agency. (This notification was over 24 hours after being made aware of the report of missing cash on 7/12/23). Interview on 8/15/23 at 9:34 AM with the facility Administrative Assistant (AA) confirmed that Resident 3 reported missing $3000 to the facility 7/12/23. AA revealed that the AA searched the resident room with their permission and was unable to find the missing cash. AA confirmed that the report of the missing cash was not reported to APS until 2 days later on 7/14/23. AA confirmed that the report to APS was not completed within 24 hours as required.

Licensure Reference Number: 175 NAC 12-006.04D2 Based on record review and interview, the facility failed to ensure there was a qualified dietary manager (DM). This had the potential to affect all residents in the building. The facility census was 26. Findings are: Record review of the Dietary Manager's employee records verified there were no educational or certification records identifying the DM successfully completing a course in food management. On 03/13/23 at 1:02 PM an interview with the DM confirmed that the educational requirements for the dietary manager was not completed. An interview on 03/15/2023 at 02:07 PM with the Administrator revealed the facility does not have a full time RD or a qualified DM.

Licensure Reference Number: 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to ensure that safety interventions were in place to prevent multiple falls with resulting fractures for one current sampled resident (Resident 1). The facility census was 29 with three current sampled residents. Findings are: Review of Resident 1's Care Plan, goal dated 11/19/19, revealed that the resident had a history of [REDACTED]. Review of the Departmental Notes revealed the following including: - 10/22/19 at 6:15 AM Staff heard the alarm and found the resident lying on right side beside the bed. The resident complained of right shoulder pain. The resident was transferred to the emergency room for evaluation. The resident returned to the facility at 10:00 AM with a [DIAGNOSES REDACTED]. - 10/22/19 at 11:30 AM The resident was sitting in the bath chair, the bath aide turned away from the resident to get clothing and felt the chair move, the resident leaned forward and fell off of the bath chair. The resident had a laceration to the middle of the forehead. The resident was transferred to the emergency room . At 1:20 PM, a family member called and reported that the resident had a skull fracture. Review of the facility investigation report Accidents, dated 10/22/19, revealed that at 5:05 AM, the resident rolled over in the high/low bed and rolled out onto the floor, resulting in a fractured right clavicle. Further review revealed that interventions to prevent the accident/incident from reoccurring included to ensure that the bed was in the lowest position possible. Review of the facility investigation report Accidents, dated 10/22/19, revealed that at 11:31 AM, the resident had finished a bath and the Aide was dressing the resident. The resident was seated in the bath chair, up off of the floor with the seat belt on. The Aide turned around to get the resident's clothing, the resident leaned forward and fell out of the chair and hit head on the floor causing a large laceration to the forehead. The resident was transferred to the hospital. Further review revealed that interventions to prevent the accident/incident from reoccurring included to use a different bath chair that has a shoulder strap rather than a lap belt and re-educate the bath aide to always lower the chair to the floor before beginning to dry and clothe the resident. The resident was transported to the hospital and x-rays and scans revealed a fractured skull and several facial fractures. Interview with NA (Nursing Assistant) A, Bath Aide, on 10/25/19 at 10:15 AM revealed that the resident was a little lethargic during the bath and had received a pain pill before the bath. NA - A stated that the resident was lifted out of the whirlpool bath with the safety belt in place, the resident was seated about three to four feet off of the ground so feet were not on the ground, turned to get clothing, stood next to the resident, felt the chair move and then heard a crash. The resident fell to the floor and hit head. NA - A called the nurse right away to help. Interview with the Director of Nursing, on 10/25/19 at 10:30 AM, confirmed that the resident was considered a high risk for falls. Further interview confirmed that the resident's bed was to be kept in the lowest position to reduce the risk of injuries from falls out of the bed. The DON confirmed that staff were to always lower the whirlpool seat to the lowest position after a bath to safely dry and clothe the resident and ensure that the safety strap was secured around the resident while seated in the whirlpool chair. Interviews with the Administrator and the Director of Nursing on 10/25/19 at 11:45 AM confirmed that staff were re-educated to not provide care while a resident was seated in the whirlpool chair in a high position, ensure that the safety belt was secured around the resident while seated in the whirlpool chair and a high back whirlpool chair with a harness strap would be used for small residents. Further interview revealed that all staff who assisted residents with bathing would have inservice training on safety and bathing competencies would be performed. On 10/25/19 during the survey, the facility abated the immediacy of the deficiency, lowering the scope and severity to a level G after the IJ (Immediate Jeopardy).

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to implement interventions to prevent weight loss for Resident 21. The facility census was 33 at the time of survey. Findings are: A. Review of Resident 21's face sheet revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident 21's annual MDS (Minimum Data Set-a comprehensive assessment tool used for developing a resident's care plan) dated 5/17/2016 revealed that Resident 21 had a short term and long term memory problem; moderately impaired cognitive skills for daily decision making, inattention, disorganized thinking, and delusions. Resident 21 required extensive assistance from staff for eating. Resident 21's weight was 95 pounds and Resident 21 received a mechanically altered diet. Review of Resident 21's weights from Resident 21's weight list and MDS assessments revealed the following: -105 pounds on 11/9/2014, which was Resident 21's admission weight. -107 pounds on 6/1/2015; -99 pounds on 9/1/2015; -97 pounds on 1/11/2016; -96 pounds on 4/11/2016; -93 pounds on 7/11/2016 which indicated a weight loss of 3% in 90 days; a 4% loss in 180 days, a 13% loss in the past year and an 11.4 % weight loss since admission. Review of Resident 21's Physician order [REDACTED]. Review of Resident 21's care plan dated 5/24/2016 revealed staff were to offer Resident 21 CIB (Carnation Instant Breakfast) three times a day. Interview with the FSS (Food Service Supervisor) on 7/13/2016 at 9:40 AM revealed the CIB provided to Resident 21 by dietary staff was not prescribed by the physician and the FSS and Dietitian offered it as an intervention when they saw weight loss. Review of Resident 21's intake documentation of the CIB for the past 30 days revealed 20 days of incomplete documentation. Interview with the FSS (Food Service Supervisor) on 7/13/2016 on 10:03 AM confirmed there was incomplete documentation of the CIB offered to Resident 21. B. Review of Resident 21's dietary notes dated 6/24/2016 revealed that Resident 21 had elevated protein needs and staff were to be offering Resident 21 Carnation Instant Breakfast with meals. Resident 21's current weight was 91 pounds. Review of Resident 21's dietary notes dated 7/11/2016 revealed that Resident 21 was to be receiving Carnation Instant Breakfast with meals and that Resident 21 continued to need some assistance at meal time. Review of Resident 21's lab reports revealed no documentation of labs being done to indicate nutritional status such as a pre-[MEDICATION NAME] level (a blood test used to assess nutritional status and evaluate liver function toward diagnosing disorders such as malnutrition and chronic kidney failure). Interview with the RD (Registered Dietitian) on 7/14/2016 at 12:13 PM revealed that the RD had not requested any labs such as a pre-[MEDICATION NAME] for Resident 21. The RD revealed that they went by a resident's weight to determine if the resident needed a supplement. The RD revealed that supplements were not ordered as fortified or enhanced foods (CIB, peanut butter, hot chocolate, extra eggs, cottage cheese, or yogurt) were implemented first. The RD confirmed that Resident 21 was to be receiving Carnation Instant Breakfast with meals and the staff were to be documenting Resident 21's intake of the CIB. The RD confirmed that Resident 21 had lost weight.