Every finding on record at Wayne Countryview Care and Rehabilitation

Licensure Reference Number 175 NAC 12-006.09(I)Based on observations, record review, and interviews; the facility failed to reassess and to put interventions in place to prevent potential elopement for 1 (Resident 33) and failed to prevent the potential for burns related to hot water temperatures in resident handwashing sinks. Six out of 35 facility resident rooms had water temperatures that exceeded 120 degrees. The sample size was 20 and the facility census was 41. Findings are: A. Review of the undated facility policy Water Temp revealed the facility tested water temperatures by letting the water run for 3-5 minutes and inserting a thermometer probe into the stream of running water all while holding the testers hand under the water to assess how the water felt on skin. Temperature checks were performed at various locations throughout the facility. There was no evidence at what temperature the water was considered acceptable or how often the temperature checks were performed. On 1/25/26 between 8:00 AM and 8:12 AM water temperature checks conducted by the survey team identified the following water temperature in the hand-washing sinks in the following resident rooms.Rm 200 - 139 degrees Fahrenheit (F)Rm 207 - 133 degrees FRm 318 - 139 degrees FRm 315 - 138.5 degrees FRm 431 - 140 degrees FRm 426 - 140.9 degrees F Review of Water Temperature Safety education provided by the facility on 1/25/26 after identifying unsafe water temperatures in the facility revealed the following: -Water temperature standards indicated water temperature must not exceed 120 degrees Fahrenheit. -Water temperatures hotter than 120 degrees Fahrenheit could cause scald burns. -Maintaining safe water temperatures was required for resident safety and regulatory compliance. -Staff were to be aware of water temperatures during all resident care activities and if the water temperatures felt unusually hot, caused discomfort upon contact, appeared to fluctuate, or felt out of range staff were to take immediate action including stopping water usage, verifying the water temperature using a thermometer located at the nurses station, and report immediately to the facility Administrator, Operations Manager, and Maintenance Director. During an interview with the Maintenance Director on 1/25/26 at 10:39 PM revealed the following: upon being made aware, staff had called this morning due to the identified hot water temperatures and when maintenance staff arrived and checked temperatures, they were around 130 degrees. The water temperature mixing valves were checked, and the hot water temperature turned down, and the subsequent temperatures had rapidly decreased and had returned to a range of 120-122 degrees. The maintenance was then checking water temperatures every 30 minutes. The Maintenance Director confirmed that water temperatures were to be at or below 120 degrees. During an interview on 1/25/26 at 12:45 PM the facility Administrator confirmed once the hot water temperatures were identified the facility implemented all staff education, monitoring of water temperatures every 30 minutes morning and afternoon, and would continue checking the temperatures 3 times daily through the week and then 5 days a week until the cold weather temperatures improved, and most likely through the winter months. The facility had placed do not use signs on the bathroom sinks and stopped bathing residents. In addition, the facility had contacted a professional plumber to determine an exact cause of the sudden rise in the water temperatures. Review of the undated facility floor plan revealed 35 total resident rooms. Review of the facility Resident list dated 1/28/26 and included the resident room numbers, revealed 26 of the resident rooms were occupied. Two of the rooms (rooms [ROOM NUMBERS]) identified as having water temperatures exceeding 120 degrees had 4 residents who were identified as capable of entering their bathroom and washing their hands without assistance. During an interview on 1/28/26 at 8:30 AM the facility Operations Manager confirmed the facility was aware water temperatures in the resident's bathroom were not to exceed 120 degrees to prevent potential resident burn injuries and the temperature ranging from 133 to 140.9 degrees on 1/25/26 were too hot to ensure the resident's safety. B. Review of the facility Elopement Policy and Assessment with a revised date of 6/2019 revealed it was the policy of the facility to provide a safe environment for all residents. The facility was to accurately assess all residents and to plan their care to prevent accidents related to wandering behavior or elopement. The following procedures were identified for assessment and identification of wandering behaviors: -history of behaviors, including wandering, was to be obtained prior to admission. -each resident's level of supervision or plan of care was to be developed based on their elopement risk assessment score and other risk factors which included but was not limited to observed wandering/exit seeking behaviors. -each resident was to be assessed quarterly and after a significant change in condition. The following steps were to be taken for residents who were identified at risk for elopement: -wander guard bracelet may be placed on the resident. -the residents care plan was to address behaviors with resident specific goals and interventions. -a current picture of the resident was to be maintained by the facility. -staff were to ensure that all exit alarms were responded to immediately. C. Review of Resident 33's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 11/24/25 revealed the resident was admitted [DATE] with diagnoses of coronary artery disease, high blood pressure, Alzheimer's disease, and malnutrition. The assessment revealed the following related to Resident 33: -cognition was severely impaired. -behaviors which included rejection of cares. -required substantial to maximal assistance with dressing, bathing, personal hygiene, bed mobility, and transfers. -frequent urinary incontinence. -history of falls. Review of an Elopement/Wandering Evaluation for Resident 33 dated 12/8/25 at 10:19 PM revealed the resident had a predisposing disease of Alzheimer's, was mobile in the wheelchair, was alert and orientated and had no history of elopement or of wandering. The resident's total evaluation score was five, indicating the resident was at low risk for elopement. Review of a Nursing Progress Notes dated 1/10/2026 at 1:00 PM, revealed the staff were informed by another resident that Resident 33 was attempting to open a door down on the 300 halls. The resident was found in the building, but with the door open. The resident was redirected back to the commons area. Review of Resident 33's medical record revealed no evidence the facility reassessed the resident's elopement risk and/or developed interventions to prevent a potential elopement. During an interview with the Director of Nursing (DON) on 1/27/26 at 3:00 PM, the DON confirmed the following regarding Resident 33: -the resident was admitted [DATE] and was to be a short term admission with the long term plan for the resident to go back home and to live with the daughter. -the facility staff were to complete an Elopement/Wandering Evaluation to determine the resident's risk for elopement within 72 hours of admission. -an Elopement/Wandering Evaluation was not completed until 12/8/25 (18 days after the resident was admitted ) for the resident. -the assessment indicated the resident was at low risk for wandering. -the resident was having increased confusion and behaviors with continued stay at the facility. -1/10/26 at 1:00 PM the resident was found after opening a door to exit out the 300 hallways. The resident had not left the building but was at the opened door. -the DON was unaware this had occurred. -the resident's elopement risk was not reassessed and no interventions were put into place to prevent a potential elopement.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(i)(3) Based on observations, record review, and interview; the facility failed to provide timely eating assistance for Residents 33 and 19. The sample size was 2 and the census was 41. Findings are: A. Review of Resident 33's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 11/24/25 revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's dementia, malnutrition, coronary artery disease, and high blood pressure. The assessment identified the following:-cognition was severely impaired;-partial/moderate assistance was provided by staff with dietary intakes; and-weight of 100 pounds (lbs.). During the breakfast meal service on 1/25/26 the following was observed related to Resident 33:-8:34 AM was seated at a table in the dining room for residents who required assistance with eating. The resident was served a glass of milk and juice, a bowl with hot cereal, and a plate with a biscuit and scrambled eggs. Nursing Assistant (NA)-D was seated at the other end of the table and was providing assistance to others. Staff failed to offer and/or provide the resident assistance with setup of the meal. The resident made no attempt to eat/drink the breakfast meal. -8:42 AM a tablemate asked Resident 33 if the resident was going to eat. The resident closed their eyes, folded arms, and backed the wheelchair away from the table. NA-D who remained at the other end of the table failed to cue the resident or to provide any assistance with eating. -9:06 AM the resident had consumed none of the breakfast meal. The resident indicated a need for toileting and attempted to stand independently from the wheelchair.-9:07 AM the resident was assisted out of the dining room by NA-D.-9:12 AM the resident returned to the dining room and was positioned at the dining table. NA-D cued the resident to try and eat the breakfast meal but provided no assistance to the resident. In addition, NA-D did not offer to warm up the resident's food which had been left uncovered since service at 8:34 AM (35 minutes prior). Resident 33 took one bite of the meal, put down the fork, closed eyes, and remained seated at the table but made no effort to eat or to drink. -9:20 AM the resident was assisted out of the dining room after consuming only one bite of the meal. B. Review of Resident 19's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of debility, heart failure, Non-Alzheimer's dementia, anxiety, and depression. The following was assessed for Resident 19:-cognition was severely impaired.-required substantial staff assistance with eating and drinking.-weight of 174 lbs. Observations of Resident 19 on 1/25/26 for the breakfast meal revealed the following: -8:20 AM was seated in a wheelchair at the assisted table in the dining room. The resident was served the breakfast meal which consisted of scrambled eggs, a biscuit, hot cereal, and glasses of orange juice and of water. The resident was holding a baby doll and made no attempt to put the doll down or to eat/drink the breakfast meal.-8:55 AM NA-D approached the resident who had remained at the table without eating and/or drinking. NA-D assisted the resident with taking a drink of orange juice while standing next to the resident. The resident accepted the drink and then staff placed down the juice and walked away. The resident made no further attempt to eat/drink.-9:06 AM NA-D buttered the resident's biscuit and then placed it on the resident's plate. NA-D exited the dining room to assist another resident with toileting. No other staff were available to cue or to assist the resident with eating. -9:22 AM (1 hour and 2 minutes after the resident's breakfast was served) NA-D sat next to the resident and provided total assistance with eating. C. During an interview on 1/27/26 at 3:00 PM, the Director of Nursing (DON) confirmed Resident 19 and 33 required extensive/total assistance with meal intakes. The DON indicated the staff should not be requesting or providing the residents' food from the kitchen until staff were able to provide them with cues/assist to eat.

Licensure Reference Number 175 NAC 12-006.09(G)(ii)(iii)Based on record review and interviews, the facility failed to complete a comprehensive discharge summary including a recapitulation of care and reconciliation of medications for 1(Resident 43) and failed to notify the State Ombudsman of discharges for 2 (Resident's 43 and 45) of 4 sampled residents. The facility census was 41.0 Findings are: A. Review of the facility policy Criteria for Transfer and Discharge with a revision date of April 2025 revealed the following: -The facility would not transfer or discharge a resident unless appropriate criteria existed. -The transfer and/or discharge were documented in the resident record and appropriate information was communicated to the receiving provider. -The physician signed a discharge summary when a resident was discharged or transferred and the summary included a post discharge plan of care, indication of where the resident would reside, any arrangements for follow up care, and any post-discharge medical and non-medical services. B. Review of Resident 43's Electronic Medical Record revealed the resident was admitted to the facility on [DATE] and discharged from the facility to an acute care hospital on [DATE]. Review of Resident 43's Electronic Medical Record revealed no evidence the facility completed a comprehensive recapitulation of the resident's stay including a reconciliation of the residents' medication/discharge summary. In addition, there was no evidence the facility notified the State Ombudsman's of the resident's discharge. During an interview on 1/28/25 at 12:00 PM the Director of Nursing confirmed the facility did not complete a recapitulation of the Resident 43's stay following the discharge including a reconciliation of the resident's medications. C. Review of Resident 45's Electronic Medical Record revealed the resident was admitted to the facility on [DATE] and discharged from the facility to home on 1/2/26. There was no evidence the facility notified the State Ombudsman of the discharge. D. During an interview on 1/28/26 at 11:00 AM the Social Services Director confirmed the facility did not notify the State Ombudsman of facility transfers and discharges as required for Resident's 43 and 45.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i) Based on observations, record review, and interview; the facility failed to implement weight loss interventions for Resident 33. The sample size was 4 and the facility census was 41. Findings are: A. Review of the facility policy Nutrition Status Management with a revision date of 4/2025 revealed it was the policy of the facility to assess each resident's status and needs, including medications and medical conditions to ensure that all residents maintained an acceptable parameter of nutritional status unless the resident's clinical condition demonstrated this was not possible. The following procedure was identified:-each resident's nutritional status was assessed at admission and at least quarterly afterwards.-dietary evaluations were to include determination of ideal body weight range, usual body weight, current diet, percentage of food eaten, possible dental problems, current illness, likes and dislikes, and any other change in medical condition that may impact weight loss.-if there was a significant change in the residents' condition related to weight or nutrition, the Registered Dietician (RD) would make recommendations to offer additional nutrition to those residents.-the Interdisciplinary Team (IDT) and/or the RD would monitor and evaluate the resident's response to the interventions.-any resident weight which varied from the previous reporting period by more than 5 percent (%) in 30 days, 7.5 % in 90 days and 10 % in 180 days would be evaluated by the IDT to determine the cause of weight loss and interventions required.-the nurse would notify the physician, family, and the resident of weight loss.-any resident meeting criteria for weight loss would be weighed weekly and reviewed by the RD.-the IDT would update and revise care plan as appropriate. B. Review of Resident 33's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 11/24/25 revealed the resident was admitted with diagnoses of Alzheimer's dementia, malnutrition, coronary artery disease, and high blood pressure. The assessment identified the following:-cognition was severely impaired;-partial/moderate assistance was provided by staff with dietary intakes. Review of Resident 33's Nursing Progress Note dated 11/20/25 at 9:44 PM revealed the resident's Primary Care Practitioner (PCP) was sent a facsimile (fax) requesting an order for Med Pass Nutritional supplement 60 cubic centimeters (cc) twice a day due to the resident's diagnosis of protein calorie malnutrition. Review of Resident 33's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature, and pulse) revealed on 11/20/25 the resident's weight was 105 lbs. Further review revealed on 11/29/25 the resident's weight was 100 lbs. (down 5 lbs. or a 5 percent (%) loss in 9 days). Review of Nursing Progress Notes revealed the following:-12/2/25 at 3:56 PM the resident was seen by the PCP and a new order was received for Lasix (medication used to treat fluid retention) to be administered 4 days for fluid in the resident's lower legs.-12/9/25 at 11:46 AM a follow-up fax was sent to the PCP regarding a request for Med Pass 60 cc twice a day as no response was received from the first fax which was sent on 11/20/25 (19 days earlier). Review of Resident 33's Weights and Vitals Summary Sheet revealed the resident's weight on 12/18/25 was 108 lbs. Review of Nursing Progress Notes revealed the following:-12/15/25 at 5:13 PM the staff sent a third fax to the residents' PCP requesting an order for the Med Pass 60 cc twice a day as the PCP had still not responded to the facilities request on 11/20/25 and on 12/9/25. -12/17/25 at 10:59 AM (27 days after the facility initially requested the order) a new order was received for Med Pass 60 cc twice a day. Review of a Nutrition Progress Note dated 12/19/25 at 2:05 PM revealed the Registered Dietician (RD) identified the resident had a weight gain of 8 % in 30 days and confirmed the resident was seen by the PCP and started on medication for the fluid gain. The note further revealed on average the resident was consuming only 50 % of food at meals. No new recommendations were identified. Review of a Weights and Vitals Summary Sheet revealed the following weights:-12/20/25 weight was 105 lbs.-12/31/25 weight was 101 lbs. Review of a Progress Note on 1/15/26 at 4:33 PM revealed the resident was seen by the PCP and a new order was received to restart the Lasix 20 milligrams (mg) daily due to fluid to lower extremities. Review of Weights and Vitals Summary Sheet revealed the resident maintained weight at 101 lbs. Review of a Nutrition Progress Note dated 1/26/25 at 12:22 PM revealed the resident's current body weight was 101 lbs. which was a significant loss of 6 % in 34 days. The residents' lower extremity fluid retention was improved. Meal intakes on average remained at 50 %. No new recommendations were identified. During the breakfast meal service on 1/25/26 the following was observed related to Resident 33:-8:34 AM was seated at a table in the dining room for residents who required assistance with eating. The resident was served a glass of milk and juice, a bowl with hot cereal, and a plate with a biscuit and scrambled eggs. Nursing Assistant (NA)-D was seated at the other end of the table and was providing assistance to others. Staff failed to offer and/or provide the resident assistance with setup of the meal. The resident made no attempt to eat/drink the breakfast meal. -8:42 AM a tablemate asked Resident 33 if the resident was going to eat. The resident closed their eyes, folded arms, and backed the wheelchair away from the table. NA-D who remained at the other end of the table failed to cue the resident or to provide any assistance with eating. -9:06 AM the resident had consumed none of the breakfast meal. The resident indicated a need for toileting and attempted to stand independently from the wheelchair.-9:07 AM the resident was assisted out of the dining room by NA-D.-9:12 AM the resident returned to the dining room and was positioned at the dining table. NA-D cued the resident to try and eat the breakfast meal but provided no assistance to the resident. In addition, NA-D did not offer to warm up the resident's food which had been left uncovered since service at 8:34 AM (35 minutes prior). Resident 33 took one bite of the meal, put down the fork, closed eyes, and remained seated at the table but made no effort to eat or to drink. -9:20 AM the resident was assisted out of the dining room after consuming only one bite of the meal. Observations of Resident 33 on 1/26/26 revealed the following:-7:29 AM the resident was lying in bed with eyes closed and call light in reach.-9:08 AM the resident remained in bed with eyes closed. NA-H entered the room and asked if the resident was ready to get up, but the resident refused and told the staff to leave the room. -10:01 AM the resident remained in bed.-10:16 AM NA-F assisted the resident with morning cares and positioned the resident in a wheelchair. The resident was taken to the commons area with other residents who were watching the television. Resident 33 was not offered anything to eat/drink despite the resident having missed the breakfast meal. Review of Resident 33's meal intakes for the breakfast meal from 1/1/26 to 1/26/26 revealed no documentation of intakes on 1/1, 1/2, 1/5, 1/6, 1/10, 1/27, 1/29, 1/20, 1/21, 1/22, 1/23, 1/25 and 1/26/2026 (13 out of 26 days). An interview with the Director of Nursing (DON) on 1/27/26 at 3:00 PM confirmed the following regarding Resident 33:-required extensive/total assistance with meal intakes. Intakes were frequently poor and the resident reported no appetite.-the staff should not be requesting or providing the residents' food from the kitchen until staff are available to provide with cues/assistance to eat.-the resident had weight fluctuations related to fluid retention and was started on a new medication to address.-11/20/25 a fax was sent to the resident's PCP requesting a nutritional supplement as the resident had a diagnosis of malnutrition. The staff had to send additional faxes on 12/9/25 and on 12/17/25 as the PCP failed to respond. 12/17/25 the PCP ordered the Med Pass nutritional supplement. The DON indicated that the facility has difficulty with some of their PCP answering/responding to faxes. Confirmed the supplement was not initiated until 12/19/25.

Licensure Reference Number 175 NAC 12-006.17Based on observations, record review, and interview; the facility failed to perform hand hygiene at appropriate intervals and to utilize the required Personal Protective Equipment (PPE) when providing management/care of Resident 39's catheter. The sample size was 2 and the facility census was 41.Findings are:A. Review of the Hand Hygiene policy with a revision date of 12/2025 revealed it was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. Hand hygiene was identified as one of the most effective measures to prevent the spread of infection. Staff were to perform hand hygiene when:-hands were visibly soiled.-before and after coming on duty.-before and after direct contact with residents.-before preparing or handling medications.-before and after handling an invasive device (urinary catheter).-before handling clean or soiled dressings, gauze pads.-before moving from a contaminated body site to a clean body site during resident care.-after contact with blood or bodily fluids.-after removing gloves.-after removing and disposing of personal protective equipment. B. Review of the facility policy Standards and Transmission-Based Precautions with a revision date of December 2025 revealed it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The policy further indicated Enhanced Barrier Precautions (EBP) referred to the use of gowns and gloves during high-contact resident care activities for residents with:-Multi-Drug Resistant Organism (MDRO-a germ that is resistant to many of the antibiotics) infection or colonization (presence of a microorganism in or on a host without causing any symptoms).-wounds and/or indwelling medical devices regardless of MDRO colonization.Examples of high-contact resident care activities that required gown and gloves use for EBP included the following:-dressing.-bathing/showering.-transferring.-providing hygiene.-changing linens.-changing briefs or assisting with toileting.-device care or use: indwelling urinary catheter, feeding tubes.-wound care: any skin opening that required a dressing.The resident would be in EBP for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at risk. C. Review of Resident 39's Minimum Data Set (MDS-federally mandated comprehensive assessment tool used to develop resident Care Plans) dated 12/16/25 revealed the resident was admitted [DATE] with diagnoses of anemia, neurogenic bladder, Non-Alzheimer's dementia, depression, previous stroke, and high blood pressure. The resident was identified as requiring substantial to total assistance with toileting hygiene, dressing, personal hygiene, bed mobility, and transfers; and as having an indwelling urinary catheter. During a care observation on 1/26/26 at 9:41 AM the following was observed:-the resident was seated in a recliner in the commons area and was watching television.-Nurse Aide (NA)-F approached the resident without use of a gown or gloves and transferred the resident from the recliner to a wheelchair then assisted the resident to their room. -without completing hand hygiene NA-F, placed on a disposable gown and gloves and emptied the resident's urinary catheter drainage bag.-NA-F disposed of the urine in the resident's bathroom and removed both the gown and gloves NA-F was wearing.-without washing hands or completing hand hygiene, NA-F returned to the resident and used an alcohol wipe to cleanse the drainage tube of the catheter bag, adjusted the residents clothing and placed foot pedals back on the wheelchair.-NA-F assisted the resident back to the commons area and transferred the resident into the recliner before performing hand hygiene. During an interview on 1/26/26 at 10:20 AM, NA-F confirmed Resident 39 was on EBP and staff should have been wearing PPE when working with the resident for transfers, repositioning and adjusting the resident's clothing. In addition, staff should not have removed PPE when working with the resident's indwelling urinary catheter.On 1/27/25 at 3:20 PM, an interview with the Director of Nursing confirmed the staff had been trained to wear gloves and gowns for direct cares and any catheter cares for Resident 39 who remained is on EBP due to an indwelling urinary catheter.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(3) Based on record review and interview: the facility failed to employ a qualified Dietary Manager (DM). This had the potential to affect food service provided to all residents who were served food from the kitchen. The total sample size was 26 and the facility census was 34. Findings are: A. Review of the facility Job Description: Dietary Manager dated 12/27/2021 revealed the DM would direct the overall operation of the Dietary Department in accordance with current applicable federal, state, local standards, guidelines, and regulations, governing the facility. The DM was to assure that quality nutritional services would be provided daily, and the dietary department would be maintained in a clean, safe, and sanitary manner. Duties and Responsibilities of the DM included: -Plan, develop, organize, implement, evaluate, direct the dietary department, programs, and activities. -Coordinate dietary services and activities with other related departments -Receive scheduled consultations from a qualified dietitian/nutritional professional. -Develop and maintain written dietary policies and procedures. -Interview residents or family members, as necessary, to obtain diet history. Visit residents periodically to evaluate the quality of meals served, likes and dislikes. -Inspect food storage rooms, utility/janitorial closets for upkeep and supply control. -Review dietary requirements of each resident admitted to the facility, as may be required, and assist the physician in planning for the resident's prescribed diet plan. -Review diet plans and menus to assure they are in compliance with the physician's orders. -Assure all dietary staff complete required compliance training and process. Required education requirements for DM position: -Must have training in cost control, food management and diet therapy. -Must be willing to complete CDM course within the first year of employment if person does not hold educational requirement -Must be knowledgeable of laws, regulations, and guidelines that pertain to long-term care. B. Review of DM-H employee file revealed no evidence DM-H had completed the required training/education for the DM position. During an interview on 10/9/24 at 8:50 AM, DM-H, confirmed that DM had not been trained or taken required classes. An interview with the facility Administrator on 10/9/24 at 10:15 AM, confirmed the DM had not been trained or taken the required classes.

Licensure Reference Number 175 NAC 12-006.11E Based on observations, record review and interview; the facility failed to maintain the kitchen in a clean and sanitary manner and failed to maintain food temperatures to prevent the potential for food borne illness. This had the potential to effect all residents who ate food from the kitchen. The facility census was 34. Findings are: A. Review of the undated Monthly and Daily Cleaning Checklist for the cooks and aides revealed the Cooks and Aides had cleaning duties daily and monthly for day and night shift. B. The Dietary Safety and Sanitation Audit Completed by the Registered Dietitian, (RD), on 10/8/24, revealed the following: -Dry storage area floor was a bit dirty. -Spills were noted down the front and sides of the steam table. -The shelf below the steam table was dusty/dirty, containers were dirty inside and out. -Floors in the kitchen remained dirty throughout. C. An observation on 10/09/24 at 8:29 AM revealed the following: -Noted dried on foods to the side and front of the stove and dried on foods to the back wall behind the prep table for toast. -The kitchen floor had dark, dried splatter spots with a dark slimy appearance. -The serving carts that were not being used to serve breakfast had crumbs on them and dried white spots. -The shelves under the prep table and steam table had crumbs on them. D. An observation on 10/10/24 at 11:30 AM revealed the following: -The kitchen floor had dark, dried, splatter spots with a dark slimy appearance covering the entire kitchen floor, included the floor where dried foods were stored. -A folded broken down box was on the floor under the prep table by the stove and on the floor by the back wall of the kitchen. -The side and front of stove had layers of dried, caked on food. -The wall behind prep table for toast had white colored, dried on food. -There were brown and white colored crumbs on the containers under the steam table and the shelves under the food preparation table. -The side and back of the steam table had dried on food. -The top of the steam table had water spots. An interview with the Dietary Manager, (DM-H), on 10/09/24 at 8:50 AM, verified that the kitchen floor had not been cleaned very well because the base board and edges of the kitchen floor had not been completed yet. An interview with Cook, (C-M), verified that the kitchen floors are to be mopped daily and this had not been done. An interview with the Administrator on 10/10/24 from 2:30 PM to 3:00 PM verified the following: -The kitchen had been remodeled, and the base board and edging to the kitchen floor had not been finished. -When the completed Dietary Safety and Sanitation Audit is received from the RD, it is the expectation of the DM to fix the problems when report received. E. Review of the undated facility form Guidelines for Food Temperatures revealed the following: -Food temperatures were taken and recorded prior to each meal service and food was reheated/cooled to ensure proper serving temperatures prior to each meal service. -Periodically temperatures were to be taken at the end of the meal service to ensure temperatures were held within acceptable ranges. The following procedure for checking the temperatures of food was identified: -Food temperatures were to be recorded on the meal temperature form. -To correctly take temperatures, the food thermometer was inserted into the center or thickest part of food for at least 15 seconds (or per instructions of the thermometer) and the thermometer was not to touch the sides or the bottom of the pan or the bone in the meat. -If temperatures were not within recommended guidelines, food/fluids were reheated/chilled until acceptable temperatures were achieved prior to service. -Hot foods which could be potentially hazardous were served at a temperature above 140 degrees Fahrenheit (F). -Cold foods were held at or below 41 degrees F. F. Review of the undated facility form Safe Storage Order and Final Cooking Temperatures revealed the following guidelines: -For food safety, stored foods were at a temperature of 41 degrees F. or below and foods were cooked to the listed internal temperature: -Ready to eat foods, produce and already cooked foods, fish and eggs were to be served at a temperature of at least 145 degrees F. -All poultry and stuffed products were to be served at a temperature of at least 165 degrees F. G. Review of the October 2024 Meal Temperature Form (form used to document the temperature of individual food items served at each meal) from 10/1/24 to 10/14/24 revealed the dietary staff failed to document any food temperatures for the evening meal on 10/1, 10/2,10/3,10/4, and on 10/6 (5 out of 14 days). In addition, the following food temperatures were documented on the form: -10/1 for the breakfast meal, pancakes were served at a temperature of 136 degrees F. For the noon meal the grilled cheese sandwich was served at 135 degrees F., the ground entree was served at 139 degrees F., the puree entree was 136 degrees F., and the puree vegetable was 135 degrees F. -10/2 for the breakfast meal egg bites were served at 135 degrees F. For the noon meal the puree entree was served at 137 degrees F. -10/3 for the breakfast meal the scrambled eggs were served at 137 degrees F. For the noon meal the ground entree had a temperature of 135 degrees F, and the puree entree was 136 degrees F. -10/4 for the noon meal the grilled cheese sandwiches had a temperature of 136 degrees F. -10/10 for the breakfast meal the eggs were served at a temperature of 135 degrees F. H. Observations conducted on 10/10/24 from 11:38 AM to 12:40 PM revealed the following temperatures: -12:39 PM the potato salad was 58 degrees F. -12:31 PM The puree chicken was 136 degrees F. An interview with Dietary [NAME] (DC)-S and the Dietary Manager (DM) on 10/16/24 at 8:20 AM confirmed the temperature of the potato salad should have been served and maintained at 41 degrees F. or less and the puree chicken should have been served and maintained at a minimum temperature of 165 degrees F. 29638 I. Review of the facility Logbook Documentation revealed the following steps for cleaning and maintaining the facility ice machine: -check the filter to ensure correctly installed and replace as needed. -sanitize the interior of the machine per manufacturer's directions. -clean out and sanitize the ice bin. -check the drain hose and make sure it is connected securely. -check the filter date and change as needed. J. Review of a Work History Report indicated the ice machine was last cleaned and provided maintenance on 7/2/24 (3 months earlier). K. Observations of the ice machine on 10/10/24 at 11:22 AM revealed the following: -the linoleum under the ice machine was missing, and the machine was positioned directly on a concrete floor. The floor had chips/gouges and remnants of glue which had been in use to affix the linoleum to the floor (not a cleanable surface). -the floor drain underneath of the ice machine was partially covered by a grate/cap. The perimeter of the drain opening had a gray/milky, slime like appearance. -a drainage tube from the ice machine was propped onto the cap/grate over the floor drain. The tube had a constant flow of water which also had a gray/milky discoloration. -filter on the side of the machine was heavily coated with a gray fuzzy substance that resembled dust/debris. An interview with the Administrator on 10/10/24 at 11:53 AM revealed the maintenance staff managed cleaning and maintenance of the ice machine. The Administrator was uncertain as to when it was last cleaned and when it was due to be cleaned/maintained again.

Licensure Reference Number 175 NAC 12-006.18(B)(C)(D) Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE- items such as gowns, gloves, face shield that are worn to protect care givers during the provision of care and to protect other residents from being exposed to potential harmful communicable disease/s) during the provision of care for Residents 12 and 235, failed to implement a mitigation plan to prevent potential water borne illness, failed to place a protective barrier for medications taken to resident care areas and then returned to the medication cart after use for Resident 21, failed to complete hand hygiene during the administration of medications and the delivery of room trays, and failed to store oxygen equipment in a manner to prevent potential cross-contamination for Resident 85. Findings are: A. Review of the facility policy Infection Control Prevention and Control Program dated 9/2017 revealed the facility had a facility wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The elements of the Infection Prevention and Control Program consisted of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Review of the facility policy Standard and Transmission-Based Precautions dated 3/2024 revealed the following: -It was facility policy to implement infection control measures to prevent the spread of communicable diseases and conditions. It was appropriate to individualize decisions regarding resident placement, balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increased the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized (when a bacteria or other organism is present but not currently causing disease) resident. It was therefore appropriate to use the least restrictive approach possible that adequately protected the resident and/or others. -Enhanced Barrier Precautions (EBP- set of infection control guidelines using PPE to reduce the spread of Multi-Drug Resistant Organisms (MRDO's- germs that are resistant to many antibiotics) in nursing homes, were used in conjunction with standard precautions and the expanded the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MRDO's to staff hands and clothing then indirectly transferred to residents or from resident to resident. -The use of gown and gloves for high-contact resident care activities were indicated, when Contact Precautions did not otherwise apply, for nursing home residents with Wounds and/or indwelling medical devices regardless of known MRDO infection or colonization. -MRDO's for which the use of EBP applied were based on local epidemiology (study of the distribution, causes, and control of health-related events aimed to prevent and control them). At a minimum, they included resistant organisms targeted by the Center for Disease Control (CDC) but could also include other epidemiologically important MRDO's. -Examples of high-contact resident care activities that required gown and glove use for EBP included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs and/or assisting with toileting, device care and use, including central vascular lines, indwelling urinary catheters, feeding tubes, tracheostomy/ventilator, and wound care. B. Review of Resident 12's Minimum Data Set (MDS-federally mandated comprehensive assessment use to develop resident care plans) dated 7/9/24 revealed the resident was dependent for toileting hygiene and received assistance with transfers and bed mobility. The resident had complex medical conditions including heart failure and respiratory failure and received oxygen therapy and hospice services. Review of Resident 12's Care Plan with a revision date of 8/10/24 revealed the resident had a history of Vancomycin Resistant Enterococci (VRE-a clinically significant antibiotic resistant infection) and required partial to moderate assistance with toileting transfers, was dependent for toileting hygiene, required partial to moderate assistance with going from sitting to lying down and lying down then sitting up, and was frequently incontinent of bladder and occasionally of bowel. In addition, staff were to clean their hands, including before entering and when leaving the room, and staff should wear gloves and a gown for the high contact care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting and device care/wound care. During an observation of the provision of care for Resident 12 on 10/10/24 at 10:28 AM Nurse Aide (NA-L) entered the resident's room (did not put on gloves or a gown) explained to resident that the aide would assist the resident to get up, dressed, and toileted. NA-L then assisted the resident to sit up in bed, removed an oxygen cannula (device that sits in the residents' nose/nares to deliver oxygen) and placed the cannula over the oxygen concentrator, provided extensive assist to lift the residents legs out of bed, applied gait belt (safety device used to support and provide safety during transfers and ambulation) to the resident and assisted the resident to walk to bathroom using a walker. MA-L then entered the bathroom and put on gloves and assisted the resident to pull down pants and sit on toilet. NA-L removed a slightly wet incontinence product, placed it in the trash, removed the gloves and washed hands, then without gloves retrieved clean clothing from the closet and a clean pull-up from a drawer in the bathroom. NA-L put on clean gloves and assisted the resident to put on the clean incontinence product, pants, shoes, and a shirt. NA-L then assisted the resident to stand and performed perineal-care (washing and caring for the genital and rectal areas of the body) using disposable wipes, then pulled up the incontinent product and pants. NA-L then removed the gloves and walked with resident back to bed. NA-L then assisted the resident to sit on the edge of the bed, removed shoes and socks (resident request) and assisted resident back into bed using extensive assist to lift legs (all while not wearing a gown or gloves). NA-L then reapplied the oxygen cannula and covered the resident with several blanket (again while not wearing gloves or a gown). Review of the undated New Hire and Refresher Education list provide by the facility for Nurse Aides revealed the refresher training included education on Infection Control: Enhanced Barrier Precautions. During an interview on 10/15/24 at 10:12 AM the facility Infection Preventionist confirmed that Resident 12 was on EBP and staff are to wear gown and gloves during hands on care including transfers, dressing, and toileting/toileting hygiene. During an interview on 10/15/24 at 2:51 PM The Director of Nursing (DON) confirmed that Resident 12 was on EBP for a history of a MRDO and staff were to wear a gown and gloves during all care provision that required hands on care such as transfers and toileting assistance. C. Review of the facility policy Water Safety Management Program (Legionella-bacteria causing a pneumonia like illness that resides in [NAME] environments such as lakes, [NAME], reservoirs, and man-made water systems) with a revision date of 1/2022 revealed the following: -the facility provided maintenance protocol guidelines for plant operations related to water safety management to ensure the reduction in potential growth of Legionella organisms in the water system of the facility. -The facility developed and maintained a water management program that included a team, a description of the facility water system, a water system diagram that described areas where legionella could grow, and spread with potential triggers and sources of bacteria growth. -The facility established control measures monitoring temperature and disinfectant levels to prevent water stagnation and bacteria growth. During an interview on 10/15/24 at 2:18 PM the Maintenance Supervisor confirmed the facility did not have a consistent plan for flushing of unused water systems to prevent water stagnation and the potential growth of water borne pathogens. During an interview on 10/16/24 at 7:39 AM the Maintenance Supervisor confirmed that a water management mitigation plan had not been implemented. 51391 D. Review of Resident 235's MDS dated [DATE] revealed the resident had a complex medical condition, surgical wound care, (intravenous) IV medication and antibiotics. Review of Resident 235's Care Plan with a date of 9/23/24 revealed the resident had a surgical site to the right great toe and had received IV medications. The resident was on EBP and staff were to wear gown and gloves for high contact care activities including wound care. During an observation of the provision of care for Resident 235 on 10/9/24, at 1:18 PM revealed a sign on the door that stated Enhanced Barrier Precautions. Further observations on 10/9/2024 at 1:18 PM revealed Licensed Practical Nurse (LPN-A) stood at the edge of bed with gloves on, no gown and removed a bandage from the resident's right foot, completed a treatment, then reapplied the bandage to right great toe. LPN-A removed the gloves and then performed hand hygiene. During an interview with Resident 235 on 10/9/24 at 1:34 PM, the resident reported staff only wore gloves, and no gowns, when dressings were changed to the right foot. During an interview with Registered Nurse (RN)-Q on 10/10/24 at 8:36 AM, RN-Q, verified Resident 235 was on EBP and gown and gloves were to be worn with wound treatments. During an interview with LPN-A on 10/10/24 at 9:41 AM, LPN-A, verified that when the dressing change was completed on 10/9/24 to Resident 235's right foot, LPN-A had a pair of gloves on, and no gown. LPN-A verified that Resident 235 was on EBP and gloves and gown should have been worn. 29638 E. Review of the facility policy Hand Hygiene with a date of 6/1/21 revealed hand hygiene was defined as a general term for hand washing, antiseptic hand wash and alcohol-based hand rub. Hand hygiene was identified as the most effective way to prevent the spread of infection. Hand hygiene was to be performed: -before and after contact with residents. -after contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident's room. -after removing personal protective equipment. -before preparing or handling medications. -before and after assisting a resident with meals. F. Observations of Resident 85's room throughout the survey revealed the following: -10/9/24 at 9:32 AM an oxygen concentrator was observed next to the resident's bed. The tubing and nasal cannula attached to the concentrator was lying directly on the floor behind the concentrator. -10/10/24 at 8:32 AM the oxygen tubing and nasal cannula attached to the oxygen concentrator was draped across the bedside table and coiled on the floor. -10/15/24 at 8:40 AM the oxygen tubing and nasal cannula attached to the oxygen concentrator was lying across the resident's bed. During an interview on 10/16/24 at 9:38 AM, Licensed Practical Nurse (LPN)-O confirmed the resident's oxygen tubing/cannula were to be stored in a bag on the side of the resident's oxygen concentrator. G. Observation of the breakfast room-tray meal service on 10/10/24 from 8:38 AM to 8:45 AM revealed the following: -8:38 AM Dietary Aide (DA)-B entered the 400 corridors with a cart containing room trays. DA-B positioned the cart in the center of the corridor. -8:39 AM without performing hand hygiene, DA-B entered resident room [ROOM NUMBER] and placed the room tray on the bedside table in front of the resident. DA provided set-up assist including helping the resident with a clothing protector. DA-B exited the room and returned to the food cart. DA-B failed to perform hand hygiene. -8:40 AM DA-B entered resident room [ROOM NUMBER] with meal tray and provided tray set-up then exited room. DA-B again failed to perform hand hygiene. -8:41 AM DA-B entered resident room [ROOM NUMBER] with a room tray. DA assisted the resident with setting up the meal tray and placing on a clothing protector then exited the room without performing hand hygiene. -8:43 AM DA-B entered room [ROOM NUMBER] and delivered a room tray. After exiting the resident room, the staff member still without completing hand hygiene took the cart back to the kitchen. Observations of the noon, room-tray meal service on 10/10/24 from 12:32 PM to 12:39 PM revealed the following: -12:32 PM DA-B exited the kitchen with a cart containing room trays for the noon meal and positioned the cart on the 400 corridors. -12:33 PM DA-B without performing hand hygiene, entered room [ROOM NUMBER] with a meal tray. DA-B placed the tray on a bedside table. DA-B moved several resident items which included a box of Kleenex, a TV remote, and the water jug to make room for the tray. Staff then provided set-up assistance for the resident before exiting the room. -12:35 PM DA-B still without completing hand hygiene, entered room [ROOM NUMBER] and placed room tray on the bedside table. DA-B re-arranged the resident's personal items on the bedside table to make room for the room tray then assisted the resident with meal set-up. -12:36 PM DA-B re-entered room [ROOM NUMBER] with a meal tray for the other resident in the room. DA-B provided the resident with set-up assistance and without performing hand hygiene exited the room. -12:37 PM DA-B entered room [ROOM NUMBER] and delivered the final room tray. DA-B exited the resident's room and returned to the kitchen with the cart still without performing any hand hygiene. During an interview on 10/10/24 at 1:00 PM, DA-B indicated the dietary staff had received no additional training regarding hand hygiene when delivering room trays. In addition, DA-B confirmed going in and out of the resident rooms to deliver room trays for the breakfast and the noon meal and not completing any hand hygiene. Observations of the breakfast, room tray meal service on 10/15/24 from 8:52 AM to 8:57 AM, revealed DA-N delivered room trays to residents in rooms 432, 434 and 436. DA-N failed to complete any hand hygiene throughout this observation and before returning to the kitchen. During an interview on 10/15/24 at 3:00 PM, the facility Administrator and the interim DON confirmed the Dietary staff should have performed hand hygiene before entering and then again when exiting the resident's rooms. 45739 H. Observation on 10/15/24 at 7:20 AM with RN-P revealed RN-P put on a pair of gloves without performing hand hygiene and opened the medication cart to obtain medications for Resident 21. RN-P gathered a nasal spray, an eye drop, an inhaler, Novolog insulin pen (a short-acting insulin), and Basaglar insulin pen (a long-acting insulin) and placed them on the medication cart. The Basaglar pen did not have enough insulin for the administration. RN-P needed a new Basaglar insulin pen, so RN-P placed all medications back into the medication cart, locked the cart, removed their gloves, and walked away. No hand hygiene was observed being performed. RN-P returned, put on new gloves without performing hand hygiene, and unlocked the medication cart. RN-P obtained all the medications from the medication cart then knocked and entered Resident 21's room. RN-P placed the medications onto Resident 21's bedside table without a barrier. RN-P handed Resident 21 the nasal spray to self-administer then the inhaler and placed them back onto the bedside table when Resident 21 was finished. RN-P still wearing the same pair of gloves instilled the eye drop into both of Resident 21's eyes and placed the eye drop back onto Resident 21's bedside table. RN-P, still wearing the same pair of gloves obtained the insulin off the bedside table and administered the insulin's one at a time. RN-P still wearing the same pair of gloves, gathered the medications off the bedside table, exited the resident room, and placed the medications on top of the medication cart without a barrier. RN-P still wearing the same pair of gloves unlocked and opened the medication cart and put the medications away. RN-P removed their gloves. No hand hygiene was observed being performed. Interview on 10/15/24 at 7:30 AM with RN-P confirmed there was no barrier placed onto Resident 21's bedside table prior to placing medications on it, gloves were not changed after administering medications, and hand hygiene was not completed after removing gloves. Interview on 10/15/24 at 2:50 PM with the Administrator and the DON confirmed a barrier should be placed before placing medications that would return to the medication cart onto the resident's bedside table, gloves should be changed after administering medications, and hand hygiene should be performed after removing gloves.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.19(A) Based on observation and interview; the facility failed to ensure a clean, comfortable, and homelike environment. The facility census was 34. Findings are: During the course of the survey from 10/9/24 through 10/16/24 the following was observed: -on 10/9/24 at 12:30 PM multiple stained and sagging ceiling tiles were observed in the hallway entrance adjacent to the south side of the dining room. In addition, the same hallway had a 10-to-12-foot pitted and chipped line in the dry wall on the east wall. -on 10/10/24 at 9:10 AM the dry-wall adjacent to Resident 1's bed in room [ROOM NUMBER] was gouged open approximately 1 inch by 24 inches. -on 10/10/24 at 9:20 AM multiple rooms in the center hallway (hall 400) were noted to be soiled and have carpet stains in rooms [ROOM NUMBER]. The threshold to room [ROOM NUMBER] was taped down with a red colored industrial tape. During an environmental tour on 10/10/24 the following was noted: -Door frames throughout the facility leading into residents' rooms had chipped and missing paint. -The floor around the door frames to resident rooms on the 300 hallway were caked with a layer of dirt and debris. -The alcove outside of the laundry area where 2 recliners and a vending machine were stored, had a heavy layer of dust and the tile was visibly dirty. -The threshold of the double door entry to the 300 hallway was taped with back, orange, and red industrial tape which was heavily scuffed and peeling at the edges. -Multiple areas of paint on the 400 hallway walls were chipped. -Paint on the drywall adjacent to Resident 12's bed in room [ROOM NUMBER] was chipping away in multiple places. -The floor beneath the ice machine located in the dining room was noted to have the floor drain cap unsecured and sitting off to the side of the drain with a clear hose lying on top of the draining with a thick slimy substance and a slow drip of clear liquid dripping from the tubing into the drain. The floor around the drain had a layer of white lime build up noted and the painted floor was chipped and heavily soiled. A filter on the side of the ice machine was heavily coated in dust and debris. -on 10/10/24 at 1:47 PM Resident 1 was lying in bed and a fall mat placed on the floor beside the bed had multiple tears and split seams present. -on 10/10/24 at 2:45 PM The linoleum in room [ROOM NUMBER] had an approximate 5 x 8-inch tear that was sticking up directly in front of a recliner. During a tour and interview with the facility Administrator on 10/16/24 at 8:42 AM the Administrator confirmed the identified concerns required repair and/or maintenance. Additional interview revealed the staff communicated maintenance concerns through a computer program and the facility had identified that the previous/former Maintenance Supervisor had been removing work orders without repairing things. The facility has now employed a new Maintenance Supervisor.

Licensure Reference Number 175 NAC 12-006.19 Based on observations, record review and interviews: the facility failed to maintain a pest free environment in Resident 235's Room and the facility kitchen. The total sample size was 26 and the facility census was 34. Findings are: A. Review of the facility Pest Control Policy dated 2007 revealed the facility had measures in place to maintain pest control in the facility and outer areas of the facility. The facility had a contract with a pest control company to do monthly scheduled inspection for pest and rodent control. B. During an interview with Resident 235 on 10/9/24 at 1:34 PM, resident stated there were tiny black bugs in the bathroom in the little basin by the sink. C. An observation on 10/9/24 at 1:37 PM revealed tiny black bugs were in resident 235 toothbrush basin, some of the bugs were moving around. An observation on 10/10/24 at 7:46 AM, noted a yellow basin in the bathroom with tiny black bugs, none of the bugs were moving. An observation on 10/10/24 at 11:30 AM, 2 windows in the kitchen had dead spiders, dust, and spider webs noted. Clean water pitchers were in front of the one window and a bread rack with loaves of white bread were in front of the other window. A screen from one of the windows had been removed and sitting on the window ledge. An observation on 10/15/24 at 8:00 AM noted that Resident 235 was moved to room [ROOM NUMBER]B, no bugs were noted in the bathroom or the little basin. An interview on 10/10/24 at 11:30 AM, with Cook, (C-M), reported that the screen had been removed to get cleaned, C-M was unable to verify who was to clean the screen or windows. An interview on 10/10/24 at 11:30 AM, with Dietary Manager, (DM-H), verified that windows and screens in the kitchen had not been cleaned, dead spiders, dust and spider webs were evident, and need cleaned. D. A review of the Service Summary Report dated 10/9/24, revealed Pest Control was in the building, interior rodent traps were serviced with little to no catches to report. E. An interview with the Administrator on 10/15/24 at 8:00 AM revealed that Resident 235 was moved to room [ROOM NUMBER] B the afternoon of 10/14/24 due to the bugs in room [ROOM NUMBER] A, Resident 235's prior room. Administrator further revealed bugs had been noted in other areas of the building also.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview; the facility failed to monitor a dialysis (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) access site for 1 (Resident 85) of 1 resident. The facility staff identified a census of 34. Findings are: A. Review of the facility policy Renal Dialysis, Care of Resident with a revision date of 6/09 revealed the following guidelines in the care of the resident on renal dialysis. -access site to be checked for condition, bruit (whooshing sound heard near the site with a stethoscope) and thrill (a thrill or buzz like vibration caused by blood flowing through the fistula) every shift. -physician to be notified of any complications. -blood pressures and venous punctures not to be performed on the extremity with the access site. -staff to prevent, identify and manage potential complications. B. Review of the resident's admission orders dated 10/8/24 revealed the resident was to receive renal dialysis 3 times a week on Mondays, Wednesdays, and Fridays. Record review of Resident 85's medical record that included Nursing Progress notes, Treatment Administration Record (TAR) and Medication Administration Form (MAR) revealed there was no evidence the facility nursing staff were monitoring the dialysis access site. During an interview on 10/15/24 at 10:25 AM, Licensed Practical Nurse (LPN)-O confirmed the staff were to assess the dialysis access site for any signs of complications after the resident's dialysis treatment and were to assess the site for bruit and thrill each shift. LPN-O confirmed there was no evidence the staff were completing assessments of the access site.

Licensure Reference Number 175 NAC 12-006.09 Based on observations, interview, and record review; the facility failed to follow Resident 85's physician order regarding a fluid restriction. The sample size was 1 and the facility census was 34. The findings are: A. Review of the facility policy Fluid Restriction with a revised date of 5/2007 revealed it was the policy of the facility to provide fluids as specified by the physician order. The following procedures were identified: -nursing was to notify dietary department of the parameters ordered for the resident's fluid restriction to include the minimum and maximum allowance. -the Dietary Manager (DM) was to divide the allotted total fluid amount for dietary among the daily meal pattern and enter the specified amounts in the resident's diet card. -nursing was to document fluid restrictions with the resident's intake and outputs on the Medication Administration Record (MAR). -the resident was to be educated regarding benefits/risks of compliance/noncompliance with fluid parameters. -water pitchers were not to be provided at the resident's bedside. B. Review of Resident 85's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/11/24 revealed the resident was admitted on [DATE] with diagnoses of cancer, anemia, coronary artery disease, heart failure, high blood pressure, end stage renal disease, seizure disorder and anxiety. The following was assessed regarding the resident: -cognition was moderately impaired. -independent with eating and drinking. -no behaviors. -resident was on oxygen and received dialysis. Review of Resident 85's admission orders dated 10/8/24 revealed the resident had an order for a 2000 milliliter (ml) fluid restriction in 24 hours with the following breakdown: -day shift nursing allotted 480 ml and 240 ml for the breakfast meal. -evening shift nursing allotted 480 ml with 240 ml for the noon meal. -evening/night nursing shift allotted 320 ml with 240 ml for the evening meal. Review of the resident's medical revealed from 10/8 through 10/10 revealed no documentation to indicate the facility was monitoring the resident's intakes and outputs to ensure compliance with the resident's physician ordered fluid restriction. Observations of the provision of fluids for Resident 85 revealed the following: -10/9/24 at 2:34 PM the resident was seated in a recliner in the resident's room. Next to the recliner was a bedside table which held a full water pitcher containing 600 ml of water despite the resident's fluid restriction. -10/10/24 at 8:32 AM the resident's bedside table contained a full water pitcher with 600 ml of water and 2 Styrofoam cups with approximately 120 ml of water left in each of the cups. An interview with the Director of Nursing (DON) on 10/10/24 at 3:03 PM confirmed the resident currently had a physician order for a 2000 ml fluid restriction. The DON further confirmed the following: -a full water pitcher should not have been provided in the resident's room. -the Charge Nurses were to document the resident's intakes and outputs for each shift on the resident's MAR to ensure the resident's fluid restriction was followed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(i)(1) Based on observations, record review and interview; the facility failed to provide toileting assistance and incontinence management for Resident 13 who required assistance with activities of daily living. The facility census was 34 and the sample size was 2. Findings are: A. Review of the facility policy Incontinent Care dated 5/2007 revealed it was the policy of the facility to provide a dry and odor free perennial care system. The policy indicated the residents were to be checked at least every 2-3 hours for incontinence. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/10/24 revealed diagnosis of diabetes, anemia, non-Alzheimer's dementia, anxiety, and depression. The same assessment indicated the resident's cognition was severely impaired, the resident was dependent with toileting hygiene, transfers and personal hygiene and indicated the resident was always incontinent of bowel and bladder. Review of Resident 13's current Care Plan with revision date of 12/11/23 indicated the resident was dependent on staff for assistance with activities of daily living. The resident wore a disposable incontinence brief, and the resident was incontinent of bowel and bladder. Observations of Resident 13 on 10/9/24 revealed the resident was seated in a wheelchair and was positioned in the center of the 400 corridor. The resident had a strong odor of feces. Several staff were observed in the corridor and passing by the resident, but no staff offered the resident assistance with toileting and/or incontinence cares. Observations of Resident 13 on 10/10/24 revealed the following: -7:15 AM the resident was awake and dressed for the day. The resident was seated in a wheelchair in the resident's room. -7:46 AM the resident was assisted to the dining room for the breakfast meal. The resident was not offered toileting assistance before going out to the dining room. -8:30 AM the resident was assisted out of the dining room and was positioned in the corridor outside of the resident's room. The resident was not offered an opportunity to use the bathroom or provided assistance with incontinence cares. -8:30 AM to 10:55 AM the resident remained in the corridor outside of the resident's room. The resident was noted to have a strong urine odor. -10:58 AM the resident was assisted to the dining room and positioned at a dining table. The resident continued to have a urine odor. -11:15 AM Nurse Aide (NA)-K assisted the resident from the dining room and back to the resident's room. NA-K and NA-J provided the resident assistance into the bathroom and prepared to transfer the resident onto the toilet. The resident's slacks, incontinence brief and the pad in the seat of the resident's wheelchair were saturated with urine. During an interview on 10/10/24 at 1:29 PM, NA-J and NA-K indicated the resident was up and had been dressed by the night shift that morning. Staff confirmed on 10/10/24 they had not assisted the resident with toileting until 11:14 AM (a minimum of four hours since the resident was last provided assistance). Staff indicated the resident should have been toileted when gotten up that morning and then again before and after the breakfast meal.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10(A)(i) Based on observations, record review and interview; the facility staff failed to evaluate Resident 85 for the ability to self-administer medications and to ensure security of medications. The total sample size was 26 and the facility census 34. Findings are: A. Review of the facility policy Self-Administration of Medications with a revision date of 5/23 revealed it was the policy of the facility to respect the wished of alert, competent residents to self-administer prescribed medications as allowable under state regulations. The following procedures were to be followed: -upon admission, alert residents were to be informed of their right to self-administer medications. -if a resident would desire to participate in self-administration, the interdisciplinary team would then assess the resident and then periodically re-evaluate as needed. -if a resident is a candidate for self-administration of medications, this will be indicated in the resident's medical record. -the resident would be instructed regarding proper administration of medications by the nurse, and this will then be care planned. -nursing will be responsible for recording self-administration doses in the resident's medical Medication Administration Record (MAR). -storage and location of drug administration will comply with state and federal requirements for medication storage. B. Review of Resident 85's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/11/24 revealed the resident was admitted on [DATE] with diagnoses of cancer, anemia, coronary artery disease, heart failure, high blood pressure, end stage renal disease, seizure disorder and anxiety. The following was assessed regarding the resident: -cognition was moderately impaired. -no behaviors. -resident was on oxygen and received dialysis. During observations on 10/9/24 at 9:32 AM, on 10/10/24 at 8:32 AM, and on 10/15/24 at 7:36 AM, Resident 85 had a container of Tums antacid tablets, without a medication label on a shelf in the resident's bathroom. Review of Resident 85's electronic medical record revealed no evidence the resident had a physician order for the Tums antacid tablets located in the resident's bathroom. In addition, there was no evidence the resident had been assessed to determine the resident was competent to self-administer medications. During an interview on 10/16/24 at 9:38 AM, Licensed Practical Nurse (LPN)-O confirmed the resident did not have an order for the Tums antacid tablets stored in the resident's bathroom and the resident had not been evaluated to determine ability to self-administer medications. The resident's cognition was moderately impaired, and LPN-O did not feel the resident was eligible to self-administer medications.

Licensure Reference Number 175 NAC 12.006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure insulin pens were dated when opened for Residents 5 and 21. The sample size was 5 and the facility census was 34. Findings are: Review of the facility policy Proper Insulin Pen Administration, undated revealed the following: -staff were to document an open date on the insulin pen, -a new safety pen needle would be screwed or clicked on, -the needle would be primed with 2 units of insulin to remove any air, -the dial would be turned to the number of insulin units needed, -the needle would be inserted into the skin and the button pressed to deliver the dose, -the pen would be held at the injection site for 10 seconds (allowing the full dose to be injected), then removed, and -the used pen needle would be removed for proper disposal in a sharp's container. Review of Resident 21's medication orders active as of 10/15/24 revealed an order for Basaglar (a long-acting insulin) at bedtime and Novolog (short-acting) insulin with meals (3 times per day) both had an order date of 1/31/24. Review of Resident 5's medication orders active as of 10/15/24 revealed an order for Basaglar Insulin at bedtime ordered 1/31/24. Observation on 10/15/24 at 7:20 AM with Registered Nurse (RN)-P revealed RN-P obtained Resident 21's insulin pen's out of the medication cart for administration. Neither the Basaglar or the Novolog insulin pens had an open date documented. Observation on 10/15/24 at 1:50 PM with RN-P pulled Resident 5's Basaglar insulin pen out of the medication cart and no open date was found documented on the pen. Interview on 10/15/24 at 7:20 AM with RN-P confirmed there was no open date documented on the insulin pens for Resident 21 and there should have been an open date documented. Further interview on 10/15/24 at 1:50 PM confirmed Resident 5's insulin pen did not have an open date documented and staff were to document an open date on the pen. Interview on 10/15/24 at 2:50 PM with the Administrator and the Director of Nursing confirmed insulin pens were to have an open date documented.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 2's physician for an ongoing weight loss. The sample size was 3 residents. The facility census was 40. Findings are: Review of the facility policy Significant Weight Loss/Gain, undated revealed the facility would monitor resident's weights monthly, identify weight loss/gain or potential weight loss/gain and determine if interventions were necessary to avoid further weight loss/gain, the Dietary Manager would address significant weight changes with the stand-up team, and notify the physician with any recommendations. Review of the facility policy Notifications, Physician, or Responsible Parties, last revised 7/19 revealed that the facility would notify the resident's attending physician of changes in condition/status which included a significant change in the resident's physical, mental or psychosocial status, if there was a need to alter the resident's treatments significantly, when the resident repeatedly refused treatments or medications three or more consecutive times, and notifications would be made within twenty-four hours of a change in condition or status. Review of Resident 2's Minimum Data Set (MDS- a federally mandated comprehensive tool used in care planning) dated 1/9/24 revealed the resident had diagnoses of hypertension, diabetes, dementia, fractures, and depression; the resident was cognitively intact; exhibited behaviors of delusions, verbal behaviors, and rejection of care; was independent with eating, and received assistance with toileting and dressing. Further review of Resident 2's MDS dated [DATE] revealed Resident Brief Interview of Mental Status (BIMS) was a 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. Review of Resident 2's Care Plan, undated revealed the following: -the resident was to have dietary consult for nutritional regimen and ongoing monitoring, -staff were to obtain weight as ordered, -the resident was independent with setup assist for eating and meals were delivered to the resident room, -the resident was bed bound per the resident preference, -the resident preferred to eat meals in the resident room, -staff were to monitor/record/report as needed to the physician for signs/symptoms of malnutrition and significant weight loss, and -the Registered Dietician (RD) was to evaluate and make diet change recommendations as needed. Review of the resident's Physician Orders revealed an order for a weekly weight with a start date of 10/17/23. Review the facility form Weights and Vitals Summary (a form used to document weights and vital signs) revealed Resident 2 had the following weights: -10/10/23: 283 pounds (lbs.), -10/17/23: 281.5 lbs., -1/4/24: 229 lbs., -1/9/24: 236 lbs., and -no documentation that the resident's weight was obtained between 10/17/23 and 1/4/24. Review of the resident's Treatment Administration Record (TAR) for October, November, December of 2023, and January 2024 revealed on 10/17/23 weight documentation of 281.5 lbs., and refusal of weights on 10/24, 10/31, and in the months of November and December; and refusals for 1/2, 1/9, and 1/16. Review of the facsimile (fax) to the Physician on 1/4/24 revealed the resident's baseline weight on 10/17/23 was 281.5 lbs and the weight on 1/4/24 was 229 lbs, (a loss of 52.5 lbs or 18.65%). Review of the facility form Nutrition Quarterly Evaluation dated 1/14/24 revealed the resident was on a regular diet, thin liquids, regular portion sizes, and had no supplement orders. Review of the resident's Progress Notes on 1/12/24 at 5:19 PM an entry by the RD revealed the resident was on a low concentrated sweets diet, had no supplementation orders, and the resident ate meals in their room independently with set up assist. The resident's weight on 1/9 was 236 lbs. and the baseline weight was 281.5 lbs, (a loss of 45.5 lbs. as of 1/9/24 in 12 weeks). According to Resident 2's progress note dated 1/12-2024 the RD had notified nursing staff that an updated weight was needed for Resident 2. Review of the resident's progress notes on 1/10/24 at 1:22 PM an entry to the Dietary Supervisor revealed the resident triggered for a significant weight loss for 90 days and 180 days. Review of Resident 2's progress notes from 10/1/23 through 1/04/24 revealed Resident 2's weight had not been addressed, no indications Resident 2 refused to allow weight to be obtained, and no indications Resident 2's physician had been notified on Resident 2's weight loss. Interview with the Administrator on 1/22/24 at 2:50 PM confirmed staff had not obtained a a weekly weight Resident 2's, there was no information identifying Resident 2 had refused to allow staff to obtain weight other than on the TAR. The Administrator confirmed Resident 2 did have a significant weight loss, and there was no information's that showed Resident 2's physician had been notified until 1/4/24, after the significant weight loss had been identified.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview the facility failed to ensure hand hygiene was completed to prevent the potential spread of infection for Residents 9,12,23, and 25, test Resident 17 when signs and symptoms of COVID-19 were present and failed to wear the appropriate Personal Protective Equipment (PPE) during care for Resident 9. The sample size was 14 and the facility census was 40. Findings are: A. Review of the facility policy Infection Prevention and Control Program with a revision date of 7/2023 revealed the following; -The infection prevention and control program was a facility wide effort involving all disciplines and individuals, and was an integral part of the quality assurance and performance improvement program, -The elements of the infection prevention and control program consisted of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health, -The program would be carried out by the facility Infection Preventionist. It was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. -The goals were to decrease the risk of infection to residents and personnel, recognize infection control practices while providing care, identify and correct problems relating to infection control, ensure compliance with state and federal regulations related to infection control, promote individual resident rights, and monitor personnel health and safety. -The program was comprehensive and addressed detection, prevention, and control of infections among residents and personnel. -The facility personnel conducted themselves and provided care in a way that minimized the spread of infection, including washing hands after each direct resident contact for which hand hygiene was indicated. B. Review of the facility policy Hand Washing dated 2/15/17 revealed the following; -It was the policy of the facility to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. -Hand washing was generally considered the most important single procedure for preventing infections. C. Review of Resident 23's Minimum Data Set (MDS- federally mandated comprehensive assessment used in the development of resident Care Plans) revealed the resident received extensive assistance with bed mobility, transfer, toileting, and dressing. In addition, the resident was occasional incontinent of bladder. During an observation of the provision of care on 10/4/23 at 7:40 AM for Resident 23 revealed Nursing Assistant (NA)- E entered the resident's room and did not perform hand hygiene. NA-E then assisted the resident to stand and walk to the bathroom using a walker. NA-E then assisted the resident to pull down pants and removed a urine-soaked disposable incontinence brief without putting on disposable gloves. NA-E then washed hands with soap and water for 10 seconds and assisted the resident to put on a clean disposable brief. NA-E then put on disposable gloves and provided perineal care to resident's buttock/anal area while the resident washed up the groins and abdominal fold. The resident was able to pull on the brief and pants. NA-E then removed the disposable gloves and assisted resident back to a recliner without encouraging the resident to hand wash or sanitize. NA-E then gathered the soiled linen and trash and exited the room, without hand sanitizing or performing hand hygiene. D. Review of Resident 25's MDS dated [DATE] revealed the resident had dementia and was severely impaired cognitively, frequently incontinent of bladder and involuntary of bowel, and required assistance with bed mobility, transfers, dressing, and toileting. During an observation of the provision of care on 10/03/23 at 8:35 AM, NA-E entered Resident 25's room and did not perform hand hygiene. NA-E assisted the resident from lying to sitting on the edge of bed, placed on a pair of slipper socks and shoes, and assisted the resident to stand and walk to the bathroom using a walker and gait belt. NA-E encouraged the resident to sit on the toilet. The resident was incontinent of urine in a disposable brief. NA-E put on disposable gloves, removed the soiled brief, assisted the resident to sit on the toilet and then removed the resident's pajamas. NA-E then put on a clean disposable brief and clean clothing wearing the same gloves used to remove the soiled brief. While continuing to use the same gloves NA-E assisted the resident to stand, provided perineal care, pulled up the clean brief and pants and walked the resident to a wheelchair. While continuing to wear the same soiled gloves NA-E assisted the resident to put in dentures and brushed the resident's hair. NA-E then removed the soiled gloves, exited the room pushing the resident in a wheelchair. Again NA-E did not wash hands or sanitize. E. Review of Resident 12's MDS dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing and toileting. In addition, the resident was frequently involuntary of bowel and had no bladder control. During an observation of the provision of care on 10/3/23 at 7:30 AM Resident 12 was taken from a commons area in a wheelchair to the resident's room. NA-E did not perform hand hygiene after entering the room or prior to providing care. The resident was transferred using a mechanical up lift with the assistance of NA-E and Medication Aide (MA)-F from the wheelchair to the toilet. NA-E and MA-F then put on disposable gloves. NA-E removed a wet brief and the resident's night gown. NA-E using the same gloves used to remove soiled brief assisted the resident to dress upper and lower body and applied a clean brief. NA-E then transferred the resident to a standing position in the mechanical lift and MA-F provided perineal cleansing. NA-E then pulled up the resident's pants and using the lift transferred the resident back into a wheelchair. NA-E then removed the soiled gloves, did not hand sanitize or wash hands and left the room with the resident in the wheelchair. F. During an interview on 10/04/23 at 2:21 PM the Infection Preventionist confirmed that staff should be performing hand hygiene prior to care, when going from a dirty to a clean task, after removing disposable gloves and prior to exiting resident rooms following the provision of care. 45739 G. Review of the facility policy Infection Prevention Control Precautions, Standard and Transmission-Based Precautions last reviewed 10/22 revealed the following: -Enhanced Barrier Protection (EBP): expand the use of PPE(Personal Protective Equipment) and refer to the use of gown and gloves during high contact resident care activities that provided opportunities for indirect transfer of Multi Drug Resistant Organisms (MDRO) to staff hands and clothing which can be indirectly transferred to residents or resident to resident, -the use of PPE (gown and gloves) for high-contact resident care activities was indicated when contact precautions (transmission-based precautions were used when a known infection that was spread by direct and indirect contact with the resident or their environment) did not otherwise apply for residents with indwelling catheters as well as residents with MDRO infection or colonization, and -examples of high-contact resident care activities requiring gown and glove use for EBP included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling urinary catheter device care, in general a gown and gloves would be required for resident care activities other than those listed above, unless otherwise necessary for standard precautions. H. Review of Resident 9's MDS, dated [DATE] revealed the resident had an indwelling catheter. Review of Resident 9's Care Plan, last revised 7/28/23 revealed the following: -the resident had an indwelling catheter, and -the resident had an intervention for Enhanced Barrier Precautions-everyone must clean their hands including entering and leaving the resident room and providers and staff were to wear gloves and gown for high contact care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs and assisting with toileting, and urinary device care. Observation on 10/2/23 at 1:57 PM there was a pink sign located on Resident 9's door Enhanced Barrier Precautions, the sign said that staff must: -clean hands when entering and leaving the room, -wear gloves and a gown for the following: high contact resident care activities such as dressing, transferring, changing linens, changing brief or toileting, and with device care including catheters. Observation on 10/3/23 at 8:30 AM revealed the Enhanced Barrier Precautions sign remained on the resident door. MA-K applied gloves and did not put a gown on. MA-K removed Resident 9's blanket and unlatched the resident's brief. MA-K provided peri care to the resident using pre-moistened wet wipes, and still wearing the soiled gloves, opened a new package of pre-moistened wet wipes, pulled a new wipe out of the package and provided catheter cares to the resident. MA-K minimally assisted the resident to roll to their side while still wearing the soiled gloves. MA-K removed the soiled gloves, applied a clean brief underneath the resident and applied new gloves without performing hand hygiene. MA-K obtained more pre-moistened wet wipes from the package and cleansed the resident's bottom. MA-K applied a barrier cream to the resident's bottom. MA-K removed their gloves, did not perform hand hygiene, applied a new pair of gloves and assisted the resident to roll onto their back. MA-K applied barrier cream to the front of the resident then removed gloves without performing hand hygiene. MA-K pulled the resident's brief up and attached it. MA-K applied new gloves and obtained a graduate from the resident's bathroom and placed the graduate onto the carpet on the floor next to the resident's bed. MA-K still was not wearing a gown, cleansed the drainage tube with alcohol, drained dark yellow urine from the catheter, cleansed the tube with alcohol and recapped the tube. MA-K emptied the urine into the toilet, rinsed the graduate and placed the graduate on the back of the toilet then removed gloves and did not perform hand hygiene. MA-K applied a new pair of gloves and assisted the resident to get dressed in bed. MA-K removed their gloves without performing hand hygiene. MA-K assisted the resident to sit on the edge of the bed until the resident was ready to transfer. MA-K asked NA-H for assistance. MA-K and NA-H, no gown or gloves were utilized, assisted the resident to transfer from the bed to the wheelchair. MA-K assisted the resident to change their shirt and then gave the resident their breakfast room tray. MA-K removed the trash and the dirty laundry from the resident's room and disposed of them appropriately. No hand hygiene was observed being performed. MA-K and NA-H entered another resident room without performing hand hygiene. I. Observation on 10/3/23 at 9:20 AM MA-K assisted Resident 34 into the bathroom. MA-K removed the resident's wheelchair pedals from the wheelchair. MA-K applied gloves without performing hand hygiene. MA-K used a gait belt to assist the resident to standing position, MA-K had the resident grab onto the grab bar and MA-K pulled the resident's pants and brief down. MA-K assisted the resident to sit onto the toilet and MA-K removed the resident's soiled brief. MA-K was talking to the resident and touched the resident's face while still wearing the same pair of gloves. MA-K applied a new brief to the resident and assisted the resident to standing position. MA-K performed peri cares using pre-moistened wet wipes. MA-K removed the soiled gloves and pulled the resident's pants up. No hand hygiene was performed. MA-K assisted the resident to pivot transfer into the wheelchair and MA-K applied the wheelchair pedals. The resident was taken out of the resident room and MA-K performed hand hygiene in the hallway using alcohol-based hand rub. J. Interview on 10/4/23 at 2:05 PM with NA-E revealed staff were to wear gowns and gloves when assisting residents in enhanced barrier rooms. K. Interview on 10/4/23 at 2:25 PM with the Administrator confirmed hand washing should be completed between glove changes, and when entering and leaving a room. Further interview confirmed that staff should be wearing a gown and gloves when dressing, transferring, and providing catheter cares for residents who have enhanced barrier precautions. 29638 L. Review of the facility Infection Control and Prevention Policy with a revised date of 9/11/23 revealed it was the policy of the facility to include preparatory plans and actions to limit and control the spread of COVID-19. The policy identified staff and/or residents were to be COVID tested with the onset of any symptoms and at day 3 and day 5 if continued symptoms or with outbreak testing. M. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/19/23 revealed the resident was admitted [DATE] with diagnoses of diabetes, non-Alzheimer's dementia, anxiety, depression, dysphagia, schizophrenia and a mild intellectual disorder. The assessment indicated the following regarding the resident; -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing and toilet use; and -frequently incontinent of bowel and bladder. Review of Resident 17's Nursing Progress Notes revealed the following: -5/28/23 at 2:28 AM the resident was administered Robitussin (medication used to treat coughs) 2 teaspoons (tsp); -5/28/23 at 10:35 PM the resident was administered Robitussin 2 tsp for coughing; -5/28/23 at 11:43 PM the resident was coughing and complained of a headache; -5/29/23 at 7:58 PM the staff heard the resident coughing from the corridor. The resident had notable wheezing to bilateral upper lobes of lungs; and -5/30/23 at 7:02 AM the resident received Robitussin 2 tsp for complaints of a cough. Review of the resident's medical record from 5/1/23 to 5/31/23 revealed the resident had not been tested for COVID-19. Interview with the Infection Preventionist on 10/3/23 at 2:30 PM confirmed Resident 17 should have been tested for COVID-19 when the resident first began displaying potential symptoms on 5/28/23.

Licensure Reference Number 175 NAC 12-006.06B Based on record review and interview; the facility failed to address food grievances to prevent sustained further resident concerns. The sample size was 16 and the facility census was 40. Review of the facility policy titled Grievances last revised 6/6/22 revealed the following: -the Grievance Official (GO) evaluated and investigated the concerns and would take immediate action to resolve the concern and prevent further potential violations of resident rights, -the Grievance Official or designee would respond to the individual expressing concern within 3 working days of the initial concern, and -the Grievance Official would take appropriate corrective action and contact all parties with the outcome. Review of the facility form titled Grievances revealed the following food concerns: January 2023: - 1/5/23: The resident stated they did not receive breakfast or lunch. The solution was that the resident's tray was made and was not delivered. The resident was encouraged to go to the dining room for meals and speak up if did not receive a meal. - 1/23/23: Resident asked for more milk and did not receive it. The solution: The aide forgot, and the GO suggested to carry a notepad. - 1/27/23: A resident only received 6 fish sticks for lunch. The solution was to educate the resident to ask for more food when hungry. - 1/27/23: Complaints of cold food. The solution was to encourage residents to go to the dining room for meals and not get a room tray. February 2023: - 2/6/23: Complaints of cold food. The solution was that the microwave was replaced. - 2/25/23: Complaints that supper was late. The solution was to encourage the resident to go to the dining room so they could be served sooner instead of getting served a room tray. March 2023: - 3/2/23: Complaint that cucumbers were not served in a small dish and the rest of the food was soggy. The solution was that dietary was advised to use small bowls for sides. - 3/7/23: The resident asked for hot tea or hot chocolate for meals and did not receive it. The solution was that dietary was advised to serve the resident hot tea when the resident got to the dining room. - 3/7/23: The resident complained that they were not receiving lunch meat sandwiches at night. The solution was to place a sign in the kitchen to remind staff. - 3/7/23: Complaints of not receiving what was on the menu. The solution was that dietary was to communicate with residents if there was a change in the menu. - 3/20/23: Complaints that soup was cold and the meat was tough. The solution was suggested to the aide to bring soup out to the resident right away, so it is hot. Also suggested the resident send food back if it is not right. April 2023: - 4/3/23: The resident asked for coffee and the dietary did not get it. The solution was the resident and dietary were advised to ask other staff for help serving if needed. - 4/12/23: The resident was served tomato soup and grilled cheese. The resident told the aide that they didn't like that meal and the aide walked away. The solution: when the aide was interviewed, stated that the resident said they didn't want anything else. Education was provided to offer other options. - 4/13/23: The resident complained that there was only one sandwich left in the fridge. The solution was to remind dietary to look at the sign posted in the kitchen to remind them, and for the resident to remind staff when sandwiches are low. - 4/26/23: Complaint that oranges were not served in a bowl and made the sandwich soggy. The solution was that dietary was advised to put sides into a small bowl. May 2023: - 5/1/23: Complaints that toast was burnt and the chili was spicy. The solution was that they purchased a new toaster. The soup is already seasoned, so the GO suggested adding more water to help with the spice. - 5/2/23: Complaints that the sandwich was soggy because soup spilled on it. The solution was that dietary offered to remake food and the resident refused. Suggested the resident go to dining room for meals. - 5/3/23: Complaint that supper was 45 minutes late. The solution was that the cook was new and received extra training. - 5/4/23: A resident complained that food wasn't served in a timely manner. The solution was to rotate what table was served first. - 5/4/23: A resident complained about the presentation of the food. The solution was to talk to the staff on how to make the food presentation better. - 5/4/23: A resident complained that they weren't satisfied with dinner and that the food was not the correct temperature. The solution was that the Dietary Manager audited food temperature and all temperatures were within limits. Encouraged residents to send food back to get reheated if it isn't hot enough. July 2023: - 7/19/23: The resident was served something they didn't like and complained to the dietary aide and asked for chicken noodle soup when the kitchen didn't offer an alternate meal. The solution was that education was provided to the dietary staff. - 7/19/23: Complained that sweet potato fries were cold. The solution was that the temperature of the fries was taken, but not documented and the resident was offered another item and refused. - 7/19/23: A resident complained that the broccoli soup was bad. The solution was that concerns were addressed with the new dietary supervisor, and they came up with a new process to help the cooks with preparation. August 2023: - 8/2/23: Complaint from a family member that a resident didn't receive breakfast by 9:00 AM. The solution was that the resident doesn't always eat breakfast. - 8/3/23: Complaint that the bacon was tough, and the resident couldn't chew it. The solution was that the cook stated they had been ordering pre-cooked bacon, and it was suggested to order regular bacon if possible. - 8/18/23: Complaint that sandwiches need to be on fresh white bread and the resident would like cream corn. The solution was that dietary was notified. September 2023: - 9/5/23: A resident complained that food was running together, making it soggy. The solution was to add onto the resident's menu to put sides in small bowls and a note was made to remind kitchen staff. In total from January through September 2023 there were 28 food related grievances filed. Observation on 10/3/23 at 12:13 PM Cook-J served a bowl of chicken noodle soup. Cook-J stated that the soup was steaming, and that cook-J could feel it was warm through the bowl. At 12:22 PM Cook-J served a hot dog. The Certified Dietary Manager (CDM)-I stopped Cook-J after serving the hot dog and asked the cook to temperature check a hot dog. The hot dog temperature was 165. The CDM provided education that all food temperatures need to be checked prior to serving. When the main dining room was completely served at 12:40 PM, a test tray was prepared. The Dietary Manager (DM)-G served 4 room trays, and then was asked to check food temperatures on the test tray. At 12:50 PM the temperatures were as follows: -chicken kiev: 123.6 degrees, -california blend vegetables: 117 degrees, and -noodles: 112.6 degrees. Interview with Admin on 10/4/23 at 2:25 PM confirmed that food grievances have not been getting addressed to prevent repeat similar food related complaints.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].04 Based on interview and record review; the facility failed to have staff who were trained and certified in Cardiopulmonary Resuscitation (CPR-emergency procedures performed if a person stops breathing or their heart stops) for transportation of residents identified as having a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive) status. This had the potential to affect 3 (Residents 19, 33 and 2) sampled residents identified as having a full code. The facility census was 40. Findings are: A. Review of the facility policy Cardiopulmonary Resuscitation with a revision/review date of ,d+[DATE] revealed it was the policy of this facility to provide Basic Life Support (BLS) including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advanced directives or a Do Not Resuscitate (DNR) order. Only staff members with current CPR certification for Healthcare Providers should perform the procedure. The facility was to ensure at least one certified staff member was always available. B. Review of the facility list of residents with a full code status revealed the following residents were designated as a full code; Residents 2, 19 and 33. During an interview on, [DATE] at 11:00 AM, the Director of Nursing (DON) and the Administrator confirmed the following: -any residents who had an appointment were currently transported by Nurse Aide (NA)-Q; -NA-Q had not completed CPR training and was not CPR certified; and -NA-Q would not be able to perform CPR if a resident stopped breathing or if their heart stopped.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, record review, and interview; the facility failed to serve food at palatable temperatures. The sample size was 16 and the facility census was 40. Findings are: A. Review of the facility policy titled Food, Reheating and Cooling during Tray Line, last revised 2/15/17 revealed the temperature of the food when the resident received it is based on palatability and the goal was to serve cold food cold and hot food hot. The recommended temperature of food at delivery to the resident was to be at the following temperatures: -cold entree: less than or equal to 50 degrees, -fruit or cold dessert: less than or equal to 50 degrees, -salads: less than or equal to 45 degrees, -hot entree: greater than or equal to 120 degrees, -waffles/pancakes, french toast: greater than or equal to 120 degrees, -starch: greater than or equal to 120 degrees, and -vegetables: greater than or equal to 140 degrees. B. Review of the facility form Food Temperature Log from 9/23 revealed the following food temperatures: -9/14/23: at 11:20 AM no temperature recorded for rice, meatballs, or vegetables, -9/22/23: at 5:05 PM tossed greens- room temperature-no temperature documented, -9/26/23: at 5:09 PM mashed potatoes- 106 degrees, -9/27/23: at 5:10 PM ham and cheese sandwich- 39 degrees/room temperature, mandarin oranges- room temperature- no temperature documented, -9/28/23: at 7:30 AM french toast- 120 degrees, -At 5:16 PM coleslaw- room temperature- no temperature documented, and -9/29/23: at 11:21 AM asparagus- 138 degrees. An observation on 10/3/23 at 11:40 AM the food temperatures were checked prior to serving by Cook-J with the following temperatures: -chicken kiev: 165 degrees, -pureed chicken: 170 degrees, -california blend vegetables: 146 degrees, -pureed vegetables: 142 degrees, -rotini noodles: 173 degrees, -hot dog: temperature not checked prior to serve out, and -chicken noodle soup: temperature not checked prior to serve out. Observation on 10/3/23 at 12:13 PM Cook-J served a bowl of chicken noodle soup. Cook-J stated that the soup was steaming, and that cook-J could feel it was warm through the bowl. At 12:22 PM Cook-J served a hot dog. The Certified Dietary Manager (CDM)-I stopped Cook-J after serving the hot dog and asked the cook to temperature check a hot dog. The hot dog temperature was 165. The CDM provided education that all food temperatures need to be checked prior to serving. When the main dining room was completely served at 12:40 PM, a test tray was prepared. The Dietary Manager (DM)-G served 4 room trays, and then was asked to check food temperatures on the test tray. At 12:50 PM the temperatures were as follows: -chicken kiev: 123.6 degrees, -california blend vegetables: 117 degrees, and -noodles: 112.6 degrees. An interview with Cook-J on 10/3/23 from 12:13 PM to 12:54 PM revealed the following: -Cook-J did not check the soup temperature prior to serving, -Cook-J does not typically check the soup temperature, -Cook-J did not check the temperature of the hot dogs prior to serving, and -Cook-J was unaware of what temperature food should be served at. Interview with DM-G on 10/3/23 at 12:50 PM revealed that DM-G was unaware of what temperature food should be served. Interview with CDM-I on 10/3/23 at 12:54 PM revealed that food should be served at 135 degrees or higher. Further interview confirmed that the vegetables and the noodles were not served at a palatable temperature. 29638 C. Review of Resident 6's Minimum Data Set (MDS-a federally mandated comprehensive assessment used in the development of the resident's care plan) dated 8/3/23 revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure and dementia; the resident's cognition was severely impaired; and the resident required set-up assist and cueing with eating and/or drinking. An interview with Resident 6's spouse on 10/2/23 at 10:55 AM revealed the resident was receiving a room tray for all meals. The spouse indicated the room trays were never delivered until the main dining room was served and the food on the room trays was always cold. During an observation on 10/2/23 at 12:32, PM the resident was served a room tray for the noon meal. The resident received roast beef with mashed potatoes and gravy and mixed vegetables. The resident upon tasting the food, indicated the food was warm but was not hot. During an observation on 10/3/23 at 7:58 AM, the resident was seated in a recliner in the resident's room. The resident's eyes were closed as if asleep. The resident had an uncovered breakfast room tray on a bedside table in front of the recliner. Medication Aide (MA)-B entered the resident's room and turned on the overhead light. Resident 6 was unaware of when the tray had been delivered and indicated the food was probably cold. There was no evidence MA-B offered to warm up the resident's food or offered the resident an alternative.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and staff interview; the facility failed to provide a safe environment for the prevention of accidents for Residents 9 and 45. Both residents sustained injuries from falls. Upon Resident 9's return from the hospital the facility failed to develop and implement interventions for the prevention of further falls. Facility census was 40. Findings are: A. Review of Resident 9's Minimum data set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/24/11 revealed [DIAGNOSES REDACTED]. The MDS further identified the resident had short and long term memory problems, unclear speech, and was totally dependent on staff for all activities of daily living. Review of the Fall Risk assessment dated [DATE] and 8/1/11 identified Resident 9 was at high risk for falls. Review of Resident Care Plan dated 8/11 revealed Resident 9 was at risk for falls due to cognitive loss and contractures of the legs and hips. The Resident Care Plan identified 1 intervention of a quarter rail to the left side of the bed. Review of Daily Notes dated 8/17/11 revealed, "Res (resident) fell out of bed at 1530 (3:30pm). C/o (complained of) R (Right) FT (foot) and ankle hurting. C/0 head hurting". Resident was taken to the local hospital and diagnosed with [REDACTED]. Review of the Resident Care Plan dated 8/27/11 revealed interventions added to the care plan were to, "Maintain splint to R lower extremity. Sheepskin b/t (between) knees all times". There were no additional interventions for the prevention of falls. Resident 9 was observed lying in bed on 9/15/11 at 2:30 PM, 9/19/11 at 7:15 AM, 8:50 AM, 9:55 AM, 9/20/11 at 9:15 AM and 9/21/11 at 7 AM with a quarter rail on the left side of the bed. No other fall prevention interventions were in place. Interview with the Director of Nurses on 9/20/11 from 3:35PM until 3:40 PM revealed additional interventions for the prevention of falls should have been implemented upon Resident 9's return from the hospital. B. Review of Resident 45's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further identified the resident ' s vision was severely impaired, had moderately impaired cognition, had short term memory problems and disorganized thinking. Review of the Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of Resident Care Plan dated 5/15/11 revealed the resident was forgetful at times and required staff reminders. The Resident Care Plan further identified the resident was at risk for falls and interventions were to assist with transfers as needed, and to work with Physical and Occupational therapies. The Care Plan further identified the resident used an electric scooter independently. Review of Resident 45's medical record revealed no assessment was performed to evaluate the resident's ability to safely use an electric scooter. Review of Daily Notes dated 6/21/11 revealed, "Behavior is worsening-getting more difficult to work with-delusional, confused". On 6/25/11 Daily Notes documented, "resident having increased confusion, unable to drive electric scooter". Review of the Change in Condition Report-Post Fall/Trauma revealed on 6/28/11 at 4:15 PM Resident 45 was being assisted into the facility van. The resident was on a scooter and was being assisted into the van via the van ramp. When the ramp was even with the van, the van driver asked the res to drive the scooter forward into the van. The resident put the scooter in reverse and drove off the van lift backwards onto the ground surface. The resident was transported to the emergency room of the local hospital. The resident had an abrasion to the back of the head. Resident 45 was treated and released back to the facility the same day. Further review of this same form revealed on 6/28/11 the Administrator documented on the Interdisciplinary Team review and Recommendations section, "Will do an evaluation for electric wheel chair. Will not be in electric wheelchair until evaluation is completed. Also will be policy put into place that no electric wheelchairs will be put on the lift for the van". Review of the Resident Care Plan following the incident revealed that on 6/29/11 an intervention was added for resident to have an electric scooter evaluation for safety. On 6/30/11 Resident 45 was evaluated for use of the electric scooter in the facility. The evaluation determined the resident was able to use the scooter in the facility but not on the van.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to implement interventions to prevent non-consensual sexual contact for 1 (Resident 1) of 4 sampled residents. The facility staff identified a census of 50. Findings are: A. Record review of an Admission Record sheet dated 6/04/2010 revealed Resident 1 was admitted to the facility on [DATE]. Record review of Resident 1's Minimum Data Set (MDS - A federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 6/09/2010 revealed the facility staff assessed the following about the resident: -Short and long term memory was ok. -Moderately impaired decision making. -Understood and was understood. -Socially inappropriate/Disruptive behaviors and resisted cares. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Independent with locomotion on and off the unit. -Wheeled self. -[DIAGNOSES REDACTED]. Record review of Resident 1's MDS dated and signed as completed on 11/24/2010 revealed Resident 1 was assessed to have "Physical behavioral symptoms directed towards others "(e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually)". Record review of Resident 1's Daily Notes dated 11/04/2010 revealed the following entry:" R (resident) was observed inappropriately touching another-female R breast area-staff immediately intervened et (and) explained R not allowed to do". Review of Resident 1's record did not contain evidence of any interventions to manage Resident 1's behavior to the female resident. During an interview on 11/29/2010 at 12:40 PM, the Director of Nursing (DON) identified Resident 2 as the female resident mentioned in Resident 1's Daily Notes dated 11/04/2010. Record review of Resident 1's Daily Notes dated 11/13/2010 revealed the following entry:" Reported to writer that this R was rubbing up (and) down the arm of another R, writer explained to R that it was not ok to touch another R...". On 11/29/2010 at 12:35 PM, an interview was conducted with Nursing Assistant (NA) A. During the interview, NA A identified Resident 2 as the resident mentioned in Resident 1's daily Notes dated 11/13/2010. NA A stated "I was the one who saw them". Record review of Resident 1's record did not contain evidence at the time of occurrence that interventions were implemented to manage Resident 1's sexual behaviors. During an interview on 11/29/2010 at 12:40 PM, the DON stated "touching (Resident 2's) arm was inappropriate due to Resident 1's prior history with (Resident 2)". Record review of Resident 1's Daily Notes dated 11/14/2010 revealed the following entry: "CNA (Certified Nursing Assistant) observed R inappropriately touching another R ... (Resident 2) -R had hand between female R legs- on outside of clothing-other R was removed immediately- et R used electric w/c (wheel chair) to return to room..." Record review of Resident 1's record did not contain evidence at the time of occurrence that interventions were implemented to manage Resident 1 sexual behaviors. Record review of a fax sheet to Resident 1's Physician dated 11/23/2010 revealed the following entry: Resident 1 "...has been witness physically touching the same female resident on 3 occasions. Twice he was rubbing her crotch and once he was rubbing her breast". Record review of Resident 1's Comprehensive Care Plan (CCP) dated 8/05/2008 revealed Resident 1 "becomes sexual towards women staff". Further review revealed on 11/23/2010 staff were to " monitor for (Resident 1) to be around female resident (Resident 2)" and to remove the resident from the situation immediately and to notify the charge nurse. B. Record review of an admission orders [REDACTED]. Record review of a Mini-Mental state Examination (MMSE - a screening for cognitive impairment) dated 1/07/2010 and 4/05/2010 revealed Resident 2 was not able to complete the exam. Record review of Resident 2's CCP dated 9/15/2010 revealed that Resident 2 had " poor communication skills and poor decision making. (Resident 2) is not able to make (gender) needs known verbally". Record review of Resident 2's MDS dated and signed as completed on 9/20/2010 revealed the facility staff assessed the following about the resident: -Resident 2 had short term memory problems. -Rarely/never understood or understands. -Independent with ambulation in the room and corridor. Record review of Resident 2's record did not contain an evaluation of Resident 2's reaction to the touching and rubbing as identified in the above information. On 11/29/2010 at 12:40 PM, an interview was conducted with the DON. During the interview, the DON confirmed Resident 1 had touched Resident 2 "inappropriately". When asked what interventions were implemented to prevent re-occurrence, the DON stated, "We we monitoring". When asked how the monitoring was being conducted, the DON stated "we just monitor where (Resident 1 and Resident 2) are". When asked if 15 minute checks should have been implemented and was that the expectation, the DON stated "yes". When asked other than the monitoring, was anything implemented to manage Resident 1's sexual behaviors towards Resident 2, the DON stated "no". During the interview, the DON confirmed Resident 2 was not able to state if anything happened or how Resident 2 felt about the inappropriate sexual touching. When the DON was asked how (gender) would feel if some one touched her in the same areas that Resident 2 was touch, the DON stated" I would be very very upset".