Every finding on record at Wilber Care Center

Licensure Reference Number 175 NA 12-006.09(I)Based on record review and interviews, the facility failed to implement interventions to provide a safe environment when residents are identified as at risk for elopement (when an individual with dementia leaves a safe or supervised area without authorization or knowledge) for Resident 1, Resident 2, and Resident 3. This affected 3 of 3 residents sampled for elopement. The facility census was 33.Findings are:A.A record review of the facility's Elopement-Missing Resident policy last revised 03/01/2024 and in place at the time of Resident 1's elopement revealed that preventative measures were:-maintenance supervisor to check all doors weekly to assure the Wanderguard doors were functioning.-identify residents at risk for elopement and put a Wanderguard device on them.-at 10:00 PM the charge nurse or designated person would ensure all alarmed doors were working properly and that all exit doors were locked.B.A record review of Resident 1's Continuity of Care Document (CCD) created 06-10-2026 revealed the facility admitted the resident on 04/22/2026 with diagnoses of Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills), and vascular dementia (a decline in thinking and reasoning skills caused by restricted or blocked blood flow to the brain).A record review of Resident 1's Resident Progress Notes revealed a note from 04/22/2026 at 10:46 AM that stated the resident was admitted from the assisted living side due to increased wandering (aimless walking in the facility, seemingly without purpose or direction) and confusion, and that the resident wore a Wanderguard (a system that combines a wearable band and a door alarm to alert staff when a resident wearing the band approaches the alarmed door) due to exit-seeking (attempts to leave a building or secured area). There was no mention of what day the Wanderguard was applied.A record review of Resident 1's Elopement Risk report completed 04/22/2026 revealed the resident was determined to be an elopement risk and that the preventative action taken was to apply a Wanderguard band and post the resident's photo.A record review of Resident 1's Care Plan (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed a care plan focus for wandering dated 05/14/2026 with an intervention dated 05/04/2026 of Equip resident with a device that alarms when wanders. Check for proper functioning of device daily and change per instructions. A record review of Resident 1's Medication Administration Record (MAR) from May 2026 revealed an order dated 05/04/2026 to check the Wanderguard to ensure placement and functioning once a day between 10:30 PM and 6:30 AM of the following day. Further review revealed that order was documented as Not Administered on 5/21/2026 through 5/24/2026 for the following reasons:5/21 wanderguard checker missing, 5/22 unablel [sic] to locate remote checker, 5/23 remote checker unavailable, and 5/24 test machine not available.A record review of Resident 1's Resident Progress Notes revealed a note from 05/25/2026 at 5:53 PM that revealed the resident had eloped and that the resident's Wanderguard had not set off the door alarm on exit or entry to the building.C.A record review of Resident 2's CCD created 06-10-2026 revealed the facility admitted the resident on 02/29/2024 and the resident had diagnoses of Alzheimer's disease and dementia.A record review of Resident 2's Elopement Risk report completed 05/15/2026 revealed the resident was determined to be an elopement risk and that the preventative action taken was to apply a Wanderguard band and post the resident's photo.A record review of Resident 2's Care Plan revealed a care plan focus for wandering dated 03/31/2026 with an intervention dated 03/31/2026 of Check wander guard placement and functioning every day.A record review of Resident 2's MAR from May 2026 revealed an order dated 03/31/2026 to check the Wanderguard device for proper functioning once a day between 10:00 PM and 6:00 AM of the following day. Further review revealed that order was documented as Not Administered on 5/22/2026 through 5/24/2026 for the following reasons:5/22 unable to locate remote checker, 5/23 remote checker unavailable, and 5/24 test machine not available.C.A record review of Resident 3's CCD created 06-10-2026 revealed the facility admitted the resident on 09/25/2024 with a diagnosis of dementia.A record review of Resident 3's Elopement Risk report completed 05/06/2026 revealed the resident was determined to be an elopement risk and that the preventative action taken was to apply a Wanderguard band.A record review of Resident 3's Care Plan revealed a care plan focus for wandering dated 05/21/2026 with an intervention dated 05/21/2026 to Please check wander guard on my walker daily to ensure it is working properly.A record review of Resident 2's MAR from May 2026 revealed an order dated 08/05/2025 to check the Wanderguard device for proper functioning and placement daily between 10:00 PM and 6:00 AM of the following day. Further review revealed that order was documented as Not Administered on 5/21/2026 through 5/24/2026 for the following reasons:5/21 wanderguard checker missing, 5/22 unable to locate remote checker, 5/23 remote checker unavailable, and 5/24 test machine not available.D.During an initial tour of the facility 06/10/2026 from 7:40 AM to 8:10 AM, the Maintenance Supervisor (MS) confirmed there was no set schedule for testing the Wanderguard system on the doors for functionality. The MS stated that they thought the nurses checked it at night, and that the MS did random checks of the system. The MS confirmed there was no documentation of those door checks.An interview on 06/10/2026 at 9:02 AM with the Interim Director of Nursing (IDON) confirmed that they thought maintenance checked the Wanderguard system on the doors. The IDON further confirmed there was no documentation of the doors being checked by nursing.An interview on 06/10/2026 at 11:03 with the Administrator (ADM) confirmed that the nurses check the wanderguard bands and doors. The ADM stated they were uncertain which doors were checked at night and confirmed there was no documentation of door checks being done.An interview on 06/10/2026 at 11:41 AM with Licensed Practical Nurse (LPN) A confirmed that the night nurses checked the doors nightly. LPN A stated they had worked nights occasionally but had not checked the doors or written it down anywhere.An interview on 06/10/2026 at 2:29 PM with the ADM confirmed that staff had not been checking residents' Wanderguard bands prior to Resident 1's elopement and that she was uncertain whether the testing device was not functioning or was missing. The ADM further confirmed there was no documentation of the Wanderguard system on the doors being tested for functionality.

Licensure Reference 175 NAC 12-006.02(H)Based on record reviews and interviews, the facility failed to submit an investigative report for Resident 1 within the required time frame. This affected 1 of 1 residents sample for reporting. The facility census was 33.Findings are:A record review of Resident 1's Continuity of Care Document created 06-10-2026 revealed the facility admitted the resident on 04/22/2026 with diagnoses of Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills), and vascular dementia (a decline in thinking and reasoning skills caused by restricted or blocked blood flow to the brain).A record review of Resident 1's Resident Progress Notes revealed a note from 05/25/2026 at 5:53 PM that revealed the resident had eloped (when an individual with dementia leaves a safe or supervised area without authorization or knowledge) and that the resident's Wanderguard had not set off the door alarm on exit or entry to the building.A review of an undated preliminary report provided by the facility Administrator (ADM) revealed that on May 25, (Resident 1) exited the supervised area of the facility.A review of Intake Information Report #3025859 and attached documents on 06/09/2026 revealed no facility investigation report.An interview on 06/10/2026 at 9:19 AM with the ADM confirmed the facility had not submitted a 5-day investigative report on Resident 1's elopement.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews and record review, the facility failed to ensure foods were sealed, labeled with date when opened and failed to follow the facility hand hygiene policy to prevent cross contamination while preparing food. This had the potential to affect all residents who ate foods served from the facility kitchen. The facility identified a census of 30. Findings are:A. Initial observation of the kitchen and dry storage room tour (looking at the kitchen from the entrance door adjacent to the dining room and working around room clockwise) on 05/18/2026 from 6:10 AM to 7:10 AM and revealed the following: Stand up freezer by kitchen entrance door temperature was -10 degrees Fahrenheit ( F) and revealed the following:-one loaf of bread dough opened and not dated-one package chicken patties opened and not dated-one package chicken strips opened and not dated Walk in refrigerator temperature 38 F log completed and revealed the following:-one package of sliced cheese opened and not dated-one package of shredded cheese opened and not dated-carrot and potato bins are noted to have residue on the outside of containers-large bowl of tuna salad made 5/14/2026 and is available for use-one bag of shredded lettuce opened and not dated Third freezer temperature was -8 F and revealed no expiration date was noted on the whipping cream in the bags or cartons. Dry storage room revealed the following:-one square plastic container with lid had raisin bran and another with corn flakes and were not dated. -one package three colored, macaroni, spiral and tube dry noodles opened in large plastic tote with lid. No date noted on open packages or tote.-one package of cherry gelatin not sealed or dated. B. Meal preparation observation on 5/20/2026 AM from 8:15 to 8:30 AM of Assistant Cook-A (AC-A) preparing lunch meal. AC-A performed hand hygiene (HH) with soap and water for 25 seconds. Then AC-A obtained nonstick spray and liquid thickener out of the cupboard, then took the cart to the supply room to obtain three jars of pizza sauce. AC-A then used bare hands to get rag from sanitizer solution bucket and wiped both preparation surfaces and did not perform HH. AC-A continued to get five cookie sheets with crusts in them from the refrigerator. AC-A then donned gloves without the benefit of HH, removed wax paper off each crust and pressed each crust down into edge of pan with soiled gloves. Then AC-A obtained two large steam tray pans from refrigerator, one with grated mozzarella cheese and one with a mixture of cooked crumbled ground beef and cooked small, cubed ham. AC-A then used spoon to spread sauce evenly on crusts, dividing the three jars of sauce to spread on the five pizza crusts. Then AC-A took the spoon to the dishwasher, obtained a new spoon to spread five scoops of meat evenly on each pizza, then continued to use same soiled gloves to spread meat to the edges on each pizza, even after touching all the other scoops and pans. The AC-A then removed the gloves, applied new gloves without HH, and obtained a new scoop for cheese. Next AC-A crumbled cheese with gloves on, filled scoop with one gloved hand, and spread the cheese on all five pizzas with soiled gloved hands. Lastly, AC-A covered each pizza with plastic wrap and placed them in the refrigerator. Observation on 5/20/2026 at 11:00 AM of AC-A pureed carrots and then performed HH for 15 seconds using soap and water. Record review of facility hand hygiene policy last revised 2/2025 revealed the following: Policy Interpretation and Implementation-Use an alcohol-based hand rub containing at least 62% alcohol or soap and waterb. before and after direct contact with residents and o. before and after eating or handling food.-Washing Hand1. Vigorously lather hands with soap and rub them together. for a minimum of 20 seconds. Interview with Dietary Manager (DM) on 05/20/2026 at 2:15 PM confirms that staff should wash hands between glove changes, according to the facility's hand hygiene policy, while preparing food. DM further confirms that AC-A should not have put gloved hands on the pizza to spread meat and cheese because this would be cross contamination. DM further confirmed food items in the kitchen should be labeled, dated and not left open to air.

Based on record review and interview, the facility failed to ensure information contained within the Facility Assessment was accurate and reviewed and updated at least annually. This had the potential to affect all residents who reside in the facility. The facility census was 30. Findings are: A record review of a folder provided to the surveyor on 5/18/2026 at 8:43 AM by the Administrator revealed it contained the Facility Assessment with a completion date of 1/27/2025. There was no evidence of the Facility Assessment being reviewed or revised since that date. An interview on 05/19/2026 at 1:50 PM with the Administrator confirmed the folder provided to the surveyor on 5//18/2026 at 8:43 AM was the facility's current Facility Assessment. Further record review of the Facility assessment dated [DATE] revealed the following information:-The facility had a total of 31residents,-The facility had 28 residents who were occasionally or frequently incontinent of bladder,-The facility had 31 residents on a urinary toileting program,-The facility had zero residents who had restraints,-The facility had zero residents requiring tube feeding,-The facility had zero residents with pressure ulcers, and -The facility had 1 resident with an ostomy. An interview on 5/20/26 at 1:30 PM with the Director of Nursing (DON) confirmed the following information:-The facility currently had one resident with a pressure ulcer,-The facility currently have one resident that required tube feeding,-The facility currently had one resident with a seatbelt restraint, and-The facility did not have any residents with an ostomy. An interview on 5/21/26 at 10:30 AM with the Administrator confirmed that the Facility Assessment was not accurate and it should have been.

Licensure Reference Number NAC 12-006.18(B) Based on observation, record review and interview, the facility failed to wear the required Personal Protective Equipment (PPE-personal protective equipment-special equipment, including gloves, gown, masks and eye protection, worn to prevent exposure to hazards such as infectious materials), place soiled linen in a linen bag, ensure supplies were placed on a clean surface and throw a soiled glove in the trash can all during wound care for Resident 1, and failed to perform peri-care in a manner to prevent cross-contamination, and complete hand hygiene when changing gloves and after assisting with cares for Residents 11 and 12. This affected 3 out of 3 sampled residents. The facility census was 30. Findings are: A. Record review of the facility's Hand Hygiene policy, last revised 02/25 revealed staff are to wash hands vigorously, lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds, or longer under a moderate stream of running water, at a comfortable temperature, rinse hands thoroughly under running water, hold hands lower than wrists do not touch finger tips to inside of sink and then dry hands thoroughly with paper towels and then turn off faucets with a clean dry paper towel, discard paper towels in trash. A review of facility policy Enhanced Barrier Precautions last revised on 04/16/2024 revealed that the facility policy statement stated EBP are utilized to reduce the transmission of multi-drug-resistant organisms to residents. The facility policy interpretation and implementation included EBP are used as an infection prevention and control to reduce transmission of multi-drug-resistant organisms to the residents. The staff are to wear gloves and gowns prior to performing high contact resident care activity. The facility examples of when to wear PPE are device care or use (central line, urinary catheter, feeding tube), wound care (any skin opening requiring a dressing.) The policy further confirmed that wounds to be included in PPE are chronic wounds such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers and unhealed surgical wounds. Record review of Resident 1's Face Sheet revealed an admission date of 7/24/24. Record review of Resident 1's Diagnosis List revealed that Resident 1 had type 2 Diabetes Mellitus without complications, hypertension (high blood pressure), chronic venous hypertension with ulcers of the bilateral lower extremities, and peripheral vascular disease. Record review of Resident 1's Order Summary dated 5/19/2026 revealed orders to: -Apply small edema wear to bilateral lower extremities from base of toes to just below knees on in the AM and off in the PM. -Paint blisters on bilateral lower extremities with betadine swab. -Assess blisters on bilateral lower legs weekly and document in wound management until resolved by facility protocol. -Resident 1's right great toe is to be assessed weekly and document in wound management until resolved. -Resident 1 is to have a weekly skin assessment on Thursday. Record review of Resident 1's undated care plan revealed Resident 1 had peripheral vascular disease and had a history of weeping vascular areas on their lower extremities. Resident 1 was at risk for further issues with the skin on their legs. There was a goal for Resident 1's open areas to heal without complication for Resident 1 to not experience an infection related to the open areas. The facility had the following approaches to assist in keeping Resident 1's bilateral lower extremities free from wounds: -Notifying the doctor if Resident 1's blisters, or open areas become worse or infected. -Resident 1 will wear edema wear as ordered. -Complete wound cares to Resident 1's lower extremities as ordered. -Staff are to encourage Resident 1 to elevate lower extremities while in bed or chair. -Facility staff to complete skin checks per facility protocol. During an observation on 05/19/2026 at 10:55 AM of Licensed Practical Nurse (LPN-G) obtained wound care supplies for Resident 1's lower extremities. LPN-G placed Vaseline gauze, gloves, scissors, a dry bordered foam dressing, and A & D ointment directly on Resident 1's bed. During a continued observation on 05/19/2026 at 10:56 AM, LPN-G washed hands with soap and water for 15 seconds and used the same paper towel to shut water off. Resident 1's right great toe was observed to have a black scab intact. LPN-G put on gloves, removed an old brown foam dry dressing from Resident 1's lower extremity and placed the soiled dressing directly on Resident 1's recliner seat. LPN-G completed hand hygiene (HH) via soap and water for 20 seconds, then wet a white towel with soap and water, put on new gloves and washed Resident 1's bilateral lower extremities, and then placed the soiled towel directly on the recliner cushion. LPN-G took off their gloves and performed HH with an ABHR (alcohol-based hand rub). LPN-G applied new gloves, cut small pieces of Vaseline gauze and applied to left lower extremity; LPN-G then placed a dry brown foam dressing over the gauze. LPN-G took off their gloves and performed HH with ABHR. LPN-G applied new gloves and then applied vitamin A & D ointment to Resident 1's right lower extremity and around the dressing to their left lower extremity. LPN-G then placed the A & D ointment tube back on Resident 1's bed. LPN-G performed HH with ABHR, applied gloves, and then painted small open areas to Resident 1's right and lower extremities with a betadine swab. LPN-G took off their right-hand glove and placed it directly on Resident 1's bed. LPN-G placed the used betadine swab in a trash can, obtained a clear trash bag and placed the soiled towel in trash bag, then removed their left-hand glove and placed it in the trash can. LPN-G then completed HH via soap and water for 20 seconds, removed wound care supplies from Resident 1's bed and placed them back in the treatment cart without first disinfecting them. During an observation on 05/20/2026 at 2:59 PM there was no Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes. EBP involves wearing a gown and gloves during high contact resident care activities, such as wound care) signage noted on the outside of Resident 1' s door or inside Resident 1's room. During an observation on 05/20/2026 at 3:00 PM Resident 1's room contained gloves, but no other PPE was noted in the room. During an interview on 05/19/2026 at 1:45 PM LPN-G confirmed that a soiled foam dressing should not have been placed on Resident 1's recliner cushion, the soiled towel should not have been placed on Resident 1's recliner, and the soiled glove should not have been placed on Resident 1's bed or used for a surface area for wound care supplies. LPN-G further confirmed that a gown should have been worn during Resident 1's wound care. During an interview on 05/20/2026 at 3:21 PM Director of Nursing (DON) confirmed that Resident 1's door should have an EBP sign and PPE should be in Resident 1's room. It was further confirmed that a gown should have been worn during wound care to Resident 1's bilateral lower extremities. The DON further confirmed that hand washing should have been at least 20 seconds. It was further confirmed that LPN-G should not have laid a soiled towel on a recliner or have wound supplies on resident bed for a clean surface and placed a soiled glove on resident bed. B. Record review of the facility policy titled Peri-care last revised 2/2025 revealed under Purpose: Perineal care should be done every time a patient is incontinent and/or every morning and every evening. Female peri-care: Wipe only front to back, use a different section of the disposable wipe, wash the buttocks and the anal area. Record review of the facility's Hand Hygiene policy last revised 2/2025 revealed under policy interpretation and implementation: Number 6: use an alcohol-based hand rub containing at least 62% alcohol or soap and water, b. before and after direct contact with residents. h. before moving from a contaminated body site to a clean body site during resident care. and m. after removing gloves. Record review of Resident 12's face sheet revealed the resident admitted to the facility on [DATE] with a diagnosis of age-related physical debility and disorientation. Record review of Resident 12's diagnosis list revealed that urge incontinence was added 7/16/2025, major depressive disorder, anxiety and dementia diagnosis were added on 8/30/2025, palliative care was added 9/2/2025 and constipation was added 2/24/2026. Record review of Resident 12's quarterly Minimum Data Set (MDS) (a federally mandated assessment that aides the facility in identifying care needs for the resident) dated 3/5/2026 revealed under Section C: a Brief Interview for Mental Status (BIMS)(a brief screening tool that assists in assessing a residents cognition, scoring 0 to 15 with 15 being cognitively intact) score of 99, which indicated the resident was unable to complete the interview and was cognitively impaired. In Section E the MDS revealed the was no rejection of cares and the resident wandered occurred daily. In Section GG it revealed the resident required assist of 2 for toileting, transfers and bed mobility. In Section O it revealed the resident was on hospice care. Record review of Resident 12's care plan last revised 12/18/2025 revealed under the Activities of Daily Living problem that the resident required assist of one to aid with dressing, toileting hygiene and locomotion. Under the Pressure Ulcer risk problem last revised 3/18/2026, staff were to provide incontinence care after each episode of incontinence. An observation on 5/20/2026 from 6:38 AM to 7:10 AM of Medication Aide (MA) - C and Nurse Aide (NA) - B providing morning cares to Resident 12 revealed the nurse aides entering the room and donning gloves without performing hand hygiene (HH). NA-B dressed Resident 12 part-way and sat the resident up on the side of the bed, put shoes on and brought the mechanical sit/stand lift close to the resident. After the staff buckled the resident in, the resident stood and the staff raised the lift and wheeled to toilet in the resident room where NA-B removed the resident's brief, which was visibly soaked, and then changed gloves without first performing HH. NA-B obtained two disposable wipes and wiped the resident from front to back with two swipes and without obtaining a new wipe, nor did NA- B cleanse the buttocks or hips of the resident. NA-B removed gloves and donned a new pair without first performing HH. NA-B then applied a new brief which MA-C pulled up, along with the resident's pants. The resident was then placed in the wheelchair utilizing the lift. MA-C washed their hands with soap and water for 12 seconds, dried them and left the room with the mechanical lift. NA-B then removed the resident's gown and applied a shirt. MA-C took the lift out of the room and did not complete HH. NA-B changed gloves without the benefit of HH and placed the resident at the sink, turned on the water and obtained a washcloth, towel, toothbrush and paste for the resident. Then NA-B applied toothpaste to the brush and removed gloves. NA-B then made the bed, applied one glove to right hand, removed the trash, obtained a bag for the dirty gown, left the room to put the linen and trash bags in the proper receptacle and then went directly across the hall to room [ROOM NUMBER] to assist another resident, without performing any type of hand hygiene. An interview with the Director of Nursing on 5/20/2026 at 2:25 PM confirmed that the expectation for peri-care would be to remove the resident's brief, clean front to back, including the buttocks, changes gloves before applying a new brief and that HH should be completed between glove changing and after resident cares. The DON confirmed the staff did not follow the policy and that no one was currently doing any peri-care audits to provide oversite to the staff. C. Record review of the facility policy titled Peri-care, last dated 2/2025 revealed wiping front to back starting in the middle working outward, never wash upward.Use clean section of cloth for each wipe. Pat the area dry in the same direction used for washing, wash buttocks working front to back. Record review of the facility's Hand Hygiene policy last revised 2/2025 revealed under policy interpretation and implementation: Number 6: use an alcohol-based hand rub containing at least 62% alcohol or soap and water, b. before and after direct contact with residents. h. before moving from a contaminated body site to a clean body site during resident care and m. after removing gloves. Record review of Resident 11's Face Sheet revealed the resident was admitted on [DATE] with a diagnosis of schizoaffective disorder, bipolar type (a mental disorder that can cause hallucinations, delusion, elevated mood, or impulsive behavior.) Record review of Resident 11's MDS dated [DATE] revealed the following: - BIMS score of 99 (which indicated the resident was unable to complete the interview) -Toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) revealed Resident 11 was dependent (resident does none of the effort to complete the activity.) -Always incontinent of bowels. -Dependent on helper for the following, toilet transfer, change in position while in bed or wheelchair. Record review of Resident 11's Care Plan, dated 3/19/2026 revealed the following: -risk for complete loss of activities of daily living (ADL) task completion; requires two assist with bed mobility and toileting, transfers -risk for skin integrity impairment; reposition with incontinent checks t/o night while laying in bed. An observation on 5/19/2026 from 9:40 AM to 9:56 AM of NA-D and NA-E providing cares for Resident 11 revealed the NAs entering the room and donned gloves without performing hand hygiene (HH). Both NAs used the mechanical full body lift to transport the resident from the tilt in space wheelchair to the bed. The nurse aides removed the resident's pants and each untaped one side of the brief and NA-D grabbed the premoistened wipes from the resident's nightstand. With the same soiled gloves, the NA reached in the package and began wiping the resident, one wipe was used for right side of the perineum, NA-D then grabbed a second wipe from the package and wiped the left side of the perineum, and then reached in the package for a third wipe while still wearing the same gloves, which was used to wipe down the middle of the perineum. Then both NAs rolled the resident to the left and NA-D removed the visibly soaked brief and discarded it in the trash. The outside layer of the brief had a brown color marking from the front to the back. NA-D then pushed the wipes down in the package and closed the top, all the while with soiled gloves. Both NAs, while still wearing the same soiled gloves, placed a new brief on the resident without providing peri-cares to the resident's buttock region. NA-D doffed gloves and both NAs continued to pull up the resident's pants. NA-E then doffed their gloves and both NAs continued to reposition the resident without first performing HH. NA-E removed the mechanical lift and tilt and space wheelchair from the room and placed them in the hallway opposite the resident's room. NA-E then came back into the room and performed HH and left the resident's room again. NA-D lowered the resident's bed to the lowest position and gave the resident a stuffed bear off the resident's nightstand. NA-D then performed HH right before leaving the room. An interview on 5/19/2026 at 9:50 AM with NA-D confirmed Resident 11's brief had been soiled. An interview with NA-B on 5/20/2026 at 2:00 PM confirmed the incontinence briefs used in the facility have a color indicator strip located from the front of the brief to the back which changes color when the brief detects moisture. An interview with the Director of Nursing (DON) on 5/20/2026 at 2:25 PM confirmed that the expectation for peri-care would be to remove the resident's brief, clean front to back, including the buttocks, changes gloves before applying a new brief and that HH should be completed between glove changing and after resident cares. The DON confirmed the staff did not follow the policy and that no one was currently doing any peri-care audits to provide oversite to the staff.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to ensure that a (As Needed) PRN antipsychotic medication was limited to 14 days for 1 (Resident 17) of 2 sampled residents. The facility census was 30. Findings are: A record review of the Policy Psychotropic Med Use dated 3-2-26 revealed PRN orders for psychotropic medications are limited to 14 days. For antipsychotic PRN orders, the order cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. A record review of Resident 17's Face Sheet with a printed date of 5/19/26 revealed that Resident 17 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (begin with mild memory loss and confusion, gradually advancing to severe cognitive and physical decline), generalized anxiety disorder (excessive, uncontrollable worry about everyday things like health, money, or work), Restlessness and agitation (feelings of severe inner tension, irritability, and an inability to be still) , and delirium due to known physiological condition (a sudden, temporary state of severe confusion and altered consciousness caused directly by an underlying medical illness, brain injury, or systemic physical stress rather than a primary mental health disorder). A record review of Resident 17's Minimum Data Set (MDS, a federally mandated comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 3/26/2026 revealed Resident 17 had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a residents cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 11/15 which indicated they had moderately impaired cognition. A record review conducted on 5/19/2026 of Resident 17's Active Orders revealed an order for Olanzapine (commonly known by the brand name Zyprexa, an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar disorder) to be given once a day As Needed (PRN). This order had a start date of 4/29/26 with an open-ended stop date, the order had been in place for 20 days. A record review of Resident 17's Medication Administration Record dated May 2026 revealed the resident received their PRN olanzapine on May 12th, 13th and 14th.An interview on 5/21/26 at 7:30 AM with the Director of Nursing (DON) stated that the nurses put in new orders into the system and the nurses were to double check the order to make sure the order was put into the system correctly. The DON confirmed that the nurses didn't always do the double checking of new orders. DON confirmed that the PRN psychotropic medication should of had a stop date on it and there was no stop date.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observations, interviews and record review, the facility failed to provide toileting to decrease the risk for skin integrity damage or infection for 2 (Residents 11 and 12) of 3 sampled residents. The facility identified a census of 30. Findings are:A.Record review on 5/18/2026 at 10:27 AM of Resident 11's Electronic Medical Record (EMR) face sheet revealed Resident 11 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type (a mental disorder that can cause hallucinations, delusion, elevated mood, or impulsive behavior.) Record review of Resident 11's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems), dated 3/04/2026 revealed the following:-Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 99 (which indicated the resident was unable to complete the interview),-Toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) revealed Resident 11 was dependent (resident does none of the effort to complete the activity),-Always incontinent of bowels, and-Dependent on helper for toilet transfers and change in position while in bed or wheelchair. Record review of Resident 11's EMR Care Plan, dated 3/19/2026 revealed the following:-risk for complete loss of activities of daily living (ADL) task completion; requires two assist with bed mobility and toileting, transfers-risk for bowel complications related to history of constipation; will have a regular, soft-formed bowel movement at least every 3 days through the next review, administer medications as ordered, document frequency of bowel movements and consult nurse with complaints of constipation or diarrhea.-cognitive loss; doesn't vocalize much, when resident does, often doesn't make sense, has difficulty communicating but at times able to make needs known. -risk for skin integrity impairment: reposition with incontinent checks t/o (throughout) night while laying in bed. Observations made from 5/18/2026 - 5/19/2026 revealed the following:On 5/18/2026:-At 6:30 AM observed Resident 11 in the dining room television area in a tilt in space wheelchair, reclined back.-At 8:10 AM Resident 11 was observed in same location as before, same position.-At 10:02 AM Resident 11 was observed in same location as before, same position. -At 10:36 AM Resident 11 was observed in same location as before, same position. -At 11:45 AM Resident 11 observed feeding self at table. Coughing noted after taking bites of food.-At 12:39 Resident 11 was moved from the table and placed in front of the TV in the dining room area. No toileting noted.On 5/19/2026:-At 7:52 AM Resident 11 was sitting up eating fruit loops and drinking regular fluids at the table in the dining room. No toileting noted.-At 8:31 AM Resident 11 was observed sitting in tilt in space wheelchair in same location and position as before.-At 8:55 AM Resident 11 was observed in same location and position as before.-At 9:41 AM Observed staff pushing Resident 11, in tilt in space wheelchair, to resident's room. Observed Nurse Aide (NA)-D and NA-E transfer resident to bed and performed perineal cares. Record review of the facility electronic medical record Point of Care documentation for toileting for Resident 11 revealed the following from 5/15/2026 to 5/19/2026:On 5/15/2026:-1:02 AM incontinent of urine-5:36 AM incontinent of urine-9:11 AM incontinent of urine-8:43 PM incontinent of bowel movement (BM)-8:44 PM incontinent of urineOn 5/16/2026:-1:26 AM incontinent of urine-5:33 AM incontinent of urine-6:33 AM incontinent of urine-1:32 PM Incontinent of BMOn 5/17/2026:-1:25 AM incontinent of urine-4:44 AM incontinent of urineOn 5/18/2026:-4:45 AM incontinent of urineOn 5/19/2026:-1:30 AM incontinent of urine-5:47 AM incontinent of urine-1:20 PM incontinent of BM During an interview with NA-B on 5/20/2026 at 12:30 PM confirmed that the staff are to document every time a resident is toileted and that this documentation goes into POC under output and that is where it shows the time, amount and whether a resident is incontinent or continent. NA-B went on to say that if a brief is soaked, they call it a large amount; if there are a few yellow spots, they call it a small. An interview with NA-B on 5/20/2026 at 2:00 PM confirmed the incontinence briefs used in the facility have a color indicator strip located from the front of the brief to the back which changes color when the brief detects moisture. NA-B further confirmed that each manufacturer has different color indicators. An interview with the Director of Nursing (DON) on 5/20/2026 at 2:27 PM confirmed when reviewing the toileting documentation for Resident 11, that the DON would have expected more toileting for Resident 11. DON also confirmed there is no toileting policy. B.Record review of Resident 12's face sheet revealed the resident admitted to the facility on [DATE] with a diagnosis of age-related physical debility and disorientation. Record review of Resident 12's diagnosis list revealed that major depressive disorder, anxiety and dementia diagnosis were added on 8/30/2025, palliative care was added 9/2/2025 and constipation added 2/24/2026. Record review of Resident 12's quarterly MDS dated [DATE] revealed under Section C a BIMS score of 99, which indicated the resident was unable to complete the interview and was cognitively impaired. Section E: no rejection of cares and wandering occurred daily. Section GG: required assist of 2 for toileting, transfers and bed mobility. Section H: Bowel and Bladder, shows frequently incontinent of urine and bowel. Record review of Resident 12's care plan last revised 12/18/2025 revealed under the Activities of Daily Living problem that the resident required assist of one to aid with dressing, toileting hygiene and locomotion. Under the Pressure Ulcer risk problem last revised 3/18/2026 provide incontinence care after each episode of incontinence. Under the Fall problem, last revised 4/03/2026, provide toileting assistance before and after meals during waking hours. Check every 2 hours during sleep hours. Observations of Resident 12 from 5/18/2026 to 5/19/2026 revealed the following:On 5/18/2026:-at 8:15 AM resident in the dining room feeding self.-at 9:15 AM resident sitting in the wheelchair in resident room in front of the bathroom door.-at 10:37 AM resident in the resident room in the wheelchair in same location, slouched down sleeping.-at 11:22 AM resident in the resident room in the wheelchair in same location, slouched down sleeping.-at 11:45 AM resident in the dining room, attempting to feed self.-at 12:40 PM resident in the dining room, attempting to feed self.-at 1:20 PM resident in the recliner in room. No observations of toileting during this observation period.On 5/19/2026:-at 7:52 AM resident in the dining room eating.-at 8:31 AM resident being assisted by staff in the dining room.-at 8:55 AM resident in the wheelchair in the resident room, trying to wheel about in room.-at 9:40 AM resident in the resident's room with hospice aide getting nails cleaned.-at 10:30 AM resident in the bath house.-at 11:45 AM resident in the beauty shop then staff took directly to dining room.-at 1:00 PM resident wheeling self out of the dining room and pulling self-down the hall with railing. -at 1:15 PM resident in the wheelchair in resident's room.-at 2:30 PM resident in same location in resident's room in wheelchair sleeping.-at 4:00 PM resident in same location in resident's room in wheelchair sleeping. An interview with NA-D on 5/19/2026 at 2:15 PM confirmed the resident had not been toileted since receiving a bath that day at 10:30 AM. Record review of the facility electronic medical record Point of Care documentation for toileting for Resident 12 revealed the following from 5/15/2026 to 5/19/2026:On 5/15/2026:-At 1:11 AM incontinent of urine.-At 5:36 AM incontinent of urine.-At 9:12 AM incontinent of urine.-At 8:46 PM incontinent of urine.On 5/16/2026:-At 1:26 AM incontinent of urine.-At 5:33 AM incontinent of urine.On 5/17/2026:-At 1:25 AM incontinent of urine.-At 14:44 AM incontinent of urine.-At 9:00 PM incontinent of BM.On 5/18/2026:-At 4:45 AM incontinent of urine and BMOn 5/19/2026:-At 1:30 AM incontinent of urine-At 5:47 AM incontinent of urine-At 1:18 PM continent of BM-At 2:55 PM incontinent of BM During an interview with NA-B on 5/20/2026 at 12:30 PM confirmed that the staff are to document every time a resident is toileted and that this documentation goes into POC under output and that is where it shows the time, amount and whether a resident is incontinent or continent. NA-B went on to say that if a brief is soaked, they call it a large amount; if there are a few yellow spots, they call it a small. An interview with the DON on 5/20/2026 at 2:25 PM confirmed when reviewing the toileting documentation for Resident 12, that the DON would have expected more toileting for Resident 12.

Licensure Reference Number 175 NAC 12-006.09 (H)(iv)(5) Based on observations, interviews and record review, the facility failed to provide bowel care according to facility protocol to keep residents from constipation for two (Residents 11 and 12) of three sampled residents. The facility identified a census of 30. Findings are: A. Record review of Resident 12's face sheet revealed the resident admitted to the facility on [DATE] with a diagnosis of age-related physical debility and disorientation. Record review of Resident 12's diagnosis list revealed that major depressive disorder, anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs) and dementia (a usually progressive condition marked by the development of multiple cognitive deficits) diagnosis were added on 8/30/2025, and palliative care was added 9/2/2025 and constipation added 2/24/2026. Record review of Resident 12's quarterly Minimum Data Set (MDS) (a federally mandated assessment that aides the facility in identifying care needs for the resident) dated 3/5/2026 revealed under Section C: a Brief Interview for Mental Status (BIMS)(a brief screening tool that assists in assessing a residents cognition, scoring 0 to 15 with 15 being cognitively intact) a score of 99, which indicates the resident was unable to complete the interview, and indicating the resident was cognitively impaired. Section E: no rejection of cares and wandering occurred daily. Section GG: required assist of 2 for toileting, transfers and bed mobility. Section O: on hospice care. Record review of Resident 12's care plan last revised 12/18/2025 revealed under the Activities of Daily Living problem that the resident required assist of one to aid with dressing, toileting hygiene and locomotion. Under the Pressure Ulcer risk problem last revised 3/18/2026 provide incontinence care after each episode of incontinence. No care plan noted to address new diagnosis of constipation that was added on 2/24/2026. Record review of Resident 12's physician orders revealed the following orders: Bisacodyl suppository; 10 milligram (mg) 1 suppository as needed (PRN); rectally: Special instruction: if no bowel movement (BM) for 3 days, administer. Bowel Protocol: If no BM. Day 1: administer 4 ounces of prune juice. Day 2: administer Milk of Magnesia (MOM) 30 milliliter (ml) orally. Day 3: Dulcolax Suppository Rectally. Day 4:Notify physician for further orders. Record review of the facility policy titled Bowel Care Policy effective date 6.28.2012 revealed: 1st day without BM, offer 4 ounces of prune juice or natural laxative. 2nd day without BM, give 30 cc orally of whatever is ordered by their physician on 6-2pm shift. 3rd day without BM give Dulcolax suppository as ordered. 4th day notify physician. Record review of Resident 12's bowel movement outputs from 5/5/2026 to 5/12/2026 revealed the following: 5/5/2026 no documentation related to BM's. 5/6/2026 none documented for BM. 5/7/2026 none documented for BM. 5/8/2026 none documented for BM. 5/9/2026 none documented for BM. 5/10/2026 small documented for BM. 5/11/2026 none documented for BM. 5/12/2026 large documented for BM. Record review of Resident 12's Medication Administration Record (MAR) for May 5 to May 12 revealed the following: 5/7/2026: Milk of Magnesium administered per PRN order 5/9/2026: Milk of Magnesium administered per PRN order 5/10/2026: Milk of Magnesium administered per PRN order 5/12/2026: Bisacodyl suppository per PRN order No evidence of prune juice being administered on Day 1 of no BM, nothing administered on Day 2, no evidence of following the Bowel Protocol or notifying the Physician after Day 4, and the suppository was given on Day 8. An interview with the Director of Nursing (DON) on 5/20/2026 from 2:25 PM through 2:55 PM revealed that the DON's expectations would be that after a resident goes 1 day without a BM, prune juice should be given, then day 2 without a BM the resident would get MOM, day 3 a suppository and day 4 an enema and notify MD if no results. The DON also confirmed that a small documented BM does not count and that the staff did not follow the bowel protocol for Resident 12. B. Record review on 5/18/2026 at 10:27 AM of Resident 11's Electronic Medical Record (EMR) face sheet, revealed the following: Resident 11 was admitted [DATE] with diagnoses that included: constipation (when the stool moves too slowly through the large intestine), Schizoaffective disorder, bipolar type (a mental disorder that can cause hallucinations, delusion, elevated mood, or impulsive behavior.) Record review of Resident 11's MDS dated [DATE] at 2:17 PM, revealed the following: -Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 99 (which indicated the resident was unable to complete the interview.) -Behavior symptom rejection of care (resident rejected evaluation or care that is necessary to achieve the resident's goal for health and well-being) was 0 (indicated resident did not exhibit behavior.) -Toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) revealed Resident 11 is dependent (resident does none of the effort to complete the activity.) -Always incontinent of bowels. -Dependent on helper for the following, toilet transfer, change in position while in bed or wheelchair. Record review of Residents' EMR Care Plan, dated 3/19/2026, revealed the following: -risk for complete loss of activities of daily living (ADL) task completion; requires two assist with bed mobility and toileting, transfers. -risk for bowel complications related to history of constipation; will have a regular, soft-formed bowel movement at least every 3 days through the next review, administer medications as ordered, document frequency of bowel movements and consult nurse with complaints of constipation or diarrhea. -cognitive loss; don't vocalize much, when resident does, often doesn't make sense, difficulty communicating but at times able to make needs known. Observations made from 5/18/2026 – 5/19/2026 revealed the following: 5/18/2026 -6:30 AM observed Resident 11 in the dining room television area in a tilt in space wheelchair, reclined back. -8:10 AM Resident 11 was observed in same location as before, same position. -10:02 AM Resident 11 was observed in same location as before, same position. -10:36 AM Resident 11 was observed in same location as before, same position. -11:45 AM Resident 11 observed feeding self at table. Coughing noted after taking bites of food. -12:39 Resident 11 was moved from the table and placed in front of the TV in the dining room area. No toileting noted. On 5/19/2026 -7:52 AM Resident 11 was sitting up eating fruit loops and drinking regular fluids at the table in the dining room. -8:31 AM Resident 11 sitting in tilt in space wheelchair in the TV area located in the dining room area. -8:55 AM Observed Resident 11 in same location and position as before. -9:41 AM Observed staff pushing Resident 11, in tilt in space wheelchair, to residents' room. Observed NA-D and NA-E transfer resident to bed and performed perineal cares. Record Review of Plan of Care subcategory bowel movement outputs from 5/13/2026-5/19/2026 revealed the following: -5/18/2026 None -5/17/2026 None -5/16/2026 Medium -5/15/2026 Large -5/14/2026 None -5/13/2026 Small -5/12/2026 None Record review on 5/19/2026 at 7:54 AM of Resident 11's Medication Administration Record (MAR) dated 5/01/2026 -5/19/2026 revealed the following: -Milk of Magnesia (magnesium hydroxide) suspension; 400 milligram (mg)/5 milliliters (mL), administer 30mL as needed (PRN) once a day, special instructions; given for constipation, notify nurse if no relief in eight hours, was given on 5/10/2026 at 1:20 PM and 5/15/2026 at 1:20 PM -Prune Juice 4oz ordered once a day PRN, special instructions; day one no bowel movement (BM) per facility protocol, none given during 5/01/2026-5/19/2026. -Dulcolax (bisacodyl) (a medication that contains a stimulant laxative to treat constipation) suppository; 10mg once a day PRN; rectal; give daily as needed for constipation. None given during 5/01/2026-5/19/2026. -Miralax (polyethylene glycol 3350) (laxative that increases the amount of water in the intestinal tract to stimulate bowel movements), 17 gram(gm)/dose, amount to administer: 8.5 grams once a day every other day.until stool is pudding consistency and is more regular BM every 1-3 days. Record Review of Bowel Care policy, effective date, June 28, 2012, revealed the following: -1st day without BM, offer 4oz prune juice or natural laxative. -2nd day without BM, give 30 cc po or whatever is ordered by their physician on 6-2 shift. -3rd day without BM give Dulcolax suppository as ordered. -4th day notify physician if no intervention is successful. No evidence of Bowel Care procedure noted in Resident 11's EMR. Facility did not provide evidence of a toileting policy/procedure, only the Bowel Care procedure. An interview with NA-B on 5/19/2026 at 1:58 PM confirmed toileting with Resident 11 should be when the resident gets up in the AM, around 10am, after lunch and at bedtime around every two to three hour range. NA-B further confirmed that toileting charting was supposed to be at the time it occurred and charted under outputs in the EMR. An interview on 5/20/2026 at 2:25 PM to 2:55 PM with DON confirmed the bowel protocol should go on each residents MAR and should document any intervention used. The DON further confirmed that Resident 11 did not have the protocol on the MAR, nor did the staff follow the facility bowel protocol.

License reference number NAC 12-007.03(K)Based on observation, and interview, the facility failed to provide a safe walkway in the hallway for ambulatory residents. This affected 1 out of 2 sampled residents but had the potential to affect all ambulatory residents. The facility census was 30.Findings are: A.Record review on 05/19/2026 at 2:58 PM revealed Resident 32 had an admission date of 02/07/2025. Record review of Resident 32's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 05/07/2026 revealed that Resident 32 had moderately impaired cognition and wandered daily. The MDS also revealed Resident 32 had vascular dementia, Alzheimer's Disease, and anxiety. Record review of Resident 32's care plan revealed that Resident 32 wandered without purpose. The facility had placed interventions on the care plan stating Resident 32 does wander and staff are to redirect Resident 32, and staff were to avoid over stimulation for Resident 32. Record review of Resident 32's Progress Notes revealed that on 05/01/2026 Resident 32 was wandering around the facility with a front wheeled walker. Record review of Resident 32's Progress Note dated 05/16/2026 revealed that Resident 32 had been confused all shift, had been pacing the hallways and was anxiously looking for their family. B.During an observation on 05/18/2026 at 10:03 AM Resident 8 was near the nurse's station beside a laundry cart that was parked in the hall. Resident 8 was attempting to walk down the hall. During an observation on 05/18/2026 10:35 AM Resident 8 was wandering up and down the 100 hall. During an observation on 05/19/2026 at 8:00 AM while Resident 32 was sitting in a recliner at the nurse's desk there were 6 large wheelchairs lining the inside of the hall. A sit-to-stand lift and a Hoyer lift were also on the inside of the wall. During an observation on 05/19/2026 at 1:41 PM Resident 32 was sitting in recliner by nurse's desk and there were 6 large wheelchairs lined up against the wall of the hallway. A sit to stand lift and a Hoyer lift were also lined up against the wall of the hallway. During an observation on 05/19/2026 at 3:34 PM there were 5 tilt and space wheelchairs, 1 sit to stand lift, 1 Hoyer lift, a tray table with an office wheeled chair pushed under the tray table, and on top of the tray table was a wireless keyboard that was lined up against the wall in the hallway. During an observation on 05/20/2026 at 6:34 AM there were 6 wheelchairs lined up against the wall, and a Hoyer lift. During an observation on 05/20/2026 at 8:33 AM there were 4 wheelchairs, 1 sit to stand lift, and 1 Hoyer lift out in the hallway lined up against the wall. During an observation on 05/20/2026 at11:33 AM there were 4 tilt and space wheelchairs, 1 sit to stand lift, and 1 Hoyer lift lined up against the wall in the hallway. During an observation on 05/20/2026 at 1:24 PM the beautician was ambulating next to Resident 32, who was utilizing a front wheeled walker to ambulate. The beautician was walking closest to the wall that had 6 wheelchairs lined up in a single file, 1 sit to stand and 1 Hoyer lift. When a staff member attempted to get past the beautician and Resident 32, the staff had to wait until they ambulated past the wheelchairs that were lined up against the wall. During an observation on 05/20/2026 at 2:45 PM Resident 8 was ambulating down hallway without assistance and had a shuffled gait. At that time there were 6 wheelchairs, 2 sit to stand lifts, and 1 Hoyer lift parked against the wall in the same hallway. In an interview on 05/20/2026 at 3:30 PM with the Director of Nursing (DON) confirmed that all the unused wheelchairs and lifts should be out of the hallway as this was a safety concern for residents who ambulated. The DON further confirmed that the facility did not have a storage policy for lifts or wheelchairs that were not in use.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report suspicions of abuse to the state agency within the required timeframe. This affected 2 residents, (Resident 1 and Resident 3). The facility census was 32. Findings are: A. A review of the facility's Investigation Report Abuse-Physical sent to the state agency's email on 02/20/2025 at 2:54 PM revealed that on 02/19/2025 at 4:30 PM a bruise was discovered on Resident 3's right back/hip and on 02/20/2025 at 1:59 PM the bruise was reported to Adult Protective Services (APS). A review of an undated summary written by the Director of Nursing (DON) revealed that Resident 3 had been unable to explain how the bruise happened. Further review revealed that the DON did not observe the area until 02/20/2025 at 1:00 PM, and the incident was not reported to APS until 02/20/2025 at 1:59 PM. An interview on 07/02/2025 at 2:31 PM with the DON confirmed that the report was called to APS more than two hours after the injury was discovered. B. A review of the facility's Investigation Report Abuse-Physical sent to the state agency's email on 03/07/2025 at 4:27 PM revealed that on 03/06/2025 at 6:20 AM a bruise was discovered on Resident 1's right hip and on 03/07/2025 at 10:30 AM the bruise was reported to APS. A review of an undated summary written by the DON revealed that when the DON spoke with Resident 1 on 03/06/2025 at approximately 11:30 AM, Resident 1 stated a Nurse Aide (NA) from a staffing agency had caused the bruise by being rough when turning the resident. and the incident was not reported to APS until 03/07/2025 at 10:30 AM. An interview on 07/02/2025 at 2:31 PM with the DON confirmed that the report was called to APS more than two hours after the allegation of abuse was made. C. A review of the facility's Investigation Report Abuse-Physical sent to the state agency's email on 06/19/2025 at 11:36 AM revealed that a bruise was discovered on Resident 1's left thigh on 06/10/2025. Further review of the report revealed that on 06/13/2025 at 9:27 PM the charge nurse notified the DON per phone that Resident 1 was stating the bruise on their left thigh had been caused by an NA pushing on the resident's thigh during a transfer. The bruise and allegation were reported to APS on 06/18/2025 at 10:06 AM. A review of an undated summary written by the DON revealed that the DON spoke with Resident 1 about the bruise on 06/14/2025 at 9:20 AM, and Resident 1 stated that NA had pushed their forearm into Resident 1's leg to adjust the resident's position while transferring them to the toilet using the Hoyer lift (a mechanical device used to lift and transfer residents). At an unspecified time on 06/17/2025 the DON was notified that Resident 1 had expressed being afraid of the NA. The incident was not reported to APS until 06/18/2025 at 10:06 AM. An interview on 07/02/2025 at 2:31 PM with the DON confirmed that the report was called to APS more than two hours after the allegation of abuse was made.

Based on record reviews and interviews, the facility failed to complete annual performance evaluations for 4 of 5 Nurse Aides sampled. This had the potential to affect all residents in the facility. The facility census was 37. Findings are: A record review of the employee file for Medication Aide (MA) D with a hire date of 09/19/2009 revealed a Staff Evaluation Report (SER) dated 09/19/2023 and signed by both the evaluator and the employee. A record review of the employee file for MA E with a hire date of 04/16/2022 revealed there was no SER available. A record review of the employee file for MA F with a hire date of 09/10/1998 revealed an SER dated 09/19/2023 and signed by both the evaluator and the employee. A record review of the employee file for MA J with a hire date of 05/18/2021 revealed an SER dated 08/17/2023 and signed by both the evaluator and the employee. A record review of the employee file for MA K with a hire date of 01/26/2022 revealed an SER dated 01/23/2024. This was signed by the evaluator only, and there was no documentation of discussion of review with the employee. An interview on 01/22/2025 at 2:12 PM with the Director of Nursing (DON) confirmed the facility had not been doing annual performance evaluations for the Nurse Aides or MAs. An interview on 01/22/2025 at 2:51 PM with the Business Office Manager (BOM) G confirmed that the facility did not have records of any SERs for MA E, and that these were the most recent SERs for MA D, MA F, MA J, and MA K.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to provide the required annual in-service training for 3 of 5 Nurse Aides sampled. This had the potential to affect all residents in the facility. The facility census was 37. Findings are: A review of the undated User Learning document provided for Medication Aide (MA) D revealed no documentation of any training completed after 10/08/2022. A review of the undated User Learning document provided for MA E revealed some training done in 2024. The Administrator (ADM) had written how many hours the individual courses were, and the total hours provided added up to 6.25 hours. A review of the undated User Learning document provided for MA F revealed no documentation of any training completed after 05/04/2023. An interview on 01/21/2025 at 3:08 PM with the ADM confirmed that MA D had no documentation of training more recent than 2022 and MA F had no documentation of training more recent than 2023. The ADM further confirmed that the hours written on MA E's User Learning record added up to less than 12 for 2024.

Licensure Reference Number 175 NAC 12-006.(18)(D) Based on observations, record reviews and interviews, the facility failed to ensure hand hygiene (using an alcohol-based hand rub (ABHR) or washing hands with soap and water) was completed in a manner to prevent cross-contamination during peri-care (washing the genitals and anal area) for Resident 8 and Resident 25 and during wound care for Resident 12. This affected 3 of 4 residents observed for peri-care and wound care. The facility census was 37. A record review of the facility's Handwashing/Hand Hygiene policy dated 12/05/2023 revealed that hand hygiene should be completed in the following situations: Before and after direct contact with residents; Before handling clean or soiled dressings; Before moving from a contaminated body site to a clean body site during resident care; After contact with blood or body fluids; After handling used dressings; and After removing gloves. The policy further revealed that glove use did not replace hand hygiene and that the procedure for washing hands with soap and water included rubbing hands together vigorously for at least 15 seconds. A record review of the facility's Standard Precautions policy dated 05/10/2024 revealed that gloves should be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. A record review of the facility's Peri Cares policy dated 2/2024 revealed that the anus is considered one of the dirtiest parts of the body and care should be taken to keep germs in the anal area away from the urethra. Peri-cares done on women should be done by separating the labia and washing around the urinary meatus (the place where urine comes out) by wiping downward from front to back. Cares should not be done by wiping upward from the anal area. A. An observation of peri-cares done on 01/21/2025 at 10:56 AM for Resident 8 revealed that the resident was transferred into the bathroom using a sit-to-stand lift. Medication Aide (MA) I and Nurse Aide (NA) L had gloves on and stated they had washed their hands prior to surveyor entering the room. MA I and NA L assisted the resident to stand in the sit-to-stand lift, then pushed the resident in the lift over to the bathroom. They stopped briefly between the wheelchair and the bathroom and MA I removed and discarded Resident 8's soiled brief, then continued to the bathroom where they lowered the resident onto the toilet. Without changing gloves or performing hand hygiene, MA I went to the closet and got a clean brief out of the package. The MA returned to the bathroom and without changing gloves or performing hand hygiene, got wipes out of the package. MA I and NA L then assisted Resident 8 to stand with the sit-to-stand lift. Without changing gloves or performing hand hygiene, MA I used the wipes to wipe down each groin fold from front to back, then between the labia from front to back. Used a different area of the wipes with each area. With the same soiled gloves, MA I put the new brief on Resident 8. MA I and NA L then pushed the resident back to the wheelchair and assisted the resident to sit. An interview on 01/21/2025 at 11:10 AM with MA I confirmed that the MA had not changed gloves or performed hand hygiene between removing the old brief and getting a new one, or between performing cares on the resident and putting on the new brief and confirmed that they should have. B. An observation of peri-cares done on 01/22/25 at 1:55 PM for Resident 25 revealed that MA E and MA M assisted Resident 25 assisted the resident to transfer from the recliner to the bed and get into position for cares to be done. MA E washed their hands with soap and water for 6 seconds, then put on gloves. MA M used ABHR and put on gloves. MA E opened Resident 25's incontinence pull-up, then used wipes to wipe under the resident's abdominal folds. MA E then changed gloves and did not perform hand hygiene. MA E and MA M assisted Resident 25 to roll to their left side, and MA E pulled the pull-up out from under the resident. MA E then got wipes and wiped the back part of the resident's peri-area and the buttocks, wiping front to back. MA E then changed their gloves without performing hand hygiene. Resident 25 then rolled back onto their back. MA E got wipes and first wiped Resident 25's groin folds back to front, and then wiped between the resident's labia from back to front. MA E then changed gloves without performing hand hygiene, put a clean pull-up on over the resident's legs, then applied a medicated cream to the resident's abdominal folds using a gloved finger. MA E then changed gloves without performing hand hygiene, and MA E and MA M assisted Resident 25 to roll back onto their left side. MA E applied barrier cream to the resident's buttocks and peri-anal area using a gloved finger, then changed gloves with no hand hygiene and started to pull up the resident's pull-up. MA E then removed their gloves, and MA E and MA M assisted the resident to stand. MA E and MA M finished pulling up the pull-up, then assisted the resident back into the recliner. MA M then removed their gloves and washed their hands with soap and water for 11 seconds. MA E then washed their hands with soap and water for 8 seconds. An interview on 01/22/2025 at 2:05 PM with MA M confirmed that they should have washed their hands for 20 seconds. An interview on 01/22/25 at 2:06 PM with MA E revealed they did not know how long hand washing should be done. MA E confirmed they should have sanitized their hands when changing gloves. The MA further confirmed that peri-cares should be done from front to back, and that they should not have wiped Resident 25's peri-area from back to front. C. An observation of wound care done on 01/21/2025 at 11:06 AM for Resident 12 revealed the Director of Nursing (DON) already had gloves on when surveyor entered room. The DON stated they had washed her hands and gathered supplies prior to putting on gloves. The DON used a wet soapy washcloth to wash Resident 12's wound on their abdomen, then used a wet washcloth to wipe the soap off. The DON then changed their gloves without performing hand hygiene, applied the ordered cream and covered the area with a 2x2 gauze dressing. An interview on 01/21/2025 at 11:06 AM with the DON confirmed they had not performed hand hygiene when changing their gloves between washing the wound and applying a new dressing. The DON confirmed they had not done hand hygiene at that time because their hands were not visibly soiled. D. An interview on 01/22/2025 at 11:24 AM with Licensed Practical Nurse (LPN) A, who is the Infection Preventionist for the facility, confirmed that handwashing would be expected when changing gloves between washing a wound and putting a clean dressing on, and that the expectation would be for gloves to be removed and hand hygiene to be performed between removing the soiled/wet brief and getting a new clean one, and between performing peri-cares and putting on a clean brief. An interview on 01/22/2025 at 2:12 PM with the DON confirmed that peri cares should be done front to back.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) regarding use of an anti-anxiety medication for Resident 8 and for use of a Bilevel Positive Airway (BiPAP-a machine used to deliver positive airway to a person's airway to prevent it from closing during sleep) for Resident 18. This affected 2 (Resident 8 and Resident 18) of 16 residents sampled for MDS accuracy. The facility census was 37. Findings are: A. A review of Resident 8's Continuity of Care Document (CCD) created 01/16/2025 revealed an admitted [DATE] and a diagnosis of anxiety. A review of Resident 8's Physician Order Report from 12/16/2024 to 01/16/2025 revealed an order for lorazepam (an anti-anxiety medication) 0.5 milligrams once a day by mouth for anxiety. A review of Resident 8's Quarterly MDS dated [DATE] revealed that Section N-Medications was not marked to show that Resident 8 was on an anti-anxiety medication. A review of Resident 8's Medication Administration Record (MAR) for November 2024 revealed the lorazepam had been signed as administered during the look-back period (the time frame during which the resident's condition is evaluated for the MDS) of 11/15/2024 to 11/21/2024. An interview on 01/22/2025 11:41 AM with the MDS Coordinator confirmed that the anti-anxiety medication was not coded on the MDS dated [DATE] and should have been. B. A review of Resident 18's CCD created 01/16/2025 revealed an admitted [DATE] and a diagnosis of obstructive sleep apnea (OSA-a condition where the throat muscles relax and narrow during sleep, interrupting breathing). A review of Resident 18's Physician Order Report from 12/16/2024 to 01/16/2025 revealed an order for a BiPAP every evening, to be worn through the night. A review of Resident 18's Admission MDS dated [DATE] revealed that Section O-Special treatments, Procedures, and Programs was not marked to indicate the resident used a Non-invasive Mechanical Ventilator, which is the BiPAP, either on admission or while a resident. A review of Resident 18's MAR for November of 2024 revealed the BiPAP had been signed as administered during the look-back period of 11/22/2024 to 11/28/2024. An interview on 01/22/2025 11:41 AM with the MDS Coordinator confirmed that the BiPAP was not coded on the MDS dated [DATE] and should have been.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to complete a trauma based assessment for 1 (Resident 7) of 5 sampled residents. The facility census was 37. Findings are: A record review of Resident 7's Significant change Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 9/20/2024 revealed an admitted [DATE], a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 1 which suggests severe cognitive impairment, and diagnosis of Anxiety, Depression and frequent pain. A record review of Resident 7's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 12/16/2024 revealed no history of trauma. In an interview on 1/15/2025 at 2:59 PM with Resident 7's representative revealed that the resident was attacked by a cow about [AGE] years ago and it messed (gender) up pretty bad. In an interview on 1/21/2025 at 9:14 AM the Director of Nursing (DON) confirmed there is not a Trauma informed care assessment completed on any resident and trauma was not identified on Resident 7's CCP. It was further confirmed there was no Social Worker at this time. Record review of the facility policy titled Comprehensive Care Plans, dated 3/2024 revealed the definition of trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. In an interview on 1/22/2025 at 3:40 PM the DON confirmed there was no facility policy regarding Trauma Informed Care or facility trauma based assessment.

Licensure Reference number 175 NAC ,d+[DATE].09 Based on record review and interviews, the facility failed to notify a resident representative and provider regarding a change in condition for 1 (Resident 37) of 1 sampled residents. The facility census was 35. Findings are: A record review of Residents 37's Face Sheet dated [DATE] revealed Resident 37 had the following diagnoses: hypertension, Pneumonia, Flu, COVID-19, arthritis, cystitis, Generalized Weakness, Peripheral vascular disease, Mixed hyperlipidemia, Hypokalemia, depressive disorder, and Anxiety disorder. A record review of the form titled [NAME] Care Center Documentation Guidelines, last updated ,d+[DATE] revealed: - document in progress notes any cognitive, medical changes that effect a residents daily functioning. This will be documented every shift until resolved and/or addressed by a physician. Record review of Resident 37's Progress Notes revealed on [DATE] at 11:30 PM the facility staff reported to the nurse that Resident 37 was having an emesis. Record review of Resident 37's Progress Notes revealed on [DATE] at 7:01 AM that Resident 37 placed their call light on and had another emesis. The Progress Note revealed the resident asked the staff member if they (the resident) was going to die today and staff responded with asking the resident why [gender] would ask that. The Progress Note revealed Resident 37 responded and stated I just wanted to die. Record review of Resident 37's Progress Notes revealed on [DATE] at 6:30 AM the facility staff found Resident 37 to be unresponsive and alerted the nurse. The Progress Note revealed the resident's vital signs were ceased and a phone call was made to the resident's family representative to inform of Resident 37's passing. Recod review of Resident 37's Progress Notes, revealed there was no documentation Resident 37's representative or provider was notified of Resident 37's change of condition until the resident expired. An interview on [DATE] at 10:30 AM with Licensed Practical Nurse (LPN) revealed that when a resident has a change of condition the resident should be assessed, a progress note should be entered into the resident's electronic health record and the medical provider and resident representative should be notified. An interview on [DATE] at 10:45 AM with the Director of Nursing (DON) confirmed when a resident has a change of condition the resident's family member and medical provider should be contacted. The DON confirmed Resident 37's Progress Notes should have contained all information of Resident 37's change of condition and the notifications to the resident's family and provider. The DON confirmed Resident 37's medical record did not contain notifications to the resident representative or medical provider.

Licensure Reference Number 175 NAC 12-006.09D7b Based interview, and record review; the facility failed to conduct a thorough investigation to determine the root-cause of falls and failed to develop and implement effective interventions to minimize and/or prevent falls for 1 (Resident 23) of 1 sampled resident. The facility census was 35. Findings are: Interview on 2/7/24 at 10:38 AM with Resident 23's resident representative (RR) revealed that Resident 23 had a fall two weeks ago and scraped up Resident 23's left arm and elbow. The RR further revealed that Resident 23 walks independently without a walker or cane and is unsteady at times. Observation on 2/7/24 at 11:40 AM revealed Resident 23, with no assistive device, standing next to the window at the nurse's station talking with the staff. Interview on 2/12/24 at 9:38 AM the Medication Aide (MA) revealed that Resident 23 can walk independently and at times Resident 23 is unsteady. MA further revealed that Resident 23 has attempted to assist Resident 23's roommate to stand. Observation on 2/12/24 at 9:40 AM revealed Resident 23 seated on a folding chair in Resident 23's room. Review of Resident 23's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 11/5/23, revealed the following: -admitted on [DATE] with diagnoses of: Alzheimer disease with late onset and orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down) -Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 4 -ambulated independently without an assistive device -had no falls in the six months prior to admission or since admission -took an anti-psychotic medication (used to treat certain mental/mood disorders) -Fall care area was triggered and the decision was made to care plan the area based on nurses' notes, observation 11/23 Review of a progress note dated 1/18/24 at 11:35 PM revealed the following: At 9:10 PM, MA reported to this nurse that resident has a blood stain on pants and floor and also has a skin tear. When asked resident, stated fall while ambulating in the hallway. Said, I slid and fall in the hallway. On Observation: resident has a skin tear (measure 2.3 x 6.5cms) on left elbow area with part of the skin missing. Dried blood observed on floor, dress and injured area. Nursing management: Cleaned with a water, painted with a betadine and steri-strips applied. Denied pain and discomforts, no other injuries/bruises noted. Full range of motions without pain/limitation. Refused pain medication. Neuro checks (checks used to identify and assess the functions of vital portions of the central nervous system) initiated. Physician notified via fax. Need to notify family member. Review of Resident 23's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 1/18/24 revealed no fall interventions in place along with the following: -Falls: I have dementia and get confused where I am, I do not want to fall, problem start date: 1/18/24 and edited 2/8/24; Long Term Goal Target Date: 3/18/24: I will not have falls, and if I do I will not get injured, created 2/8/24; Approach Start Date 1/18/24: I had a fall that I reported to the nursing staff, I did have a left elbow skin tear noted, created 2/8/24 Review of the facility Resident Fall Event Documentation policy, dated 10/11/23, revealed the following: -1. When a fall is reported/observed the charge nurse will assess resident status. Vitals, ROM (range of motion) level, cognition level, body assessment to check for injury, staff and resident interview will be completed. Paying close attention to surrounding environment and location of assistive devices as well as any obstacles that may be immediate area. -3. The charge nurse will document even in the Event Section of Matrix (computerized health system) under WCC Fall form-SNF. Each section of event documentation must be completed. Review of the event report: Safety report Copy of WCC ([NAME] Care Center) fall form snf (skilled nursing facility), dated 1/18/24, revealed the following: -What did the RESIDENT SAY They were trying to do at time of event? While walking resident slid on the floor -What was the reason this event/fall occurred: unknown -Indicate initial measures taken to prevent further falls: place the resident sit at the nurse's station and occupy with a task. Review of the facility January Nurse Meeting Agenda, dated 1/16/24, revealed that an immediate intervention needs placed on the CP (care plan) or progress notes. Review of the facility Fall Prevention and Management Program, dated 1/29/24, revealed the following: -B. Fall and Post Fall Assessment and Management: When a resident has fallen, the resident will be assessed regarding the nature of the fall and associated consequences, the cause of the fall and the post fall care management needs. Interview on 2/12/14 at 1:26 PM the Interim Director of Nursing (IDON) confirmed that the root cause of Resident 23's fall on 1/18/24 was not determined, and that neither the initial measure of having the resident sit at the nurses' station and occupy or the approach/intervention created on the care plan on 2/8/24 addressed the root cause of the fall. The IDON further confirmed that a root cause should be determined with each fall and the care plan should be updated with an approach/intervention that addresses the root cause.

175 NAC 12-006.05(5) Based on record review and interviews, the facility failed to provide a written notice of transfer to Resident 23 and Resident 6 and/or their representatives upon transfer to the emergency room (ER). The facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) of transfer for Resident 23 and Resident 6. This affected 2 of 2 residents sampled for hospitalization . The facility census was 33. Findings are: A. Record review of Resident 23's Electronic Health Record (EHR) revealed the resident was sent to theER on [DATE] with respiratory complaints and returned to the facility on [DATE]. Resident 23's EHR revealed Resident 23 was sent back to the ER with a change in responsiveness and a decreased oxygen saturation (an indication of how well the lungs are working) and was admitted to the hospital. An interview on 04/06/23 at 10:48 AM with the Social Services Director (SSD) revealed the facility did not complete a written notice of transfer to the ER for Resident 23. An interview on 04/06/23 at 01:45 PM with the Director of Nursing (DON) revealed the facility did not notify the Ombudsman of resident transfers to the hospital. 47406 B. Record review of Resident 6's EHR revealed that Resident 6 was transferred to theER on [DATE] with symptoms of pale skin, lethargy, low oxygen saturation and diminished lung sound and was admitted to the hospital. Record review revealed that there was not documentation that the facility notified the resident or resident's representative of the transfer in a written notice and the reason for the move in writing and in a language and manner they understand. An interview with the SSD on 4/10/23 at 11:45 am revealed the facility did not notify the resident or the resident's representative of the written notice of transfer of the ER and did not notify the Ombudsman of transfer to the ER.

Based on observation, record review, and interview; the facility failed to put measures in place to prevent cross-contamination (the transfer of disease-causing organisms from one surface to another) by failing to store oxygen cannulas (the part of the tubing that goes into the nostrils) for Resident 25 and a CPAP (Continuous Positive Airway Pressure - a treatment that uses mild air pressure to keep your breathing airways open) mask for Resident 6 in a clean manner. This affected 2 of 2 residents sampled for respiratory care. The facility census was 33. Findings are: A. An observation on 04/05/23 at 09:37 AM of Resident 25's room revealed the resident had a portable oxygen tank attached to the wheelchair (w/c) with oxygen tubing hanging over the w/c handle and the cannula resting on the w/c seat. An observation on 04/05/23 at 10:04 AM of Resident 25's room revealed the oxygen tubinghanging over the w/c handle and the cannula resting on the w/c seat. An observation on 04/05/23 at 12:55 PM of Resident 25's room revealed the oxygen tubing and cannula were hanging on the w/c handle. An interview on 4/05/23 at 12:55 p.m. with Resident 25 revealed that resident had recently returned to his room from lunch in the w/c. An observation on 04/06/23 at 07:20 AM of Resident 25's room revealed resident's oxygen tubing was hanging over the back of the w/c. An observation on 04/06/23 at 10:35 AM of Resident 25's room revealed the oxygen tubing hanging over the back of the w/c. Record review of the facility's Oxygen Administration Policy dated 3/7/22 revealed no direction regarding storage of oxygen tubing/cannula. An interview on 04/06/23 at 02:19 PM with the Director of Nursing (DON) confirmed that resident's oxygen tubing and nasal cannula was not being stored in a manner to prevent contamination. 47406 B. An observation on 04/05/23 at 9:00 AM revealed Resident 6's CPAP mask was laying on top of CPAP machine without being covered. An observation on 04/06/23 at 11:25 AM Resident 6's CPAP mask was laying on top of CPAP machine without being covered. Record review of CPAP/BIPAP Cleaning Policy dated 3/7/11 did not mention how to store a CPAP mask to prevent contamination. Interview with the Infection Preventionist (IP) on 4/6/23 at 1:40 PM revealed that the resident's CPAP mask was not being stored in a manner to prevent contamination. Interview with the Director of Nursing (DON) on 04/06/23 at 2:00 PM revealed that the resident's CPAP mask was not being stored in an manner to prevent contaminiation.

Based on record review and interview, the facility failed to notify the physician of a significant change of condition related to weight loss for Resident 2. The sample size was 12. The facility census was 35. Findings are: A record review revealed the facility Matrix (a document used to identify pertinent care categories for the last 30 days for all residents) indicated a significant weight loss for Resident 2. A record review of the weights for Resident 2 revealed a weight on 7/31/21 of 153.2lb and a weight on 12/6/21 of 109.5 which equaled a 28.76% weight loss in the last 6 months. A record review of the Progress Notes dated 7/14/21 through 12/14/21 revealed no physician notification related to weight loss over the last 6 months. A record review of a documents section titled Doctor notifications dating 7/14/21 through 12/14/21 revealed no physician notification related to Resident 2's weight loss. A record review of the documents titled Dietary Communication to Physician and dated 12/8/21 revealed a request had been sent to the physician to begin a new supplement to increase calories and protein intake, but did not mention weight loss or give a current weight. An interview on 12/14/21 at 09:05 AM with the CDM (Certified Dietary Manager) after review of the documents titled Dietary Communication to Physician and dated 2/10/21 through 12/8/21, confirmed that no physician notification of Resident 2's continued weight loss had occurred since February 2021.

Licensure Reference Number: 175 NAC 12-006.09D7b Based on observation record review and interview, the facility failed to identify causal factors and implement individualized interventions to prevent reoccurrence of falls and injury for three of three sampled residents involved in falls, (Residents 2, 18, and 43). The facility census was 48. Findings are: A. On 8/29/2019 at 11:44 AM interview with MDS (Material Data Set, a comprehensive assessment tool use to complete care plan for residents) Coordinator confirmed that multiple interventions were the same in Resident 43's care plans for falls. MDS Coordinator and DON (Director of Nurses) confirmed that on dates 1/2/18 and 12/29/17 assessments did not have causal factors documented for Resident 43. On 8/29/18 at 11:00 interview with DON and Administrator revealed that they are not able to staff the special care unit with 2 care givers and the staff should be calling for help if they are in a room with resident for extended periods of time. On 08/27/18 at 10:01 AM an observation of resident 43 had been ambulating in the hallway wondering back and forth. The Certified Medication Aide (CMA) B was in the bathroom giving a bath to Resident 5. Therapy Staff Member came out of a room and took Resident 2 off the unit and the door alarm sounded. The CMA B that was with Resident 5 in the bath house came to the door of the bath house to see what set the alarm off, leaving Resident 5 unattended in the bath tub. House Keeping Staff Member A was left in the resident area to monitor residents while the CMA B was in the bath house, the Housekeeper A had mopped floor and had been attempting to keep Resident 43 off the wet floor. Resident 43 was able to get to the wet floor nearly slipped and almost fell . The Housekeeper A was able to steady Resident 43. Resident 43 had been in room [ROOM NUMBER] and room [ROOM NUMBER] without supervision. Record review of Fall Investigation/Occurrence Report dated 6/16/18 at 4:15 PM revealed Resident 43 fell in day room. Resident 43 had fallen over the feet of another resident. Resident 43 was ambulating independently with shoes and was continent of urine. The resident had an injury requiring sutures. Record review of Progress notes dated 6/16/18 at 9:15 PM revealed at 4:15 PM the resident walked around in living area and tripped over another resident's feet. Resident 43 fell and put hand out to catch self. This resulted in a 8 cm laceration on the residents chin which required sutures. Record review of Care Plan interventions dated 6/17/18 for the fall on 6/16/18 revealed an intervention to monitor closely when ambulating. Record review of Fall Investigation/Occurrence Report dated 6/17/18 at 5:10 PM revealed Resident 43 had a fall in the activity room. Resident 43 tripped on a walker. Resident 43 was alert but disoriented, ambulated independently without a device with shoes on and was continent. The root cause was object in the way. Record review of Care Plan interventions dated 6/18/18 for fall on 6/17/18 revealed walk with Resident 43 as much as allowed by resident and monitor for safety. Record review of Progress note dated 6/17/18 8:41 PM Revealed Resident 43 had a fall by tripping over a walker and falling on buttocks without injury. Record review of Fall Investigation/Occurrence Report dated 6/21/18 6:00 AM revealed Resident 43 had a fall to the floor in the dining area while ambulating independently with shoes. Resident 43 was alert but confused and was continent. The root cause was unsteady gait and questioning shoes sticking to floor. Record review of Fall Investigation/Occurrence Report dated 7/6/18 0840 AM revealed Resident 43 had a fall in the lounge of the Special Care unit. There were no factors noted. Resident 43 had an injury of a bruise to the left cheek bone. The root cause had Unknown and Questioned poor gait. Record review of Progress note dated 7/6/18 at 4:15 PM revealed Resident 43 was observed on floor at 08:40 AM. Resident 43 was laying on the left side in front of television in the lounge area. At 11:00 AM an area bruising had been noticed on the right cheek and measured 3 cm x 3 cm. Record review of Care Plan interventions dated 7/6/18 revealed to encourage rest periods after breakfast. B. Record review dated 12/9/17 MDS section C revealed BIMS (Brief Interview for Mental Status) an assessment tool for cognition status, Resident 2 scored 09 indicating moderate impairment. On 8/9/18 MDS (Material Data Set) an assessment used to develop a comprehensive care plan, Section C BIMS score was 04 indicating severe impairment. Record review of Resident 2's progress notes revealed the following: - Fall on 12/18/2018: no Injury - Fall on 1/3/2018: no Injury Fall investigation dated 12/18/17 at 3:35 AM revealed that there were no factors observed at the time of fall. Resident 2 was bare foot, alert but confused. Resident 2 had a bed alarm that had been used, unknown if the alarm had been sounding. Resident 2 was incontinent. No injury. The box with what appears to be the root cause is blank. Record review of Progress noted dated 1/3/18 at 0247 Observed on floor in Special Care Unit in dining area. Had back toward chair. By the time this nurse got to him, he managed to get himself up and into the dining room chair. Is uncooperative and agitated at the time. When asked what happened he states I know but I'm not telling anyone. Neuro checks started but refused to participate in most things asked. When returned to do next set of neuro checks, was more cooperative and joking with staff again. At that time when asked what happened states, I don't remember. Blood pressure elevated first set but back down to normal range with second Blood pressure taken. Denies any pain. No injury noted. Record review of Fall Investigation/Occurrence Report dated 1/11/18 0410 Factors: Resident slipped, Lost Strength/Appeared to get weak, rolled out of bed, alert but disoriented, bare feet, and incontinent. Medications were: anti-anxiety/anti-psychotic, antidepressant, narcotic, hypoglycemic. Root cause: I am not sure anymore. He gets on the floor then gets up then next time he is unable to get up. Intervention: sit in doorway and remind him to stay in bed, and pull tabs. Review of Care Plan dated 6/7/17 the intervention of Sit in doorway and remind him to stay in bed was not located in the care plan. Record review revealed that Resident 2 had 19 falls since (MONTH) of (YEAR) and Resident 43 had 17 falls since (MONTH) of (YEAR). C. A review of a PHYSICIAN UPDATE AND ORDER SHEET, faxed to Resident 18's Primary Care Physician on 2/9/18, revealed the resident had an observed fall. The resident had lost balance and fell , while trying to pick up toilet riser from the floor. The Nursing Update documented Full AROM (Active Range of Motion)-will monitor. The document did not include information related to the interventions in place to prevent reoccurrence. A review of the facility's Incident logs, revealed Resident 18 was involved in the following occurrences: on 3/26/18 and 4/2/18, the resident was found on the floor by recliner; on 4/8/18 the resident was lowered to the floor from wheelchair; on 5/17/18 the resident was observed on the floor in the bathroom. Observations on 08/27/18 9:21 AM-10:30 AM, revealed Resident 18 seated in a recliner in the resident's room. The chair was in a reclined position and a personal safety alarm was noted to be attached to the back of the chair and Resident 18's blouse at the right shoulder area. The controller for the electric recliner/lift chair was noted to be resting on the floor next to Resident 18's chair. The call light was within the resident's reach, however, Resident 18 was noted to be calling out, requesting a drink of water. An unidentified Nursing Staff member entered the Resident's room and was overheard to report that the water pitcher was empty, and that staff would refill the pitcher as soon as possible. The staff member left Resident 18's room without offering to assist the resident with an immediate drink of water. Resident 18 appeared restless and uncomfortable, frequently attempting to reposition causing the safety alarm to sound. LPN (Licensed Practical Nurse)-D was noted to step into Resident 18's room, picked the control for the electric recliner up off the floor and gave the controller to the resident, step back out of the Resident's room, and directed Nursing Assistants to assist the resident out of the recliner. Staff were overheard to reply it will be a minute. A few minutes later, Resident 18 was overheard calling out for help. A Nursing Assistant who was walking by in hallway, immediately entered the room to assist Resident 18, closing the door to the resident's room. An observation on 08/27/18 at 11:02 AM revealed, Resident 18 seated in a wheelchair (w/c), with a long amount of oxygen tubing wrapped around self and in the resident's lap. A personal safety alarm was in place to the back of the w/c and attached to the resident's clothing at right shoulder area. An interview on 8/29/18 at 8:38 AM with Registered Nurse (RN)-C, revealed Resident 18 exhibited fluctuating levels of confusion/forgetfulness which may be related to the Resident's respiratory status or illness. The RN explained that Resident 18's respiratory concerns exacerbate quickly, and the resident was recently treated for [REDACTED]. RN-C reported that Resident 18 was safe to have control of the lift recliner, and confirmed that a personal safety alarm was in use to alert staff of attempted unassisted transfers. A review of the Care Plan for Resident 18 revealed Problem(s) with Start Date of 05/10/2017 including a self-care deficit related to: [MEDICAL CONDITION] (a chronic respiratory disease), back pain, weakness, dementia with anxiety, and inability to stay on track to complete task at hand; very poor safety awareness and being very impulsive. This indicates a high risk for falls. Interventions implemented on 5/10/17 included: Restorative program (a program that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) as outlined, 3-5 times per week; Keep my pain under control, this will help decrease my chances of falling; Keep room clean and free of clutter and call light within reach at all times; Please give me frequent reminders about things like locking my wheelchair brakes, using call light, etc; Remind me frequently that I need to call for help, and not attempt to do things on my own; At this time I need one staff to help me with transfers, ambulation, locomotion, dressing, bathing and toilet use. With encouragement and supervision, I believe I can do these things on my own. If I can not stand safely then I will need to transfer with the EZ Stand (a mechanical device used by staff to assist residents to transfer from one surface to another); Due to my lung conditions, I do have good and bad days so please be aware of this and give me more assistance as I need; I am able to ambulate (walk) with my walker and one staff assistance but often refuse to do this. Please encourage me to continue ambulating and to wheel myself short distances; When having increased anxiety remind me of safe strategies. I have a tendency to forget what is safe for me. I do have a very compulsive personality. I like to drink coffee and like to have my things within my reach so I don't have to try and get up to reach them. When I am at an activity and seem to get more anxious or and trying to pay attention to what everyone else is doing, I will tend to not always pay attention to where I am going with my w/c. Remind to watch for others. Further review of the Care Plan revealed no documented evidence that safety interventions had been reviewed or updated following the fall for Resident 18, on 2/9/18. The documentation indicated: on 3/27/18 the resident Slid from chair due to playing with controls. Monitor frequently and remind to not play with controls. Consider using regular recliner instead of lift chair; on 4/2/18 fell from recliner. No injuries. Monitor frequently. Remind on how to use control frequently and ask (gender) to call for help if is not sure; on 4/8/18 Slid out of wheelchair. Offer recliner or bed when sleeping in chair; and on 5/18/18 Fall taking self to bathroom. Offer to assist resident to bathroom many times through our shift. The document did not contain information related to the personal safety alarm noted to be in use. A review of MDS (a mandatory comprehensive assessment tool used for care planning) information for Resident 18 indicated a declining BIMS (Brief Interview for mental status) score. For an annual assessment dated [DATE] the BIMS score was 10 (scores of 8-12 indicates moderately impaired) and for a quarterly assessment dated [DATE] the Resident's score was 8. A review of an undated facility policy titled Fall Prevention and Management Program revealed the Program Objectives included: a. To improve and maintain a resident's optimal functional level and quality of life b. To identify and reduce or eliminate environmental risk factors for residents c. To identify and reduce or eliminate risk factors for residents d. To reduce the frequency of falls e. To reduce the severity of injuries from falls f. To ensure best practice interventions for residents who have fallen g. To monitor and track trends related to resident falls. An interview, on 08/30/18 at 08:30 AM, with the DON (Director of Nursing) revealed that the facility had not implemented true safety interventions for a resident who exhibited signs of dementia. Resident 18 would need more than repeated reminders and monitoring in order to prevent the potential for reoccurrence or injury during a fall.