**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new PASARR (Pre-admission Screening and Resident Review- a tool used to ensure residents receive the care they require for mental illness) screen was completed related to a mental health diagnosis for 1 (Resident 4) of 1 sampled resident. The facility census was 27. Findings are: Review of the facility policy PASARR dated 2017 revealed the following: -the facility would coordinate assessments with the PASARR, -the purpose was to develop guidelines related to those with mental illnesses to ensure they received the care and services they needed in the most appropriate setting, and -the facility would refer all residents with newly evident or possible serious mental illness disorders for a Level II review. Review of Resident 4's Quarterly Minimum Data Set (MDS-a comprehensive assessment tool used in Care Planning) dated 12/5/23 revealed the resident had diagnoses of: Cerebrovascular Accident, Depression, Chronic Lung Disease and Psychotic Disorder; and no documentation that the resident was taking an antipsychotic medication (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion. Review of the resident's Annual MDS dated [DATE] revealed the resident did not have a PASARR Level II determination and the resident was receiving an antipsychotic medication routinely. Review of Resident 4's PASARR screen dated 6/25/18 revealed on the resident's screen, it was marked no to the question that asked if the resident had a serious mental illness such as psychotic disorder. Review of Resident 4's Care Plan last revised 12/31/23 revealed no documentation that the resident had a Level II screen completed. Review of the facility facsimile (fax) to Resident 4's physician revealed a diagnosis dated 1/24/23 for Psychosis in absence of Dementia. Interview on 2/8/24 at 2:20 PM with the Director of Nursing (DON) confirmed the resident had a diagnosis of psychosis in absence of dementia and a new PASARR should have been completed.

Licensure Reference Number 175 NAC 12-006.17 Based on record review and interview; the facility failed to implement an opportunistic waterborne pathogens plan, to prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility's water system. This had the potential to affect all facility residents. The facility census was 27. Findings are: Reviewed the facility Legionella Management Policy dated 1/18 with a revision date of 1/24 revealed the following; the facility defined and controlled the management of Legionella bacteria in the water systems within the facility, the facility Legionella management team included the facility Administrator, the facility Maintenance Director, and the facility Infection Preventionist and or Quality Assurance Coordinator, the facility used a description of the water system using a flow diagram to identify areas where Legionella bacteria could grow, identified actions to prevent the growth and spread of Legionella and identified who was responsible for maintaining areas and cleaning frequencies. Record review revealed no evidence the facility had identified areas of potential concern through mapping of the facility water system. During an interview on 2/8/24 at 1:00 PM the facility Maintenance Supervisor confirmed no awareness of a facility plan to prevent the growth of waterborne bacteria in the facility water system. In addition, the maintenance department was not aware of any potential areas that had been identified as a potential for stagnant water to occur, or any knowledge of where to test the water system in the event a waterborne illness identified in the facility. In addition, the Maintenance Supervisor was unaware of what waterborne bacteria was, and how to prevent stagnant water from occurring in the facility water system. During an interview on 2/12/24 at 11:12 AM the Infection Preventionist (IP) confirmed the IP was unaware of the facility Legionella policy, had no knowledge of a mapping of the water system to identify potential waterborne illness, and was unaware of any plan for testing the system, should Legionella be identified. Further interview confirmed the IP was not aware what if any measures were in place to identify or prevent stagnant water in the facility water system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C3a Based on record review and interviews, the facility failed to: 1) notify Resident 1's legal representative of a change in condition related to respiratory complications that required evaluation at the emergency room (ER) and a significant change with the resident's urinary status, and 2) notify Resident 181's legal representative of a change in condition related to the development of wounds on the resident's feet with subsequent hospitalization. The total sample size was 24. The facility census was 27. Findings are: A. Review of the facility's Policy and Procedure Notification of Changes with Resident dated 9/4/2015 revealed: It is the policy of the facility to immediately inform the resident, the resident's legal guardian or family member if known, and the resident's physician when there is a significant change with the resident's physical, mental or psychosocial status (such as a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) a need to alter treatment significantly (such as a need to discontinue an existing form of treatment). The facility must also promptly notify the resident, and the resident's legal guardian or family member if known when there is a change in room or roommate assignment. B. Review of the facility's policy Ulcer and Wound Management and Prevention dated 2/2012 revealed the following: - All residents will be assessed for pressure ulcer risk upon admission, readmission and quarterly and with a significant change in condition. All residents' skin will be checked for condition changes on admission, readmission, weekly and as needed by a nurse. Any skin issues will be addressed upon identification and notification made to the physician and family as soon as possible. - Upon finding new skin issues the nurse will create an incident report and a wound/skin assessment sheet. The nurse finding the skin issue will notify the physician as soon as possible during their shift. The infection control nurse, assessment coordinator, dietary staff and the family will be notified. The nurse will measure and describe skin issues on the Comprehensive Skin Assessment sheet weekly, provide treatment per the physician's orders and document on the Treatment Administration Record (TAR). The nurse will discontinue treatment/cares when skin issues are closed or resolved and document this on the TAR and the wound/skin assessment sheet. C. Review of Resident 181's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 8/4/22 revealed diagnoses of diabetes, heart failure, high blood pressure, and anemia. The assessment indicated the resident's cognition was moderately impaired and required limited assistance with bed mobility, transfers, toileting, dressing and personal hygiene. In addition, assessment of the resident's skin revealed no skin issues were indicated. Review of Resident 181's medical record revealed the following: - A nursing progress note dated 10/21/22 at 5:09 PM, indicated the resident had an open area to the right foot on top of the 2nd toe. There was no evidence the resident's legal representative or the physician was notified of the wound. - A nursing progress noted dated 10/25/22 at 9:58 AM, indicated the resident had an open area to the resident's left foot on the 4th toe with a small amount of pussy drainage present. There was no evidence the resident's legal representative was notified of the wound. - A Non-pressure Skin Condition Report dated 11/23/22 at 1:45 AM, indicated the toes on the resident's right foot were scabbed with a small amount of bleeding. Further review revealed no evidence the resident's legal representative and/or the physician was notified of the wounds. Review of Resident 181's Non-pressure Skin Condition Reports revealed the resident had several skin issues on the right foot: - On 11/24/2022 the top of the right foot 2nd toe was described as a bruise that measured [0.5 centimeters (cm) long by 0.8 cm wide]. There was no evidence the resident's legal representative and/or the physician was notified on this date. - On 11/24/2022 the right foot on the side of the 3rd toe was described as a popped blister that measured [1.1cm (L) X 0.6cm (W)]. On 11/26/22 the report indicated the wound had increased in size [1.5cm (L) X 0.8cm (W)] and had slough (the yellow/white material in a wound that consists of dead cells that accumulate in wound drainage) present. There was no evidence the resident's legal representative or the physician was notified on this date. - On 11/24/22 the right foot on the side of the 4th toe was described as a popped blister that measured [0.9cm (L) X 0.5cm (W)] with a scant amount of clear drainage noted. There was no evidence the resident's legal representative or the physician was notified on this date. Review of Resident 181's medical record revealed the following: - On 12/5/22 the resident was seen by the physician and was prescribed an oral antibiotic (Keflex 500 milligrams (mg) daily for 10 days) for wounds to the resident's right foot and made a referral to the wound clinic for further evaluation. - On 12/7/22 the resident was seen at the wound clinic and subsequently admitted to the hospital for an infection to the right foot. D. During an interview with the resident's legal representative on 1/25/23 at 10:40 AM, the resident's legal representative indicated [gender] had not been notified of the resident's foot wounds until [gender] visited the resident at the facility on 12/5/22. The legal representative also confirmed the resident was admitted to the hospital from the wound clinic on 12/7/22 for an infection to the resident's foot. E. During an interview with the administrator on 1/24/23 at 2:40 PM, the administrator confirmed there was no evidence the Resident 181's legal representative was notified of the foot wounds on 10/21/22, 11/23/22, and 11/24/22 and should have been. The administrator also confirmed the resident was subsequently admitted to the hospital on [DATE] for an infection to the resident's foot. F. Review of Resident 1's MDS dated [DATE] revealed diagnoses of bilateral amputation of lower extremities, anemia, anxiety, depression, legally blind and urinary tract infection (UTI) in the last 30 days. The following was assessed regarding Resident 1: -cognitively intact; -verbal behaviors directed at others and rejection of cares during assessment period; -received extensive to total staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; and -indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). Review of the resident's Nursing Progress Notes dated 8/3/22 revealed the following: -3:24 AM the staff reported to the Charge Nurse the resident was short of breath and was wheezing. The resident's oxygen saturation level was 90 percent (%). The resident was hot to the touch with chills; and -4:00 AM the resident's respirations and pulse were rapid. The resident was sent to the ER for evaluation and then admitted to the hospital. Review of the resident's medical record revealed no evidence the resident's representative/family were notified regarding the resident's change in condition and need for hospitalization. Review of Nursing Progress Notes dated 8/13/22 revealed the following: -9:53 AM the resident's indwelling urinary catheter was removed; -11:08 AM the resident was upset regarding removal of the catheter and requested to have re-inserted; and -4:13 PM indwelling urinary catheter was replaced, and bright red blood clots were noted to the catheter. The catheter was removed with moderate amounts of bright red blood along with several clots. Triage nurse at the hospital was notified and indicated clotting was normal, to monitor and to re-insert the catheter. Review of a Progress Note dated 8/16/22 at 2:57 PM revealed an indwelling urinary catheter was inserted with bright red blood clots at the insertion site. Review of the resident's medical record revealed no evidence the resident's representative/family were notified of the removal of the urinary indwelling catheter and the issues encountered when the catheter was replaced. During an interview on 1/22/23 at 12:50 PM the resident's representative indicated the facility did not always notify the representative when the resident had new orders or a change in condition. During an interview on 1/25/23 at 10:55 AM, the Interim Administrator confirmed the resident's responsible party should have been notified regarding the resident's change of condition and need for hospitalization on 8/3/23 and of the issues with the resident's indwelling urinary catheter which started 8/13/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interview and record review; the facility failed to report, investigate and then to submit the investigation to the State Agency within the required time frame an elopement for Resident 180 and to submit an investigation related to an allegation of potential staff to resident abuse for Resident 1. The sample size was 3 and the facility census was 27. Findings are: A. Review of the facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 10/22 revealed in response to allegations of abuse, neglect, exploitation, misappropriation or mistreatment, the facility must: -assure allegations are reported immediately, but not later than 2 hours after the allegation is made if bodily injury or not later than 24 hours if events do not result in serious bodily injury; -conduct an investigation, preventing further potential abuse and/or neglect while the investigation is in the process; and -report the results of the investigation to the State Agency within 5 working days of the incident. B. Review of Resident 180's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/22 revealed the resident was admitted [DATE] with diagnoses of cancer, anemia, hip fracture, high blood pressure, renal insufficiency and arthritis. The following was assessed regarding the resident: -cognition was moderately impaired; -no behaviors; -required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; and -occasionally incontinent of urine and frequently involuntary of bowel. Review of Resident 180's Nursing Progress Notes dated 8/26/22 revealed the following: -7:38 PM the resident eloped out the North door and the resident was found in the parking lot. The resident told the staff the resident was going home. The resident was not wearing a wander-guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door) and the door did not alarm; and -7:50 PM the resident refused to be assessed and the resident indicated feeling trapped. The resident's physician was notified, and the resident was sent to the emergency room (ER) for evaluation due to the resident's unusual behavior. Review of facility investigations from 9/28/21 through 1/22/23 revealed Adult Protective Services (APS) were notified of the resident's elopement on 8/29/22 (3 days after the resident eloped on 8/26/22) at 4:30 PM. Further review of facility investigations revealed an investigation was completed and was then sent to the State Agency on 9/5/22 (10 days after the resident's elopement) at 1:21 PM. During an interview on 1/24/23 at 8:45 AM, the Interim Administrator confirmed Resident 180's elopement was not reported, the investigation completed and then submitted within the required time frames. C. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of malnutrition, anxiety and respiratory failure. The following was assessed regarding the resident: -cognition was moderately impaired; -other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming or disruptive sounds) which occurred daily; and -required limited to extensive assistance with dressing, bed mobility, transfers, toilet use and personal hygiene. Review of facility investigations from 9/28/21 through 1/22/23 revealed an APS report was completed 10/26/22 at 3:14 PM. Resident 5 reported to the staff about a month ago a staff member had pushed the resident into bed. The resident could not recall the staff but could point them out if the resident saw them again. The report indicated an investigation was ongoing. Further review of facility investigations revealed no evidence an investigation was completed and/or submitted to the State Agency. During an interview on 1/23/22 at 11:30 AM, the Interim Administrator verified an investigation was initiated but the Administrator failed to complete and to submit the results of the investigation as required to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to provide ongoing assessment and monitoring to prevent skin breakdown for Resident 181 who developed foot wounds and was subsequently hospitalized . The sample size was 1 and the facility census was 27. Findings are: A. Review of the facility's policy Ulcer and Wound Management and Prevention dated 2/2012 revealed the following: - All residents will be assessed for pressure ulcer risk upon admission, readmission and quarterly and with a significant change in condition. All residents' skin will be checked for condition changes on admission, readmission, weekly and as needed by a nurse. Any skin issues will be addressed upon identification and notification made to the physician and family as soon as possible. - Upon finding new skin issues the nurse will create an incident report and a wound/skin assessment sheet. The nurse finding the skin issue will notify the physician as soon as possible during their shift. The infection control nurse, assessment coordinator, dietary staff and the family will be notified. - The nurse will measure and describe skin issues on the Comprehensive Skin Assessment sheet weekly, provide treatment per the physician's orders and document on the Treatment Administration Record (TAR). The nurse will discontinue treatment/cares when skin issues are closed or resolved and document this on the TAR and the wound/skin assessment sheet. B. Review of Resident 181's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 8/4/22 revealed diagnoses of diabetes, heart failure, high blood pressure, and anemia. The assessment indicated the resident's cognition was moderately impaired and required limited assistance with bed mobility, transfers, toileting, dressing and personal hygiene. In addition, assessment of the resident's skin revealed no skin issues were identified. Review of Resident 181's medical record revealed the following: - A nursing progress note dated 10/21/22 at 5:09 PM, indicated the resident had an open area to the right foot on top of the 2nd toe. There was no evidence the resident's legal representative or the physician was notified of the wound and no evidence of additional nursing assessment and monitoring of the wound or if the wound had healed. - A nursing progress noted dated 10/25/22 at 9:58 AM, indicated the resident had an open area to the resident's left foot on the 4th toe with a small amount of pussy drainage present. There was no evidence of additional nursing assessment and monitoring of the wound or if the wound had healed. - A nursing progress note dated 11/20/22 at 1:12 PM, indicated the resident had increased swelling to [gender] lower legs, feet and toes. Further review revealed the skin was shiny and tight and the resident also had multiple scattered scratches to [gender] upper right calf, middle left calf, front of both thighs, chest and abdomen. There was no evidence of documentation there were wounds on the resident's feet or toes. - A Non-pressure Skin Condition Report dated 11/23/22 at 1:45 AM, indicated the toes on the resident's right foot were scabbed with a small amount of bleeding. There was no evidence of interventions implemented to prevent additional skin breakdown. - A Non-pressure Skin Condition Report dated 11/24/2022, identified a wound to the resident's right foot on the side of the 3rd toe described as a popped blister that measured [1.1cm (L) X 0.6cm (W)]. On 11/26/22 the report indicated the wound had increased in size [1.5cm (L) X 0.8cm (W)] and had slough (the yellow/white material in a wound that consists of dead cells that accumulate in wound drainage) present. There was no evidence the resident's legal representative or the physician was notified on this date. Further review revealed no evidence of documentation after 11/26/22, related to ongoing nursing assessment and monitoring of the 3rd toe wound. - A Non-pressure Skin Condition Report dated 11/24/2022, identified a wound to the top of the right foot 2nd toe described as a bruise and measured [0.5 centimeters (cm) Length (L) by 0.8 cm Width (W)]. There was no evidence the resident's legal representative and/or the physician was notified on this date. On 12/6/22 the wound had increased in size [1.2cm (L) X 0.8cm (W)] and had slough present. - A Non-pressure Skin Condition Report dated 11/24/2022, identified a wound to the right foot on the side of the 4th toe described as a popped blister that measured [0.9cm (L) X 0.5cm (W)] with a scant amount of clear drainage noted. There was no evidence the resident's legal representative or the physician was notified on this date. On 12/6/22 the wound measured [1.0cm (L) X 0.7 cm (W)] and had black/brown eschar (a collection of dry, dead tissue within a wound). - On 12/5/22 the resident was seen by the physician and prescribed an oral antibiotic (Keflex 500 milligrams (mg) daily for 10 days) for wounds to the resident's right foot. In addition, the physician made a referral to the wound clinic for further evaluation of the foot wounds. - On 12/7/22 the resident was seen at the wound clinic for the foot wounds and was subsequently admitted to the hospital for an infection to the right foot. C. During an interview with the resident's legal representative on 1/25/23 at 10:40 AM, the resident's legal representative indicated [gender] was unaware of the resident's foot wounds until [gender] visited the resident at the facility on 12/5/22 and requested the resident be evaluated at the wound clinic. In addition, the legal representative indicated [gender] was at the appointment with the resident on 12/7/22 and subsequently admitted to the hospital for an infection to the resident's foot. D. During an interview with the administrator on 1/24/23 at 2:40 PM, the administrator confirmed the following: - nursing staff are expected to document any new skin issues upon discovery, notify the physician and the resident's representative and document the resident's skin/wound assessments weekly; - there was no evidence of documentation of ongoing skin/wound assessments for the resident's foot wounds identified on 10/21/22 and 10/25/22; - there was no evidence the physician was notified of the resident's foot wounds on 10/21/22, 11/23/22, and 11/24/22 and should have been; - there was no evidence of additional skin/wound assessment documentation for the resident's right foot 3rd toe wound after 11/26/22; and - the resident was admitted to the hospital on [DATE] for an infection to the resident's foot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09D7 Based on record reviews and interviews; the facility failed to: 1) ensure interventions were in place for the prevention of further elopements (when a resident leaves the premises or a safe area without authorization and/or supervision) for Resident 180; and 2) assess causal factors and develop and/or revise interventions to prevent ongoing falls for Resident 5. The sample size was 4 and the facility census was 27. Findings are: A. Review of Resident 180's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/22 revealed the resident was admitted [DATE] with diagnoses of cancer, anemia, hip fracture, high blood pressure, renal insufficiency and arthritis. The following was assessed regarding the resident: -cognition was moderately impaired; -no behaviors; -required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; -occasionally incontinent of urine and frequently involuntary of bowel; -history of falls with a fall in the last month prior to admission which resulted in a fracture; and -surgical repair of hip fracture. Review of a Wandering Risk Scale dated 6/22/22 at 2:00 AM revealed the resident had no history of wandering. The resident was alert and orientated with no desire to leave the facility until the resident was recovered from hip fracture. The resident was identified as low risk for wandering. Review of Resident 180's Nursing Progress Notes revealed the following: -8/9/22 at 3:02 PM the resident's representative was notified the resident had been self-transferring to the bathroom. The resident had been re-educated on the need to call for and then wait for staff assistance, but the resident continued to refuse; -8/19/22 at 2:26 PM the resident's representative was notified Resident 180's roommate had tested positive for COVID-19. Resident 180 tested negative but was moved to a different room; -8/25/22 at 10:40 AM the resident again tested negative for COVID-19; -8/26/22 at 7:38 PM the resident eloped out the North door and indicated the resident was going home. The resident was found in the parking lot. The resident was not wearing a wander-guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door) and the door did not alarm; and -8/26/22 at 7:50 PM the resident refused to be assessed and the resident indicated feeling trapped. The resident's physician was notified, and the resident was sent to the emergency room (ER) for evaluation due to the resident's unusual behavior. Review of a Resident/Employee Incident/Accident Reporting Form dated 8/26/22 revealed the following observation; at 7:30 PM: Nurse Aide informed staff the resident was exit seeking and staff were to watch Resident 180. Dietary staff to the resident's room to remove the evening meal tray and the resident was not in the room. The resident was then found in the parking lot. Further review of the report revealed there was no documentation to indicate what actions were put into place to prevent a reoccurrence. Review of an additional Resident/Employee Incident/Accident Reporting Form dated 8/26/22 at 7:45 PM revealed the resident was very confused and agitated. The report identified the need for placement of a wander-guard as an intervention to prevent reoccurrence but indicated there were none in the building. Review of a facility investigation dated 9/5/22 regarding the resident's elopement on 8/26/22 at 7:30 PM revealed the following new interventions to prevent further potential elopements; -resident moved to a different room away from the exit doors; and -15-minute checks to be completed on the resident. Review of a 15 Minute, Visual Checks form used to document the checks the staff completed on Resident 180 revealed the checks were not initiated until 8/31/22 (5 days after the resident's elopement). During an interview with the Interim Administrator on 1/23/23 at 3:15 PM the following was confirmed: -staff had witnessed the resident at the exit door and the resident was attempting to open the door however, no increased supervision was provided despite the resident's exit seeking behaviors; -the resident was sent to the emergency room to be evaluated as behavior was not typical for the resident. The resident returned to the facility the same night; -the resident was moved to a different room, but there was no documentation as to what room the resident was moved to or when the move had occurred; -there was no evidence in the resident's medical record to indicate the 15-minute checks were started until 8/31/22 which was 5 days after the resident's elopement; and -the facility did have a supply of wander-guard bracelets, but the bracelets were stored in the Social Service Director's office. No education was provided to the staff regarding B. Review of the facility Fall Prevention Program Policy (undated) revealed each resident was to be assessed for risk of falling and was to receive care and services in accordance with the level of risk to minimize the likelihood of falls. Residents with an assessment score of 10 or above would be considered at high risk for falls and would be placed on the facility's Fall Prevention Program. When any resident experienced a fall the facility would: -assess the resident; -complete a post fall assessment; -complete an incident report; -review the resident's care plan and update as indicated; and -document all assessments and actions. C. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of anemia, diabetes, Alzheimer's disease, dementia, anxiety, malnutrition and dementia. The following was assessed for Resident 5: -short-and long-term memory loss with severely impaired decision-making skills; -required total staff assistance with dressing, bed mobility, transfers, toilet use and personal hygiene; -always incontinent of urine and frequently involuntary of bowel; and -at risk for falls with 2 falls without injury since the previous assessment. Review of the resident's Care Plan dated 1/19/22 revealed the resident was at risk for falls with the following interventions: -tilt-n-space (wheelchair which shifts its position on its frame as one unit, while maintaining the angle of the hips, knees and ankles) chair for positioning and comfort; -staff educated on need to tilt wheelchair slightly when resident alone in room; -fall mat next to the bed; -offer frequent toileting; and -assist with lying on the floor per resident's request. Review of a Fall Risk Evaluation dated 4/18/22 at 1:59 PM revealed the resident scored a 20 which indicated the resident was at high risk for falls. Review of Nursing Progress Notes dated 6/3/22 revealed the following: -10:42 AM at approximately 10:10 AM, the resident was found face down on the floor of the resident's room. The resident had pain with range of motion to the right leg and was sent to the ER for evaluation; and -12:36 PM the resident returned to the facility with no injuries identified. Review of the resident's medical record revealed no evidence the resident was assessed for causal factors, a new intervention was developed, or current interventions revised to prevent further falls. Review of Nursing Progress Notes dated 6/8/22 revealed the following: -1:39 PM the resident's representative was notified the resident was on the floor this morning; and -4:08 PM the resident did climb out of the wheelchair and onto the floor at 9:00 AM. Alarms/mats were in place. Review of the resident's medical record revealed no evidence the resident's fall was assessed for causal factors or that fall interventions were changed and/or developed. Review of a Nursing Progress Note dated 8/13/22 at 1:20 AM, revealed the resident was heard crying and staff found the resident face down on the ground next to the resident's bed. Causal factors were not assessed, and interventions were not revised/developed for further fall prevention. Review of a Nursing Progress Note dated 8/27/22 revealed at 4:28 AM, the resident was found by the mattress on the floor. No injuries were identified. In addition, no causal factors or revised interventions were identified to prevent further falls. Review of a Nursing Progress Note dated 8/31/22 at 8:00 PM revealed the resident was on the floor, lying on the fall mat next to the resident's bed. Review of the resident's medical record revealed no evidence the facility determined causal factors or developed new interventions for ongoing falls. Review of Nursing Progress Notes dated 10/17/22 at 2:47 AM revealed the resident was on the floor, lying face down on the fall mat. No injuries were identified. The resident was assisted into bed and the call light was placed within reach. The resident's bed was in the lowered position and the fall mat was on the floor next to the bed. No additional interventions were identified. Review of a Nursing Progress Note dated 10/19/22 at 11:26 PM revealed at 10:45 PM, the resident was lying on the floor, on the fall mat next to the resident's bed. Review of a Post Fall assessment dated [DATE] at 11:51 AM revealed no causal factors were assessed, current interventions were not revised, and no additional interventions put into place. Review of a Nursing Progress Note dated 11/2/22 revealed when staff entered the resident's room at 9:15 PM, the resident was seated on the fall mat on the floor next to the resident's bed. Review of a Nursing Progress Note dated 11/3/22 at 11:56 AM revealed a scoop mattress (a special type of mattress with raised sides which may be employed as a fall prevention measure) and an air mattress overlay were placed on the resident's bed to prevent further falls. Review of a Nursing Progress Note dated 11/6/22 at 12:35 AM revealed the resident was found lying on the floor. Review of the resident's Care Plan revealed a new fall intervention dated 11/13/22 (7 days after the resident's fall on 11/6/22) to position a body pillow when the resident was in bed. Review of a Nursing Progress Note dated 11/14/22 (8 days after the resident's fall on 11/6/22) revealed the facility discontinued and removed the air mattress overlay on Resident 5's bed to prevent further falls. During an interview on 1/25/23 at 12:59 PM, the Interim Administrator confirmed the staff failed to complete an Incident Report and a Post Fall Evaluation after each of Resident 5's falls. In addition, causal factors were not assessed, fall interventions were not revised and/or new interventions implemented in a timely manner to prevent further falls.

Licensure Reference Number 175 NAC 12-006.17A Based on interview and record review; the facility failed to prevent the potential spread of COVID-19 as the facility failed to perform a COVID-19 test for Residents 1 and 14 who had reported signs and symptoms. The total sample size was 24 and the census was 27. Findings are: A. Review of the facility's Infection Prevention and Control Program Policy with an effective date of 9/22 revealed residents who had signs or symptoms of Covid-19 (fever, cough, sore throat, stomach pain, respiratory distress, diarrhea or other symptoms unusual to their normal bodily function) must be tested and placed on isolation precautions pending test results. B. Review of Resident 14's Nursing Progress Notes revealed the following: -10/9/22 at 9:39 PM the resident was noted to have a harsh cough. The resident had a wheeze to bilateral upper lobes of the resident's lungs; -10/10/22 at 9:02 AM the resident had a harsh, productive cough with yellow colored drainage and the resident continued with a slight wheeze to lungs; and -10/12/22 at 1:50 AM the resident complained of coughing all night the previous evening. Review of Resident 14's medical record revealed no evidence the resident received a COVID test despite the residents ongoing potential symptoms from 10/9/22 to 10/12/22. C. Review of Resident 1's Nursing Progress Notes revealed the following: -10/2/22 at 11:45 PM the resident's temperature was 102.4 degrees Fahrenheit (F); -10/3/22 at 12:49 AM the resident's temperature was 100 degrees F; and -10/3/22 at 8:19 AM indicated at 6:00 AM, the resident's temperature was 100.9 degrees F. The resident was lethargic and drooling and was unable to hold food in mouth from the breakfast meal. Review of Resident 1's medical record revealed no evidence the resident received a COVID test despite the resident's elevated temperature and increased lethargy. D. Interview with Registered Nurse (RN)-M on 1/24/23 at 1:16 PM confirmed RN-M was the facility Infection Preventionist. Further interview revealed the facility should have COVID tested both Residents 1 and 14 when the resident's began displaying potential symptoms of COVID-19.

Based on record review and interview; the facility failed to ensure 3 (Residents 21, 23 and 77) of 5 sampled residents were offered and/or received Pneumococcal vaccinations. The facility census was 27. Findings are: A. Review of the facility policy Pneumococcal Vaccine Series (undated) revealed upon admission, each resident and/or representative were to receive the Vaccination Information Statement (VIS) for pneumococcal vaccines. The staff were to review all the resident's vaccinations and provide/document education on the benefits and potential side effects of the vaccinations for which the resident was eligible. If the resident/representative consented to the vaccine staff were to obtain a physician order, obtain written consent, obtain/document temperature and complete screening questions prior to administering the vaccine then administer the vaccine. B. Review of an Immunization Report dated 1/23/23 revealed no evidence the VIS regarding the Pneumococcal Vaccination was provided, vaccination histories were reviewed to determine eligibility for the Pneumococcal Vaccination, or an attempt was made to obtain consent from residents/representatives for Residents 21, 23 and 77 to administer the vaccine to the residents. C. Interview with the facility Interim Director of Nursing (DON) on 1/23/23 at 1:03 PM verified the facility failed to assess Residents 21, 23 and 77's pneumococcal immunization status upon admission, and the residents had not been offered an/or administered the pneumococcal vaccination during their stay at the facility.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to implement infection control practices to prevent potential cross contamination including the spread of COVID-19 related to: 1) performing hand hygiene at appropriate intervals during the provision of incontinence cares for Resident 5; and 2) failure to develop/implement interventions for unvaccinated staff to assure mitigation of COVID-19. This had the potential to affect all residents in the facility. The total sample size was 24 and the census was 27. Findings are: A. Review of the facility policy Hand Hygiene Procedure dated 9/22 revealed it was the policy of the facility to educate and to provide work practices to aid in the prevention of the spread of infection. Hand hygiene was considered the most important factor in preventing and controlling the spread of infection. The following was identified regarding when staff were to wash hands: -before each resident contact; -after touching a resident or handling their belongings; -whenever hands were soiled; -after any contact with body fluids; -after handling contaminated items; and -before and after gloving. B. Observations of incontinence cares for Resident 5 on 1/24/23 from 9:48 AM to 10:12 AM revealed the following: -Nursing Assistant (NA)-F and NA-K washed hands in the resident's bathroom and placed on clean gloves; -Resident 5 was transferred with a full lift from the resident's wheelchair and into the resident's bed; -NA-K indicated the resident's slacks were soiled with urine and feces. NA-K removed the resident's slacks and placed into a disposable bag to take to the laundry; -without removing soiled gloves, NA-K took clean wash cloths into the resident's bathroom, placed into the bottom of the hand washing sink and saturated the cloths with warm water. NA-K used the soiled gloves to remove excess water from the cloths and then took the cloths to the resident's bedside; -NA-K and NA-F removed the resident's urinary incontinence brief which was heavily soiled with urine and feces. NA-K proceeded to use the washcloths to provide the resident with incontinence cares. NA-K used a clean surface of the washcloth each time the resident was wiped, until all surfaces were soiled. NA-K without use of a barrier, placed the soiled cloths directly onto the resident's bed linens; -without removing soiled gloves, NA-K and NA-F placed a clean incontinence brief on the resident, repositioned the resident in bed and placed a pillow behind the resident's back; -NA-F positioned the pendant call light on the resident while NA-K lowered the resident's bed and placed a blanket on the resident; and -NA-F and NA-K removed soiled gloves but failed to complete hand hygiene before exiting the resident's room. During an interview on 1/24/23 at 10:26 AM, NA-F confirmed staff should perform hand hygiene before putting on clean gloves and when removing soiled gloves. In addition, NA-K failed to follow good infection control practices when touching clean items in the resident's room with soiled gloves and placing soiled wash clothes on the resident's bed linens. C. Interviews and observations on 1/22/23 from 8:00 AM to 10:30 AM revealed the following: -Registered Nurse (RN)-A was unvaccinated and was a contracted staff member. RN-A had been COVID-19 tested twice a week since starting at the facility as this was the facility policy. RN-A reported no additional interventions had been put into place. RN-A was not wearing any personal protective equipment (PPE); -Licensed Practical Nurse (LPN)-B was vaccinated and was a full-time employee at the facility. LPN-B indicated all staff were being tested twice a week per facility policy. LPN-B wore no PPE; -NA-D was a full-time employee at the facility and had not been vaccinated. NA-D confirmed being COVID tested twice a week per facility policy. NA-D reported no additional interventions despite staff's vaccination status and NA-D wore no PPE; and -NA-K, NA-I, and NA-F were all fully vaccinated, were all tested twice a week and were not wearing PPE. During an interview with RN-M the Infection Preventionist on 1/24/23 at 1:16 PM, the following was confirmed: -the facility staff and visitors did not have to wear masks unless the Community Transmission level was high; -the Community Transmission level was currently substantial; and -the facility should have additional interventions in place for the unvaccinated staff to prevent the potential spread of COVID-19.