**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(F)The facility failed to put in new interventions in the comprehensive care plan to prevent falls for 2 (Resident 2 and Resident 6) out of 3 sampled residents. The facility census was 52.Licensure Reference Number 175 NAC 12-006.09(F) A record review of the admission Record revealed Resident 2 was admitted to the facility on [DATE] with diagnoses of Adult failure to thrive (a collection of symptoms that include weight loss, decreased appetite, fatigue, and cognitive decline), Diarrhea (frequent, loose, or watery bowel movements), Constipation (a condition where bowel movements are infrequent or difficult to pass, often characterized by hard, dry stools), Urinary tract infections (an infection in any part of the urinary system), insomnia (trouble falling asleep, staying asleep (usually through the night), or waking up too early in the morning), Arial fibrillation (a heart condition where the heart beats irregularly and rapidly), and Hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream).A record review of the Minimum Data Set (MDS) (A comprehensive assessment of each residents functional capabilities) with an Assessment Reference Date of 5/28/2025 revealed Resident 2 had 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 15 which indicates Resident 2 is cognitively intact. Resident 2 requires supervision or touching assistance with activities of daily living (ADL's).A record review of Resident 2 progress notes revealed:-On 12/12/24 Resident 2 had a fall when (gender) slid out of bed. Resident 2 had gripper socks on. Vital signs were taken and assisted off the floor with no assessment of what the resident was doing prior to fall.-On 1/12/25 -per report from a Nursing Assistant (CNA) Resident 2 is needing more assistance with ADL's.-On 1/13/25 Resident 2 had a fall at 4:58 PM when (gender) trying to make the bed. -On 7/7/25 Resident 2 had a fall. Resident 2 floor was wet and was wearing (genders) gripper socks. Vital signs taken and assisted off the floor with no assessment of what the resident was doing prior to fall.A record review of Resident 2 Care Plan revealed that Resident 2 is at risk for falls related to gait/balance problems and hearing/vision problems. The care plan revealed that interventions for Resident 2 falls:-12/12/24 - intervention was to assist resident out of bed each morning.-1/13/25 - intervention for fall was to make Resident 2 bed before 10 AM. -7/7/25 -intervention was to Please assist resident to bed between 8-830 pm. be sure resident is wearing gripper socks or non-slip foot ware at all times while out of bed. There had been no new or revised interventions that had been put in place for the falls on 12/12/24, 1/13/25, and 7/7/25. A record review of the Fall Prevention Program with policy revised date of 12/2/19 revealed:7. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: a) Interventions will be monitored for effectiveness, b) the plan of care will be revised as needed. An interview on 7/11/25 at 2:30 PM with the Director of Nursing (DON) confirmed that the interventions for Resident 2 falls had not been revised or new interventions put in place and new/revised interventions should have been put in place on the care plan. B.A record review of the admission Record revealed Resident 6 was admitted to the facility on [DATE] with the diagnosis of Altered mental status (a change in a person's level of awareness, alertness, or cognitive function), pain, depression (a persistent state of low mood and aversion to activity that can significantly interfere with daily life), fracture of the left femur (thigh) and humerus (upper arm), and weakness (lack of physical or muscle strength, or a feeling of being tired and having low energy).A record review of the Minimum Data Set (MDS) (A comprehensive assessment of each residents functional capabilities) with an Assessment Reference Date of 5/23/2025 revealed Resident 6 had 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 00 which indicates Resident 6 is severely impaired. Resident 6 requires one assist with activities of daily living (ADL's).A record review of the progress notes for Resident 6 revealed:-On 12/11/24 Resident 6 was observed on the floor in Resident 6's room. Vitals signs taken and was assisted off the floor, with no assessment of what the resident was doing prior to fall.-On 2/9/25 Resident 6 was observed on the floor in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.-On 4/21/25 Resident 6 was observed on the floor in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.-On 4/22/25 Resident 6 was observed on floor between the water sink in room and the bathroom in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.-On 4/28/25 Resident 6 was observed on the floor with Resident 6 back up against the recliner and wheelchair in front of Resident 6. Resident had on tennis shoes. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.-On 6/20 Resident 6 was observed on the floor beside recliner with walker knocked over in front of Resident 6. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.-On 7/6/25 Resident 6 was observed on the floor besides bed frame. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.-On 7/19/25 Resident 6 was on the roommates' side of the room and was on the floor by roommates foot board. It appeared that Resident 6 had taken (gender) to the bathroom.A record review of the Care Plan revealed that Resident 6 was at risk for falls related to gait/balance problems, unaware of safety needs and vision/hearing problems. The care plan revealed interventions for Resident 6 falls:12/11/25 - There were no interventions for Resident 6 with the date of the fall found.2/9/25- Intervention for Resident 6 was to keep floor clear.4/21/25 - Intervention for Resident 6 was to start antibiotic for UTI BID x 5 days, 1 assist with cares and ADL's.4/22/25 - Intervention for Resident 6 was lab work for CMP, Amylase, Lipase drawn.4/28/25 - Intervention was the door to Resident 6's room was to be open and anti-roll back brakes on wheelchair.6/20/25- There were no interventions for Resident 6 with the date of the fall found.There had been no revision in the interventions or why the resident had fallen for appropriate interventions that had been put in place for the falls on 12/11/25 and 6/20/25. A record review of the Fall Prevention Program with policy revised date of 12/2/19 revealed :7. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: a) Interventions will be monitored for effectiveness, b) the plan of care will be revised as needed. An interview on 7/11/25 at 2:30 PM with the Director of Nursing (DON) confirmed that the interventions for Resident 6 falls had not been revised or new interventions put in place and new/revised interventions should have been put in place on the care plan. xxxx A.A record review of the admission Record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of Adult failure to thrive (a collection of symptoms that include weight loss, decreased appetite, fatigue, and cognitive decline), Diarrhea (frequent, loose, or watery bowel movements), Constipation (a condition where bowel movements are infrequent or difficult to pass, often characterized by hard, dry stools), Urinary tract infections (an infection in any part of the urinary system), insomnia (trouble falling asleep, staying asleep (usually through the night), or waking up too early in the morning) , Arial fibrillation (a heart condition where the heart beats irregularly and rapidly, and Hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream).A record review of the Minimum Data Set (MDS) (A comprehensive assessment of each residents functional capabilities) with an Assessment Reference Date of 5/28/2025 revealed Resident 2 had 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 15 which indicates Resident 2 is cognitively intact. Resident 2 requires Supervision or touching assistance with activities of daily living (ADL's).A record review of Resident 2 progress notes revealed that :On 12/12/24 Resident 2 had a fall when (gender) slid out of bed. Resident 2 had the gripper socks on. Vital signs taken and assisted off the floor with no assessment of what the resident was doing prior to fall.On 1/12/25 -per report from a Nursing Assistant (CNA) Resident 2 is needing more assistance with ADL's.(Activities of daily living)On 1/13/25 Resident 2 had a fall at 4:58 PM when (gender) trying to make the bed. On 7/7/25 Resident 2 had a fall. Resident 2 floor was wet and was wearing (genders) gripper socks. Vital signs taken and assisted off the floor with no assessment of what the resident was doing prior to fall.A record review of Resident 2 Care Plan revealed that Resident 2 is at risk for falls related to gait/balance problems and hearing/vision problems. The care plan revealed that interventions for Resident 2 falls:12/12/24 - intervention was to assist resident out of bed each morning.1/13/25 - intervention for fall was to make Resident 2 bed before 10 AM. 7/7/25 -intervention was to Please assist resident to bed between 8-830 pm. be sure resident is wearing gripper socks or non-slip foot ware at all times while out of bed. There had been no revision in the interventions that had been put in place for the falls on 12/12/24, 1/13/25, and 7/7/25. A record review of the Fall Prevention Program with policy revised date of 12/2/19 revealed :7. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: a) Interventions will be monitored for effectiveness, b) the plan of care will be revised as needed. An interview on 7/11/25 at 2:30 PM with the Director of Nursing (DON) confirmed that the interventions for Resident 2 falls had not been revised or new interventions put in place and new/revised interventions should have been put in place on the care plan. B.A record review of the admission Record revealed Resident 6 was admitted to the facility on [DATE] with the diagnosis of Altered mental status(a change in a person's level of awareness, alertness, or cognitive function), pain, depression (a persistent state of low mood and aversion to activity that can significantly interfere with daily life), fracture of the left femur (thigh), humerus (upper arm), and weakness (lack of physical or muscle strength, or a feeling of being tired and having low energy). A record review of the Minimum Data Set (MDS) (A comprehensive assessment of each residents functional capabilities) with an Assessment Reference Date of 5/23/2025 revealed Resident 6 had 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 00 which indicates Resident 6 is severely impaired. Resident 6 requires one assist with activities of daily living (ADL's).A record review of the progress notes for Resident 6 revealed that :On 12/11/24 Resident 6 was observed on the floor in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 2/9/25 Resident 6 was observed on the floor in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 4/21/25 Resident 6 was observed on the floor in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 4/22/25 Resident 6 was observed on floor between the water sink in room and the bathroom in Resident 6 room. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 4/28/25 Resident 6 was observed on the floor with Resident 6 back up against the recliner and wheelchair in front of Resident 6. Resident had on tennis shoes. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 6/20 Resident 6 was observed on the floor beside recliner with walker knocked over in front of Resident 6. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 7/6/25 Resident 6 was observed on the floor besides bed frame. Vitals signs taken and assisted back up off the floor, with no assessment of what the resident was doing prior to fall.On 7/19/25 Resident 6 was on the roommates' side of the room and was on the floor by roommates foot board. It appeared that Resident 6 had taken (gender) to the bathroom.A record review of the Care Plan revealed that Resident 6 was at risk for falls related to gait/balance problems, unaware of safety needs and vision/hearing problems. The care plan revealed interventions for Resident 6 falls:12/11/25 - There were no interventions for Resident 6 with the date of the fall found.2/9/25- Intervention for Resident 6 was to keep floor clear.4/21/25 - Intervention for Resident 6 was to start antibiotic for UTI BID x 5 days, 1 assist with cares and ADL's.4/22/25 - Intervention for Resident 6 was lab work for CMP, Amylase, Lipase drawn.4/28/25 - Intervention was the door to Resident 6 room was to be open and anti-roll back brakes on wheelchair.6/20/25- There were no interventions for Resident 6 with the date of the fall found.There had been no revision in the interventions or why the resident had fallen for appropriate interventions that had been put in place for the falls on 12/11/25 and 6/20/25. A record review of the Fall Prevention Program with policy revised date of 12/2/19 revealed :7. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: a) Interventions will be monitored for effectiveness, b) the plan of care will be revised as needed. An interview on 7/11/25 at 2:30 PM with the Director of Nursing (DON) confirmed that the interventions for Resident 6 falls had not been revised or new interventions put in place and new/revised interventions should have been put in place on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number 175 NAC 12-006.09 (H)(iv)(5)The facility failed to monitor bowel status and administer PRN meds to prevent constipation for three residents (Resident 2, 41 and 52) out of six sampled residents. The facility census was 52.Findings: A. A record review of Resident 41’s “Minimum Data Set” (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 4/28/2025 revealed a brief interview for mental status (BIMS) score of 13 which indicated the resident’s cognitive function is considered intact and Resident 41 was dependent for toileting. A record review of Resident 41’s “Care Plan” dated 8/6/2025 revealed a diagnosis of constipation without interventions associated with prevention of constipation. A record review of Resident 41’s “Bowel Monitoring Form” dated 4/1/2025-8/12/2025 revealed no bowel movements documented 4/13/2025-4/18/2025 (six days no bowel movement), 5/3/2025-5/8/2025 (six days no bowel movement), 5/25/2025-6/4/2025 (11 days no bowel movement), 6/8/2025-6/11/2025 (four days no bowel movement), 6/29/2025-7/3/2025 (five days no bowel movement), 7/26/2025-7/29/2025 (four days no bowel movement), and 7/31/2025-8/4/2025 (5 days no bowel movement). A record review of Resident 41’s “Medication Administration Record” dated May, June, July, and August 2025 revealed no bowel medications had been administered. A record review of Resident 41’s current orders revealed: · Bowel protocol day two: four ounces of prune juice every day as needed for bowel management. · Bowel protocol day three: Sennosides Tablet 8.6 milligrams (MG), give two tablets by mouth every 24 hours as needed for bowel management. · Bowel protocol day four: Milk of Magnesia 30 milliliters (ML) by mouth every 24 hours as needed for bowel management · Dulcolax Rectal Suppository 10 MG, insert one suppository rectally every 24 hours as needed for bowel management. A record review of the Facility’s Bowel Care Protocol with a revision date of 10/22/2024 revealed: a. Day two of no bowel movement- four ounces of prune juice. b. Day three of no bowel movement- Senna 8.6 two tabs every day. c. Day four of no bowel movement- Milk of Magnesia 30 ML every day. d. Day five of no bowel movement- Dulcolax Suppository every day. e. If no results, contact the Physician to update on client’s bowel status, may request routine bowel medications or enema administration. A record review of the Facility's Bowel Movement policy dated 4/29/2011 and a revision date of 10/22/2024 revealed: The nurse aide will document the resident's bowel movements each shift for their assigned residents on the medication record. 1. All staff will observe cognitively impaired residents for behaviors that could indicate need to evacuate bowels, i.e. restlessness, digging in rectum, agitation, a continuous oozing of diarrheal stool, etc. These behaviors will be reported to the Cart Nurse for follow up. 2. The night nurse will review the current medication administration record to identify the number of days each resident has not had a bowel movement. Medication aides/Cart Nurse on day shift will double check. 3. The nurse will document all residents identified as not having a bowel movement for two or more days on the Bowel movement (BM) list. The BM list will be attached to each halls report sheet. 4 Residents on the BM list will be assessed by the charge nurse for individual bowel schedule, possible side effects from pain meds, bowel sounds, and impaction. 5. If the resident has been identified, the Cart Nurse will notify the Physician, office nurse, and DON. In interview on 8/11/2025 at 10:49 AM with MA-C confirmed the night shift runs the bowel report for the residents and the charge nurse monitors the BM list. An interview on 8/11/2025 at 10:50 AM with LPN-D confirmed the bowel report is run by the night shift and the results are communicated to the day shift. “There is a bowel protocol that the nurses follow on day two, three, and day four”. LPN-D confirmed there were no bowel medications administered to Resident 41 during the days of 5/25/2025-6/4/2025. An interview on 8/11/2025 at 10:58 AM with the DON confirmed the bowel protocol: · Day one of no bowel movement requires no intervention. · Day two, three, and four of no bowel movement, there is a protocol. The night nurse makes up the bowel list and reports to day shift for follow up. An Interview on 8/11/2025 at 10:58 AM with the DON confirmed no bowel medications were administered to Resident 41 during the days of 5/25/2025-6/4/2025. The DON confirmed no bowel movement documented for resident 41 during the days of 5/25/2025-6/4/2025 and should have had follow up. B. A record review of the admission Record revealed Resident 2 was admitted to the facility on [DATE] with diagnoses of Adult failure to thrive (a collection of symptoms that include weight loss, decreased appetite, fatigue, and cognitive decline), Diarrhea (frequent, loose, or watery bowel movements), Constipation (a condition where bowel movements are infrequent or difficult to pass, often characterized by hard, dry stools), Urinary tract infections (an infection in any part of the urinary system), insomnia (trouble falling asleep, staying asleep (usually through the night), or waking up too early in the morning), Arial fibrillation (a heart condition where the heart beats irregularly and rapidly, and Hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream). A record review of the Minimum Data Set (MDS) (A comprehensive assessment of each residents functional capabilities) with an Assessment Reference Date of 5/28/2025 revealed Resident 2 had 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 15 which indicates Resident 2 is cognitively intact. Resident 2 requires Supervision or touching assistance with activities of daily living (ADL's). An interview on 8/6/25 at 9:30 AM with Resident 2 revealed that Resident 2 states (gender) have issues with constipation. A record review of nursing assistant task for Resident 2 revealed that April 26th through 5/1/25 there was nothing marked for bowel movements (BM's). A record review of nursing assistant task for Resident 2 revealed 5/4/25 through 5/7/25 no BM was recorded, 5/9/25 through 5/13/25 no BM was Recorded 5/16/25 through 5/19/25 no BM was recorded. A record review of nursing assistant task for Resident 2 revealed 6/1/25 through 6/4/25 no BM was recorded, and 6/12/25 through 6/19/25 no BM was recorded. A record review of the nursing assistant task for Resident 2 revealed 7/15/25 through 7/22/25 no BM was recorded. A record review for the April 2025 medication administration record revealed no PRN's(as needed) for Bowel care had been given A record review for the May 2025Medication administration record revealed no PRN's for Bowel Care had been given A record review for the June 2025 Medication administration record revealed no PRNs for Bowel Care had been given A record review for the July 2025 Medication administration record revealed no PRN;s for Bowel care had been given A record review of the Physicians orders revealed Bowel management orders for Prune juice 4 ounces daily as needed for bowel management , Dulcolax suppository 10 mg (a unit of mass, often used in measuring small quantities of substance, including medications. rectally as needed every 24 hours for bowel management, Milk of Magnesia (MOM) Suspension 400 mg/5ml give 30 ml by mouth every 24 hours as needed for bowel management, Senna 8.6 mg tablet give 2 tablets as needed every 24 hours for bowel management. A Record review of the facility Bowel Movements policy dated 4-29-2011 revealed Bowel Care Protocol a. On day two of no bowel movement-4oz of prune Juice every day c. On day three of no bowel movement-Senna 8.6-2 mg tabs every day d. On day four of no bowel movement -30cc MOM every day e. On day five of no bowel movement -Dulcolax Suppository every day f. If no results, contact the physician to update on clients= bowel status, may request routine bowel medications or enema administration An interview on 8/11/25 at 11:45 AM with the Director of Nursing (DON) confirmed that the bowel management program should have been followed with Resident 2 and it wasn't. DON confirmed that no PRN bowel medications was given to Resident 2 in the months of April, May, June and July 2025 and it should have been. The DON confirmed that the physician had not been contacted when Resident 2 had gone over 5 days of no bowel movements. C. A record review of Resident 52’s admission record dated 08/06/2025 revealed that the resident was admitted to the facility on [DATE]. A record review of Resident 52’s medical diagnosis printed on 08/12/2025 revealed a primary diagnosis of unspecified dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia [a loss or impairment of the power to use or comprehend words usually resulting from brain damage], and the inability to plan and initiate complex behavior), generalized muscle weakness, and anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it.), restlessness, agitation, and repeated falls. A record review of Resident 52’s “Minimum Data Set” (MDS, a federally mandated comprehensive assessment tool used to determine a resident’s functional capabilities and assists nursing home staff identify health problems) dated 07/04/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 3 indicating severe cognitive impairment. A record review of Resident 52’s MDS section GG revealed that the resident is dependent on staff for all toileting and is unable to walk to the bathroom and in Section H, Bladder and Bowels, revealed that the resident is always incontinent of bowels. A record review of Resident 52’s Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) printed on 08/06/2025 revealed no mention of risk for constipation or interventions to avoid constipation. A record review of facility Bowel Movements” policy dated 04/29/2011 revealed “Bowel Care Protocol a. On day two of no bowel movement-4oz of Prune Juice Q (every) Day. c. On day three of no bowel movement-Senna 8.6-2 tabs Q Day. d. On day four of no bowel movement 30cc (cubic centimeters) of MOM (Milk of Magnesia) Q Day. e. On day five of no bowel movement -Dulcolax Suppository Q Day. f. If no results, contact the physician to update on clients= bowel status, may request routine bowel medications or enema administration.”. A record review of Resident 52’s “Task: Bowel and Bladder (B&B) Bowel Elimination” report printed 08/07/2025, revealed that the staff charted that the resident had no bowel movements (BMs) between the following dates: 05/31/2025 to 06/06/2025. 06/12/2025 to 06/20/2025. 07/01/2025 to 07/10/2025. 07/13/2025 to 07/21/2025. 07/25/2025 to 07/26/2025. 07/28/2025 to 08/2/2025. A record review of Resident 52’s “Medication Administration Record” (MAR) dated June, July and August 2025 revealed prescribed PRN (as needed) bowel medications: Polyethylene Glycol 3350 (MiraLAX) 17 GM (grams)/scoop given orally every 24 hours as needed for bowel management. Senna 8.6 MG (milligrams) give 2 tabs every 24 hours for bowel management. Milk of Magnesia (MOM) 400 MG/5ML (milliliter) every 24 hours are needed for constipation. Bisacodyl Suppository 10MG every 24 hours as needed for bowel management. A record review of Resident 52’s MAR dated June, July, and August 2025 revealed no PRN bowel medication was given for constipation. In an interview on 08/11/2025 at 11:24AM with Registered Nurse (RN)-G confirmed that the facility does have a bowel protocol but has never had to use it. RN-G reported that a different resident did receive MOM over the weekend as reported by the night nurse, so RN-G followed up to see if the medication was effective. RN-G reported that the night nurse is to run the list of residents on the bowel list and inform oncoming day nurse so that they can provide the needed PRN bowel medications. In an interview on 08/11/2025 at 12:15 with the Director of Nursing (DON), confirmed that no PRN bowel medications were administered during the months of June, July, and August of 2025 and should have been given, and confirmed that Resident 52’s bowel elimination report revealed that no BMs were charted for the following dates: 05/31/2025 to 06/06/2025. 06/12/2025 to 06/20/2025. 07/01/2025 to 07/10/2025. 07/13/2025 to 07/21/2025. 07/25/2025 to 07/26/2025. 07/28/2025 to 08/2/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review, the facility failed to implement interventions (action taken to improve the situation) to prevent potential falls for 1 (Resident 42) of 3 sampled residents. The facility census was 52.Findings are: A record review of the facility's Fall Prevention Program dated 02/28/2025 revealed that when a resident had a fall, the facility would review the resident's care plan and add an intervention before the end of the shift. The resident's risk factors and environmental hazards would be evaluated when developing the resident's care plan and interventions would be monitored for effectiveness. The care plan would be revised as needed. A record review of Resident 42's Clinical Census dated 08/11/2025 revealed the resident was admitted to the facility on [DATE].A record review of Resident 42's Medical Diagnosis dated 08/11/2025 revealed the resident had diagnoses of Paranoid Schizophrenia (delusions and seeing things), Morbid Obesity (very overweight), Attention-Deficit Hyperactivity Disorder (ADHD)(trouble paying attention), Anxiety, and Depression.A record review of Resident 42's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 078/15/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 9 which indicated the resident was moderately cognitively impaired. The resident was independent for eating, needed supervision with oral hygiene (cleaning), needed substantial/maximal assistance with dressing, footwear, toileting, and personal hygiene, and dependent of staff for bathing. The resident's fall history for 6 months before the MDS was blank and the resident had not fallen since the last MDS.A record review of the facility's Incidents By Incident Type report dated 09/05/2025 - 08/06/2025 revealed Resident 42 had fallen on 10/17/2024, 10/23/2024, 10/24/2024, 11/04/2024, 11/06/2024, 11/08/2024, 11/10/2024, 11/10/2024, 11/11/2024, 12/14/2024, 12/27/2024, 01/04/2025, 01/14/2025, 02/20/2025, 03/30/2025, and 04/16/2025.A record review of Resident 42's Post Fall Huddle Form dated 10/24/2024 revealed the resident fell on that date at 10:35 AM and all interventions were in place at the time of the fall. The resident fell because the resident was dizzy and hungry. The new intervention was move closer to nurse's station and offer snack between meals. The staff emailed the Director of Nursing (DON) regarding fall and new intervention. A record review of Resident 42's Care Plan with an admission date of 07/10/2024 revealed the resident had a focus area of the resident being at risk for falls related to poor balance, poor communication/comprehension (ability to convey and understand information). The resident had one intervention for the 10/24/2025 fall and that was to move the resident closer to the nurse's station.A record review of Resident 42's Electronic Medical Record did not reveal that the resident or the resident's family had refused to change resident rooms. An observation on 08/07/2025 at 1:50 PM revealed Resident 42 was sleeping in resident room [ROOM NUMBER] which was the last room on the [NAME] side of the [NAME] hallway.An observation on 08/11/2025 at 7:40 AM revealed Resident 42 was sleeping in resident room [ROOM NUMBER] which was the last room on the East side of the East hallway which was approximately 129 feet from the nurse's station.An observation on 08/11/2025 at 11:48 AM revealed Resident 42 was sleeping in resident room [ROOM NUMBER] which was the last room on the [NAME] side of the [NAME] hallway.In an interview on 08/11/2025 at 1:46 PM, the facility's Social Worker (SW) confirmed on 07/10/2024 Resident 42 was in room [ROOM NUMBER]A, on 10/25/2025/ the resident was moved to bed B in room [ROOM NUMBER] which was further from the nurse's station, and on 06/27/2025 the resident was moved to room [ROOM NUMBER], bed A which again further from the nurse's station. The SW confirmed it was not documented that the resident or the resident's family refused a room change closer to the nurse's station.In an interview on 08/11/2025 at 2:25 PM, the MDS Coordinator (MDS) confirmed that the intervention for Resident 42's 10/24/2025 fall was to move the resident closer to the nurse's station and that was not done. MDS confirmed MDS was not sure why the staff thought that would have been a good intervention anyway because there was only 1 semi-private room that would have worked, and the resident was Medicaid and couldn't afford a private room.In an interview on 08/12/2025 at 7:40 AM the facility's Administrator confirmed the intervention for the 10/24/2025 was to move Resident 42 closer to the nurse's station and the facility staff did not. The Administrator was unsure why the staff used that as an intervention for the 10/24/2025 fall because there was not a room for the resident at the time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g)Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 53) of 1 sampled resident's oxygen order was followed. The facility census was 52.Findings are:A record review of the facility's Oxygen Concentrator policy dated 8/11/2025 revealed oxygen was to be administered under order of the physician. The nurse would verify the orders for the flow rate and turn the unit on to the desired flow rate.A record review of the facility's Oxygen Administration policy dated 8/11/2025 revealed oxygen was administered consistent with professional standards of practice. Oxygen was administered under the orders of a physician.A record review of Resident 53's Clinical Census dated 08/11/2025 revealed the resident was admitted to the facility on [DATE].A record review of Resident 53's Medical Diagnosis dated 08/11/2025 revealed the resident had diagnoses of Chronic Respiratory Failure (long term breathing disorder resulting in low oxygen), Hypoxemia (low oxygen in the blood), Obstructive Sleep Apnea (stop breathing during sleep), and Williams syndrome (a genetic disorder that causes developmental delays). A record review of Resident 53's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/25/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) that was blank. The resident needed supervision with eating, partial/moderate assistance with oral hygiene (cleaning) and dependent on staff for toileting, bathing, dressing, footwear, and personal hygiene. The resident was on oxygen.A record review of Resident 53's Care Plan with an admission date of 07/23/2024 revealed the resident had a focus area of the resident being at risk for ineffective breathing and an intervention to administer oxygen as prescribed. A record review of Resident 53's Order Summary Report dated 08/11/2025 revealed the resident had an order of oxygen at 2 liters per minute (l/m) per nasal cannula (a tube that goes in the nose to deliver oxygen) at all times as needed for saturations (oxygen in blood) below 88 percent (%), ordered on 07/15/2025. A record review of Resident 53's Weights and (&) Vitals dated 08/11/2025 at 11:53 AM revealed the resident's oxygen saturation on 08/11/2025 at 8:07 AM was 88% with oxygen on via nasal cannula. An observation on 08/06/2025 at 9:14 AM revealed Resident 53 was lying in bed in the resident's room and the oxygen concentrator (a machine used to purify oxygen) was set at 3 l/m. An observation on 08/11/2025 at 11:15 AM revealed Resident 53 was sitting on the bed in the resident's room with the nasal cannula laying on the floor and the oxygen concentrator was running and set at 3 l/m. Three different staff members walked by and looked at the resident between 11:15 AM and 11:40 AM and none of them asked the resident to put the oxygen nasal cannula on. At 11:40 AM the facility's Social Worker (SW) entered the room and assisted the resident to the dining room and the resident did not have oxygen on. An observation on 08/11/2025 at 11:47 AM - 12:01 PM revealed Resident 53 was seated in the dining room without oxygen on and breathing through the mouth. An observation on 08/11/2025 at 12:01 PM with Registered Nurse (RN)-G revealed following: being asked if the resident should be on oxygen, RN-G tested Resident 53's oxygen saturation and the resident's oxygen saturation was 83% on Room Air. RN-G got the resident's concentrator from the resident's room and took it to the dining room and placed the nasal cannula on the resident. The oxygen concentrator was set at 3 l/m.An observation on 08/11/2025 at 1:37 PM with RN-G revealed Resident 53 was lying in bed in the resident room with the oxygen on at 3 l/m. In an interview on 08/11/2025 at 1:37 PM, RN-G confirmed Resident 53's oxygen saturation at 12:01 PM was 83% on room air and the resident should have been on oxygen. RN-G confirmed the oxygen concentrator was set a 3 l/m and the order was for 2 l/m, so RN-G decreased the oxygen to 2 l/m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.18(D) The facility failed to sanitize the blood glucose monitoring machine prior to and after obtaining a blood sugar on three (Resident 41, 43. and Resident 50) out of three sampled residents, perform proper hand hygiene while administering medications, keep Resident 53's oxygen nasal cannula off the floor and concentrator filter clean to prevent potential cross contamination. The facility census was 52. Findings are: Findings: A. A record review of the Facility’s “Glucometer Disinfection” policy dated 19/2000 with a review date of 6/2025 revealed: The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, the meter should not be used for multiple patients. The glucometers should be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C, and Hepatitis B virus. Glucometers should be cleaned and disinfected after each use and according to manufacturer’s instructions regardless of whether they are intended for single resident or multiple resident use. Procedure: a. Obtain needed equipment and supplies b. Wash hands c. Explain procedure to the resident d. Provide privacy e. Put on gloves f. Obtain blood sampling g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if needed i. Retrieve two disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil. k. After cleaning, use second wipe to disinfect the glucometer machine thoroughly with the disinfectant wipe, following the manufacturer’s instructions. l. Discard disinfectant wipe in the waste receptacle. m. Perform hand hygiene A record review of the Facility’s undated “Hand Hygiene” policy revealed: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with acceptable standards of practice. 2. Additional considerations: the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. An observation on 8/07/2025 at 10:59 AM revealed LPN-E obtaining a blood sugar on Resident 41 without sanitizing the blood glucose monitoring machine prior to or after obtaining the blood sugar. An observation on 8/07/2025 at 11:09 AM revealed LPN-E obtaining a blood sugar on Resident 9 without sanitizing the blood glucose monitoring machine prior to or after obtaining the blood sugar. Following the procedure, LPN-E removed gloves but failed to perform hand hygiene prior to leaving Resident 41’s room. An interview on 8/07/2025 at 11:24 AM with the LPN-E confirmed the glucose machine was not sanitized after Resident 41 and before Resident 9. LPN-E confirmed the glucose monitoring machine is to be sanitized between each resident use and it was not done. An observation on 8/07/2025 at 11:52 AM revealed LPN-E at medication cart preparing to give resident medications, no hand hygiene was observed. LPN-E proceeded to pull medications from the cart, checked the Electronic Medical Record (EMR), popped medications into a cup from the medication cassette, scooped pudding into a cup with a spoon, locked the cart, and proceeded to walk down the hall to a resident room. LPN-E entered resident room without performing hand hygiene, administered the medication to the resident, placed resident’s legs up on the foot pedals, moved the resident to a different location in the room, placed resident’s feet back on floor, and returned the foot pedals to the up position. LPN-E left the room without performing hand hygiene. LPN-E returned to the medication cart, proceeded to look through the EMR, no hand hygiene was observed. An interview on 8/11/2025 at 12:37 PM with the Infection Preventionist (IP) confirmed the expectation for hand hygiene and cleaning of the glucose monitoring machine: 1. Washing hands in between residents or use hand sanitizer. 2. Sanitize glucose monitoring machine between residents. B. An observation on 8/7/2025 at 11:15 AM revealed Medication Aide (MA-A) was observed standing beside Resident 43 preparing to poke the resident’s finger without gloves on. MA-A stopped, picked up supplies, and went to the medication cart, stating, “I forgot, the resident has their own device.” The MA-A then looked in the computer and stated, “It needs to be replaced so I will need to poke the resident’s finger. MA-A then performed hand hygiene using hand sanitizer, applied gloves, returned to the resident, wiped the resident’s finger with an alcohol pad, used a lancet to puncture the finger, wiped away the first drop of blood, and obtained a sample. The glucometer displayed a reading of “E13,” so the MA-A obtained new supplies and repeated the process, which resulted in a reading of “338.”MA-A placed the glucometer on the medication cart, walked to a cupboard, obtained a Sani cloth germicidal wipe and wiped the device for 8 seconds before placing it back into the cart. A Record review on 8/7/2025 at 11:22AM with MA-A of the Sani cloth germicidal wipe container revealed that the manufacturer’s recommendation required A two-minute wet period on the surface of the equipment to sanitize it. An interview on 8/7/2025 at 11:24AM with MA-A confirmed that the germicidal wipe was not in contact with the glucometer for 2 minutes and MA-A responded, “I didn’t know about a 2 minute wet time.” C. A record review of the facility's “Oxygen Concentrator (a machine used to purify oxygen)” policy dated 8/11/2025 revealed the staff was to follow manufacturer’s instructions for cleaning the filter, change the nasal cannula (a tube that goes in the nose to deliver oxygen) monthly and if it becomes contaminated (infected or dirty), and keep the oxygen delivery devices in a plastic bag when not in use. A record review of the facility’s “Oxygen Administration” policy dated 8/11/2025 revealed the staff was to follow manufacturer’s instructions for cleaning the filter, change the nasal cannula monthly and if it becomes contaminated, and keep the oxygen delivery devices in a black cloth bag when not in use. A record review of the “AirSep Newlife Elite Patient Manual” dated 03/02 revealed the air intake filter on the back of the oxygen concentrator should be cleaned weekly. https://oxygenalliance.org/wp-content/uploads/2024/03/AirSep-NewLife-Elite-Patient-Manual.pdf A record review of Resident 53’s “Clinical Census” dated 08/11/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 53’s “Medical Diagnosis” dated 08/11/2025 revealed the resident had diagnoses of Chronic Respiratory Failure (long term breathing disorder resulting in low oxygen), Hypoxemia (low oxygen in the blood), Obstructive Sleep Apnea (stop breathing during sleep), and Williams syndrome (a genetic disorder that causes developmental delays). A record review of Resident 53's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/25/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident’s cognitive abilities) that was blank. The resident needed supervision with eating, partial/moderate assistance with oral hygiene (cleaning) and dependent on staff for toileting, bathing, dressing, footwear, and personal hygiene. The resident was on oxygen. A record review of Resident 53’s “Care Plan” with an admission date of 07/23/2024 revealed the resident had a focus area of the resident being at risk for ineffective breathing and an intervention to administer oxygen as prescribed. A record review of Resident 53’s “Order Summary Report” dated 08/11/2025 revealed the resident had an order of oxygen at 2 liters per minute (l/m) per nasal cannula (a tube that goes in the nose to deliver oxygen) at all times as needed for saturations (oxygen in blood) below 88 percent (%), ordered on 07/15/2025. An observation on 08/06/2025 at 9:14 AM revealed Resident 53 was lying in bed in the resident’s room and the AirSep Newlife oxygen concentrator was set at 3 l/m and the resident had a nasal cannula in the nose. The filter on the back of the machine had a thick coating of a gray fuzzy substance on it. An observation on 08/11/2025 at 11:15 AM revealed Resident 53 was sitting on the bed in the resident’s room with the nasal cannula laying on the floor and the AirSep Newlife oxygen concentrator was running and set at 3 l/m and the filter on the back had a gray fuzzy substance on it. Three different staff members walked by and looked at the resident between 11:15 AM and 11:40 AM and none of them asked the resident to put the oxygen nasal cannula on. At 11:40 AM the facility’s Social Worker (SW) entered the room and assisted the resident to the dining room and the resident did not have oxygen on. An observation on 08/11/2025 at 11:47 AM - 12:01 PM revealed Resident 53 was seated in the dining room without oxygen on and breathing through the mouth. An observation on 08/11/2025 at 12:01 PM with Registered Nurse (RN)-G revealed RN-G tested Resident 53’s oxygen saturation and the resident’s oxygen saturation was 83% on Room Air. RN-G got the resident’s concentrator from the resident’s room and took it to the dining room and placed the nasal cannula on the resident. The AirSep Newlife oxygen concentrator was set at 3 l/m. The filter on the back of the oxygen concentrator had a gray fuzzy coating on it and RN-G did not clean or replace the nasal cannula that had been on the floor in the resident’s room before placing it in Resident 53’s nose. An observation on 08/11/2025 at 1:37 PM with RN-G revealed the resident was lying in bed in the resident room with the oxygen on at 3 l/m and the AirSep Newlife oxygen concentrator’s filter had a gray fuzzy coating on it. In an interview on 08/11/2025 at 1:37 PM, RN-G confirmed the resident’s saturation was 83% on room air and the resident should have been on oxygen. RN-G confirmed the oxygen concentrator filter had a fuzzy gray coating on it and RN-G cleaned the filter. RN-G confirmed the filter should have been cleaned monthly and did not appear it had been, so RN-G cleaned the filter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12.004.02 Based on observation, interview, and record review, the facility failed to ensure staff performed proper hand hygiene during food preparation and between glove changes, ensure expired foods were discarded, ensure food brought in by family was labeled and dated, and ensure staff food was stored separately from residents' food in the unit refrigerators to prevent potential foodborne illness. This had the potential to affect all 52 residents in the facility who consume food prepared in the kitchen.A.An observation during the initial kitchen tour on 8/6/2025 from 8:20 AM to 9:25 AM revealed the following:One box of thickened hot cocoa mix with expiration date 5/4/2025.Two bottles of honey thickener with expiration date 6/6/2025.Upright freezer with an open bag of chicken strips not dated or sealed.In the dry storage, two totes of Panko breadcrumbs opened 5/6/2025 with no expiration date found, and six boxes of chicken noodle soup with expiration date of 4/2025.An interview with the Dietary manager (DM) on 8/6/25 at 8:27 AM confirmed the expired items and the breadcrumbs did not have an expiration date. An observation of the supplement refrigerator located on [NAME] Hall on 8/6/2025 at 9:25 AM revealed the following:One meat and cheese sandwich dated 3/2/25.An unlabeled and undated opened chocolate snack pack pudding. An unlabeled and undated slice of pizza and chicken wings, with a staff name on it.Two bottles of grape jelly stuck to the shelf, with expiration dates of 10/24/2023 and 1/22/2025. One Yoplait yogurt with an expiration date of April 22, 2025, which belonged to a resident. One bottle of prune juice with an expiration date of 1/3/25.An undated and unlabeled opened container of apple sauce. An observation of the supplement refrigerator located on [NAME] Hall further revealed dried spilled liquids and food on shelving and sticky substances on the top door shelf and drawer. An interview with the DM on 8/6/2025 at 9:37 AM confirmed the uncleanliness of the refrigerator, the undated /unlabeled items, staff food in the refrigerator, expired items and the DM verbalized that they would probably not serve the sandwich. A record review of the temperature log / cleaning log located on the front of the refrigerator revealed under the column indicating if the refrigerator was cleaned the staff had written in no for the first five days of August. An observation of the Locked Unit supplement refrigerator on 8/6/2025 at 9:37 AM revealed the following:Two bags of beef jerky sticks labeled with a resident's name, no date noted on package.One cup of small cherry tomatoes labeled MM with no dates.One jar of peach halves labeled with a first name on it and no dates. One unlabeled and undated container of small tomatoes. One bottle Hershey's syrup with an expiration date of 2/2025.One Boost Breeze nutritional drink with an expiration date of 7/11/2025.Six snack bags of strawberry Chex Mix with expiration dates of 6/11/2025.Four snack bags of regular Chex Mix with expiration dates of 7/2025.One opened bag Tostitos not sealed and marked opened 5/2025.Staff food (Great Value mayonnaise, Melissa's BBQ sauce, Tostitos queso dip) stored with residents' food. An interview with the DM on 8/6/2025 at 9:50 AM confirmed the outdated items and resident/staff food without label and dates. A Record review of the facility policy Use and Storage and Food Brought in by Family or Visitors last revised 3/3/21 under #2. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the residents within 3 days. If not consumed within 3 days, food will be thrown away by facility staff. B.An observation of food preparation on 8/7/2025 at 9:32 AM, with the Registered Dietitian (RD) present, revealed [NAME] 1 performing hand hygiene for 30 seconds, applied gloves, prepared onions, and discarded scraps. After removing gloves, the cook performed hand hygiene for 45 seconds. The cook then measured eggs, meat, breadcrumbs, tomato paste, Worcestershire sauce, minced garlic, Italian seasoning, salt, and pepper and placed the items into a mixing bowl. Without performing hand hygiene, the cook applied gloves and mixed the ingredients by hand. After removing the gloves, the cook applied non-stick spray to a pan liner and then applied new gloves without performing hand hygiene and pressed the meat mixture into the cooking pan with gloved hands. The pan was covered with foil and placed in the oven. An interview on 8/7/2025 at 10:00 AM with the (RD) confirmed the cook should have performed hand hygiene before both glove applications when handling the meat mixture. An interview on 8/7/2025 at 11:00 AM, with the DM and RD confirmed there was no system for labeling food brought in by family or discarding old resident food. An interview on 8/12/2025 at 9:12 AM, with the DM confirmed all 52 residents consume food prepared in the facility's kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report a fall resulting in serious bodily injury to the state agency within the required time frame for 2 residents (Resident 1 and Resident 4) of 3 residents sampled, and the facility failed to ensure the written investigations were submitted within five working days for 2 residents (Resident 1 and Resident 2) of 3 residents sampled. The facility census was 54. Findings are: A record review of the facility's Abuse, Neglect and Exploitation policy dated 03/21/2024 revealed that facility procedures include reporting of all alleged violations to the state agency and/or Adult Protective Services (APS) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Further review of the policy revealed the Administrator would report the results of the investigation when final within 5 working days of the incident, as required by state agencies. A. A record review of Resident 1's admission Record printed 09/26/2024 revealed the resident was admitted on [DATE] and had a primary diagnosis of multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control) and a diagnosis of quadriplegia (a partial or complete inability to move both arms and both legs). A record review of Resident 1's Progress Notes revealed a note dated 09/03/2024 at 5:06 AM that stated the resident had fallen and was complaining of left shoulder pain. Resident 1 was sent to the emergency room (ER) by ambulance to be evaluated. Further review of the Progress Notes revealed a note dated 09/03/2024 at 8:41 AM that stated the resident had returned with orders to Keep left shoulder immobilizer and sling on at all times until follow up with [orthopedic surgeon]. Record review of a Progress Note dated 09/04/2024 at 11:51 AM addressing the fall on 09/03/2024 revealed Resident 1 was sent to ER for x-rays and later returned with results of a fracture. A record review of the facility Investigation Report for this fall revealed the incident was not reported to APS until 09/03/2024 at 5:00 PM. Further review revealed the Investigation Report was not sent to the state agency until 09/18/2024. An interview on 09/26/2024 at 4:55 PM with the Administrative Trainee (AT) confirmed the fall resulting in a fracture was not reported to the state agency within the required time frame, and further confirmed that the investigative report was not submitted within five working days of the incident. B. A record review of Resident 4s admission Record printed 09/26/2024 revealed the resident was admitted on [DATE] and had a primary diagnosis of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities). A record review of Resident 4'sProgress Notes revealed no documentation of the resident's fall on 09/15/2024. Review of a Progress Note dated 09/16/2024 at 5:49 AM revealed the resident was complaining of shoulder pain and that paperwork was ready for transportation to make an appointment. Further review of the Progress Notes revealed the resident left for an appointment on 09/16/2024 at 2:23 PM and returned to the facility on [DATE] at 4:47 PM with a diagnosis of a fractured right clavicle (collarbone). Review of a Progress Note dated 09/17/2024 at 5:19 PM stated the resident had a fall on 09/15/2024 and sustained a right clavicle fracture. A record review of the facility Investigation Report for this fall revealed the incident was not reported to APS until 09/19/2024. No time was listed on the report. An interview on 09/26/2024 at 4:55 PM with the AT confirmed the fall resulting in a fracture was not reported to the state agency within the required time frame. C. A record review of Resident 2's admission Record printed 09/26/2024 revealed the resident was admitted [DATE] and had a primary diagnosis of Alzheimer's disease (a form of dementia), and a diagnosis of Down Syndrome (a genetic disorder resulting developmental delays, and mental and physical challenges). A record review of Resident 2's Progress Notes revealed a note dated 09/06/2024 at 9:52 AM that stated the resident had fallen at 7:15 AM and received a laceration to the right side of the face. The resident had gone to the ER and returned to the facility at 9:50 AM with sutures. Further review revealed a Progress Note dated 09/09/2024 at 12:39 that addressed the fall with laceration received on 09/06/2024. A record review of the facility Investigation Report for this fall revealed the Investigation Report was not sent to the state agency until 09/18/2024 at 5:00 PM. An interview on 09/26/2024 at 4:55 PM with the AT confirmed that the investigative report was not submitted within five working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on record review, observation, and interview, the MDS (Minimum Data Set, a federally mandated assessment used for care planning) did not reflect the use of a C-PAP (continuous positive airway pressure, a machine that treats sleep-related breathing disorders by keeping airways open during sleep) for 1 (Resident 28) of 12 sampled residents. The facility census was 47. Findings are: A record review of the admission Record with a list of diagnosis of a printed date of 8/29/24 revealed diagnosis of Paranoid Schizophrenia (is characterized by paranoia, delusions, and hallucinations), Chronic Respiratory Failure with Hypercapnia(a condition that occurs when the body has too much carbon dioxide (CO2) in the blood and can't get rid of it.), Morbid (severe) obesity with Alveolar Hyperventilation(A decrease in the body's ability to ventilate), obesity (an excessive accumulation of body fat that can negatively impact health), obstructive sleep apnea (a sleep condition that occurs when the upper airway becomes blocked during sleep, interrupting breathing), and Parkinsonism (a general term for a group of conditions that cause similar symptoms). An observation on 08/28/24 11:08 AM revealed in Resident 28 room there was a C-pap mask and tubing connected to machine and hanging from built in dresser in a basket. An observation on 08/29/24 10:40 AM revealed in Resident 28 room there was a C-pap mask and tubing connected to machine and hanging from built in dresser in a basket laying on top of unopened potato chip bag. A record review of the Medication Administration record for the month of August 2024 revealed an order for the C-PAP at bedtime for sleep apnea, with signatures indicating that Resident 28 wore the C-PAP nightly. A record review of the MDS dated [DATE] in Section O Special Treatments, Procedures and Programs was marked as None of the Above for the C-PAP. An interview on 8/29/24 at 3:30 PM with the MDS-C confirmed that the C-PAP should have been marked on the MDS and it wasn't marked on the MDS.

Based on record reviews and interview, the facility failed to ensure that PASARR (readmission Screening Resident Reviews) for individuals with a mental disorder or intellectual disability were accurately completed to determine if a Level 11 PASARR review was warranted for 1 (Resident #28) of 12 sampled residents. The facility census was 47. Findings are: A record review of Resident 28 admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/17/24, revealed that Resident 28 had diagnoses including Schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). Further review revealed that Resident 28 had not been evaluated by Level 11 as indicated with a serious mental illness( health conditions involving changes in emotion, thinking or behavior (or a combination of these) diagnosis. A record review of the current PASRR evaluation dated 7/1/24 revealed that Section 111 PASRR Conditions:1. Mental Illness or suspected Mental Illness (all that apply) was answered No mental health diagnosis is known or suspected. An interview on 8/29/24 at 10:00 AM with the MDS-C confirmed that Resident 28 was admitted with the mental illness diagnosis and was not referred for a Level 11 PASARR to ensure that the facility could meet Resident 28 needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6(7) Based on interviews, record reviews, and observations, the facility failed to obtain a physician order for 1 (Resident 25) of 1 sampled resident continuous positive airway pressure (CPAP, is a machine that uses mild air pressure to keep breathing airways open while you sleep). The facility census is 47. Record review of Resident 25's admission Record revealed Resident 25 admitted on [DATE]. Record review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 6/6/24 revealed in Section C: Resident 25's BIMS (Brief Interview for Mental Status, 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) scored 14. Section O revealed using a non-invasive ventilator. Record review on 8/28/24 revealed there was no order for a CPAP. Record review of a Physician referral form dated 8/31/24 revealed diagnosis for CPAP is Obstructive Sleep Apnea. An interview on 8/28/24 at 9:45 AM with Resident 25 revealed Resident 25 wears a CPAP with oxygen all the time due to shortness of breath. An interview on 8/29/24 at 1:00 PM with Resident 25's family member revealed Resident 25 was sitting in wheelchair with CPAP and O2 on. The family member futher revealed the resident has used a CPAP before they were admitted . An observation on 9/3/24 at 8:41 AM revealed Resident 25 was lying in bed with CPAP and O2 on. An observation on 9/4/24 at 8:20 AM Resident 25 was lying in bed with CPAP and O2 on. An interview with the Director of Nursing (DON) on 8/29/24 at 1:38 PM confirmed that the facility did not have an order for Resident 25's CPAP. An interview on 9/4/24 at 8:56 AM with DON revealed Resident 25 has used the CPAP since admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.18 (D) Based on record review, observatations and interview, the facility failed to provide Enhanced Barrier Precautions(EBP, involves wearing specific personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities) to Residents 13, 14, 21, 25, 41 and 50, and the facility failed to provide storage/cleaning to the respiratory equipment to prevent cross contamination for Residents 41 and 28 and the facility failed to perform hand hygiene cares for wound care and catheter cares for Resident 14 and Resident 25 to prevent cross contamination for 4 sampled residents out of 24 sampled residents. The facility census was 47. Findings are: A. A record review of Resident's on Enhanced Barrier Precautions with no dated noted provided by the facility upon entry revealed that Resident 13, 50, 14, 41, 25 ,21 were on the list for Enchanced Barrier Precautions. An observation on 08/28/24 at 09:22 AM revealed that Resident 41, 25, 21 with catheter bag hanging from bed frame with urine in catheter bag touching the floor. There was no cover over the catheter bag. There was no Enchanced Barrier Precautions in Resident 41, 25 and 21 rooms for the catheter cares. An observation on 8/28/24 at 10 AM revealed that in Resident 13, 50 and 14 rooms there was no Enchanced Barrier Precautions for wound cares. A record review of in-service for Enhanced Barrier Precaution at the facility revealed a due date of June 1, 2024. An interview on 08/29/24 at 10:18 AM with the Director of Nursing (DON) confirmed that there are no enhanced barrier precautions in rooms with catheters, or wound care. DON confirmed that the facility just finished a policy and procedure on enhanced barrier precautions, got it signed for approval and will have an in-service on the enhanced barrier precautions and get the supplies to the rooms needed. B. An observation on 08/28/24 at 11:08 AM in Resident 28's room revealed a C-PAP(continuous positive airway pressure, a machine that treats sleep-related breathing disorders by keeping airways open during sleep) machine that the mask and tubing connected to machine was hanging from built in dresser in a basket. An Observation on 08/29/24 at 9:30 AM in Resident 28's room revealed a C-PAP machine with the mask and tubing connected to machine was hanging from built in dresser in a basket laying on top of unopened potato chip bag . Record review of the Policies and Procedures dated 19/2020 revealed: CPAP/BIPAP cleaning: Cover with plastic bag or completely enclosed in machine storage when not in use. C. A record review of the admission Record with the printed date of 9/3/24 for Resident 41 revealed the diagnoses of pressure ulcer of buttocks( injuries to the skin and underlying tissue that occurs when the area of skin is under pressure for a prolonged period of time), chronic obstructive pulmonary disease ( a lung disease that causes breathing difficulties by damaging the lungs and airways)and candidiasis of skin and nails(yeast infection that can affect the skin and nails). An observation on 08/29/24 at 9:30 AM in Resident 41's room revealed a nebulizer machine(a nebulizer or nebuliser is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) sitting on recliner with no barrier and the nebulizer mouthpiece and tubing was sitting on the side of nebulizer machine with no barrier. An observation on 09/03/24 at 1:35 PM in Resident 41's room revealed a nebulizer machine was sitting on the recliner with no barrier and nebulizer mouthpiece and tubing with no barrier was lying on recliner seat. An interview on 09/03/24 at 1:46 PM with the DON confirms that the DON's expectations are the nebulizer equipment is to be cleaned and stored after use and the C-PAP/BiPAP are to be cleaned and stored to prevent contamination and they are not being cleaned after each use and stored to prevent contamination. A record review of the Policies and Procedures for the Nebulizer Therapy dated 1/11 revealed: It is the policy of this facility for nebulizer treatments, once ordered to be administered by nursing staff as directed using proper technique and standard precautions. Under the section Care of the equipment revealed to store the nebulizer cup and the mouthpiece in a zip lock bag. D. A record review of the admission Record dated 9/3/24 for Resident 14 revealed the diagnoses of acquired absence of left leg below the knee amputation (removing the knee joint and part of the upper and lower leg), Amputation of the right toes (removing the toes), and Peripheral Vascular Disease. A record review of the Medication Administration Record for the month of August 2024 for Resident 14 revealed a Physician's Order for the right-foot, wash with soap and water, apply tap water moistened TheraBand(a dressing to promote healing) to wound bed and cover with dry dressing. An observation on 9/3/24 at 3:30 PM revealed that the Licensed Practical Nurse (LPN)-B was preparing to do the wound care dressing change to the right foot for Resident 14. LPN-B did not perform hand hygiene when entering the resident's room or before gathering the supplies. LPN-B gathered a 4x4 gauze, wound cleanser bottle, and 3 x 3 gauze and the kerlix wraps and laid the supplies on the bed with no barrier down. LPN-B then took out gloves from [genders] scrub shirt pocket. LPN-B applied the gloves and removed the old dressing from Resident 14's right foot. LPN-B then removed [gender] gloves and applied a new pair of gloves from [gender] scrub pocket without performing hand hygiene. LPN-B then took the 4x4 gauze and wound cleanser and cleaned the wound. LPN-B then removed the gloves and did not perform hand hygiene and took another set of gloves out of [gender] scrub shirt pockets and applied the gloves to [gender] hands and with the 3 x 3 gauze covered the wound. The LPN-B did not perform hand hygiene after completion of the wound care dressing change. An interview on 9/3/24 at 3:45 PM with LPN-B confirmed that [gender] should have performed hand hygiene before and after the wound care. The LPN-B confirmed that [gender] should have gotten the gloves out of the glove box and not [genders] scrub shirt pocket to prevent infection. The LPN-B confirmed that [gender] should have put a barrier down for the clean dressings and did not. An interview on 09/04/24 at 9:55 AM with the DON confirmed that the DON expectations of wound care is to wash hands prior to the start of wound cares and after wound cares, and to place a barrier down for the dressings and to wash hands in between changing of gloves and that that had not been done. E. Record review of Resident 25's admission Record revealed Resident 25 admitted on [DATE]. Record review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 6/6/24 revealed in Section C: Resident 25's BIMS (Brief Interview for Mental Status, 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) scored 14. In Section H revealed having an indwelling catheter ( is a flexible tube used to empty the bladder and collect urine in a drainage bag). Record review of Resident 25's Physician Order dated 6/29/24 revealed diagnosis for catheter is neuromuscular dysfunction of bladder. Record review of Resident 25's Care Plan revealed Resident 25 has an indwelling catheter per resident/family request. Resident 25 has a 16fr (French is the size of a catheter) indwelling catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Observations on 8/28/24 at 9:45 AM revealed Resident 25 has a catheter drainage bag hanging on the bed frame with urine side facing the door of the room. There were no EBP in or by the resident's room. Observation of Resident 25's catheter cares on 9/3/24 at 11:43 AM with Medication Aide (MA)-A. EBP was hanging on back of door. MA-A did not put on any personal protective equipment in the EBP. MA-A washed hands with soap and water then donned (put on) gloves. MA-A then removed the brief tabs to bare the resident's peri (genital) area. Next MA-A cleansed the right groin with a cleansing wipe and then with the same wipe went directly to the resident's urinary meatus (urethral opening) and wiped the meatus. MA-A then got a new wipe, folded the wipe and wiped the left groin, then folded the wipe and cleansed the right groin. MA-A took a new wipe and cleansed the left groin again then with the same wipe went directly to the urinary meatus and wiped the [NAME] and continued wiping down the catheter tubing. MA-A then changed gloves and did not compelete hand hygiene between the glove change. Next MA-A went to the bathroom to get a graduate container and alcohol wipes. MA-A cleansed the drainage bag valve with an alcohol wipe and drained urine into the greaduate container. MA-A then used a new alcohol wipe and cleansed the valve again and attached it to the bag. MA-A emptied the container of urine in the toilet. MA-A changed gloves and did not completed hand hygiene between the glove change, and applied a clean brief to the resident. MA-A then removed gloves and performed hand hygiene with hand sanitizer gel and took trash to the hopper room. Interview with MA-A on 9/3/24 at 11:54 AM revealed that MA-A should have cleansed hands between glove changes, cleaned the catheter tubing with a new wipe each time and to use the EBP. MA-A said [gender] didn't know the EBP was there or was supposed to use it. Interview with DON on 9/3/24 at 11:56 AM revealed MA-A should have cleansed hands in between the glove changes, use a clean wipe for the catheter tubing, and used EBP with doing catheter cares. Record review of Catheter Care Policy dated/signed 11/12/2019 revealed: Policy Statement-It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Procedure as follows: -Gently expose the urinary meatus. -Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). -Use a new part of the cloth or different cloth for each side. -With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, record review and interview; the facility staff failed to perform hand hygiene to prevent the spread of infection and prevent cross contamination during peri-care for Resident 7 and wound care for Resident 3. This affected 2 of 3 sampled residents. Facility census was 40. Findings are: A. Observation on 10/3/2023 at 12:05 PM of peri-care completed on Resident 7 by Medication Aide (MA)-D and Nursing Assistant (NA) -C, with Director of Nursing (DON) present, revealed the following: Resident 7 was placed on the bed pan. At this time, MA-D applied soap to their hands, lathered for 7 seconds, then rinsed the soap off with water. NA-C applied soap to their hands, lathered for 15 seconds, then rinsed soap off of their hands with water. NA-C and MA-D applied gloves. Resident 7 was positioned to their right side and the bedpan removed by MA-D, along with the protective dressing to Resident 7's coccyx. MA-D and NA-C did not remove their soiled gloves and hand hygiene was not completed. MA-D performed peri-care, applied cream to Resident 7's buttocks, and then applied a clean brief, without the removal of soiled gloves and performing hand hygiene. NA-C applied soap to their hands, lathered for 13 seconds, then rinsed their hands. Record review of the facility policy Hand Hygiene dated 9/26/23 revealed the following: -5. Hand hygiene technique when using soap and water: d. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers-under nails and 2 inches above wrists, e. Rinse hands with water, pointing fingertips down. Record review of facility policy Perineal Care dated 9/26/2023 revealed the following: -6. Perform hand hygiene and put on gloves. -16. Remove gloves and discard. Perform hand hygiene. Interview on 10/3/2023 at 12:20 PM the DON confirmed that hand hygiene was not performed for at least 20 seconds before and after cares or throughout the observation and should have been. B. An observation on 10/3/23 from 10:43 AM to 10:50 AM of wound care by Licensed Practical Nurse (LPN)-A, with the Director of Nursing (DON) present, for Resident 3 revealed the following: LPN-A entered Resident 3's room and sat down on the floor. After LPN-A retrieved gloves from the pocket of LPN-A's top, a glove dropped on the floor. LPN-A picked up the glove and applied to hand along with the other glove retrieved from the pocket. LPN-A lifted the blanket up from Resident 3's legs, removed pressure relieving boot from Resident 3's left lower extremity along with the non-skid sock on Resident 3's foot. The boot and sock were placed on the floor next to LPN-A. LPN-A removed the gauze from Resident 3's left foot, followed by the treatment in place on Resident 3's left lateral foot wound. Both the gauze and treatment were placed in the trash can next to LPN-A. LPN-A removed both gloves, placed the gloves in the trash can and then applied new gloves. No hand hygiene was completed after removal of gloves or putting on the new gloves. After the treatment to Resident 3's wound was completed, LPN-A removed the gloves, threw gloves in trash can and proceeded to place both hands on the floor then stood up. No hand hygiene was completed after removal of gloves. LPN-A left the room to obtain tape to secure the gauze. Upon return to Resident 3's room, LPN-A did not complete hand hygiene and placed a piece of tape on the gauze. LPN-A then applied Resident 3's sock and boot. In an interview on 10/3/23 at 2:01 PM the DON confirmed that LPN-A had dropped a glove on the floor, did not complete hand hygiene after removal of gloves, pushed up from floor with bare hands, and applied tape without gloves on. The DON further confirmed that LPN-A should not have used the glove that was dropped, and that hand hygiene should have been completed after removal of gloves. Review of the facility policy, Clean Dressing Change, dated 9/26/23, revealed the following: -10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. -11. Wash hands and put on clean gloves. -16. Secure dressing and mark with initials and date -17. Discard disposable items and loves into appropriate trash receptacle and wash hands.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to properly store food and failed to keep a clean environment in the kitchen to prevent the potential for cross contamination and food borne illness. This had the potential to affect 40 of 40 residents that ate food prepared in the facility kitchen. The facility census was 40. Findings are: Observation on 10/2/23 from 8:25 AM to 9:00 AM during initial kitchen tour revealed the following: -dust on top of ice machine -white build up inside of ice machine -plastic bag of powdered sugar opened -opened plastic bag with dark brown sticky substance on it with opened package of sugar free lemon gelatin dessert mix - dark brown crumbs on tray holding packages of sugar free lemon gelatin dessert mix -food particles and dust behind stoves/ovens and metal rack for tray -dirt build up around baseboard throughout main kitchen and dishwashing areas -splattered dried food on back wall and lower cupboards in prep area Observation on 10/3/23 from 2:33 PM to 2:45 PM during final kitchen tour revealed the following: -dust on top of ice machine -white build up inside of ice machine -plastic bag of powdered sugar opened -opened plastic bag with dark brown sticky substance on it with opened package of sugar free lemon gelatin dessert mix -dark brown crumbs on tray holding packages of sugar free lemon gelatin dessert mix -food particles and dust behind stoves/ovens and metal rack for tray -dirt build up around baseboard throughout main kitchen and dishwashing areas -splattered dried food on back wall and lower cupboards in prep area -food particles on cart holding trays An interview on 10/3/23 from 2:33 PM to 2:45 PM, the Dietary Consultant (DC) confirmed the dust on top of ice machine, white build up inside of ice machine, plastic bag of powdered sugar opened, opened plastic bag with dark brown sticky substance on it with opened package of sugar free lemon gelatin dessert mix, dark brown crumbs on tray holding packages of sugar free lemon gelatin dessert mix, debris and dust behind stoves/ovens and metal rack for tray, dirt build up around baseboard throughout main kitchen and dishwashing areas, splattered dried food on back wall and lower cupboards in prep area and food particles on cart holding trays. The DC further confirmed that the above noted issues should be clean and free of dust and food particles and/or build up. A review of the facility policy, Storage (Receipt and Issue included), undated, revealed the following: -Containers and proper materials to store items in dry storage: 2. Opened dry items, such as pasta, rice, and crackers are stored in labeled containers of corrosion-resistant materials with tight fitting lids. -Food Storage Areas: 1. The storeroom is dry without water leakage or contamination. The area is clean, well-lighted and well-ventilated and maintain a temp of 60 to 70 degrees Fahrenheit. 2. The shelving is clean, preferable metal.