**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. An observation on 06/02/25 at 10:42 AM revealed Resident 10 laying in bed with hair that appeared oily and shiny. During an interview on 06/02/25 at 10:43 AM Resident 10 revealed that (gender) cannot remember the last time (gender) had a bath or washed (gender) hair. An observation on 06/04/25 at 2:28 PM revealed Resident 10 lying in bed with hair that appeared oily and shiny. During an interview on 06/04/25 at 2:29 PM Resident 10 confirmed (gender) would like a bath at least once a week but cannot remember the last time (gender) took a bath or washed (gender) hair. Record review of Resident 10's admission Record revealed that the resident was originally admitted to the facility on [DATE]. Record review of Resident 10's Significant change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/11/2025 revealed that the resident 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 8, that the resident requires supervision or touching assistance with ADL's and bathing. Record review of Resident 10's bathing task log from 4/1-6/5/2025 revealed bathing was documented on: -4/9/25 -5/14/25 -5/21/25 Record review of un-named facility bath log 4/25-5/29/25 revealed that Resident 10 had baths documented on: -5/5/25 -5/21/25 Record review of Resident 10's progress notes from 4/1/2025- 6/5/2025 revealed no documentation of bed baths given or resident refusals. Record review of Resident 10's Comprehensive Care plan focus date initiated on 3/12/2024 revealed an ADL (activities of daily living) self care deficit and no bathing interventions or preferences listed. During an interview on 6/4/25 at 2:40 PM the Administrator confirmed they do not have a facility bathing policy. During an interview on 06/05/25 at 8:31 AM Licensed Practical Nurse (LPN) - D confirmed there was not a bath aide scheduled daily. During an interview on 06/04/25 at 2:58 PM the Director of Nursing confirmed the following: -It is the facility's expectation that every resident should receive at least 1 bath a week and that baths are based on resident preferences. -Resident 10 only received 1 bath in the month of April and 2 baths in the month of May. -All baths, including bed baths, and refusals should be documented under the bathing task. -Upon admission to the facility, residents are asked their bathing preferences and bathing preferences should be care planned. -Currently the facility does not have a full time bath aide. If there are 4 nursing assistants scheduled, then 1 assistant is assigned to provide the resident baths. -Staffing does not always allow for a nursing assistant to be assigned to provide resident baths. Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review, the facility failed to provide bathing per resident preference for 2 (Resident 34 and Resident 10) of 2 sampled residents. The total facility census was 49. Findings are: A. A record review of Care Plan with an admission date of 02/01/2023 for Resident 34 revealed diagnoses of polyneuropathy (multiple peripheral nerves become damaged that affects the nerves in the skin, muscles, and organs, leading to symptoms such as numbness and burning pain) and restless leg syndrome (a neurological disorder that is characterized by an uncomfortable feeling in the legs). Resident 34 required extensive assistance for bed mobility and transfers but did not reveal interventions for bathing. A record review of Resident 34's Minimum Data Set (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 04/29/2025 revealed that the resident requires maximum assistance for bathing. The MDS revealed a brief interview for mental status (BIMS) 15 of 15 which indicated that the resident was cognitively intact. A record review of the facility's Bathing Schedule dated May 2025 revealed Resident 34 had two baths, one on 05/07/25 and one on 05/15/2025. A record review of facility's Social Service Routine Assessment dated 04/28/2025 for Resident 34 revealed no assessment for bathing preferences. A record review of the un-named facility's bath log dated 04/25/2025-05/29/2025 revealed Resident 34 received a bath on 04/30/2025 and 05/07/2025. An interview on 06/02/2025 at 11:03 AM with Resident 34 confirmed that the resident had not had a bath for at least a month. The resident confirmed it was because the facility was short of staff. Resident 34 confirmed that the resident's preference is to have a bath weekly. The resident confirmed there was a wound on the resident's leg and was told by staff that a bath would help, but there was no one to give the resident a bath. An interview with the Administrator (Adm) on 06/03/2025 at 3:38 PM confirmed there was no other resident assessments for Resident 34 bathing preferences other than what was already provided. An interview with the Nursing Assistant (NA)-A confirmed that the NA giving the bath will ask the resident's preference, but baths have not been done in a long time due to being short staffed. NA-A confirmed that baths should be done weekly. An interview with Licensed Practical Nurse (LPN)-B confirmed that the facility was a little behind on baths, but they will get caught up. LPN-A confirmed that baths should be done weekly. An interview with the Director of Nursing (DON) on 06/03/2025 confirmed that the facility's bath logs are thrown away after they are documented in the Electronic Medical record (EMR) and the residents should have a bath at least weekly. The DON stated that they are trying to complete baths weekly but sometimes get behind. An interview with the Adm on 06/04/2025 at 2:40 PM confirmed the facility did not have a specific bathing policy.

Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN-a form that lists the items or services that the facility expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay) and the Notice of Medicare Non-Coverage (NOMNC, a required notice allowing the resident to appeal the facility decision to end Medicare Part A coverage) was given to a beneficiaries at least two days prior to the end of covered services which affected 1 (Resident 9) of 4 sampled residents. The facility census was 49. Findings are: A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility for Resident 9 revealed that the resident's Last Covered Day (LCD) for Medicare Part A services was 04/30/2025, and the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. A further review of the form revealed the facility provided a SNF ABN, and a NOMNC to Resident 9. A record review of Resident 9's SNF ABN revealed it was signed electronically by the Resident 9 with a date of 04/30/2025, and initialed electronically by the Social Services Director (SSD) with no date. A record review of Resident 9's NOMNC revealed it was signed electronically by the Resident 9 with a date of 04/30/2025, and initialed electronically by the Social Services Director (SSD) with no date. An interview on 06/05/2025 at 8:32 AM with the SSD confirmed that the SNF ABN and NOMNC for Resident 9 were not signed within the required time frame prior to the LCD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(E)(i) Based on interview and record review the facility failed to ensure the individualized care plans covered the psychotropic (affects mental status) medication and discharge planning for 2 (Residents 26 and 48) of 4 sampled residents. The facility census was 49 Findings are: A record review of the facility's Care Planning policy and procedure with the revision date of 03/2019 revealed individual resident-centered care planning begins when the resident is admitted and doesn't end until the resident is discharged . The goal for the care plan is directly related to the resident's discharge plan. The physician's orders which include the resident medications are part of the care plan. Care plans should be updated between care conferences to reflect current care need of the individual resident as changes occur. A. A record review of Resident 26's Clinical Census dated 05/13/2025 revealed the resident was admitted to the facility on [DATE] A record review of Resident 26's Medical Diagnosis dated 05/13/25 revealed the resident had diagnoses of Hypertension (increased blood pressure), Diabetes Mellitus (increased blood sugar), Diabetic Neuropathy (pain and numbness in legs and feet), Major Depressive Disorder, Muscle Weakness, Permanent Atrial Fibrillation (irregular, often rapid heartbeat), Acute Kidney Failure (kidneys can't filter waste from the blood). A record review of Resident 26's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 05/19/2025 revealed Resident 26 had a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) of 13 of 15 which indicated the resident is cognitively oriented. The resident needed moderate to extensive assist with oral and personal hygiene, upper and lower body dressing, transferring and putting on footwear. A record review of Resident 26's Physician orders dated 05/13/2025 revealed the resident was on Celexa (antidepressant) and Remeron (antidepressant) daily for depression. A record review of Resident 26's Care Plan dated 05/19/2025 did not reveal that the antidepressant medication was addressed on the care plan. In an interview with the Director of Nursing (DON) on 06/04/2025 at 1:04 PM confirmed that each department is responsible for their own areas on the care plan. The DON is responsible for the resident's sections involving addressing the medication on the care plan. The DON confirmed there was not medications addressed on Resident 26's care plan and should have been. B. A record review of Resident 48's Clinical Census revealed an admission of 07/08/2024 and a discharge date of 04/01/2025. A record review of Resident 48's Medical Diagnosis dated 07/08/2024 revealed the resident has diagnoses of Hypertension (high blood pressure), low back pain, muscle weakness, unsteadiness on feet, difficulty with walking, and disease of esophagus (moves food and fluid from mouth to stomach). A record review of Resident 48's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 04/01/2025 revealed a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) was a 15 of 15 indicating Resident 48 is cognitively intact. A record review of Resident 48's Physician Order dated 03/31/2025 revealed order for Resident 48 to discharge from the current facility to an Assisted Living Facility on 04/01/2025. A record review of Resident 48's Care Plan dated 03/25/2025 did not reveal the care plan addressed the discharge plan for Resident 48. In an interview with the Social Service Director (SSD) on 06/04/2025 the SSD confirmed Resident 48's discharge plans were not on the Care Plan and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview the facility failed to update the Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) to accurately reflect the fall interventions for 1 (Resident 10) of 3 sampled residents. The facility census was 49 at the time of survey. Findings are: Review of the facility's policy titled Fall Prevention and Response Policy dated revised April 2025 revealed that when a fall occurs the care plan will be updated with any new or updated fall interventions. Review of the facility's policy titled Care Planning dated revised March 2019 revealed that careplanning is constantly in progress and it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. Record review of Resident 10's admission Record revealed that the resident was originally admitted to the facility on [DATE]. Record review of Resident 10's Significant change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/11/2025 revealed that the resident 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 8, which indicated a moderate cognitive impairment, that the resident had diagnosis of history of fall with fracture, that the resident requires assistance with ADL's, and that the resident had a fall without injury. Record review of Resident 10's fall risk evaluation dated 5/5/25 revealed that the resident had a history of falls in the last 3 months. Record review of Resident 10's progress notes dated 5/7/2025 revealed that the resident rolled off the bed and hit (gender) head and was sent to the emergency room. Record review of facility provided incident report dated 5/7/2025 revealed that Resident 10 fell on 5/7/25 and that no new fall interventions were identified. Record review of Resident 10's CCP revealed: -Fall Prevention focus dated last revised 4/27/2025 -Most recent fall intervention dated 6/26/2023 During an interview on 06/03/25 at 12:08 PM the Director of Nursing (DON) confirmed there were no new fall interventions on the resident's CCP after the 5/7/2025 fall and there should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09(H)(i)(3) Licensure Reference 175 NAC 12-006.09(H)(iv)(3) Based on observations, interviews, and record reviews the facility failed to provide timely repositioning and incontinence care for 1 (Resident 2) of 2 sampled residents for dependent cares. The facility census was 49 at the time of survey. Findings are: Record review of facility policy titled Repositioning Policy and dated [DATE] revealed that repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, for residents who are in bed should be on a every 2 hour repositioning schedule or alternate schedule based on resident assessment, and residents with a stage 1 or above pressure ulcer the every 2 hour repositioning schedule maybe inadequate. An observation on 06/02/25 at 10:02 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/03/25 9:13 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/04/25 08:15 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/05/25 08:02 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. Record review of Resident 2's quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/26/25 revealed that the resident was admitted to the facility on [DATE], 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 0 which indicates severely impaired cognitive skills, the resident is dependent for ADL's, and a stage 2 pressure ulcer was not present on admission. Record review of Resident 2's diagnosis revealed a diagnosis of Cerebral Infarction, Dementia, Mood Disturbance, and Anxiety. Record review of Resident 2's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed: -the resident has a pressure ulcer related to immobility date initiated on 11/24/2024 -intervention dated 5/9/2025 the resident needs to be turned/repositioned at least every 2 hours, more often as needed. -intervention dated 5/9/2025 the resident requires 1-2 staff to turn and reposition in bed. Record review of Resident 2's wound care consultation notes from visit dated 5/1/25 revealed an order to apply Therabond to wound on back and cover with mepilex. Record review of Resident 2's Braden Scale risk assessment dated [DATE] revealed a score of 13, which indicates the resident is at risk for skin breakdown and that the resident's skin is often moist. An observation on 06/04/25 at 10:55 AM Licensed Practical Nurse (LPN) - H repositioning Resident 2 and removing the resident's brief in order to perform wound care and pericares. An observation on 06/04/25 at 11:02 AM of Resident 2 lying in bed with brief noted to be heavily saturated with dark yellow urine and with a foul odor. During an interview on 06/04/25 at 11:04 AM Nursing Assistant (NA) - E confirmed that the resident had not been checked, changed or repositioned since before 6 am when the night shift left, and that 5 hours was too long for a resident not to be checked, changed or repositioned. Observation on 6/5/2025 at 8:25 AM of Resident 2 lying in bed with an incontinent brief on was noted to be heavily saturated with dark yellow urine and had a foul odor. During an interview on 06/05/25 at 8:27 AM interview with NA - A confirmed that they (facility staff) have not checked or changed or repositioned the Resident 2 since they got to the facility at 6 AM. It was also confirmed that they do walking rounds at 6 am when they get here with the night shift before they leave, the night shift always tells them that the last time the resident was checked or changed or repositioned was between 5 and 5:30 AM. It was also confirmed that 3 hours is too long for a resident not to be checked, changed or repositioned. Record review of Resident 2's undated nursing care sheet revealed that peri cares should be provided after each incontinence episode. During an interview on 06/04/25 at 4:29 PM the DON confirmed there is no facility wound care policy. During an interview on 6/5/2025 at 1:12 PM the DON confirmed that all residents especially those with wound issues should be checked, changed and repositioned every 2 hours and that all refusals of care should be documented.

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review the facility failed to use proper hand hygiene (cleaning) and use of personal protective equipment (PPE) when providing wound care for one (Resident 8) of two sampled residents. The facility census was 49. Findings are: A record review of the Handwashing/Hygiene policy and procedure with revision date of 01/2020 revealed hand hygiene needs to be completed before and after direct physical contact with a resident, before and after handling any dressing, and objects soiled during or after resident care. Hand hygiene should have been completed immediately after or as soon as possible following contact of such body areas with blood or other potentially infectious material. The use of gloves does not replace handwashing/hand hygiene. A record review of Glove Use with Resident Cares: Policy and Purpose with revision date of 03/2019 revealed the purpose was to provide guidelines for the use of gloves for resident and employee protection. The staff should remove soiled undergarments following performing or assisting with peritoneal (peri)-care. When peri-care were completer staff was to remove gloves and wash hands. Apply clean gloves and assist/place clean undergarments, brief, clean clothing or pajamas. A record review of the facility Policy and Procedure implemented 08/2024 revealed, Enhanced Barrier Precautions (EBP) was an infection control intervention to reduce transmission of multi-resistant organisms (MDRO's) in nursing facilities which involved staff wearing gloves and gown during high-contact residents infected with MDRO's during care, such as wound care. The EBP Policy Explanation and Compliance guidelines dated 08/2024 revealed gowns and gloves should be available near or outside of the resident's room. A gown and gloves should be donned (put on) prior to high-contact resident activities involving the changing of the resident's briefs or assisting with toileting and wound care requiring a dressing. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk. A record review on 06/04/2025 of Resident 8's Clinical Census revealed an admission date of 12/23/2011. A record review of Resident 8's Medical Diagnosis dated 01/02/2025 revealed: Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, Hypothyroidism, unspecified, Acquired absence of left leg above knee, Mild cognitive impairment of uncertain or unknown etiology, Other specified mental disorders due to known physiological condition, Senile (decrease in ability to think or remember) degeneration of brain, not elsewhere classified, Muscle weakness generalized, Peripheral Vascular Disease (PVD) the reduced circulation of blood to a body part), Absence of right leg above knee. A record review of Resident 8's dated 01/02/2025 Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 01/02/2025 revealed the resident was at risk for pressure ulcers. A record review of the MDS for review dated 3/27/2025 revealed Resident 8 as being at risk for a pressure ulcer. A Brief Interview for Mental Status (BIMS) a brief screener that aids in detecting cognitive impairment score) is at 99 which explains Resident 8 is unable to complete the interview. The MDS areas revealed Resident 8 was dependent on staff for all cares and needed substantial/maximum assist for turning and repositioning. Resident 8 is frequently incontinent of bowel and bladder had no pressure ulcer A record review of Resident 8's Progress Note dated 05/27/2025 at 8:54 PM revealed the nursing skin assessment evaluated the left buttock pressure ulcer injury (breakdown of skin from pressure) had partial thickness of skin loss with exposed dermis (second layer of skin). The wound was acquired in-house (in facility). A record review of the Resident 8's Care Plan revealed: • The resident has STAGE 2 pressure ulcer left buttock related to history of ulcers, Immobility • The residents Pressure ulcer will show signs of healing and remain free from infection by/through review date. • Administer treatments as ordered and monitor for effectiveness. • Follow facility policies/protocols for the prevention/treatment of skin breakdown. • last to get up, first to lay down • The resident needs to turn/reposition at least every 2 hours, more often as needed or requested. An observation on 06/03/2025 at 2:45 PM of Licensed Practical Nurse (LPN)-B, and LPN -C performed wound care for Resident 8. LPN-C provided the treatment for Resident 8 without donning a gown. LPN-C washed hands prior to providing treatment as follows: - place the Optifoam (foam waterproof dressing) Gentle on barrier on bedside table along with clean med cup. - LPN-C pulled the dirty brief down from back of Resident 8's buttock which exposed the urine and stool in it and took off the dirty dressing from left buttock wound which was the Optifoam with a Therabond (dressing that draws extra fluid from open wound) piece in it. - LPN-C left Resident 8's bedside and went into the bathroom to moisten the Therabond. During this time Resident 8 turned onto (genders) back exposing uncovered wound to the dirty brief. - LPN-C washed (genders) hands and replaced gloves. - LPN-C then returned from the bathroom with the Therabond in the cup. LPN-C assisted Resident 8 back onto (genders) right side. - LPN-C cleaned Resident 8's wound with a washcloth with soap and water and then used a second washcloth and rinsed and dried the wound. - LPN-C using the same gloves from cleaning the wound then placed the moistened Therabond into Resident 8's clean wound and covered it with a clean Optifoam Gentle. - LPN-C then using the same gloves took the moist peri wipes and cleaned Resident 8's buttocks of stool and placed clean brief on Resident 8 with the same soiled gloves on. - LPN-C assisted Resident 8 onto genders back and cleaned pubic area and with the same gloves on assisted Resident 8 to turn onto left side for clean brief to be positioned. - LPN-C continued with the same dirty gloves as used with peri care took Resident 8's right hand to get (gender) to release grip from the bedside positioning bar and turned Resident 8 onto (genders) back. - Resident 8 was positioned on the left side with pillow to position. - LPN-C then washed their hands after removing gloves. An interview on 06/03/2025 at 3:15 PM with LPN-C revealed: - LPN-C confirmed that (gender) did not put on gown prior to providing Resident 8's wound treatment or dressing change and confirms they should have. - LPN-C confirmed that (gender) should have changed gloves and washed hands after cleaning stool from Resident 8's buttocks and peri area. - LPN-C confirmed Resident 8's mid left buttock wound should not have been exposed until after the peri care and cleaning of Resident 8's buttocks was done. An interview on 06/03/2025 at 3:15 PM with LPN-B revealed: - LPN-B confirmed that (gender) did not don a gown prior to resident care and should have. - LPN-B confirmed Resident 8's mid left buttock wound should not have been exposed until after the peri care and cleaning of buttocks was done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(D) The facility failed to provide a minimum of three nurse aides on each shift per the facility assessment and to ensure call lights were answered to meet the needs of the residents. This had the potential to affect all residents that resided in the facility. The total facility census was 49. Findings are: A record review of the Facility Assessment dated 07/01/2024 revealed the facility has an average daily census of 55 that requires 1-3 licensed nurses, 3-9 nurse aides, and 1-3 other nursing personnel. A record review of the facility's Posted Daily Staffing dated 05/04/2025 revealed three licensed nurses and no nurse aides on the day shift. A record review of the facility's Posted Daily Staffing for May 1st- May 31st, June 1, 2, and 3, 2025 revealed two nurse aides staffed on the night shift. A record review of the facility's Schedule Sheet dated May 2025 revealed two NA's scheduled for night shift every night. A record review of the facility's Past Calls for resident room [ROOM NUMBER] dated 12/1/2024-1/14/2025, all shifts, revealed 31 times the call lights were on more than 30 minutes with the longest time of one hour and 21 minutes on 01/01/2025 at 3:30 AM. A record review of the facility's Past Calls for resident room [ROOM NUMBER] dated 05/05/2025-06/03/2025, all shifts, revealed 23 times the call lights were on more than 30 minutes with the longest time of 59:26 minutes on 05/12/2025 at 6:08 AM. A record review of the facility's Past Calls for resident room [ROOM NUMBER] dated 05/05/2025-06/03/2025, all shifts, revealed 10 times the call lights were on more than 30 minutes with the longest time of 1:20 (1 hour and 20 minutes) on 05/09/2025 at 9:35 AM. A record review of the facility's Bathing Schedule dated May 2025 revealed Resident 34 had two baths, one on 05/07/25 and one on 05/15/2025. A record review of the un-named facility's bath log dated 04/25/2025-05/29/2025 revealed Resident 34 received a bath on 04/30/2025 and 05/07/2025. An observation on 06/04/2025 at 9:00 AM of Resident 4 revealed the call light was on and not answered until 9:36 AM. A record review of the facility's Past Calls dated 06/04/2025 for Resident 4 revealed the call light was on for 38:29 minutes. An interview on 06/02/2025 at 11:03 AM with Resident 34 confirmed that the resident had not had a bath for at least a month. The resident confirmed it was because the facility was short of staff. Resident 34 confirmed that the resident's bathing preference is weekly. The resident confirmed there was a wound on the resident's leg and was told by staff that a bath would help, but there was no one to give the resident a bath. An interview with the Administrator (Adm) on 06/02/2025 at 11:25 AM confirmed the Facility Assessment staffing plan on page 13 is a range of nursing staff needed for each shift. An interview on 06/03/2025 at 7:32 AM with Resident 15 confirmed the facility is short of staff on weekends. An interview with the Nursing Assistant (NA)-A confirmed the NA giving the bath will ask the resident's preference, but baths have not been done in a long time due to being short staffed. NA-A confirmed that baths should be done weekly. An interview on 06/04/2025 at 10:15 AM with NA-E confirmed the call lights should be answered within 5-6 minutes but often it takes much longer. NA-E confirmed that the facility could use more staff but are doing the best they can. An interview on 06/04/2025 at 1:10 PM with NA-F confirmed the expectation for answering call lights is 5-10 minutes but this does not always happen. NA-F confirmed that staffing is general okay but depends on who is working. An interview on 06/04/2025 at 1:15 PM with NA-G revealed the facility could use more help. NA confirms the facility only allows two NA's at night and that is not enough when one NA is on the memory care unit. An interview on 06/05/2025 at 8:38 AM with the DON confirmed the facility does not complete call light logs for tracking, nor do they have action plans to address the long call light response times. The DON states that they just talk to the staff. An interview on 06/04/2025 at 2:41 PM with the Adm confirmed that 30 minutes for a call light response time is not acceptable. An interview on 06/04/2025 at 2:41 PM with the DON confirmed the facility assessment requires a minimum of three NA's on night shift but they only staff with two NA's. The DON confirmed the expectation of 10-15 minutes for call light response time but states this is not always possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09D2 Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 47) of 3 sampled resident's wound care was completed as ordered by the provider. The total facility census was 52. Findings are: A record review of Resident 47's Clinical Census dated 05/22/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Type 2 Diabetes Mellites With Diabetic Chronic Kidney Disease (uncontrolled blood sugars that resulted in kidney disease), Secondary Malignant Neoplasm of Bone (bone cancer) Weakness, and lung disorders. A record review of Resident 47's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 12 of 15 which indicates the resident was moderately cognitively impaired. The resident needed partial/moderated assistance putting on footwear, supervision or touching assistance with toileting and dressing, and setup or clean-up assistance with eating and oral hygiene. The MDS revealed the resident was at risk for developing pressure ulcers/injuries but did not have any at the time of the MDS. A record review of Resident 47's Care Plan did not reveal the resident had wounds to the BLE. A record review of Resident 47's Wound - Initial (New) Documentation Form (one wound per form) - V 1 dated 04/27/2024 revealed Resident 47 had an abrasion (damage by scraping or wearing away of skin) to the front of the left lower leg that was 1.7 centimeter (cm) long, 1.6 cm wide, and 0 deep that has a scant (small) amount of clear drainage. A record review of Resident 47's Progress Note dated 05/17/2024 revealed the resident had fluid filled blisters that remained to the bilateral lower extremities (BLE, both lower legs) and treatment in place as ordered. A record review Resident 47's Skilled Status Evaluation - V 5 dated 05/20/2024 revealed the resident had scattered intact (not damaged) and nonintact blisters that remained to the BLE and treatment remained in place as ordered. A record review of Resident 47's Physician's Orders dated 05/15/2024 revealed the facility was to use Betadine Paint (an antiseptic liquid that kills germs/bacteria) to BLE blistered areas, cover with Telfa (a non-adherent dressing) and army battle dressing (ABD, used to absorb discharges from draining wounds) 2 times per day (BID) and apply Triple Antibiotic Ointment (TAO) to any ulcerated area (open sore) on BLE after applying Betadine. An observation on 05/21/2024 at 10:37 AM revealed Licensed Practical Nurse (LPN)-A performed handwashing, got on the floor, gloved and applied Povidone-Iodine swab stick (an antiseptic liquid that kills germs/bacteria) to the front of Resident 47 BLE but did not paint the blistered areas on the sides of the lower legs. In an interview on 05/22/2024 at 8:43 AM, LPN-A confirmed LPN-A thought the order was to paint the open area, not the blisters, I misread it. LPN-A confirmed the blisters on Resident 47's BLE did not get painted with Betadine per the provider's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on observations, interviews, and record review; the facility failed to ensure all infection control measures were followed during wound care for 1 (Resident 47) of 3 sampled residents, ensure 1 (Resident 54) of 1 sampled resident's nebulizer kit (used to deliver liquid medication to the lungs) and mask were cleaned after each treatment, and failed to perform hand hygiene between gloves changes while providing catheter cares for 1 (Resident 41) of 1 sampled resident. The total facility census was 52. Findings are: A. A record review of the facility's Handwashing/Hygiene policy with a revision dated of Jan. 2020 revealed hand hygiene needed to be completed before donning (putting on) and after removal of gloves. A record review of Resident 47's Clinical Census dated 05/22/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Type 2 Diabetes Mellites With Diabetic Chronic Kidney Disease (uncontrolled blood sugars that resulted in kidney disease), Secondary Malignant Neoplasm of Bone (bone cancer) Weakness, and lung disorders. A record review of Resident 47's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 12 of 15 which indicates the resident was moderately cognitively impaired. The resident needed partial/moderated assistance putting on footwear, supervision or touching assistance with toileting and dressing, and setup or clean-up assistance with eating and oral hygiene. The MDS revealed the resident was at risk for developing pressure ulcers/injuries but did not have any at the time of the MDS. A record review of Resident 47's Care Plan did not reveal the resident had wounds to the BLE. A record review of Resident 47's Progress Note dated 05/17/2024 revealed the resident had fluid filled blisters that remained to the bilateral lower extremities (BLE, both lower legs) and treatment in place as ordered. A record review of Resident 47's Wound - Initial (New) Documentation Form (one wound per form) - V 1 dated 04/27/2024 revealed Resident 47 had an abrasion (damage by scraping or wearing away) to the front of the left lower leg that was 1.7 centimeter (cm) long, 1.6 cm wide, and 0 deep that has a scant (small) amount of clear drainage. A record review Resident 47's Skilled Status Evaluation - V 5 dated 05/20/2024 revealed the resident had scattered intact (not damaged) and nonintact blisters that remained to the BLE and treatment remained in place as ordered. A record review of Resident 47's Physician's Orders dated 05/15/2024 revealed the facility was to use Betadine Paint (an antiseptic liquid that kills germs/bacteria) to BLE blistered areas, cover with Telfa (a non-adherent dressing) and army battle dressing (ABD)(used to absorb discharges from draining wounds) 2 times per day (BID) and apply Triple Antibiotic Ointment (TAO) to any ulcerated area (open sore) on BLE after applying Betadine. An observation on 05/21/2024 at 10:37 AM revealed Licensed Practical Nurse (LPN)-A performed handwashing, got on the floor, put on gloves, and applied TAO on Resident 47's ulcerated areas on the front of both of the resident's lower legs, removed and discarded the gloves, and applied a new pair of gloves, but the observation did not reveal that LPN-A performed hand hygiene between changing gloves. LPN-A placed 2 dressing pads on the residents left leg, but as LPN-A started to wrap the resident's lower leg with Kerlix (a stretch dressing), 1 of the dressing pads fell on the carpeted floor, wound side down. LPN-A picked up the dressing pad and placed it back on Resident 47's left lower leg over the wound and continued to wrap the leg with Kerlix. The same side of the dressing pad the touched the carpet was the same side that was applied to the blisters. In an interview on 05/22/2024 at 8:43 AM, LPN-A confirmed hand hygiene should have been completed between glove changes during Resident 47's wound care to the BLE. In an interview on 05/22/2024 at 9:02 AM, LPN-A confirmed the dressing pad that fell on the floor during Resident 47's wound care to the left lower leg should have been discarded following touching the carpeted floor and a new one applied prior to being wrapped with kerlix. B. A record review of the facility's Nebulizer Cleaning Policy with a revision date of March 2019 revealed the nebulizer kit and mask would be cleaned after each use and placed upside down on a paper towel to dry. A record review of Resident 54's Clinical Census dated 05/21/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 54's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Personal History Of Other Malignant Neoplasm of Bronchus And Lung (lung cancer), Other Forms Of Dyspnea (shortness of breath), Emphysema, Unspecified (lung disease), and Anxiety Disorder, Unspecified. A record review of Resident 54's MDS dated 05/12/2024 revealed the resident had a BIMS of 15 of 15 which indicated the resident was cognitively aware. The resident needed minimal assistance with all activities of daily living (ADLs). A record review of Resident 54's Care Plan did not reveal the resident was on nebulizer treatments. A record review of Resident 54's Order Summary Report dated 05/22/2024 revealed the provider had ordered Arformoterol Tartrate Inhalation Nebulization Solution (liquid medication for the lungs) BID, Budesonide Inhalation Suspension (liquid steroid) BID, and Albuterol Sulfate Inhalation Nebulization Solution (a liquid medication to open the lungs) every 2 hours as needed. A record review of Resident 54's Medication Administration Record (MAR) dated May 2024 revealed the resident was administered nebulizer treatments at least every morning and every evening. In an observation on 05/20/2024 at 10:35 AM revealed Resident 54's nebulizer kit and mask were laying on the resident's bedside table by the resident's recliner. The nebulizer kit had a residual (small, left over) amount of fluid in the nebulizer kit and facial oils on the mask. In an observation on 05/21/2024 at 10:42 AM revealed Resident 54's nebulizer kit and mask were laying on the resident's bedside table by the resident's recliner. The nebulizer kit had a residual amount of fluid in the nebulizer kit and facial oils on the mask. In an observation on 05/21/2024 at 1:56 PM revealed Resident 54's nebulizer kit and mask were laying on the resident's bedside table by the resident's recliner. The nebulizer kit had a residual amount of fluid in the nebulizer kit and facial oils on the mask. In an interview on 05/20/2024 at 10:35 AM, Resident 54 confirmed the staff did not clean the nebulizer kit and mask after each treatment. In an interview on 05/21/2024 at 1:56 PM, Resident 54 confirmed the staff did not clean the nebulizer kit and mask after each treatment. In an interview on 05/21/2024 at 2:50 PM, LPN-A confirmed the staff was to rinse the nebulizer kit after each treatment and confirmed it had not been done. C. A record review of the document titled admission Record dated 3/21/24 revealed Resident 41 had been re-accepted into the facility on 9/25/23 with a primary diagnosis of Acute Congestive Heart Failure (CHF, a long-term condition that happens when your heart can't pump enough blood). An observation on 05/21/24 at 9:20 AM of catheter cares completed by Nurse Aide (NA)-J revealed that NA-J had cleansed Resident 41's genetalia and groin area and then donned (put on) a new pair of gloves without completing any hand hygiene. The observation on 05/21/24 at 9:20 AM of catheter cares completed by Nurse Aide (NA)-J revealed that NA-J then cleansed down the catheter tubing and then donned new pair of gloves without completing any hand hygiene. The observation on 05/21/24 at 9:20 AM of catheter cares completed by Nurse Aide (NA)-J revealed that NA-J then began to assist Resident 41 with (gender) clothing and had not completed hand hygiene. An interview on 05/21/24 at 9:59 AM with NA-J confirmed that hand hygiene had not been completed between glove changes when providing catheter cares to Resident 41 and should have been. An interview on 05/21/24 at 10:10 AM with the facility DON (Director of Nursing) confirmed that the facility expectation was that hand hygiene was to be done between glove changes. A record review of the facility policy titled Catheter Cares with a revision date of October 2022 revealed the following guidelines and procedure steps: -Wash the resident's genitalia and perineum thoroughly with soap and water or perineal wipes. Rinse the area well and towel dry. -Place soiled linen into designated container -Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. -Put on gloves -Provide privacy -Use a clean washcloth with warm water and soap or clean perineal wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward -Check drainage tubing and bag to ensure that the catheter is draining properly -Discard disposable items into the designated containers. Remove glove and discard into designated container. Wash and dry your hands thoroughly.

Licensure Reference Number 175 NAC 12-006.04C2 Based on record interview and record review; the facility failed to ensure sufficient staffing related to 8-hour daily RN (Registered Nurse) coverage, this had the potential to affect all residents who reside in the facility. The facility identified a census of 52. Findings are: A record review of the staffing schedules for 5/1/24 through 5/20/24 revealed no 8-hour RN coverage on 5/12/24 and 5/16/24, but did reveal there was only 4 hours of RN coverage on 5/12/24. An interview with the facility Administrator on 05/23/24 at 8:07 AM confirmed that after pulling timecards it was found that the facility did not have RN coverage on 5/6/24 and 5/12/24 and only 4 hours of RN coverage on 5/11/24. A record review of the documents titled Facility Assessment Tool (used to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) dated 6/5/23 revealed the following guidance related to RN coverage: Staffing plan 3.2 Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interviews; the facility failed to ensure that 5 of 5 reviewed nursing assistants (NA's) had completed 12 mandatory education hours annually, this had the potential to affect all residents who reside in the facility. The facility identified a census of 52. Findings are: A record review of the continuing education hours for 5 employees hired more than one year ago revealed that the following staff had received or completed the following education hours; -NA-K had 6.7 hours of continuing education completed in the last 12 months. -NA-L had 0.50 hours of continuing education completed in the last 12 months. -NA-M had 5.05 hours of continuing education completed in the last 12 months. -NA-N had 0.50 hours of continuing education completed in the last 12 months. -NA-O had 1.75 hours of continuing education completed in the last 12 months. An interview with the facility Administrator on 05/21/24 at 3:20 PM confirmed that Nursing Assistants who had been employed in the facility for more than 1 year had not completed 12 hours of continuing education hours and should have. An interview on 05/22/24 at 10:15 AM with NA-N revealed [gender] was not aware of the need for 12 hours of continuing education annually. A record review of the documents titled Facility Assessment Tool (used to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) dated 6/5/23 revealed the following guidance related to NA training; Training All required federal and state trainings will be completed including and along with the following: These trainings will be completed by all Associates, and Contractual Staff: Abuse, neglect, and exploitation - Training includes: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. The following trainings will be completed by NA's: The above-mentioned trainings and these required in-service training for nurse aides: Continuing competence of nurse aides, at least 12 hours per year. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 12-007.04D Based on observation and interview, the facility failed to ensure the ventilation systems were operational in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) occupied resident's bathrooms on the 300 hallway of the facility. The facility identified a census of 55. Findings are: Observation on 5/22/23 at 9:00 AM of room [ROOM NUMBER]'s bathroom revealed the vent did not draw a 1 square ply of toilet paper when tested for ventilation. Observation on 5/22/23 at 9:10 AM of room [ROOM NUMBER]'s bathroom revealed the vent did not draw 1 square of ply of toilet paper when tested for ventilation Interview on 5/23/23 at 10:54 AM with Maintenance Director revealed room [ROOM NUMBER] and 304 bathroom ventilation systems were not functioning. Interview on 5/23/23 at 10:54 AM with the Administrator confirmed the ventilation system was not functioning in room [ROOM NUMBER] and 304 bathrooms.