Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent the development of pressure ulcers for 1 (Resident #10) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: An admission Record revealed the facility admitted Resident #10 on 09/22/2023. According to the admission Record, the resident had a medical history that included a diagnosis of pressure-induced deep tissue damage of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with lower body dressing and was dependent on staff for putting on/taking off footwear. According to the MDS, the resident was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. Resident #10's Care Plan Report included a focus area initiated 10/02/2023 and reviewed 04/03/2023, that indicated the resident had a potential for skin breakdown. Interventions directed staff to provide pressure-relieving devices to the resident's chair and bed at all times (initiated 10/02/2023), a pressure relieving cushion to the resident's wheelchair and recliner when being used (initiated 04/22/2024), and for the resident to wear off-loading boots to bilateral feet while in bed or recliner (initiated 10/28/2023). Resident #10's Order Recap Report for the timeframe 01/01/2025 - 04/30/2025, revealed an order dated 09/24/2024, that directed the staff to ensure the resident always wore off-loading boots to both feet except when ambulating or transferring every shift for skin integrity. During an observation on 04/15/2025 at 8:00 AM and 8:14 AM, Resident #10 was noted at a table for breakfast. The resident did not have a pressure-relieving device in their chair. During an observation on 04/15/2025 at 10:57 AM, Resident #10 was noted in a chair in the activity room and the resident did not have a pressure-relieving device. During an observation on 04/15/2025 at 10:58 AM, Nursing Assistant (NA) H assisted Resident #10 in walking back to their room. NA H placed the resident in their recliner, but did not place off-loading boots on the resident's bilateral feet. During an interview on 04/15/2025 at 11:07 AM, NA H stated that when they took Resident #10 back to their room, they elevated the resident's legs and placed their boots on. NA H acknowledged the resident was not wearing their off-loading boots at the present time and they did not ask the resident if they wanted the off-loading boots on. During a concurrent observation and interview on 04/15/2025 at 11:48 AM, NA A stated every time Resident #10 was in their recliner or bed, the resident was supposed to have their off-loading boots on and a cushion should be placed in their chair. Per NA A, Resident #10 had the off-loading boots and cushion because they had a sore on their bottom. NA A observed the resident in their room and stated the resident did not have their off-loading boots on. NA A looked in the resident's room for the off-loading boots and found them in the resident's closet. During an interview on 04/15/2025 2:08 PM, Registered Nurse (RN) B stated everyone was responsible for implementing a resident's care plan interventions. RN B stated Resident #10 should have the pressure-relieving cushion in place. During an observation on 04/15/2025 at 2:56 PM, Resident #10 was in activities and there was no pressure-relieving device in their chair. During a follow-up telephone interview on 04/15/2025 at 3:23 PM, NA A stated when they came to work at 6:00 AM on 04/15/2025 Resident #10 was in their recliner and had off-loading boots on. NA A stated they removed the resident's off-loading boots when they took the resident to breakfast at 7:30 AM. According to NA A, an unknown person removed the resident from activities and took them to their room and did not place the resident's off-loading boots on when they placed the resident in their recliner that did not have a pressure-relieving cushion During an interview on 04/16/2025 at 10:33 AM, the Director of Nursing (DON) stated Resident #10 was to have off-loading boots on when in bed. The DON stated Resident #10 had a pressure relieving cushion which should be used in their recliner. The DON stated a resident's care plan was used by the staff to direct them as to the care provided to the resident and it should be implemented by the staff. During an interview on 04/16/2025 at 11:53 AM, the Administrator stated they deferred questions to the clinical team. During a follow-up interview on 04/16/2025 at 12:04 PM, the DON stated the facility did not have a policy for care plans but followed professional standards of care.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer treatment interventions were implemented in an effort to prevent new or worsening pressure ulcers for 1 (Resident #10) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: An admission Record revealed the facility admitted Resident #10 on 09/22/2023. According to the admission Record, the resident had a medical history that included a diagnosis of pressure-induced deep tissue damage of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with lower body dressing and was dependent on staff for putting on/taking off footwear. According to the MDS, the resident was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. Resident #10's Care Plan Report included a focus area initiated 10/02/2023 and reviewed 04/03/2023, that indicated the resident had a potential for skin breakdown. Interventions directed staff to provide pressure-relieving devices to the resident's chair and bed at all times (initiated 10/02/2023), a pressure relieving cushion to the resident's wheelchair and recliner when being used (initiated 04/22/2024), and for the resident to wear off-loading boots to bilateral feet while in bed or recliner (initiated 10/28/2023). Resident #10's Braden Scale for Predicting Pressure Sore Risk dated 03/29/2025 indicated the resident was at risk for the development of pressure ulcers. Resident #10's Pressure Ulcer Record indicated on 04/01/2025, the resident's unstageable pressure ulcer measured 0.2 centimeter (cm) by (x) 0.2 cm x 1.3 cm and on 04/08/2025, the resident's pressure ulcer measured 0.2 cm x 0.2 cm x 1.4 cm. Per the Pressure Ulcer Record, the resident continued with a chronic wound to their coccyx. Resident #10's Order Recap Report for the timeframe 01/01/2025 - 04/30/2025, revealed an order dated 09/24/2024, that directed the staff to ensure the resident always wore off-loading boots to both feet except when ambulating or transferring every shift for skin integrity. During an observation on 04/15/2025 at 8:00 AM and 8:14 AM, Resident #10 was noted at a table for breakfast. The resident did not have a pressure-relieving device in their chair. During an observation on 04/15/2025 at 10:57 AM, Resident #10 was noted in a chair in the activity room and the resident did not have a pressure-relieving device. During an observation on 04/15/2025 at 10:58 AM, Nursing Assistant (NA) H assisted Resident #10 in walking back to their room. NA H placed the resident in their recliner, but did not place off-loading boots on the resident's bilateral feet. During an interview on 04/15/2025 at 11:07 AM, NA H stated that when they took Resident #10 back to their room, they elevated the resident's legs and placed their boots on. NA H acknowledged the resident was not wearing their off-loading boots at the present time and they did not ask the resident if they wanted the off-loading boots on. During a concurrent observation and interview on 04/15/2025 at 11:48 AM, NA A stated every time Resident #10 was in their recliner or bed, the resident was supposed to have their off-loading boots on and a cushion should be placed in their chair. Per NA A, Resident #10 had the off-loading boots and cushion because they had a sore on their bottom. NA A observed the resident in their room and stated the resident did not have their off-loading boots on. NA A looked in the resident's room for the off-loading boots and found them in the resident's closet. On 04/15/2025 at 1:43 PM, the surveyor observed Registered Nurse (RN) B provide wound care for Resident #10. RN B measured the resident's coccyx pressure ulcer and stated the wound measured 0.2 cm x 0.2 cm x 0.2 cm. During an interview on 04/15/2025 2:08 PM, RN B stated Resident #10 should have the pressure-relieving cushion in place. During an observation on 04/15/2025 at 2:56 PM, Resident #10 was in activities and there was no pressure-relieving device in their chair. During a follow-up telephone interview on 04/15/2025 at 3:23 PM, NA A stated when they came to work at 6:00 AM on 04/15/2025 Resident #10 was in their recliner and had off-loading boots on. NA A stated they removed the resident's off-loading boots when they took the resident to breakfast at 7:30 AM. According to NA A, an unknown person removed the resident from activities and took them to their room and did not place the resident's off-loading boots on when they placed the resident in their recliner that did not have a pressure-relieving cushion. During an interview on 04/15/2025 at 3:27 PM, the RN - Staff Development (RN SD) stated they was the facility's wound care nurse. The RN SD stated Resident #10's pressure ulcer was facility-acquired and the wound was much better now as the facility had made a significant amount of progress in healing the resident's pressure ulcer. The RN SD stated Resident #10 should have their off-loading boots all the time except when they were ambulating. During an interview on 04/16/2025 at 10:33 AM, the Director of Nursing (DON) stated Resident #10 was to have off-loading boots on when in bed. The DON stated Resident #10 had a pressure relieving cushion which should be used in their recliner. During an interview on 04/16/2025 at 11:53 AM, the Administrator stated they deferred questions to the clinical team.

Based on observation, interview, and record review, the facility failed to store respiratory equipment when not in use to prevent contamination for 1 (Resident #9) of 3 sampled residents reviewed for respiratory care. Findings included: An admission Record revealed the facility admitted Resident #9 on 11/13/2018. According to the admission Record, the resident had a medical history to include a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident was severe cognitive impairment. The MDS indicated that the resident required oxygen therapy. Resident #9's Care Plan Report included a focus area initiated 06/26/2024, that indicated the resident was at risk for altered respiratory function related to oxygen therapy. Interventions directed staff to check oxygen saturation as required and monitor for shortness of breath as needed. Resident #9's physician's order dated 11/15/2024, indicated oxygen at 2 liters per minute (L/min) via nasal cannula (NC) to be titrated to maintain oxygen saturation greater than 90%. During an observation on 04/14/2025 at 10:02 AM, Resident #9 was resting in bed receiving oxygen therapy at 2 L/min. The oxygen tubing was attached to Resident # 9's oxygen concentrator, which was dated 04/13/2025. Resident #9 had a portable oxygen tank attached to the side of their wheelchair and the oxygen tubing with the cannula was not in a bag but was tucked into the pocket on the back of the resident's wheelchair. During an observation on 04/15/2025 at 9:45 AM, Resident #9 was in the common area and had oxygen on and the oxygen was set at 2 L/min. During a concurrent observation and interview on 04/15/2025 at 9:54 AM, Resident # 9 was in the community area resting with portable oxygen at 2 L/min via NC. The tubing was dated 04/13/2025. Medication Aide (MA) E stated Resident #9 came out of their room for activities and would sit in the community area to watch television. MA E stated residents would use portable oxygen canisters when they were out of their room or out of the facility and oxygen concentrators were used in resident rooms. MA E stated Resident #9 received continuous oxygen at 2 L/min and Nursing Assistant (NA) F put the resident's oxygen on that morning. MA E stated oxygen tubing and cannulas should be stored in black bags when not in use or they could get soiled which could lead to the resident breathing in dirt. MA E verified Resident #9 did not have the black bag for oxygen tubing storage. During an interview on 04/15/2025 at 10:08 AM, NA F revealed they was trained to store oxygen tubing in the black bags when not in use. NA F stated they cared for Resident #9 and helped the resident out of bed that on 04/15/2025. NA F stated they noticed the resident's oxygen tubing was not stored in the black back and meant to change out the tubing but forgot to do so. NA F stated if the oxygen tubing was not stored properly, the tubing would become contaminated. During an interview on 04/16/2025 at 10:05 AM, Licensed Practical Nurse (LPN) G stated oxygen concentrators should have a black bag attached to oxygen concentrator or portable canister for storage. LPN G stated oxygen tubing should be rolled up and placed in the bag while not in use. LPN G stated this was important for infection control. LPN G stated they were familiar with Resident #9 and that the resident received oxygen at 2 L/min. During an interview on 04/16/2025 at 3:20 PM, the Director of Nursing (DON) stated oxygen tubing and cannulas should be stored in black bags while not in use. The DON stated all nursing staff were responsible for ensuring and monitoring for oxygen tubing being stored properly. The DON stated Resident #9 was on continuous oxygen at 2 L/min. The DON stated the expectation would be that the concentrator and the portable oxygen would both have storage bags. The DON stated if any oxygen tubing were left unbagged while not in use, the expectation would be to change the tubing to a new one. During a follow-up interview on 04/16/2025 at 1:58 PM, the DON stated the facility did not have a policy related to storage of oxygen tubing and cannulas.

Based on observation, interview, and review of the 2022 Food Code, the facility failed to ensure: 1) there was a trash can near the handwashing sink; 2) pots and pans were stored inverted; 3) expired food items were discarded; and 4) staff washed their hands when they entered the kitchen before they began to prepare food. These deficient practices affected all residents who received food from the kitchen. Findings included: 1. Section 4-903 Storing of the 2022 Food Code published by the United States Food and Drug Administration, indicated (B) Clean equipment and utensils shall be stored as specified under [symbol] (A) of this section and shell be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. Section 6-301.20 Disposable Towels, Waste Receptables. A handwashing sink or group of adjacent handwashing sinks that is provided with disposable towels shall be provided with a waste receptable as specified under [symbol] 5-501.16(C). During a concurrent observation and interview on 04/14/2025 at 9:00 AM, the surveyor noted there was not a trash can by the handwashing sink. The surveyor also noted there were six to 10 quart size pots stored that were not inverted and five ladles exposed to debris. The Culinary & Dining Coordinator (CDC) stated the pots and pans were always stored inverted. During an interview on 04/16/2025 at 10:33 AM, the CDC stated there should be a trash container that opened with food control at every handwashing sink. During an interview on 04/16/2025 at 11:18 AM, the Administrator stated pots and pans should be hung or stored inverted to avoid contamination. 2. During a concurrent observation of the facility's refrigerator and interview on 04/14/2025 9:15 PM, the surveyor noted there was a three-pound bag of mini cauliflower that had black spots in various areas and one rancid tomato with black and white spots. The CDC stated the cauliflower had black mold and the black and white spots on the tomato was mold. The CDC discarded the tomato. During a concurrent observation of the facility's freezer and interview on 04/14/2025 9:20 PM, there was a package of hot dogs that had a manufacturer date of 12/12/2024. The CDC stated the hot dogs were expired and discarded them. During an interview on 04/16/2025 at 10:33 AM, the CDC stated Culinary Lead (CL) I entered the facility's refrigerator on 04/15/2025 and noticed the rancid tomato, was going to return to the refrigerator to discard the tomato but got called to do something else and forgot to return to the refrigerator to discard the tomato. 3. During a concurrent observation and interview on 04/15/2025 at 11:08 AM, Culinary Assistant (CA) C entered the kitchen and did not wash their hands before they began to prepare food. CA C stated they were trained and were supposed to wash their hands when they entered the kitchen. CA C stated they normally washed their hands, but spaced out and forgot. CA C stated it was important for staff to wash their hands because of germs. During an observation on 04/15/2025 at 11:18 AM, CL D entered the kitchen without washing their hands and began to prepare a hamburger. During an interview on 04/16/2025 at 11:18 AM, the Administrator stated the first thing staff should do when they enter the kitchen was wash their hands to ensure their hands were clean before they handled food items to avoid contamination. During an interview on 04/16/2025 at 1:13 PM, CL D stated they were supposed to wash their hands when they entered the kitchen. During an interview on 04/16/2025 at 3:37 PM, the Director of Nursing (DON) stated staff should wash their hands all the time. Per the DON, there was supposed to be a trash can by the handwashing sink. The DON stated she did not know how pots and pans should be stored.

Licensure Reference 175 NAC 12-06.09(J)(i)(1) Based on record reviews and interviews, the facility staff failed to implement interventions to manage weight loss for 2 (Resident 1 and 2) of 3 sampled residents. The facility staff identified a census of 97. Findings are: A record review of an undated facility policy Significant Weight Loss indicated the following: - Significant weight loss in 1 week is 1-2%; more than 1-2% is considered severe weight loss. - Significant weight loss over 1 month is 5%; more than 5% is considered severe weight loss. - Significant weight loss over 3 months is 7.5%; more than 7.5% is considered severe weight loss. - Significant weight loss over 6 months is 10%; more than 10% is considered severe weight loss - The policy defined avoidable weight loss as an individual that did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: evaluate the individual's clinical condition, define and implement interventions, monitor and evaluate the impact of the interventions, and revise the interventions as appropriate. A. A record review of an admission Record indicated the facility admitted Resident 1 on 6/7/2023 with diagnoses of Dementia, duodenitis (inflammation in the first part of your small intestine,) depression, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone,) and difficulty swallowing. A record review of Resident 1's quarterly (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 11/7/2024 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) of 12/15, indicating Resident 1 had moderate cognitive impairment. The MDS also indicated Resident 1 required supervision with eating. It also indicated Resident 1 was noted to have a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months and was not on a physician-prescribed weight-loss regimen. A record review of Resident 1's Care Plan revealed a focus area that indicated Resident 1 was at risk for potential impaired nutrition status related to pain, duodenitis, poor food intake, and depression with a last revised date of 11/12/2024. A record review of Resident 1's Weight Summary as of 1/22/2025 revealed the following information: -7-22-2024, weight (wt) was 116. lbs. -10-21-2024, wt was 97. lbs, a loss of 18 lbs or 15.51 %. The facility implemented the intervention of carnation breakfast with cereal at breakfast, ensure (supplement) twice a day and a milkshake at bed time. -11-21-2024, wt was 93. Lbs A record review of Resident 1's Order Summary Report as of 1/22/2025 revealed an order for a house supplement of 2-cal with directions to give 8 ounces four times a day as a weight loss supplement with a start date of 11/19/2024. A record review of Resident 1's Treatment Administration Record for the month of November 2024 revealed Resident 1's House Supplement was not given with a reason of Other/See Progress Note for the following dated: 11/24 8:00 PM dose, 11/25 8:00 PM dose, 11/26 4:00 PM dose, 11/26 8:00 PM, 11/28 4:00 PM dose, and 11/28 8:00 PM. A record review of Resident 1's Treatment Administration Record for the month of December 2024 revealed Resident 1's House Supplement was not given with a reason of Other/See Progress Note for the 12/7 8:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM. A record review of Resident 1's Treatment Administration Record for the month of January 2025 revealed Resident 1's House Supplement was not given with a reason of Other/See Progress Note for the 1/9 8:00 PM dose, 1/21 5:00 PM dose, and 1/21 8:00 PM dose. A record review of Resident 1's Progress Notes from 11/24/2024 to 1/21/2024 revealed the following entries: - 11/24/2024 7:27 PM: House Supplement not given with a text entry reason of None available. Nurse notified. - 11/25/2024 8:34 PM: House Supplement not given with a text entry reason of Only 2 ounces available in fridge. - 11/26/2024 5:04 PM: House Supplement not given with a text entry reason of Waiting on kitchen. - 11/26/2024 7:09 PM: House Supplement not given with a text entry reason of Waiting on kitchen. - 11/28/2024 3:11 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 11/28/2024 7:19 PM: House Supplement not given with a text entry reason of Pending kitchen. - 12/7/2024 8:17 PM: House Supplement not given with a text entry reason of No 2-cal available. Nurse notified. - 12/12/2024 7:34 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 12/13/2024 7:02 PM: House Supplement not given with a text entry reason of None available, notified Charge Nurse. - 1/9/2025 7:24 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 1/21/2025 3:49 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 1/21/2025 7:39 PM: House Supplement not given with a text entry reason of Pending kitchen supply. An interview on 1/22/2025 at 4:22 PM with the Health Information Manager (HIM) and Clinical Coordinator RN-A confirmed Resident 1's supplements on the following dates were documented as not given: 11/24 8:00 PM dose, 11/25 8:00 PM dose, 11/26 4:00 PM dose, 11/26 8:00 PM, 11/28 4:00 PM dose, 11/28 8:00 PM dose, 12/7 8:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM dose, 1/9 8:00 PM dose, 1/21 5:00 PM dose, and 1/21 8:00 PM dose. B. A record review of an admission Record indicated the facility admitted Resident 2 on 8/2/2022 with diagnoses of Dementia, anemia (low red blood cells,) depression, and difficulty swallowing. A record review of Resident 2's quarterly MDS with an ARD of 1/1/2025 indicated that Resident 2 had a BIMS score of 3/15, which indicated Resident 2 had severe cognitive impairment. The MDS also indicated Resident 2 required supervision with eating and was on a mechanically altered diet. A record review of Resident 2's Care Plan reveal a focus area that indicated Resident 2 was at risk for potential impaired nutritional status related to poor food intake, weight loss, Dementia, anemia, difficulty swallowing, and depression with a last revised of 1/2/2025. A record review of Resident 2's Weight Summary as of 1/22/2025 revealed the following information: -7-20-2024, wt was 129.5 lbs. -10-19-2024, wt was 126.5 lbs. -12-21-2024, wt was 125.0 lbs. -1-21-2024, weight was 121.0 A record review of Resident 2's Order Summary Report as of 1/22/2025 revealed an order for a house supplement of 2-cal with directions to give 4 ounces four times a day as a nutritional supplement with a start date of 10/10/2024. A record review of Resident 2's Treatment Administration Record for the month of November 2024 revealed Resident 2's House Supplement was not given with a reason of Held/See Progress Note for the 11/5 8:00 AM dose and Other/See Progress Note on 11/6 8:00 PM dose, 11/25 8:00 PM dose, 11/26 8:00 PM dose, 11/28 5:00 PM dose, and 11/28 8:00 PM dose. A record review of Resident 2's Treatment Administration Record for the month of December 2024 revealed Resident 2's House Supplement was not given with a reason of Other/See Progress Note for the 12/12 5:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM dose. A record review of Resident 2's Progress Notes from 11/5/2024 to 12/13/2024 revealed the following entries: - 11/5/2024 9:47 AM: House Supplement not given with a text entry reason of Pending kitchen. - 11/6/2024 7:51 PM: House Supplement not given with a text entry reason of Awaiting pharmacy. - 11/25/2024 7:23 PM: House Supplement not given with a text entry reason of Not enough available in fridges. - 11/26/2024 7:35 PM: House Supplement not given with a text entry reason of Waiting on kitchen. - 11/28/2024 5:02 PM: House Supplement not given with a text entry reason of Pending kitchen. - 11/28/2024 7:48 PM: House Supplement not given with a text entry reason of Missing. - 12/12/2024 5:17 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 12/12/2024 8:03 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 12/13/2024 7:10 PM: House Supplement not given with a text entry reason of None available, notified Charge Nurse. An interview on 1/22/2025 at 4:22 PM with the Health Information Manager (HIM) and Clinical Coordinator RN-A confirmed Resident 2's supplements were documented as not given on the following dates: 11/6 8:00 PM dose, 11/25 8:00 PM dose, 11/26 8:00 PM dose, 11/28 5:00 PM dose, 11/28 8:00 PM dose, 12/12 5:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM dose. An interview on 1/22/2025 at 4:20 PM with the Certified Dietary Manager (CDM) revealed the dietary department makes the house supplements every morning and calculate enough for all residents' supplements for the day. The CDM also revealed that nursing was responsible for letting the dietary department know if they were running low before close, as nursing does not have access to additional supplement after the kitchen closes around 7:30 PM. An interview on 1/23/2025 at 9:50 AM with Medication Aide (MA) - D revealed that MA-D charts pending kitchen supply when the house supplement is not available and not available to be given. MA-D revealed frequent difficulties with having the house supplement available and has met challenges with calling the dietary department and being told it is not available as they do not have any and/or not being brought to nursing. An interview on 1/23/2025 at 10:00 AM with MA-E confirmed nursing is responsible for calling the dietary department if they are in need of additional house supplement. MA-E also confirmed that a note of pending kitchen supply means the house supplement was not given due to being unavailable. MA-E also confirmed that they frequently run out of house supplement for the 8:00 PM administration and the kitchen has already closed, so there is no access to obtaining additional supplement to be able to administer it.

C. A review of an admission Record revealed the facility admitted Resident #60 on 08/22/2020. The admission Record revealed the resident had a diagnosis of need for assistance with personal care. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident required setup or clean-up assistance with eating. During an interview on 04/15/2024 at 11:52 AM, Resident #60 stated their only complaint was that the facility did not serve meals to those seated at the table in the dining room at the same time. The resident said they sat at a table with three other residents and that it could take up to 20 minutes for everyone at the table to receive their meal. Resident #60 stated they did not like watching others eat while he/she was hungry and did not like to eat while others did not have their food. An observation was made of the noon meal being served in the 500 Unit dining room on 04/18/2024 at 12:03 PM. Resident #60 was seated at a table with three other residents with the first resident at the table was served at 12:04 PM, and the second resident was served at 12:05 PM. After serving the second resident seated at Resident #60's table, staff served residents at two separate tables before returning to Resident #60's table. Resident #60 received their tray at 12:10 PM. During an interview on 04/18/2024 at 8:59 AM, Registered Nurse (RN) C stated staff were taught to serve all residents at one table before moving to another table. RN C stated that when a resident was not served at the same time as their tablemate's it was considered a dignity issue. During an interview on 04/18/2024 at 9:47 AM, the Social Services Director (SSD) stated staff were encouraged to serve everyone at a table before proceeding to the next table and added that it was important so all residents could eat their meal together. The SSD stated it was considered a dignity issue to make tablemate's wait for their meals. During an interview on 04/18/2024 at 1:10 PM, DON stated if all residents seated at the same table were ready to be served, staff were expected to serve all residents at the table before serving another table. Licensure Reference Number 172 NAC 12-006.05(21) Based on observations, interviews, record reviews, and facility policy review, the facility failed to maintain the dignity of 3 (Residents #43, #87, and #60) of 3 residents who were observed during dining. The facility failed to serve all residents who were sitting at the same table their meal at the same time before proceeding to the next table, leaving the residents to watch their tablemate's eat. The facility census was 99. Findings are: An undated excerpt from the employee handbook titled [Name of facility ownership] Values revealed, We will create a living environment that radiates love, peace, spiritual contentment, dignity and safety, while encouraging personal independence. A. A review of an admission Record revealed the facility admitted Resident #43 on 04/02/2017. According to the admission Record, the resident had a medical history that included diagnoses of hypertension and dementia. A review of Resident #43's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/2024 revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required supervision or touching assistance from staff with eating. A review of Resident #43's care plan revealed a Focus area revised on 04/04/2024 that indicated the resident required assistance with activities of daily living (ADLs). Interventions indicated the resident could eat independently after the meal was set up. B. A review of an admission Record revealed the facility admitted Resident #87 on 10/02/2023 with diagnoses of unspecified dementia with behavioral disturbances and unspecified anxiety disorder. A review of Resident #87's quarterly MDS, with an ARD of 03/27/2024, revealed Resident #87 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required setup or clean-up assistance from staff with eating. A review of Resident #87's care plan revealed a Focus area initiated on 10/15/2023 that indicated the resident required assistance with ADLs. Interventions indicated the resident could eat independently after the meal was set up. An observation was made of the breakfast service in the 300 unit dining room on 04/17/2024 beginning at 8:15 AM. There were six tables in the dining room, with two to three residents seated at each table, for a total of 13 residents having breakfast in the dining room. Resident #43 was seated at a table with two other residents. At 8:30 AM, a tablemate of Resident #43 was served their breakfast. This was the first resident to receive their breakfast, and immediately, staff started to assist the resident with eating. Resident #43 and the other tablemate were sitting and looking at the resident who was eating. Resident #43's other tablemate was served at 8:40 AM. Resident #43 was the last resident in the dining room to receive their breakfast tray at 8:50 AM. During this same observation, Resident #87 was observed seated at a table with one other resident. Resident #87's tablemate was served breakfast at 8:35 AM. Resident #87 stated loudly, Where is my breakfast? Everyone is eating but me. Staff tried to assure the resident that their meal would be served shortly. Two other residents received their breakfast tray, at which time Resident #87 again stated, Where is my food? Resident #87 received their tray at 8:40 AM. During an interview on 04/17/2024 at 8:52 AM, Medication Aide (MA) A stated they had been trained to serve all residents at one table before starting meal service at other tables. MA A stated they would feel bad if they had to sit and wait 20 minutes to receive their meal tray and watch their tablemate's eat, as had happened between Resident #43 and their tablemate's. MA A stated they had no reason why they had not followed the meal service process as they had been trained. During an interview on 04/17/2024 at 9:00 AM, Registered Nurse (RN) B, who had been in the dining area assisting residents during the meal service, stated staff had been trained to serve all residents at one table before beginning meal service at another table. RN B stated it was important to serve all residents at one table at the same time so no resident would feel left out. RN B stated the expectation was for one table to be completely serviced before proceeding to the next table. RN B acknowledged that Resident #43 should not have waited to receive the breakfast tray for 20 minutes after the first resident at their table had been served. RN B acknowledged they had heard Resident #87 yelling out for their breakfast tray and stated everyone else was eating but Resident #87. During an interview on 04/18/2024 at 8:59 AM, RN C stated staff were taught to serve all residents at one table before moving to another table. RN C stated that when a resident was not served at the same time as their tablemate's, it was considered a dignity issue. During an interview on 04/18/2024 at 9:47 AM, the Social Services Director (SSD) stated staff were encouraged to serve everyone at a table before proceeding to the next table and added this was important so all residents could eat their meals together. The SSD stated that dining in the facility was like dining in a restaurant and that it was a dignity issue to make tablemate's wait for their meals. During an interview on 04/18/2024 at 12:18 PM, the Social Services Assistant (SSA) stated that during the past few months, residents had mentioned an issue regarding not all residents at one table being served at the same time. The SSA stated they understood how not being served at the same time as tablemate's would bother some residents, but added the facility had open-concept dining, which meant residents came to the dining room as they wished. The SSA stated that when Resident #87 asked where their food was during the observation, the staff should have served Resident #87 next and not passed other trays. During an interview on 04/18/2024 at 1:10 PM, the Director of Nursing (DON) stated the facility was trying to get away from a strict dining schedule and give the residents more choices. The DON stated if all residents were sitting at a table ready to be served, they expected all residents at the table to be served before moving to another table. During an interview 04/18/2024 at 12:38 PM, the Administrator stated they did not see residents at one table not being served at the same time as a dignity issue since the facility had an open concept dining plan. The Administrator stated they did not want anyone to feel bad about not having their meal served and the facility tried to serve everyone as quickly as possible.

Licensure Reference Number 175 NAC 12-006.14 Based on observation, interviews, record review, and facility policy review, the facility failed to provide routine dental services for 1 (Resident #71) of 1 sampled resident reviewed for dental services. The facility census was 99. Findings are: A review of the facility policy titled Dental Policy dated August 2017, revealed the Facility must arrange for transportation to and from the dental services locations; and must assist residents who are eligible to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan such as Medicaid. A review of an admission Record indicated the facility admitted Resident #71 on 04/13/2021 with diagnoses of unspecified dementia and convulsions. The admission Record identified Dental Provider D as Resident #71 dental provider and indicated the resident was a Medicaid recipient. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #71 required supervision or touching assistance from staff for the completion of oral hygiene. The MDS further indicated Resident #71 had no dental/oral issues and no significant weight loss. A review of Resident #71's care plan revealed a Focus area revised on 03/22/2024 that indicated the resident had an activities of daily living (ADL) self-care performance deficit and identified the resident's teeth as being in poor condition and the resident was missing a majority of their teeth. The care plan further indicated the resident had upper partials. Further review of the care plan revealed a Focus area revised on 03/22/2024 that indicated dental exams would be tracked to meet the overall resident's dental needs. Interventions directed staff to set up appointments and allow the provider to be chosen as indicated. The care plan revealed that Resident #71 had last seen the dentist on 06/29/2021. A review of Resident #71's quarterly Nutritional Risk Assessment dated 01/03/2024 indicated Resident #71 had no significant weight changes. The assessment failed to address the resident's dental status. A review of Resident #71's Order Summary Report, with active orders as of 04/18/2024, revealed an order to remove the resident's partial dentures at bedtime and clean and soak the dentures in a denture cup. The Order Summary Report for Resident #71 did not contain orders for dental appointments. An observation was made on 04/15/2024 at 10:01 AM. Resident #71 was missing teeth. The resident was unable to relay if the missing teeth were causing a problem. Registered Nurse (RN) C was interviewed on 04/17/2024 at 3:53 PM. RN C stated dental appointments for residents were arranged by the Social Services Director (SSD) and the Administrator. RN C added the facility utilized a contract dental company that visited the facility every six months, while other residents had their own established dental providers. RN C stated a resident's payer source determined which provider they were seen by. RN C stated local dental providers rarely accepted Medicaid as a payment source. RN C stated that upon admission, the resident and/or the family signed a contract for dental service. RN C stated all residents were offered the option of seeing a dentist at least yearly but had the right to refuse dental services. The Social Services Director (SSD) was interviewed on 04/18/2024 at 9:12 AM. The SSD stated residents were seen by the dentist quarterly. The SSD stated dental services were provided by two companies, which included Dental Provider D and Dental Provider E. The SSD stated Dental Provider E started last fall, and all residents were asked to enroll. The SSD reviewed the list of residents who had signed up for Dental Provider E and stated Resident #71 was not on the list because the family chose not to accept the offer. The SSD stated there was no documentation that a conversation about dental services had been held with Resident #71's family or that the family had declined dental services. The SSD confirmed Resident #71 had not been seen by a dentist for routine dental care, cleaning, or assessment of their remaining teeth since 2021. A telephone interview was held with Resident #71's Power of Attorney (POA) on 04/18/2024 at 10:50 AM. Resident #71's POA acknowledged the facility had asked if they would like for Resident #71 to be seen by Dental Provider E, and stated they told the facility the preference was for Resident #71 to be seen by Dental Provider D, where the resident was already comfortable. Resident #71's POA stated that a co-pay for Dental Provider E was not discussed, but the preference was still for Resident #71 not to change dentists, and they wanted Resident #71 to be seen by a dentist as needed. The Director of Nursing (DON) was interviewed on 04/18/2024 at 1:10 PM. The DON defined routine dental services as being as the public would see a dentist, such as yearly or every six months. The DON stated they were unaware Resident #71 had not seen a dentist in three years. The DON added they were sure contact had been made with the family regarding dental services, but it probably had not been documented. The DON stated they would have expected arrangements to be made for Resident #71 to be seen by dental services within the past three years. The Administrator was interviewed on 04/18/2024 at 12:38 PM. The Administrator stated if any resident chose not to sign up with Dental Provider E, that resident would continue to be seen by Dental Provider D. The Administrator stated the problem with Dental Provider D was the company did not accept appointments, and residents had to show up and wait in line. The Administrator stated they were surprised Resident #71 had not been seen by a dentist in three years and stated they would have expected staff to present the option of a dental visit to the resident and family within the past three years.