Licensure Reference Number 175NAC 12-006.04(F)(i)(5) Based on interviews and record reviews, the facility failed to notify the physician and resident representative of medication given outside of physician ordered parameters. This had the potential to affect 1 (Resident 52) out of 24 sampled residents. The facility census was 39. Findings are: Record review of Resident 52's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 4/07/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. The MDS manual identifies a score of 13-15 as cognitively intact. Record review of the admission Orders for Resident 52 dated 4/03/2025 revealed an order for Hydralazine ( Medication to control blood pressure),100 milligram (mg) to be administered three times a day. The order for the Hydralazine directed staff to hold the medication if Resident 52's systolic blood pressure (SBP, systolic blood pressure is the top number in a blood pressure reading, representing the highest pressure in your arteries when your heart beats) was less than 150 related to diagnosis of Essential (Primary) hypertension (HTN). Record review of Resident 52's Medication Administration Record (MAR, a medication administration record documents every medication a patient receives, including the name, dose, route, and time) dated April 2025 revealed Resident 52 had received Hydralazine on: -4/04/2025 with no blood pressure (BP) entered on (MAR); -4/05/2025 at 8:00 PM with a BP of 102/61. -4/06/2025 at 8:00 AM with a BP of 102/61, -4/06/2025 at 8:00 PM with a BP of 122/60. -4/07/2025 at 8:00 PM with a BP of 134/84; -4/09/2025 at noon with a BP of 123/76, and at 8:00 PM with a BP 136/78. An interview was conducted with Resident 52's Family Member (FM) on 4/08/2025 at 9:00 AM regarding the resident's blood pressure (BP) medications. The FM was concerned the nurses were not following orders and gave the resident Hydralazine when it should not have been given or held the medication when it should have been given. The FM reported the nurse on 4/05/2025 administered the medication Hydralazine when Resident 52 had a BP of 149/59. An interview was conducted with the Director of Nursing (DON) on 4/08/2025 at 2:00 PM. During the interview the DON confirmed that Hydralazine given outside of parameters was a concern. The DON reported the expectation would be for the nurse to call the primary physician to report the Hydralazine was not given or given outside of BP parameters, and to chart a progress note. The DON confirmed this was not done. A record review of the facility's undated Medication Administration Policy revealed the following: Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 20. Sign MAR after administration. For those medications requiring vital signs, record vital signs onto the MAR. A record review of the facility's undated Medication Errors Policy revealed the following: Policy Explanation and Compliance Guidelines: 1. Facility shall ensure medications will be administered as follows: a. According to physician's orders. 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(E) Based on interview and record review, the facility failed to develop a Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) that accurately reflected the care needs of the resident related to respiratory care and oxygen use for 2 (Resident 28 and Resident 10) of 2 sampled residents for respiratory services. The facility census was 39. Findings are: A. Record review of an undated facility policy entitled Oxygen Administration revealed the following information: Policy: Oxygen is administered to residents that need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the residents goals and preferences. Policy Explanation and Compliance Guidelines: 4. The residents care plan shall identify the interventions for oxygen therapy, based upon the residents assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and /or when to discontinue. c. Equipment setting for prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. B. Observation on 07/07/25 at 12:51 PM revealed Resident 28 seated in a recliner in the resident's room with an oxygen cannula in place in the resident's nose. The cannula and tubing were connected to an oxygen concentrator and the flow rate was set at 3 L [liters] per minute. Record review of Resident 28's admission 5 day 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 3/18/25 revealed an admission date of 3/12/25. Resident 28's MDS identified diagnoses of chronic respiratory failure with hypoxia [Low oxygen levels in body tissues] and acute pulmonary edema [The abnormal build up of fluid in the lungs that can cause shortness of breath and difficulty breathing]. The MDS identified that Resident 28 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. The MDS manual identified a score of 13 -15 meant that cognition was intact. The MDS identified Resident 28 used a walker and wheelchair, had lower extremity range of motion limitations, required substantial assistance with toileting, showering, lower body dressing, placement of footwear and required partial to moderate assistance with transfers. Section O of the MDS identified Resident 28 used continuous oxygen while a resident at the facility. Record review of Resident 28's Physician Order Summary dated 04/08/25 revealed that Resident 28 was to have oxygen at 3 L per home baseline two times per day and apply oxygen PRN [as needed] to keep saturation levels above 90% as needed. These orders were started on 03/12/25 upon admission to the facility. Record review of Resident 28's Medication Administration Record [MAR] dated March and April 2025 revealed documentation was present that indicated Resident 28 received oxygen as ordered by the physician. Record review of Resident 28's CCP dated 03/13/25 revealed no information related to Resident 28's respiratory care needs or oxygen use. Interview on 04/09/25 at 9:08 AM with the MDS coordinator [MDSC] confirmed Resident 28's CCP did not address oxygen use or specific respiratory care needs. The MDSC confirmed a CCP should have been developed related to Resident 28's oxygen use and respiratory care needs. Interview on 04/10/25 at 7:08 AM with the Director of Nursing [DON] confirmed Resident 28's CCP did not contain any specific information related to the use of oxygen or respiratory care needs and should have. The DON confirmed that the facility policy for Oxygen Administration had not been followed in regards to the CCP for Resident 28. C. Record review of Resident 10's admission orders dated 3/21/2025 revealed an order for Ipratropium-albuterol 0.5-2.5 (3) mg/3 mL (a medication often used to relax the airway muscles, and to open the airway to make breathing easier) nebulizer (A nebulizer changes medication from a liquid to a mist so it can be inhaled into the lungs) to be given three times a day for seven days related to Acute Respiratory Failure with Hypoxia (a medical condition where the lungs are unable to adequately provide oxygen to the blood, leading to a deficiency of oxygen in the blood), and Pulmonary Fibrosis (a lung disease that includes scarring and thickening of lung tissue, making it hard to breath). Record review of Resident 10's Comprehensive Care Plan (CCP) on 4/08/2025 revealed no indiactions of Resident 10's respritory care needs. Record review of Resident 10's MDS dated [DATE] revealed continuous oxygen use was identified in Section O. Record review of Resident 10's Physician orders on 4/08/2025 revealed an order to apply oxygen PRN to keep saturation levels above 90% as needed. An observation on 4/07/2025 8:49 AM of Resident 10's oxygen concentrator (a device that produces more pure oxygen) revealed the setting was 2 Liters per minute. An Observation on 4/09/2025 7:57 AM revealed Resident 10 was not in the room. There was a nebulizer machine on the bedside stand and the oxygen concentrator was off. Interview with Licensed Practical Nurse (LPN)-C on 4/09/2025 7:56 AM revealed the nurse was unaware of any current nebulizer orders for Resident 10 and further reported being unsure why there was a nebulizer machine in Resident 10's room. Interview with the MDS Coordinator on 4/09/2025 9:11 AM confirmed Resident 10's CCP did not address oxygen use or specify respiratory care needs. The MDS coordinator further confirmed a CCP should have been developed related to Resident 10's oxygen use, and respiratory care needs.

Licensure Reference Number 175 NAC 12-006.09(I)(i) Based on record review, observation, and interview the facility staff failed to implement assessed interventions to prevent falls for 1 (Resident 46) of 3 sampled residents. The facility identified a census 39. Findings are: Record review of Resident 46's Transfer/Discharge Report dated 4/08/2025 revealed the admission date was 4/04/2025 and admitted with Primary Osteoarthritis, Urinary Tract Infection (UTI), and Repeated Falls. Record review of Resident 46's Care Plan revealed on 4/6/25 and entry was made that Resident 46 required the assistance of 2 (Ax2) staff for transfers and wheelchair for all in room and hallway mobility. Record review of a provider note written by Advanced Practice Registered Nurse (APRN) J dated 4/07/2025 revealed the provider was notified of an incident, where Resident 46 was transferred with 1 staff assisting versus the recommended 2 staff that were required. An interview with Resident 46 on 4/07/2025 at 8:32 AM revealed Resident 46 reported having a fall in the bathroom a couple of days ago. Resident 46 further reported their right arm and shoulder hurt. An observation on 4/08/2025 at 9:31 AM revealed Resident 46 sitting at the side of the bed. Occupational Therapist (OT) G and Nursing Assistant (NA) I were in the room to assist with the transfer. Resident 46 had a gait belt on and was being instructed by OT-G on the transfer process. OT-G positioned the walker in front of Resident 46 and OT-G instructed Resident 46 to transfer to the chair. Resident 46 followed the directions provided completed the transfer without a 2 person assisting Resident 2 with the transfer. An interview with OT-K on 4/10/25 at 10:58 AM revealed Ax2 indicted the resident was to be transferred with 2 staff members. OT-K revealed that Resident 46 was transferred from the toilet to chair with out 2 staff assisting the resident. OT-K further reported there should have been 2 staff members assisting Resident 46 with the transfer.

Licensure Reference Number 175 NAC 12-006.19 Based on observation and interview, the facility failed to maintain the cleanliness of the interior and exterior of ventilation covers in 8 (Rooms 130, 131, 134, 144, 146, 147, 148, 150 ) of 21 occupied resident rooms on the south hallway of the facility. The facility census was 39. Findings are: Observation on 04/10/25 between 8:45 AM and 9:26 AM with the facility Administrator (ADM) and Maintenance Director (MD) revealed interior and exterior ventilation covers in resident bathrooms in rooms 130, 131, 134, 144, 146, 147, 148, and 150, on the south hallway of the facility, were coated with a white and gray fuzzy substance that resembled dust. Interview on 04/10/25 at 9:28 AM with the facility ADM confirmed the presence of the build up of a gray and white substance on the interior and the exterior of the ventilation covers. The ADM confirmed that the ventilation covers were cleaned monthly or if a resident had been discharged from the facility. The ADM confirmed the facility staff should have been cleaning them more frequently to make sure that no dust built up. Record review of a undated document entitled Cleaning Assignments revealed a list of daily and weekly cleaning tasks. Under the Other Notes portion of the cleaning assignments, a note read: Check and wipe all vents in both bathrooms and patient rooms. Record review of hand written cleaning documentation (some dated and some not dated) for the south side of the facility revealed that cleaning had been marked as complete in various rooms on the south side of the facility. The cleaning documentation was not consistent to include dates when the cleaning had been completed. Record review of an undated facility policy entitled Routine Cleaning and Disinfection revealed the following information: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Interview on 04/10/25 at 9:50 AM with the facility Administrator confirmed that the Cleaning Assignments needed to be more specific in relation to how often the ventilation systems should be cleaned or how these assignments were to be documented as completed. The ADM confirmed the facility policy Routine Cleaning and Disinfection explanation and compliance guidelines did not address the cleaning of ventilation covers in resident bathrooms.

Licensure Reference Number 175 12-007.04D Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 11 (Rooms 127, 130, 139, 143, 144, 146, 147, 148, 149, 150, 152) of 21 occupied resident bathrooms on the south hallway of the facility. The facility census was 39. Findings are: Observation on 04/10/25 between 8:45 AM and 9:26 AM with the facility Administrator (ADM) and the facility Maintenance Director (MD) revealed that the ventilation system was not functional and would not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 127, 130, 139, 143, 144, 146, 147, 148, 149, 150, 152 on the south hallway of the facility. Interview on 04/10/25 at 09:25 AM with the MD confirmed that the ventilation system did not draw a 1 square ply of toilet paper in resident bathrooms in resident rooms 127, 130, 139, 143, 144, 146, 147, 148, 149, 150, 152 on the south hallway of the facility. The MD confirmed that the ventilation system had not been routinely checked for draw in the resident bathrooms in the facility. The MD confirmed that the ventilation system had been checked once since the MD started in October 2024. Interview on 04/10/25 at 9:28 AM with the facility ADM confirmed that staff should have checked the ventilation system for draw every month at a minimum and confirmed that it should have been done more frequently, weekly, to ensure the operation of the ventilation system. Record review of a undated document entitled Bathroom Ventilation Clean /Blow out revealed documentation that the ventilation systems were last checked for operation on 11/24/25 facility wide. Interview on 04/10/25 at 9:50 AM with the facility ADM confirmed that the last time the ventilation systems were checked for operation was on 11/24/25. The ADM confirmed no other documentation had been completed related to check of the ventilation systems in the facility. Record review of an undated facility policy entitled HVAC (heating, ventilation, air conditioning) system revealed the following information: 1. Documentation regarding the facility HVAC system is maintained by the Maintenance Director. 6. Documentation of all inspections, tests, and maintenance shall be maintained by the Maintenance Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09(H)(iv) Based on interview and record review, the facility failed to ensure 1 (Resident 1) of 1 sampled resident's Dulcolax (a medication for constipation) was administered (given) per provider's orders and that PRN (as needed) Imodium (a diarrhea medication) was administered to treat Resident 1's recurrent diarrhea. The facility census was 26. Findings are: A record review of Resident 1's Clinical Census dated 11/25/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 11/25/2024 revealed the resident had diagnoses of Partial Intestinal Obstruction, Ileus (bowel doesn't work correctly), Volvulus (intestine twist arounds itself), and Noneffective Gastroenteritis and Colitis (inflammation of the stomach and intestines). A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 10/21/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) score of 14/15 which indicated that the resident was cognitively intact. The resident required partial/moderate assistance with dressing and bathing, and supervision or touching assistance with toileting. The MDS revealed the resident was always continent (had control) of bowels. A record review of Resident 1's Care Plan with an admission date of 10/17/2024 revealed the resident had focus areas related to intestinal blockage and an intervention of monitor/document/report to medical doctor (MD) possible medical causes of incontinence, bladder infection, constipation, loss of bladder tone, and weakening of control muscles. A. A record review of the facility's Consulting Physician/Practitioner Orders policy dated 2018 revealed for provider orders received by telephone, the nurse would document the order on the physician order form, noting the time, date, name, and title of the person providing the order, and the signature and title of the person receiving the order. A record review of Resident 1's un-named patient concerns/physician order form dated 10/26/2024 revealed Registered Nurse (RN)-A took a verbal order from Advance Practice Registered Nurse (APRN)-B for clear liquids only and Dulcolax suppository (inserted in rectum) BID (2 times per day) until resolved. The form did not reveal a nurse signature or time, the provider order was in the patient concerns area, it was not signed by anyone, but was noted by RN-A on 10/26/2024. The form did not indicate a concern or reason for the order. A record review of Resident 1's Order Summary Report dated 11/25/2024 revealed an order for Bisacodyl (a medication for constipation) Suppository 10 milligram (MG), insert 1 suppository per rectum twice daily until resolved that had an order date of 10/25/2024. The indication for use was listed as constipation. There was also a Dulcolax Suppository 10 MG (Bisacodyl) insert 1 suppository rectally every 24 hours as needed for constipation order that was started 10/17/2024. A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated October 2024 revealed an order for Bisacodyl (a medication for constipation) Suppository 10 milligram (MG) insert 1 suppository per rectum twice daily until resolved that had an order date of 10/25/2024 that was entered as PRN and had not been administered. There was a Dulcolax Suppository 10 MG (Bisacodyl), insert 1 suppository rectally every 24 hours as needed for constipation order that was started 10/17/2024 and had been administered 1 time on 10/26/2024 at 11:02 AM. In a telephone interview on 11/26/2024 at 12:17 PM, APRN-B confirmed APRN-B gave a telephone order for BID Dulcolax on 10/26/2024 for a suspected bowel obstruction. In an interview on 11/26/2024 at 7:39 AM, RN-A confirmed RN-A received a telephone order from APRN-B on 10/26/2024 for BID Dulcolax, put it in the computer, and faxed it to the pharmacy. RN-A confirmed RN-A administered the medication at 11:02 AM on 10/26/2024 and told the RN coming on the next shift about the order. RN-A confirmed RN-A reviewed the October 2024 MAR & TAR and confirmed that was the only time the Dulcolax was administered in October, and taht it should have been administered twice per day. In an interview on 11/26/2024 at 9:55 AM, the Director of Nursing (DON) confirmed the DON reviewed the October 2024 MAR & TAR and confirmed the Dulcolax suppository should have been administered twice a day and had not been due to the person that entered the order in the system marked it as PRN instead of BID per the provider's order. B. A record review of the facility's un-dated PRN Medications policy revealed PRN medications required an assessment for need and effectiveness and the medical record would support the indications for use. The order would have clear instruction for how and when to administer, such as for a symptom. A record review of Resident 1's Order Summary Report dated 11/25/2024 revealed an order for Loperamide 2 MG capsule, take 1 capsule by mouth every day as needed for loose stools. A record review of Resident 1's Follow Up Question Report dated 10/17/2024 through 10/28/2024 revealed Resident 1 had loose stools every day except on 10/18/2024, 10/19/2024, and 10/21/2024. A record review of Resident 1's MAR & TAR dated October 2024 revealed the provider order for Loperamide capsule 2 MG take 1 capsule by mouth every day as needed for loose stool was only administered on 10/22/2024 at 3:30 PM and was effective. In an interview on 11/25/2024 at 11:10 AM, Resident 1's family member was upset due to Resident 1 had loose stools almost every day while at the facility and the facility only gave the resident the medication to treat it once. In an interview on 11/26/2024 at 7:39 AM, RN-A confirmed Resident 1 had a lot of diarrhea and RN-A did not assess the resident or the resident's stools. RN-A confirmed the Nursing Assistants had told RN-A about the resident having loose stools and the Nursing Assistant confirmed it was very liquid and was just running out of the resident. RN-A confirmed RN-A had not administered Resident 1's as needed Loperamide for loose stool and that APRN-B had instructed RN-A not to administer it starting on 10/26/2024. A record review of Resident 1's Electronic Medical Record dated 10/17/2024 through 10/28/2024 revealed the as needed order for Loperamide remained an active order throughout this time frame and had not be placed on hold. In an interview on 11/26/2024 at 11:02 AM, the DON confirmed the DON reviewed Resident 1's Follow Up Question Report dated 10/17/2024 through 10/28/2024 and the resident had loose stools on all but 3 days. The DON confirmed that the as needed Loperamide order was in the MAR & TAR that was dated October 2024 and had been administered once on 10/22/2024 at 3:20 PM but should have also been offered to the resident for their loose stools on the other dates even if the resident didn't request it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.04(G) Based on interview and record review, the facility failed to ensure resident's call lights were answered within 20 minutes as expected for 4 (Residents 1, 2, 3, and 4) of 4 sampled residents. The facility census was 26. Findings are: A record review of the facility's Call Lights: Accessibility and Timely Response policy dated 2018 revealed call lights would directly relay to a staff member to ensure appropriate response. All staff members who see or hear an activated call light are responsible for responding but did not reveal a timeframe the call light was to be answered in. A record review of the facility's Patient Concern Forms dated 05/15/2024 through 10/28/2024 revealed 4 residents had complained about long call light times. A. A record review of Resident 1's Clinical Census dated 11/25/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 11/25/2024 revealed the resident had diagnoses of Partial Intestinal Obstruction, Ileus (bowel doesn't work correctly), Volvulus (intestine twist arounds itself), and Noneffective Gastroenteritis and Colitis (inflammation of the stomach and intestines). A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 10/21/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) score of 14/15 which indicated the resident was cognitively intact. The resident was independent with footwear, partial/moderate assistance with dressing and bathing, and supervision or touching assistance with oral hygiene (cleaning) and toileting. The MDS revealed the resident was occasionally incontinent (lack of control) of urine and always continent (had control) of bowel. A record review of Resident 1's Care Plan with an admission date of 10/17/2024 revealed the resident had an intervention of I need prompt response to all requests for assistance. A record review of Resident 1's Patient Concern Form dated 10/28/2024 revealed the resident's family voiced concerns of long call light response times. A record review of Resident 1's Past Calls log dated 10/17/2024 through 10/29/2024, revealed 18 call lights that were greater than 20 minutes: -On 10/18/2024 at 4:33 AM the call light ran for 27:28 minutes, -On 10/18/2024 at 8:51 AM the call light ran for 25:50 minutes, -On 10/18/2024 at 9:36 AM the call light ran for 22:06 minutes, -On 10/18/2024 at 7:20 PM the call light ran for 35.32 minutes, -On 10/19/2024 at 9:30 AM the call light ran for 21:27 minutes, -On 10/20/2024 at 8:59 AM the call light ran for 35:54 minutes, -On 10/20/2024 at 11:00 AM the call light ran for 30:11 minutes, -On 10/20/2024 at 6:39 PM the call light ran for 27:58 minutes, -On 10/21/2024 at 8:48 AM the call light ran for 21:28 minutes, -On 10/21/2024 at 2:22 PM the call light ran for 22:00 minutes, -On 10/21/2024 at 5:39 PM the call light ran for 29:59 minutes, -On 10/22/2024 at 7:16 PM the call light ran for 28:47 minutes, -On 10/22/2024 at 10:23 PM the call light ran for 33:04 minutes, -On 10/24/2024 at 6:19 PM the call light ran for 28:11 minutes, -On 10/25/2024 at 6:55 PM the call light ran for 21:22 minutes, -On 10/26/2024 at 8:15 AM the call light ran for 25:59 minutes, -On 10/26/2024 at 9:26 AM the call light ran for 22:58 minutes, -On 10/27/2024 at 1:53 PM the call light ran for 24:56 minutes. In a telephone interview on 11/25/2024 at 11:10 AM Resident 1's family member confirmed that one time the resident pressed the call light because the resident had vomited and it took 25 minutes for staff to come in to clean the resident up after the call light had been pushed. On Saturday, 10/26/2024, the resident pressed the call light at about 9:20 AM and the staff did not respond until 9:47 AM. The resident had a diarrhea episode while waiting for staff to respond. On Sunday, 10/27/2024, the resident pressed the call light at about 1:55 PM due to the resident had to use the restroom and the staff did not respond until 2:18 PM. The family member confirmed the administrator was notified of the events and the resident's concerns. B. A record review of Resident 4's Clinical Census dated 11/26/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 4's Medical Diagnosis dated 11/26/2024 revealed the resident had diagnoses of COVID-19, left hip fracture, and presence of a cardiac pacemaker (a device to keep the heart in rhythm). A record review of Resident 4's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 which indicated the resident was cognitively intact. The resident needed set up assistance with upper body dressing and oral and personal hygiene. Resident 4 needed partial/moderate assistance with bathing and substantial/maximal assistance with toileting, lower body dressing and footwear. The MDS revealed the resident was frequently incontinent of bowels and had a urinary catheter (a tube inserted in the bladder to assist with urination). A record review of Resident 4's Care Plan with an admission date of 10/17/2024 revealed the resident had an intervention of I need prompt response to all requests for assistance. A record review of Resident 4's Past Calls log dated 11/07/2024 through 11/26/2024 revealed 11 call lights greater than 20 minutes: -On 11/07/2024 at 6:45 PM the call light ran for 32:14 minutes, -On 11/08/2024 at 10:02 AM the call light ran for 30:36 minutes, -On 11/11/2024 at 8:27 PM the call light ran for 42:12 minutes, -On 11/17/2024 at 9:52 PM the call light ran for 25:26 minutes, -On 11/18/2024 at 6:32 PM the call light ran for 41:28 minutes, -On 11/19/2024 at 1:34 AM the call light ran for 26:58 minutes, -On 11/22/2024 at 6:34 AM the call light ran for 24:40 minutes, -On 11/23/2024 at 5:29 PM the call light ran for 46:15 minutes, -On 11/23/2024 at 9:00 PM the call light ran for 20:44 minutes, -On 11/25/2024 at 4:44 PM the call light ran for 42:10 minutes, -On 11/26/2024 at 5:54 AM the call light ran for 35:13 minutes. In an interview on 11/26/2024 at 12:05 PM, Resident 4 confirmed it took a long time for staff to answer call lights when activated, sometimes over 40 minutes. Resident 4 confirmed that Resident 4 has had a bowel incontinence accident in the bed while waiting for staff to respond to their call light. Resident 4 confirmed it was the resident's expectation that the call light would be responded to within 10-15 minutes. C. A record review of Resident 2's Clinical Census dated 11/26/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 2's Medical Diagnosis dated 11/26/2024 revealed the resident had diagnoses of COVID-19, multiple right rib fractures, history of falls, constipation, and syncope and collapse (fainting). A record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS of 12/15 that indicated the resident was moderately cognitively impaired. The resident needed set up assistance with personal hygiene. Resident 2 needed partial/moderate assistance with upper body dressing and oral hygiene, and substantial/maximal assistance with toileting, bathing, lower body dressing and footwear. The MDS revealed the resident was frequently incontinent of urine and occasionally incontinent of bowels. A record review of Resident 2's Care Plan with an admission date of 10/17/2024 revealed the resident had an intervention of I need prompt response to all requests for assistance. A record review of Resident 2's Past Calls log dated 10/26/2024 through 11/26/2024 revealed 23 call lights greater than 20 minutes: -On 10/29/2024 at 6:34 PM the call light ran for 25:14 minutes, -On 10/31/2024 at 12:54 PM the call light ran for 42:37 minutes, -On 11/01/2024 at 9:09 AM the call light ran for 21:50 minutes, -On 11/03/2024 at 8:16 PM the call light ran for 22:57 minutes, -On 11/04/2024 at 8:33 AM the call light ran for 25:30 minutes, -On 11/05/2024 at 8:19 AM the call light ran for 39:40 minutes, -On 11/05/2024 at 3:46 PM the call light ran for 45:46 minutes, -On 11/05/2024 at 5:13 PM the call light ran for 35:41 minutes, -On 11/05/2024 at 6:55 PM the call light ran for 20:11 minutes, -On 11/06/2024 at 8:50 PM the call light ran for 24:39 minutes, -On 11/07/2024 at 7:44 PM the call light ran for 25:36 minutes, -On 11/07/2024 at 9:17 PM the call light ran for 28:12 minutes, -On 11/09/2024 at 8:07 AM the call light ran for 27:26 minutes, -On 11/10/2024 at 9:42 AM the call light ran for 21:23 minutes, -On 11/10/2024 at 5:07 PM the call light ran for 29:53 minutes, -On 11/11/2024 at 8:36 PM the call light ran for 20:24 minutes, -On 11/15/2024 at 8:15 AM the call light ran for 37:36 minutes, -On 11/15/2024 at 6:29 PM the call light ran for 25:52 minutes, -On 11/16/2024 at 9:24 AM the call light ran for 20:25 minutes, -On 11/17/2024 at 3:23 PM the call light ran for 30:15 minutes, -On 11/17/2024 at 6:30 PM the call light ran for 58:15 minutes, -On 11/18/2024 at 5:14 AM the call light ran for 30:52 minutes, -On 11/25/2024 at 5:16 PM the call light ran for 26:43 minutes. In an interview on 11/26/2024 at 11:56 AM, Resident 2 confirmed some call lights take too long to get answered. The resident's expectation would be that call lights would be answered within 20 minutes. D. A record review of Resident 3's Clinical Census dated 11/26/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 3's Medical Diagnosis dated 11/26/2024 revealed the resident had diagnoses of right knee and hip fractures, history of falls, and diverticulosis (formation of small pouches) of the large intestine. A record review of Resident 3's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 which indicated the resident was cognitively intact. The resident needed set up assistance with oral hygiene and upper body dressing. Resident 3 needed partial/moderate assistance with bathing and toileting, and substantial/maximal assistance with lower body dressing and footwear. The MDS revealed the resident was frequently incontinent of urine and the bowels were not rated. A record review of Resident 3's Care Plan with an admission date of 10/17/2024 revealed the resident had an intervention of I need prompt response to all requests for assistance. A record review of Resident 3's Past Calls log dated 11/05/2024 through 11/26/2024 revealed 9 call lights greater than 20 minutes: -On 11/11/2024 at 11:39 PM the call light ran for 28:57 minutes, -On 11/12/2024 at 8:36 PM the call light ran for 44:05 minutes, -On 11/13/2024 at 4:14 PM the call light ran for 1:00:50 hour, -On 11/13/2024 at 6:32 PM the call light ran for 35:10 minutes, -On 11/13/2024 at 7:55 PM the call light ran for 20:11 minutes, -On 11/17/2024 at 6:58 AM the call light ran for 22:59 minutes, -On 11/18/2024 at 11:45 AM the call light ran for 24:15 minutes, -On 11/18/2024 at 8:14 PM the call light ran for 45:38 minutes, -On 11/19/2024 at 8:47 AM the call light ran for 20:01 minutes. In an interview on 11/26/2024 at 12:13 PM, Resident 3 confirmed the resident has had to wait a long time for staff to answer the call light, sometimes over 40 minutes. The resident's expectation would be that the staff would answer the call light within 15 minutes during the day when it may be busier, and 10 minutes at night when there was not as much going on. In an interview on 11/26/2024 at 11:02 AM, the DON confirmed it was the facility's administration's goal for call lights to be answered within 6-7 minutes, but 20 minutes would be the DON's expectation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(D) Based on record reviews and interviews, the facility failed to ensure that Resident 1 was free from significant medication errors. This affected 1 of 5 residents sampled for medication administration. The facility census was 33. Findings are: A record review of Resident 1's admission Record printed 07/24/2024 revealed the resident was admitted to the facility on [DATE] and had diagnoses of respiratory failure, heart failure, atrial fibrillation (an irregular heartbeat that may lead to blood clots), venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart), and the presence of a pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm). A record review of Resident 1's Order Summary printed 07/24/2024 revealed the resident had orders for the following: Warfarin (an anticoagulant, or medication that helps prevent blood clots by making the blood clot more slowly) 5 milligrams (MG) by mouth once a day on Sundays, Mondays. Wednesdays, and Thursday; and Warfarin 7.5 MG by mouth once daily on Tuesdays, Thursdays, and Saturdays. Both orders had a start date of 07/17/2024. A review of a communication form dated 07/19/2024 for Resident 1 revealed the resident had an INR (International Normalized Ratio-a standardized lab value that measures how long it takes blood to clot) of 5.6. The form also listed the resident's warfarin orders and included the response of the Advance Practice Registered Nurse (APRN) to 1 hold (to hold a medication means to not administer it) warfarin and 2 INR Sunday 07/21/2024. A review of the National Library Of Medicine page on INR (https://www.ncbi.nlm.nih.gov/books/NBK507707/#:~:text=%5B8%5DFor%20patients%20who%20are,increase%20the%20risk%20of%20bleeding) revealed the following: For patients who are on anticoagulant therapy, the therapeutic INR ranges between 2.0 to 3.0. INR levels above 4.9 are considered critical values and increase the risk of bleeding. A record review of Resident 1's Medication Administration Record (MAR) revealed that the warfarin 5 MG dose was documented as given on Friday 07/19/2024 and as not administered on Sunday 07/21/2024. The warfarin 7.5 MG dose was documented as given on Saturday 07/20/2024. Further review revealed that both warfarin orders were placed on hold on 07/22/2024. A review of Resident 1's Progress Notes revealed a note from 07/21/2024 that stated the warfarin was held that date. A review of a communication form dated 07/21/2024 for Resident 1 revealed the resident had an INR of 8.0. Further review revealed the form was addressed by the APRN on 07/22/2024 with 1 hold warfarin and 2 INR Wednesday 07/24/2024. A review of the facility policy Medication Errors dated 01/08/2024 revealed: 'Significant medication error' means one which causes the resident discomfort or jeopardizes his/her health and safety or causes harm. 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. An interview on 07/23/2024 at 4:49 PM with the DON confirmed Resident 1 had a high INR on 07/19/2024, the APRN gave an order on 07/19/2024 to hold the medication and recheck the INR on 07/21/2024, and Resident 1 received doses of warfarin on 07/19/2024 and 07/20/2024 and should not have. The DON further confirmed that the INR drawn on 07/21/2024 was higher than on 07/19/2024. An interview on 07/23/2024 at 7:23 PM with Licensed Practical Nurse (LPN) A confirmed that giving the warfarin when the order was to hold it was a significant medication error because of how high the INR was on 07/19/2024 and how much higher the INR was on 07/21/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to provide written notification of discharge to 1 resident (Resident 50) of 1 sampled resident, or to the resident's representative and failed to provide a written reason of discharge to 1 resident (Resident 50) of 1 resident sampled or to the resident's representative. The facility claimed a census of 35. Findings are: A record review of Resident 50's Electronic Health Record revealed Resident 50 was admitted to the facility on [DATE] with the following diagnoses: Pneumonia, Acute Respiratory Failure with Hypoxia, Sepsis, Lymphocytosis, Major depressive disorder, Mixed hyperlipidemia. A record review of Resident 50's Progress Notes dated 1/15/2024 revealed the following information: During report (the report given by the off going staff to the incoming staff) the day nurse reported to the night shift nurse that the resident's oxygen saturation (O2 sats) were in the 60s and low 70s during the day. The nurse stated that based upon their assessment the resident did not need to be sent out. At the end of report the night nurse assessed the resident and found the resident to be visibly struggling to breathe. The resident reported shortness of breath (SOB) at rest and lightheadedness. The resident denied having chest pain. The resident's vital signs were Blood Pressure 142/60, Pulse 93, Temperature 98.3, Respirations 26 and O2 74%. The resident was barrel chested, the left lung sounded clear to auscultation, (the act of listening to internal sounds from the body, usually with a stethoscope) the right lung had wheezes throughout. The resident's provider was notified at 6:52 PM of the resident's condition. The provider gave an order for the resident to be sent to the hospital. The residents' daughter was notified of the transfer. The resident was taken to the hospital by the rescue squad at 7:30PM. Author: Registered Nurse B. A record review of the Emergency Transfer Form dated 1/15/24 for Resident 50 revealed the family was notified of the transfer and the following documents were sent with the Resident to the hospital; face sheet, MAR/TAR (Medication Administration Record/Treatment Administration Record), Order summary, Code Status, therapy status and the following belongings: hearing aids, glasses and cane. A record review of the facility's undated Transfer and Discharge policy, Copyright 2023. The Compliance Store, LLC., revealed the following: Policy Explanations and Compliance Guidelines: 5. Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: (c) An immediate transfer or discharge is required by the resident's urgent medical needs. 6. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC Ombudsman as soon as practicable before the transfer or discharge. 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. (g) Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. An interview on 4/15/2024 at 3:36PM with the facility Administrator (Admin) confirmed the facility did not send a written reason for discharge to Resident 50 or to Resident 50's representative. An interview on 04/16/2024 at 8:52AM with the facility Admin further confirmed the facility did not provide a notice of discharge to Resident 50 or to Resident 50's representative.

Based on record review and interview; the facility failed to complete tracking/discharge Minimum Data Sets (MDS, a federally mandated assessment tool used for care planning) for 17 (2, 4, 5, 10, 15, 17, 19, 21, 22, 25, 27, 33, 37, 39, 40, 41, 42, 44) of 17 residents. Findings are: A record review of sampled resident's discharge Electronic Health Records revealed the following Residents do not have a tracking discharge (MDS) completed: Those are Residents 2, 4, 5, 10, 15, 17, 19, 21, 22, 25, 27, 33, 37, 39, 40, 41, 42 and 44. An interview on 04/11/2024 at 11:45AM with the newly hired MDS Coordinator, (a person whose primary responsibility is to manage and assess patient care), confirmed a tracking discharge MDS should be completed within 3 days of a resident's discharge from the facility. The MDS coordinator revealed [gender] had begun [gender] new position on 04/08/2024. An interview on 04/11/2024 at 2:45PM with the facility Administrator confirmed they were not aware that the tracking discharge MDS were not completed for Residents 2, 4, 5, 10, 15, 17, 19, 21, 22, 25, 27, 33, 37, 39, 40, 41, 42 and 44. The administrator confirmed they should have been completed after the residents discharged from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09D6(7) Based on record review, observation, , and interview; the facility failed to have a physician's order for Continuous Positive Airway Pressure (CPAP-a machine that uses mild air pressure to keep breathing airways open while you sleep) for 1 (Resident 56) of 1 resident sampled. The facility staff identified a census of 35. Findings are: Record review of Resident 56 clinical census revealed the resident was admitted on [DATE]. Record review of Resident 56's Diagnosis Report revealed the resident had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, unspecified diastolic (congestive) heart failure, and essential hypertension. Record review of the History and Physical dated 4/2/24 by Medical Doctor/Hospitalist at Catholic Health Initiatives (CHI) Alegent [NAME] Hospital Medicine revealed a diagnosis of sleep apnea with the use of CPAP. Record review of Resident 56's Care Plan dated 4/8/2024 revealed a focus of I have an Activity of Daily Living (ADL) self-care performance deficit because of my weakness and having heart issues that cause me to tire easily. I also have COPD that I use the CPAP machine, so if not used, I am tired. A record review of Resident 56's form entitled Order Summary revealed no order for the CPAP machine. A record review of Resident 56's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no order for the CPAP machine. Observation on 4/10/24 revealed a CPAP sitting on the bedside table in Resident 56's room. Interview with Resident 56 on 4/10/24 confirmed Resident wore the CPAP every night. Resident 56 confirmed nursing staff assisted with application of the CPAP and bleeding in the prescribed Oxygen (O2). Interview with LPN-A confirmed no order was found for the CPAP or for the O2 bled into the CPAP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of Resident 3's Electronic Health Record (EHR) revealed Resident 3 admitted to the facility on [DATE] after hospitalization for Acute Respiratory Failure, Acute on Chronic Heart Failure, Diabetes Type 2 and a history of stroke with right sided weakness. A review of Resident 3's Comprehensive Care Plan (CCP) dated 10/25/2023 Resident 3 was assessed as being at risk for falls. Review of Resident 3's CCP dated 10/25/2023 revealed Resident 3 fell 6 times, on 11/05/2023, 12/04/2023, 12/13/2023 at 12:00 AM and the at 4:05 PM and 12/19/23. Review of Resident 3's PN 11/05/2023 revealed there was not a indication the facility staff had notified Resident 3's family or physician concerning a fall on 11/05/2023. A review of Resident 3's PN dated 12/04/2023 revealed Resident 3's physician was not notified of the fall on 12/04/2023. A review of Resident 3's PN dated 12/13/2023 revealed Resident 3's family was not notified of the fall on 12/13/2023 at 12:00 AM. A review of Resident 3's PN dated 12/13/2023 at 4:05 PM revealed Resident 3's physician was not notified of the fall on 12/13/2023 at 4:05 PM. A review of Resident 3's PN dated 12/19/2023 revealed Resident 3's family or physician was not notified of the fall. Review of Resident 3's EHR for faxes, physician orders, phone orders revealed there was no indications Resident 3 physician and/or family was notified as identified in the above information. An interview on 03/05/2024 at 2:45 PM was conducted with the facility Administrator (ADM). During the interview the facility ADM confirmed family and/or physician notifications concerning falls were not done for Resident 3. Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interviews, the facility staff failed not notify the practitioner or responsible party of a fall for 2 (Resident 1 and 3) of 3 sampled residents The facility identified a census of 17. Findings are: A review of the facility's undated policy titled Fall Prevention Program indicated A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force Further review revealed the following: -Policy Explanation and Compliance Guidelines: -# 9. When any patient experiences a fall, the facility will: -d. Notify the physician and family. A review of the facility's undated policy titled Notification of Changes revealed staff were to notify the physician and the residents' representative consistent with their authority, when there is a change requiring notification. A review of the residents Census List indicated the facility admitted Resident 1 on 1/8/24 with diagnosis of Respiratory Syncytial Virus Pneumonia, Hypoxia, increased weakness, Diabetes Type II, Congestive Heart Failure, and other fractures in routine healing. A review of Resident 1's Care Plan dated 1/15/24 identified Resident 1 needed 1 person assisting with transfers and using a walker or wheelchair. A review of Resident 1's Clinical assessment dated [DATE] indicated the facility assessed Resident 1 with a BIMS (Brief Interview for Mental Status) score of 12. According to the MDS [NAME] a score of 8-12 indicates a person had moderately impaired cognition. A review of Resident 1's Care Plan printed on 3/5/24 revealed Resident 1 was at risk for falls with interventions to prevent falls as follows: -Encourage Resident to wear nonskid footwear. -Anticipate and meet the Resident's needs. -Be sure Resident's call light is within reach and encourage to use it for assistance. -Resident needs a safe environment with; even floors free from spills and/or clutter; adequate, glare free light; a working and reachable call light, handrails on walls, personal items within reach. A review of Resident 1's Incident Audit Report dated 2/12/24 at 7:31 AM indicated Resident 1 was found by a Nursing Assistant (NA) to be laying on the floor, close to the recliner with recliner legs reclined. The report continued to reveal that Resident 1 head hit the floor. The report also indicated Resident 1 suffered injuries such as skin tear left arm, skin tear right chest, and bump left temple. A review of Resident 1's progress Progress Note (PN) dated 2-12-2024 revealed Resident 1's family was not notified of the fall on 2/12/24. An interview on 3/5/24 at 10:52 AM with Resident 1's Emergency Contact # 1. During the interview Emergency Contact #1 reported the facility staff did not call and notify them of Resident 1's fall with injury on 2/12/2024 On 3/5/2024 at 11:51 AM an interview was conducted with the facility Administrator. During the interview the facility Administrator confirmed Resident 1's representative was not notified of the fall with injury on 2/12/2024.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to ensure a significant injury was reported as potential neglect or an investigation was submitted to the state survey agency within 5 working days for 1 [Resident 4] of 4 sampled residents. The facility had a total census of 34. Findings are: Record review of a facility incident report dated 5/1/23 at 4:50 AM revealed Resident 4 was observed laying on their belly with their head turned towards the right with Resident 4's hands and arms at the side. The incident report revealed Resident 4 had a large amount of blood coming from the right side of their head. Record review of Progress Note dated 5/1/23 at 4:50 AM revealed Resident 4 had sustained a laceration to the right side of their head and a bump to the right brow. An order was received to send Resident 4 to the hospital and Resident 4 was transported by Medics to the hospital by stretcher. Record review of the incident report, facility investigations, and Resident 4's electronic medical record did not reveal Resident 4's injury was reported or an investigation was completed and submitted to the state survey agency. Interviews on 7/3/23 at 11:12 AM, 4:19 PM and 5:17 PM, the Administrator confirmed that Resident 4's injury was not reported or investigated. The Administrator reported that Resident 4 was discharged to the hospital and the facility did not receive any information from the hospital regarding Resident 4's injuries. The Administrator revealed fractures, lacerations that required staples or stitches, and injuries that result in a change of functional status are reported. Record review of undated facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed the following procedure for Administrator or designee for reporting when suspicion of abuse/neglect/exploitation: -Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. -Obtain statements from direct care staff. -Suspend the accused employee pending completion of the investigation. -Follow up with appropriate agencies, during business hours, to confirm the report was received. -Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service. -Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions take, if the allegation was verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Record review of Resident 37's admission Record revealed that Resident 37 was admitted to the facility on [DATE]. Record review of Resident 37's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated, [DATE], Resident 37 was discharged and return was not anticipated on [DATE]. Record review of the progress notes during Resident 37's stay from [DATE] through [DATE] there was no recapitulation (a concise summary of the resident's stay and course of treatment while in the facility) or a discharge summary noted for Resident 37. Record review of undated Discharge Summary Policy, stated It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. In an interview on [DATE] at 07:31 AM with the Administrator it was confirmed there was no recapitulation of the stay completed for Resident 37. Licensed Reference Number NAC 12-006.093C Based on record review and interview; the facility failed to ensure a discharge summary that met the discharge summary requirements for 3 sampled residents (Resident 33, 36, and 37) of 7 closed resident records reviewed. The facility census was 41. Findings are: A. Reord review of Resident 36's admission record revealed Resident 36 was admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident 36's medical record revealed there was no discharge summary. An interview on [DATE] at 7:31 AM with the Administrator confirmed there was not a Discharge Summary completed for Resident 36. B. Reord review of Resident 33's admission record revealed Resident 33 was admitted to the facility on [DATE] and expired on 1-16-2023. Record review of Resident 33's medical record revealed there was no discharge summary. An interview on [DATE] at 7:31 AM with the Administrator confirmed there was not a Discharge Summary completed for Resident 33.

Licensure Reference Number 175 NAC 12-007.04D Based on record review, observations and interview, the facility failed the bathroom vents in rooms 120,125,126, and 127 were functioning. The facility identified a census of 41. Findings are: Observation on 3/20/23 at 1:05 PM revealed the bathroom vents in rooms 120, 125, 126, and 127 were not functioning. An Interview with the Administrator on 3/20/23 at 1:05 PM confirmed that the bathroom vents in rooms 120, 125, 126 and 127 were not working properly. Record review revealed of the facility's Maintenance Discharge Checklist revealed that the list did not contain checking the bathroom vents. On 3/21/23 at 9:00 AM Interview with the Administrator confirmed that the vents to be checked were not on the maintenance checklist.