Licensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure Resident 4's as needed antipsychotic (a type of medication which alters chemicals in the brain to effect changes in behavior, mood and emotion) medication was reviewed for continued need and renewed every 14 days as required. The sample size was 5 and the facility census was 27. Findings are: Review of the facility policy Antipsychotic Drug Use Policy, last revised 10/10 revealed the following: -all residents having antipsychotic drug orders would have a proper diagnosis, -resident behaviors would be monitored daily, -the Pharmacy would routinely monitor and request appropriate dose reductions, -the facility would utilize the lowest effective dose based on behaviors, -residents would have interventions on their care plans to assist in redirecting undesired behaviors, and -the resident's responsible party and/or the resident would be educated on the medication, diagnosis, dose changes, and side effects of the medications. Review of Resident 4's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 12/4/24 revealed the resident had severe cognitive impairment, didn't exhibit any behaviors, was dependent with toileting, dressing, and hygiene, and had a diagnosis of dementia, anxiety and depression. Review of Resident 4's Care Plan last revised 1/2/25 revealed the following: -the resident had delusions and hallucinations, -was socially inappropriate at times, -had impaired cognitive function due to dementia, -used Haloperidol (an antipsychotic medication) for behavior management, and -required assistance with toileting, dressing, and hygiene. Review of the facility form Physician Orders for Resident 4 revealed the resident had an order for Haloperidol 5 milligrams (mg) by mouth every 8 hours as needed for agitation with a start dated of 11/25/24. Review of an email the Consulting Pharmacist sent to the Director of Nursing (DON) dated 11/26/24 revealed Resident 4 had an order for Haloperidol as needed with a stop date of 5/7/25. Recommendations were that since the Haloperidol is an antipsychotic medication, it was limited to 14 days, the resident would need to be seen by the provider for an evaluation every 14 days, and a follow-up visit was needed by 12/10/24. Review of the Consultant Pharmacist's Medication Regimen Review dated 1/15/25 revealed the last documented administration of the Haloperidol 5mg as needed was on 11/28/24. Review of the facility forms for Physician Visits revealed the following: -on 10/29/24 a Physician recertification visit had an order for Haloperidol 5mg every 8 hours as needed for agitation, -a visit on 11/12/24 revealed no documentation that the as needed Haloperidol was addressed (14 days after order), -a Physician visit on 11/19/24 revealed no documentation that the as needed Haloperidol was addressed (21 days after order), -a Physician visit on 12/24/24 revealed the Physician wrote to continue the as needed Haloperidol 5 mg every 8 hours as needed for dementia with psychosis (56 days after original order), but did not document a resident specific rationale, -a Physician recertification visit on 1/7/25, the Physician wrote to continue the Haloperidol 5 mg every 8 hours as needed for psychosis but did not document a resident specific rationale, -a visit on 1/21/25 the Physician wrote the Resident still needs Haloperidol and to continue Haloperidol as needed for dementia with psychosis but did not document a resident specific rationale, -a visit on 1/28/25 the Physician wrote Haloperidol 5 mg every 8 hours as needed for diagnosis of dementia with psychosis, but did not document a resident specific rationale, -a visit on 2/4/25 there was no documentation that the as needed Haloperidol was addressed, and -a visit on 2/11/25 there was no documentation that the as needed Haloperidol was addressed (14 days since it was last renewed). Interview on 2/19/25 at 12:50 PM with Registered Nurse (RN)-C confirmed the resident had not been seen every 14 days as required for the as needed Haloperidol. Further interview confirmed the resident had not had any adverse behaviors, the resident did not need to use the medication, and had not received the medication since 11/28/24. Interview on 2/19/25 at 1:45 PM with RN-C and the DON confirmed Resident 4 was not seen every 14 days for the as needed Haloperidol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006(D)(vi) Based on observation, record review and interview; the facility failed to ensure insulin pens were dated when opened to ensure safe administration of insulin for Resident 17 and Resident 129. The sample size was 4 and the facility census was 27. Findings are: A. Review of the facility policy Insulin Administration with a revised date of [DATE] revealed the following: -The purpose of the Insulin Administration policy was to provide guidelines for the safe administration of insulin to residents with diabetes. -Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial. Review of Resident 129's February 2025 medication administration record (MAR) revealed an order for Aspart (rapid acting insulin)10 units in the morning. An observation on [DATE] at 7:35 AM with Licensed Practical Nurse (LPN)-G obtained Resident 129's insulin pen out of the medication cart for administration. The Aspart Insulin did not have an open date or expiration date documented. Inspection of the medication cart on [DATE] at 11:30 AM revealed Resident 17's Toujeo (long-acting insulin) insulin pen did not have an open date or expiration date documented. Review of Resident 17's February 2025 physician orders revealed an order for Toujeo 24 units at bedtime. Interview on [DATE] at 7:35 AM with LPN-G verified that the insulin pen for Resident 129 was not dated when opened or dated when expired and insulin pens were to be dated when opened and expired. Interview on [DATE] at 11:30 AM with LPN-G verified that the insulin pen for Resident 17 was not dated when opened or dated when expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. Review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning ) dated 1/1/25 revealed the resident had moderate cognitive impairment, received substantial assistance with dressing and hygiene, was incontinent of bowel and bladder, and had dementia. Review of Resident 14's Care Plan with a revision date of 10/29/24 revealed the resident had dementia with difficulty making decisions and intermittent confusion. In addition, the resident took medications to treat Congestive Heart Failure and Depression. There was no evidence of treatment for a current or recent respiratory infection. Review of Resident 14's Progress Notes revealed the following: -1/14/25 at 12:31 PM the resident was seen by the physician in the facility and had coarse lung sounds and a loose cough. The physician ordered an antibiotic and anti-inflammatory medication. -1/15/25 at 10:29 AM the resident continued to have coarse lung sounds and a cough -1/16/25 at 6:11 AM the resident continued taking an antibiotic for a respiratory infection and continued to nasal drainage and coughing. -Further review revealed there was no evidence the facility completed COVID testing when the resident presented with signs and symptoms of a potentially infectious respiratory illness. During an interview on 2/18/25 at 3:41 PM the DON revealed the facility was not routinely COVID testing residents who presented with respiratory illness signs and symptoms. The DON would check to see if a COVID-19 test was completed for Resident 14 when respiratory illness symptoms were identified on 1/15/25. During an interview on 2/19/25 at 4:47 PM the DON confirmed the facility did not complete a COVID-19 or any type of respiratory panel testing to identify which respiratory illness Resident 14 had, when the resident presented with respiratory illness symptoms on 1/15/25. F. Review of Resident 21's MDS dated [DATE] revealed the resident had pneumonia and lung disease, however the resident was offered but declined a pneumonia vaccine. Review of Resident 21's Care Plan with a revision date of 1/2/25 revealed the resident had respiratory disease, shortness of breath and dementia. The resident displayed anxiety and anxiousness when having shortness of breath. Oxygen was used as needed. There was no indication the resident had a recent respiratory infection. Review of Resident 21's Progress Notes revealed the following: -on 1/26/24 at 2:50 PM the resident complained of signs and symptoms of a cold, a loose cough and was given oxygen to help with anxiety and discomfort. -on 1/27/24 at 1:00 AM the resident had a moist cough, labored breathing, and an oxygen level of 83% (90-100% is considered normal). The resident's oxygen levels did not improve with oxygen and thus the resident was transferred to the hospital by ambulance. -Further review revealed there was no evidence the facility completed COVID testing when the resident presented with signs and symptoms of a potentially infectious respiratory illness. During an interview on 2/18/25 at 3:41 PM the DON revealed the facility was not routinely COVID testing residents who presented with respiratory illness signs and symptoms. The DON would check to see if a COVID-19 test was completed for Resident 21 when respiratory illness symptoms were identified on 1/26/24. During an interview on 2/19/25 at 4:47 PM the DON confirmed the facility did not complete a COVID-19 or any type of respiratory panel testing to identify which respiratory illness Resident 21 had, when the resident presented with respiratory illness symptoms on 1/26/24. G. Review of Resident 26's MDS dated [DATE] revealed the resident had dementia, a respiratory condition, diabetes and had taken insulin and an antibiotic in the preceding week. Review of Resident 26's Care Plan with a revision date of 1/15/25 revealed the resident had impaired cognition and required assistance with activities of daily living. In addition, the resident had a history of falling, was diabetic and received insulin daily. There was no evidence the resident had current or recent respiratory illness. Review of Resident 26's Progress Notes revealed the following: -On 12/26/24 at 3:21 PM the resident had congestion and general malaise and an occasional cough. -On 12/28/24 at 5:24 PM the resident continued to complain of head congestion and requested a room tray for dinner. -On 12/29/24 at 9:47 AM the resident congestion was not improving, and the facility called and updated the provider on the resident's symptoms. The provider ordered an anti-inflammatory medication. -On 12/30/24 at 5:17 PM the provider visited the resident in the facility and ordered an antibiotic and nebulizer (inhaled breathing) treatments. -Further review revealed there was no evidence the facility completed COVID testing when the resident presented with signs and symptoms of a potentially infectious respiratory illness. During an interview on 2/18/25 at 3:41 PM the DON revealed the facility was not routinely COVID testing residents who presented with respiratory illness signs and symptoms. The DON would check to see if a COVID-19 test was completed for Resident 26 when respiratory illness symptoms were identified on 12/26/24. During an interview on 2/19/25 at 4:47 PM the DON confirmed the facility did not complete a COVID-19 or any type of respiratory panel testing to identify which respiratory illness Resident 26 had, when the resident presented with respiratory illness symptoms on 12/26/24. Licensure Reference Number 175 NAC 006.18(B) Based on observation, record review, and interview the facility failed to Covid 19 test 6 of 6 sampled residents (Resident 10, 11, 14, 17, 21, and 26) when respiratory illness symptoms were displayed and failed to implement isolation procedures for Resident 10 when respiratory symptoms were displayed. The facility failure had the potential to effect all residents in the building. The sample size was 6 and the census was 27. Findings are: A. Review of the facility policy Upper Respiratory Illness with a revision date of 9/4/24 revealed the following: -The facility made every attempt to prevent the transmission of any upper respiratory illness from entering the facility and also reduce the transmission of illness with the facility. -To reduce the transmission of upper respiratory illness mask and sanitizer was available at the main entrances, visitors were asked to use hand sanitizer before visiting residents, staff strictly adhered to hand, respiratory, and cough hygiene, and vaccinations were offer to all staff and residents. -To reduce the transmission of upper respiratory illness within the facility staff strictly adhered to hand respiratory and cough hygiene and were encouraged to report symptoms on themselves and/or others as soon as possible, precautions were instituted in rooms where there were suspected or confirmed cases of any transmissible respiratory illness, and any person/s that had fever or symptoms of transmissible respiratory illness including but not limited to COVID and influenza, isolated for at least 5 days from onset of symptoms or the first day of positive test results. -Infected residents were isolated and closely monitored and positive cases were investigated and tracked for case origination. The Director of Nursing (DON) or designee determined who needed to be tested and to determine outbreak testing. -Staff having signs and symptoms of COVID should test to determine if they need to isolate. B. Review of Resident 10's Progress Notes revealed the following: -2/14/2025 at 9:52 AM Resident 10 was confused and required increased assistance with getting dressed and completing cares. Oxygen level was 80% on room air. Oxygen per nasal cannula was applied at 2 liters per nasal cannula. (No follow up oxygen level was charted.) -2/15/25 at 8:00 PM revealed Resident 10 had a harsh cough was noted and both eyes had yellow color drainage. Oxygen level was 91% with oxygen at 2 liters per nasal cannula. -2/16/25 at 7:00 PM revealed Resident 10 continued with a harsh moist cough. -2/17/25 9:25 AM revealed Resident 10 had a moist, harsh, non-productive cough. Crackles were noted in bilateral lungs with diminished air exchange. Oxygen level was 82% on room air, oxygen was applied at 2 liters per nasal cannula, oxygen level increased to 90%. -2/17/25 at 9:42 AM the facility staff received a physician's order for an antibiotic medication for Pneumonia. -2/18/25 at 1:52 PM revealed Resident 10 continued with a moist cough. Lung sounds were diminished in upper lobes with crackles in the lower lobes bilaterally. Observations of Resident 10 revealed the following: - 2/18/24 at 8:50 AM revealed Resident 10 was sitting in a recliner in room, voice crackled, and a loose nonproductive cough was noted. -2/19/25 10:00 AM revealed Resident 10 was in the bathroom, had loose productive cough noted and had coughed up yellow colored phlegm. C. Review of Nursing Progress Notes for Resident 11 revealed the following: -1/30/25 at 10:52 AM revealed Resident 11 had sinus and nasal congestion, both eyes were mattery and puffy under eyes. -1/30/25 at 1:59 PM revealed the facility staff received physicians order for a decongestant and cough medication. 1/31/25 at 10:36 AM revealed Resident 11 continued with nasal congestion and had a non-productive cough. -2/1/25 9:05 AM revealed Resident 11 had a productive cough, head was congested, lung sounds were diminished. -2/4/25 at 9:56 AM, Resident 11 continued with nasal congestion and complained of ears feeling full. Face was puffy with a moist nonproductive cough. Both eyes had drainage. -2/4/25 at 12:31 PM, the resident was seen by physician and received an order for an antibiotic for pneumonia. -2/5/25 at 2:50 PM, Resident 11 continued with a harsh productive cough, lung sounds were diminished bilaterally upper and lower lobes. -2/7/25 at 10:50 AM the resident continued with an occasional moist non-productive cough noted. D. Review of Nursing Progress Notes for Resident 17 revealed the following: -2/8/25 at 10:46 AM, Resident 17 complained of sinus and nasal congestion. -2/8/25 at 12:09 PM,Physician order received for Benadryl 25 milligrams (mg) every 6 hours as needed for sinus and nasal congestion. -2/9/25 at 10:56 AM, Resident 17 continued with sinus and nasal congestion. -2/10/25 at 1:06 PM, Resident 17 continued to have nasal and sinus congestion. -2/11/25 at 2:05 AM hoarse voice was noted when speaking. An interview with Registered Nurse (RN)-C, infection control nurse, on 2/18/25 at 11:55 AM verified residents 10, 11 and 17 did not have a Covid 19 test or respiratory panel completed when respiratory symptoms started. RN-C further confirmed Resident 10 was not placed in isolation when respiratory symptoms started.

Liscensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report a potential allegation of abuse to the State Agency for Resident 16. The sample size was 1 and the facility census was 31. Findings are: A. Review of the facility's undated policy Abuse, Neglect, and Misappropriation of Resident Property revealed the following: -The facility encouraged and supported residents, staff, families, visitors, volunteers and resident representatives to report any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property. -Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. -The nursing home administrator or designee will report abuse to the State Agency per state and federal requirements. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of residents, irregardless of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident. -If an incident or allegation is considered reportable, the administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five working days. B. Review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment tool used to develop a resident's plan of care) dated 1/3/24 revealed the following about the resident: -moderate cognitive impairment; -diagnoses of: fracture of the left leg; heart failure, high blood pressure, elevated fat levels in the blood, dementia, anxiety, and lung disease; and -required moderate assistance with toileting, transfers, personal hygiene, and dressing. Review of Resident 16's nursing progress notes dated 11/27/23 at 4:24 PM revealed the resident reported a staff member had ripped [gender] shirt off, sprayed [gender] in [gender] face with something so [gender] couldn't see and was banging the bed board this morning before [gender] was up and Resident was upset and crying. Review of facility investigations submitted to the State Agency between 11/7/22 and 1/29/24 revealed no evidence Resident 16's allegation of potential abuse documented on 11/27/23 was reported to the State Agency as required. An interview with the Director of Nurses (DON) on 1/31/24 at 2:10 PM confirmed the facility had not reported the allegation of potential abuse that was documented in the resident's medical record on 11/27/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Review of the facility policy Parkside Manor Preadmission Screening and Annual Resident Review (PASARR), undated revealed the following: -the facility would coordinate the assessment process with the PASARR program which would incorporate recommendations from the PASARR Level II determination and evaluation in the resident's assessment, care plan, and transition of care, and -an individual was considered to have a serious mental illness if the individual met the following requirements on diagnoses had schizophrenia; had mood, paranoid, panic or other severe anxiety disorder; and/or the resident did not have a primary diagnosis of dementia. Review of Resident 13's MDS dated [DATE] revealed the following: -the resident did not have a Level II PASARR determination, -the resident was cognitively intact, -the resident had a diagnosis of schizophrenia, and -the resident received an antipsychotic medication (medications that alters chemicals in the brain to effect changes in behavior, mood and emotion). Review of Resident 13's Care Plan revealed a problem that Resident 13 required a follow up for a PASARR Level II screen with an onset date of 12/4/23. Review of Resident 13's MAR dated January 2024 revealed the resident received Olanzapine (an antipsychotic medication) 2.5 mg at bedtime for a diagnosis of schizophrenia and Quetiapine (an antipsychotic medication) 25mg twice per day for paranoid schizophrenia. Review of Resident 13's PASARR screen revealed the evaluation was completed on 12/23/22 and a determination was made that the resident did have a serious mental illness and was a Level II PASARR. Interview with the DON on 1/31/24 at 10:02 AM confirmed Resident 13 did have a diagnosis of schizophrenia and a Level II PASARR determination. Further interview confirmed that the resident MDS assessment dated [DATE] was not accurately coded and should have indicated the resident did have a Level II PASARR determination. C. Review of Resident 28's MDS assessment dated [DATE] revealed the resident received an anticoagulant medication. Review of Resident 28's MAR dated November 2023 revealed no documentation the resident had received an anticoagulant medication. Interview with the DON on 2/1/24 at 12:15 PM confirmed Resident 28 did not receive an anticoagulant in November of 2023, the MDS dated [DATE] was not accurately coded and that anticoagulant should not have been marked on the resident's assessment. Liscensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure resident assessments had accurate information for 3 residents (Resident's 15, 13 and 28) related to; 1) Resident 15's antiplatelet medication [a blood thinner used to prevent blood cells from clumping together to form a clot] 2) Resident 13's Level II Preadmission Screening and Annual Resident Review (PASARR) status and 3) Resident 28's anticoagulant medication [a blood thinner used to slow down the process of making clots]. The sample size was 3 and the facility census was 31. Findings are: A. Review of Resident 15's Minimum Data Set (MDS- a mandatory assessment tool used to develop residents comprehensive care plans) dated 1/10/24 revealed the section related to medications had a check mark that indicated the resident received an anticoagulant medication and had not received an antiplatelet medication. Review of Resident 15's Medication Administration Record (MAR) dated January 2024, revealed the resident received Plavix [an antiplatelet medication] 75 milligrams (mg) daily. There was no evidence the resident received an anticoagulant medication in the resident's medical record. Interview with the Director of Nurses (DON) on 1/31/24 at 10:15 AM confirmed Resident 15 was not taking an anticoagulant medication and the resident assessment dated [DATE] was not accurate and should have been marked as an antiplatelet medication.

Liscensure Reference Number 175 NAC12-006.11C Based on observation, interview and record review, the facility failed to ensure a resident's perishable food item was dated to prevent the potential of foodborne illness. The sample size was 1 and the facility census was 31. Findings are: Review of the undated facility policy Foods Brought in from Outside Sources revealed the facility will ensure food items brought in from other sources are safe and follow food safety code standards by labeling the items with the resident's name, date the item was purchased or prepared and the name of the item. In addition, perishable food items that require refrigeration will be discarded after 72 hours if the food is not consumed by the resident. An observation on 1/30/24 at 11:45 AM revealed the dining room refrigerator had a package of steak tenders stored for a resident and did not contain a date. An interview on 1/30/24 at 11:45 AM with the Dietary Manager (DM) confirmed the package of meat should have been dated and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7 and 175 NAC 12-006.09D7(a) (b) Based on record review and interview; the facility failed to: 1) assess causal factors related to an incident resulting in significant bruising for Resident 19; and 2) failed to assess causal factors and to revise current interventions and/or develop new interventions to prevent ongoing falls for Resident 23. The sample size was 4 and the facility census was 29. Findings are: A. Review of a facility policy titled Falls and Neurological Assessments with a revision date of 10/2010 revealed residents were to be assessed and interventions placed to prevent injuries to the resident. A fall risk assessment form was to be completed at the time of admission, quarterly, and/or with significant changes. At the time of a fall occurrence the following procedures were to be followed: -monitor resident for injuries; -notify the resident's physician; -document in the Nurses Notes the fall occurrence; -complete a fall incident report; and -implement an intervention on the care plan to prevent another fall from occurring. B. Review of Resident 23's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/12/22 revealed diagnoses of anemia, atrial fibrillation (an irregular, rapid heart rhythm) high blood pressure, urinary tract infection in the last 30 days, arthritis, diabetes and dementia. The assessment indicated the resident was cognitively intact and required extensive staff assistance with dressing, bed mobility, transfers, toilet use and personal hygiene. The resident was frequently incontinent of urine and occasionally involuntary of bowel. No falls were identified since the previous assessment. Review of a Nursing Progress Note dated 7/3/22 at 11:30 AM revealed staff heard the resident yell, and the resident was found on the floor beside the resident's bed. The resident stated, I rolled over and out of bed. The staff were educated on need for the adjustable bed to be kept in the lowered position. Review of a Nursing Progress Note dated 7/5/22 at 2:42 AM revealed the resident's bed was to be adjusted to the lowest position, call light pendant to be in reach and a pillow was to be placed on the right side of bed to keep the resident's feet and legs in bed. Review of a Nursing Progress Note dated 7/8/22 at 3:43 PM revealed fall interventions which included a fall mat and routine toileting. Review of a Nursing Progress Note dated 8/5/22 at 1:43 AM revealed the resident was found seated on the floor next to the resident's bed. The bed was in the lowered position. The resident reported, I tried to get out of bed and then I was on the floor. The resident was assisted to the bathroom and then back into bed. Review of the resident's medical record revealed no evidence the resident's fall was assessed for causal factors, current interventions were revised, or a new fall intervention was developed to prevent further falls. Review of a Nursing Progress Note dated 8/30/22 at 1:09 PM revealed at 10:40 AM, the staff were walking by the resident's room and observed the resident lying face down on the floor in front of the resident's lift recliner. The resident had held onto the recliner remote until the resident fell face forward out of the chair. The resident had a large bump and a hematoma to the center of forehead. The resident was transferred to the Emergency Room. Review of an Incident Report dated 8/30/22 at 10:45 AM revealed causal factors for the resident's fall included recent urinary tract infection and upper respiratory infection with increased confusion and disorientation. Review of a Fall Care Plan revealed on 8/30/22 the resident had placed the lift recliner in the high position and the resident fell forward face planting on the floor. An intervention was identified to unplug the lift recliner or to place the controls in the side pocket of the recliner when the resident was seated in it. During interview on 11/7/22 at 11:27 AM, Registered Nurse (RN)-A confirmed the following regarding Resident 23: -had been assessed at high risk for falls; -no causal factors were identified with the resident's fall on 8/5/22 at 1:43 AM; -current fall prevention interventions were not revised, or additional interventions developed after the resident's fall on 8/5/22 and the resident had a subsequent fall with injury on 8/30/22 at 1:09 PM. C. Review of Resident 19's MDS dated [DATE] revealed diagnoses of Parkinson's disease, anxiety, depression, and psychotic disorder. The assessment indicated the resident's cognition was severely impaired and the resident had behaviors which included delusions and hallucinations. The resident required extensive staff assistance with bed mobility, transfers, dressing, personal hygiene and toilet use and the resident was frequently incontinent of bowel and bladder. Review of a Nursing Progress Note dated 10/27/22 at 4:14 PM revealed staff observed a bruise on the resident's right lateral shin to the ankle which measured 21.5 centimeters (cm) by 10 cm. The resident was unable to identify how the bruising had occurred. The note further revealed the resident had been noted in the past to have the resident's leg between the foot-rest of the recliner and the resident would move the calf pad on the resident's wheelchair also indicating the resident had been more restless. Review of the resident's medical record revealed no evidence an injury of unknown origin investigation was completed regarding the resident's 21.5 cm by 10 cm bruise to the resident's right lower leg. Review of a Nursing Progress Note dated 10/28/22 at 11:59 AM revealed the resident continued with the bruise to the right lateral calf. The note indicated the resident was able to use the mechanical sit-to-stand lift (a mobile lift that allows for patient transfers from a seated position to a standing position and designed to support only the upper body of the resident with a requirement for the resident to have some weight-bearing capability) the same as ever. Review of a Nursing Progress Note dated 10/28/22 at 11:59 PM revealed the resident was to be placed in a Broda chair for pressure relieving and comfort. Review of Resident 19's Nursing Progress Notes dated 10/30/22 (3 days after the resident's bruising to the right lower leg was identified) revealed the following: -6:38 PM dark purple discoloration from the resident's right knee to the foot. The area was edematous and warm to the touch; and -10:20 AM right lateral leg from the knee to the foot, purple in color and swollen, tender to the touch. The full sling lift to be used to transfer the resident due to complaints when the resident was stood up. Review of a Nursing Progress Note dated 10/31/22 at 2:37 PM revealed the resident used the sit-to-stand lift for toileting and the resident was able to stand for a short time. Review of Nursing Progress Notes dated 11/1/22 revealed the following: -3:15 PM the resident was seen by the physician due to increased swelling, pain and bruising to the right lower leg and an x-ray was ordered; and 5:24 PM the x-ray was completed and revealed a trimalleolar (ankle) fracture. Review of a Temporary Problem List form used for permanent documentation of temporary problems (those with anticipated duration of 14 days or less) dated 11/2/22 (6 days after the bruising was first noted to the resident's right lower leg) revealed the following approaches: -splint to right lower extremity always; -non-weight bearing with use of a full lift for all transfers; -change of seating system to the Broda chair; and Observe for signs of pain. During an interview with RN-A on 11/7/22 at 11:44 AM, RN-A verified staff were uncertain how the resident had obtained the bruising to the resident's right lower leg. Staff failed to determine causal factors and to put interventions in place to prevent a potential reoccurrence for 6 days after the bruising was first identified.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, record review and interview; the facility failed to utilize Personal Protective Equipment (PPE) according to facility policy and to wash hands and change gloves at to prevent cross contamination during the provision of care for Resident 12 and 19. The sample size was 21 and the facility census was 29. Findings are: A. Review of the undated facility policy, Hand Hygiene revealed the following; -the objective was to prevent the spread of infection through adherence to good hand hygiene, -hand hygiene was a general term that applied to handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis, and -all personnel should wash their hands with soap and water or use hand sanitizer products to prevent the spread of infections; between patient contacts, after removing gloves, after using the restroom, sneezing, combing hair, smoking, before and after meals, anytime hand were soiled, and when going from a dirty to a clean function on the same patient. B. Review of the undated facility policy, Personal Protective Equipment/ Using Face Masks revealed the objective was to prevent the transmission of infectious agents, to prevent the transmission of infections that could be spread by direct contact, to prevent the splashing of blood or body fluids into the mouth or nose, and to prevent exposure to viruses from blood or body fluids. Further review revealed that staff were to do the following; - put a face mask on before entering the room, and after cleaning hands, - be sure the face mask covered the nose and mouth while performing treatment or services for the resident, - do not remove the mask while performing treatment or services for the resident, - handle the mask only by the strings, - never touch the mask while it is in use, and - follow established handwashing techniques. C. Review of the undated facility policy, Personal Protective Equipment/Using Gloves revealed the objective was to prevent the spread of infection, protect wounds from contamination, protect hands for potentially infectious material, and to prevent exposure to viruses. Further review revealed that staff were to use disposable single use gloves for the following; - when touching excretions, secretions, blood, body fluid, mucous membranes, or non-intact skin, - when an employees' hands had scrapes, cuts, wounds, chapped skin, dermatitis etc., - when cleaning potentially contaminated items, and - whenever in doubt. Further review revealed staff were to wash hands after glove removal, and that gloves did not replace handwashing. D. During on observation on 11/2/22 at 9:00 AM Nurse Aide (NA)-I was noted walking in the facility attending to residents and wearing a mask covering the mouth but not the nose. E. During an observation on 11/2/22 at 9:15 AM NA -I provided transfer via full body mechanical lift and positioning into bed for Resident 12. During the episode of care NA-I was wearing a face mask covering the mouth, but not the nose. After completing the care NA-I exited Resident 12's room and did not perform hand hygiene. F. During an Interview on 11/7/22 at 12:15 PM Registered Nurse (RN)-A confirmed staff should always wash hands after performing resident cares, staff are to wear surgical face masks covering both the mouth and the nose when providing care, or in resident care environments per COVID-19 protocols, and staff should not touch the surface of their facemask during the provision of care and resume care without hand hygiene. G. Observation on 11/2/22 at 12:23 PM of the facility dining room revealed NA-I was seated at a table next to Resident 19. NA-I wore a surgical mask which covered staff's mouth, but NA-I had nose completely exposed. NA-I used right hand to repeatedly touch the outside surface of the mask to pull the mask over the staff's nose. Without completing hand hygiene, NA-I would then touch the resident and/or the resident's dinnerware before again trying to adjust placement of the mask. H. During observation of incontinence care for Resident 19 on 11/4/22 at 6:44 AM, NA-C and NA-D without performing hand hygiene placed on clean gloves. NA-D lowered the resident's slacks and disposable incontinence brief which were soiled with urine and feces. NA-D provided perineal hygiene for the resident, but without removing soiled gloves, placed a clean incontinence brief, adjusted the resident's clothing and blankets and assisted to reposition the resident in bed. NA-D removed soiled gloves but failed to complete hand hygiene before lowering the resident's bed, placing the call light within the resident's reach and closing the closet door. NA-D then entered the resident's bathroom and washed hands. I. During an interview on 11/7/22 at 12:15 PM, RN-A confirmed staff were to complete hand hygiene before putting on clean gloves and when removing soiled gloves. In addition, staff should remove gloves when soiled and should place on clean gloves when completing cares.