Florence Home

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1 & 2). Based on observation, interview and record review, the facility failed to conduct weekly skin evaluations to prevent the potential for pressure ulcer development and failed to evaluate and monitor a new wound for 1 (Resident 19) of 2 sampled residents. The facility census was 80. The findings are:Record review of the facility policy titled Pressure Ulcer Prevention and Interventions dated 08-2025 revealed any resident with a Braden Scale (a tool healthcare professionals use to assess a patient's risk of developing a pressure ulcer) score of 16 or below will be assessed by a nurse every week with individualized skin interventions based on the Braden score. Record review of the facility policy titled Skin Protocol dated 02-2024 revealed the purpose of the policy was to provide clear expectations regarding reporting and subsequent documentation of skin issues. Weekly skin checks are to be done on all residents by a nurse. Anytime a new skin concern is found the nurse wo is on duty is responsible for: assessing the skin condition, including measurements and description. Record review of Resident 19's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-25-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person cognitively intact. - required extensive assistance with hygiene, and bed mobility.-required total assistance with dressing, toileting, bathing and transfers.-had a pressure ulcer. Record review of Resident 19's Electronic Health Record (EHR) revealed a Braden Scale dated 09-17-2025 scored at a 14, which indicated a mild risk of pressure ulcer development. Record review of Resident 19's Electronic Health Record revealed weekly wound evaluations but no weekly skin evaluations. An observation on 09-24-2025 at 10:00 AM of Registered Nurse (RN) B and the Assistant Director of Nursing (ADON) performing wound care for Resident 19 which revealed a large stage 4 pressure ulcer to the right buttock approximately 8 centimeters (cm) length by 3 cm width by 3 cm depth. The observation also revealed another wound to the right buttock that was approximately 4 cm in length by 2 cm in width by 0.1 cm in depth with yellow slough present in the wound bed. Record review of Resident 19's wound evaluations for 09-07-2025 and 09-14-2025 revealed only one wound to the right buttock, not 2. Interview with the ADON on 09-25-2025 at 2:00 PM revealed the second wound on the right buttock was identified by the facility staff on 09-15-2025 and confirmed the wound was not assessed or monitored since 09-15-2025 and should have been upon discovery and weekly going forward. An interview with the Director of Nursing (DON) on 09-25-2025 confirmed weekly skin evaluations were not conducted for Resident 19 and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(E). Based on interview and record review the facility failed to provide baths according to preference for 2 (Resident 8 and 12) of 2 residents sampled. The facility census was 80. The findings are:A.Record review of Resident 8's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 08-27-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -required limited assistance with upper body dressing and bed mobility.-required extensive assistance with bathing.-required total assistance with toileting, lower body dressing and transfers. Record review of the facility grievance log revealed the following concerns voiced by Resident 8:-06-23-2025 Resident 8 was concerned because it had been over a week since (gender) had a shower.-07-07-2025 Resident 8 was concerned that staff did not provide a shower on 07-04-2025.-07-25-2025 Resident 8 reported (gender) did not get a bath this week. An interview conducted on 09-23-25 at 7:30 AM with Resident 8 revealed Resident 8 wanted 2 baths or showers a week and was not getting them.Observation on 09-23-2025 at 7:35 AM revealed a white board in Resident 8's room that indicated Resident 8 was to get a bath on Monday and Wednesday.Record review of Resident 8's bathing record for July 2025 revealed a shower was given on 07-25-2025. Resident 8 should have received 9 showers in July.Record review of Resident 8's bathing record revealed the following for August 2025:-08-04-2025 shower-08-11-2025 shower-08-19-2025 shower-08-25-2025 showerResident 8 should have had a shower on 08-06-2025, 08-14-2025, 08-20-2025, and 08-28-2025. Record review of Resident 8's bathing record revealed the following for September 2025:-09-03-2025 shower-09-15-2025 showerResident 8 should have had a shower on 09-01-2025, 09-08-2025, 09-10-2025, 09-17-2025, 09-22-2025 and 09-24-2025. Record review of Resident 12's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS score was 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required extensive assistance with hygiene and bed mobility.-required total assistance with toileting, bathing, dressing and transfers. B.Record review of Resident 12's Comprehensive Care Plan (CCP) dated 11-04-2024 revealed Resident 12 would like 2 baths a week.An interview conducted with Resident 12 on 09-22-2025 at 10:02 AM revealed a preference of 2 baths a week but doesn't always get 2.Record review of Resident 12's bathing record for July 2025 revealed the following:-07-03-2025 shower-07-08-2025 bath-07-29-2025 bathResident 12 should have received a bath or shower on 07-01-2025, 07-10-2025, 07-15-2025, 07-17-2025, 07-22-2025, 07-24-2025 and 07-31-2025. Record review of Resident 12's bathing record for August 2025 revealed the following:-08-12-2025 bed bath-08-19-2025 showerResident 12 should have received a bath or shower on 08-05-2025, 08-07-2025, 08-14-2025, 08-21-2025, 08-26-2025 and 08-28-2025. Record review of Resident 12's bathing record for September revealed the following:09-18-2025 bed bathResident 12 should have received a bath or shower on 09-02-2025, 09-04-2025, 09-09-2025, 09-11-2025, 09-16-2025 and 09-23-2025. An interview conducted with the Director of Nursing (DON) on 09-25-2025 confirmed baths were not provided according to preference and Resident 8 and Resident 12 should have had 2 baths a week.

Based on interview and record review, the facility failed to ensure residents were protected from potential abuse by allowing an employee who was accused of abuse by Resident 5, to finish their shift. This had the potential to affect Residents in rooms 201-205 and 219-220 on the 200 hall. The facility had a census of 80.Findings are:An interview on 9/24/25 at 1:00pm with the Director of Nursing (DON) revealed the following:On 7/13/2025 the resident (Resident 5) made a statement that they did not want the Nurse Aide (NA-C) to change the resident because the NA throws the resident against the wall. Licensed Practical Nurse D (LPN) assigned another employee to care for the resident for the rest of the evening. The DON confirmed they were not aware of the incident until 7/14/1025 when they read Resident 5's progress notes from the evening before. The DON confirmed they contacted LPN D who wrote the progress note and received a verbal report from LPN D about the incident on 7/14/2025.The DON confirmed LPN-D should have contacted the DON immediately after the incident and LPN-D had not done so.The DON confirmed that LPN-D did not send NA-C home after LPN-D was informed of the incident and should have done so. The DON confirmed they had educated LPN-D verbally about informing management immediately of any accusations of abuse, but the DON had not documented the verbal education. An interview on 9/25/25 at 3:27 PM with the DON revealed NA - C worked on the 200 hall from 6-10 PM covering rooms 201-205 and covering rooms 201-204 and 219-220 from 2-6 PM. The DON confirmed NA-C would have had the potential to affect the residents in these rooms on 7/13/2025.A record review of a progress noted dated 7/13/2025 by LPN D revealed the following:Resident (5) refuses care from their assigned NA - C because they throw me against the wall, nurse educated resident that NA-C will be in the room to help spot the replacement NA since the resident requires 2 people during transfers. LPN-D witnessed brief change and NA-C did not overexert any strength during the brief change.A record review of the facility's Abuse Policy dated 1/28/2025 revealed the following: The policy stated the residents' rights to be free from verbal, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees of the Organization recognize its residents, regardless of cognitive ability, to be vulnerable and will take action to protect and prevent mistreatment, abuse, neglect, and misappropriation of resident property within the facility by:intervening in the situationReporting the situation to the proper authoritiesInvestigating the allegationPreventing abuse, neglect, and misappropriation while the investigation is in process.Document evidence that the Organization intervened, reported, prevented abuse/neglect/misappropriation, and investigated.Not employing individuals who have been:Found guilty of abusing or mistreating individuals by a court of law.Entered into the State Nurse Aide Registry concerning abuse, neglect, and mistreatment of residents or misappropriation of their property.Reporting any knowledge, it has of actions by a court of law against an employee for service as a Nurse Aide to the State Nurse Aide Registry of Licensing Authorities.The facility procedure consists of Pre-hire screening, Volunteer screening, employee and volunteer training, prevention, identification, reporting, immediate intervention, and investigation.

Based on interview and record review the facility failed to report an allegation of abuse against Resident 5 within the required timeframe. The facility had a census of 80. Findings are:An interview on 9/24/25 at 1:00 PM with the Director of Nursing (DON) revealed the following:On 7/13/2025 the resident (Resident 5) made a statement that they did not want the Nurse Aide (NA-C) to change the resident because the NA throws the resident against the wall. Licensed Practical Nurse D (LPN) assigned another employee to care for the resident for the rest of the evening. The DON confirmed they were not aware of the incident until 7/14/1025 when they read Resident 5's progress notes from the evening before. The DON confirmed they contacted LPN D who wrote the progress note and received a verbal report from LPN D about the incident on 7/14/2025.The DON confirmed LPN-D should have contacted the DON immediately after the incident and LPN-D had not done so.The DON confirmed that LPN-D did not send NA-C home after LPN-D was informed of the incident and should have done so. The DON confirmed they had educated LPN-D verbally about informing management immediately of any accusations of abuse, but the DON had not documented the verbal education. An interview on 9/25/25 at 3:27 PM with the DON revealed NA - C worked on the 200 hall from 6-10 PM covering rooms 201-205 and covering rooms 201-204 and 219-220 from 2-6 PM. The DON confirmed NA-C would have had the potential to affect the residents in these rooms on 7/13/2025.A record review of a progress noted dated 7/13/2025 by LPN D revealed the following:Resident (5) refuses care from their assigned NA - C because they throw me against the wall, nurse educated resident that NA-C will be in the room to help spot the replacement NA since the resident requires 2 people during transfers. LPN-D witnessed brief change and NA-C did not overexert any strength during the brief change.A record review of the facility's Abuse Policy dated 1/28/2025 revealed the following: The policy stated the residents' rights to be free from verbal, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees of the Organization recognize its residents, regardless of cognitive ability, to be vulnerable and will take action to protect and prevent mistreatment, abuse, neglect, and misappropriation of resident property within the facility by:intervening in the situationReporting the situation to the proper authoritiesInvestigating the allegationPreventing abuse, neglect, and misappropriation while the investigation is in process.Document evidence that the Organization intervened, reported, prevented abuse/neglect/misappropriation, and investigated.Not employing individuals who have been:Found guilty of abusing or mistreating individuals by a court of law.Entered into the State Nurse Aide Registry concerning abuse, neglect, and mistreatment of residents or misappropriation of their property.Reporting any knowledge, it has of actions by a court of law against an employee for service as a Nurse Aide to the State Nurse Aide Registry of Licensing Authorities.The facility procedure consists of Pre-hire screening, Volunteer screening, employee and volunteer training, prevention, identification, reporting, immediate intervention, and investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09(H) Based on observation, interview, and record review, the facility failed to ensure compression stockings were applied and weekly weights were completed per the provider's orders for 1 (Resident 89) of 4 sampled residents and failed to monitor and treat 1 (Resident 49) of 4 sampled resident's lower extremity edema. The facility census was 80. Findings are:A record review of the facility's Following Physician's Orders policy with a revised date of 08/2025 revealed all aspects of physician or non-physician practitioner's order must be followed in their entirety. A record review of the facility's Ace Wraps, Compression Stockings (TED HOSE, [NAME] STOCKINGS, SUPPORT HOSE, etc.) guideline revealed the staff were to apply ace wraps or stockings to the resident per the provider's order. A.A record review of Resident 89's Profile Face Sheet dated 09/24/2025 revealed the resident was admitted to the facility 02/28/2025. The resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Orthostatic Hypotension (decrease of blood pressure on standing), and Cerebellar Ataxia (lack of muscle coordination and balance). A record review of Resident 89's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 08/20/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware. The resident required limited assistance for bed mobility, transfer, and toilet use and was independent for eating. The resident was not on therapy. A record review of Resident 89's Care Plan dated 03/20/2025 - 11/20/2025 revealed the resident was at risk for impaired skin integrity related to age, diagnoses, and decreased mobility, but did not reveal interventions for compression stockings (garments worn on the legs to apply pressure, promote blood flow, and reduce swelling). A record review of Resident 89's Physician's Orders dated 09/24/2025 revealed an order for compression stockings or equivalent on in AM (morning), off on PM (afternoon) for fluid overload. A record review of Resident 89's Grievance/Complaint Report dated 08/12/2025 revealed the resident told the Veteran's Administration (VA) staff that the residents TED hose had not been put on every day and the VA staff notified the facility. An observation on 09/22/2025 at 10:17 AM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had significant swelling from edema (a condition where excess fluid builds up in the body causing swelling) in the bilateral lower extremities (BLE)(both legs and feet). The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/22/2025 at 3:12 PM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE with not compression stockings on but there were 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/24/2025 at 8:11 AM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE. The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/25/2025 at 9:06 AM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE. The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/25/2025 at 9:12 AM with Licensed Practical Nurse (LPN)-A that was the charge nurse revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE. The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. In an interview on 09/22/2025 at 10:17 AM, Resident 89 confirmed the facility's staff had not offered to put the resident's compression stockings on for the last 2 days. In an interview on 09/25/2025 at 9:06 AM, Resident 89 confirmed the facility's staff had not offered to put the resident's compression stockings on and the resident had been out of bed since 6:30 AM. In an interview on 09/25/2025 at 9:12 AM, LPN-A confirmed the resident did not have compressions stockings on and should have had. The compression stockings should be put on when the nursing assistants (NA) assist Resident 89 out of bed in the mornings. B.A record review of Resident 89's Physician's Orders dated 09/24/2025 revealed an order for Document Weight Weekly to be done every week per the resident's physician. A record review of Resident 89's Medication Record For 08/2025 - 09/2025 dated 08/2025 and 09/2025 revealed weekly weights were not completed 08/15/2025, 08/29/2025, and 09/12/2025. A record review of Resident 89's Resident Weight Tracking System Report dated 09/25/2025 revealed the resident had not been weighed 08/15/2025, 08/29/2025. In an interview on 09/25/2025 at 12:15 PM, the facility's Director of Nursing (DON) confirmed Resident 89's weights were not being completed weekly and should have been. C.A record review of Resident 49's Profile Face Sheet dated 09/25/2025 revealed the resident was admitted to the facility 06/12/2025. The resident had diagnoses of Malignant Neoplasm Of Intrathoracic Nodes (cancer in the lymph nodes in the chest), Malignant Neoplasm Of Liver And Bile Duct, Atherosclerotic Heart Disease (plaque buildup in the arteries of the heart), Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (uncontrolled blood sugars) and Hypothyroidism (underactive thyroid gland). A record review of Resident 49's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively aware. The resident was independent with dressing, eating, toileting and mobility. The resident required setup or clean-up assistance with bathing, personal hygiene (cleaning) and footwear. The resident was not on therapy. The resident was not on hospice and was not on a diuretic. A record review of Resident 49's Care Plan dated 03/20/2025 - 11/20/2025 revealed the resident was at risk for impaired skin integrity related to age, diagnoses, and decreased mobility, and had an intervention to notify the medical doctor of any areas of impaired skin and skin check per facility protocol. but did not reveal interventions for compression stockings (garments worn on the legs to apply pressure, promote blood flow, and reduce swelling. The resident had cancer and was receiving chemotherapy (cancer treatment). A record review of Resident 49's Physician's Orders dated 09/24/2025 revealed an order for weekly skin assessment but did not reveal and order for edemawear or a diuretic (a medication used to eliminate excess fluid from the body). A record review of Resident 49's Medication Record dated 07/2025 - 09/2025 revealed weekly skin assessment marked completed 7/16/2025, 07/30/2025, 08/27/2025, 09/03/2025, and 09/17/2025. Refused 07/09/2025, 07/23/2025, 08/06/2025, 08/20/2025, and 09/24/2025. The medication records were marked the resident was out of the facility 07/02/2025, 08/13/2025, and 08/10/2025. A record review of the facility's Skin Evaluation Form dated 07/01/2025 - 09/25/2025 revealed two evaluations done, 1 on 07/30/2025 and only skin concern was a great toenail concern 07/30/2025 and no issues on 08/27/2025. An observation on 09/22/2025 at 9:41 AM revealed Resident 49's right ankle and foot had edema and was red on the top from above the ankle and entire foot and scab on the lateral side (outside). An observation on 09/22/2025 at 12:12 PM revealed Resident 49's left lower extremity (LLE)(left lower leg and foot) had edema. The resident did not have compression stockings on or in the room. An observation on 09/23/2025 at 2:54 PM with Registered Nurse (RN)-B revealed the resident had BLE swelling with 3 plus (+) pitting edema in the LLE and cellulitis (skin infection) on the right lower extremity (RLE). In an observation on 09/24/2025 at 8:28 AM revealed edema in BLE and RLE appeared to have improved in color. No compressions stockings on resident or in the room. In an observation on 09/25/2025 at 9:06 AM revealed edema in BLE and RLE appeared to have improved in color. No compressions stockings on resident or in the room. In an observation on 09/25/2025 at 9:25 AM with the DON revealed edema in BLE. No compressions stockings on resident or in the room. In an interview on 09/23/2025 at 3:16 PM, RN-B confirmed Resident 49 did have BLE edema and resident had 3+ pitting on LLE that was not being treated. RLE had cellulitis and that was being treated with and antibiotic. RN-B confirmed RN-B seen the resident earlier in the morning and RN-B did not notice the LLE edema. In an interview on 09/25/2025 at 9:06 AM, LPN-A confirmed RN-B had contacted hospice regarding LLE edema on 09/23/2025, but Resident 49's physician had not been contacted, and no treatment changes had been made. In an interview on 09/25/2025 at 9:37 AM the DON confirmed the resident had BLE edema and treatment was not being completed for the LLE and should have been. The DON confirmed the staff were not doing weights and skin assessments as ordered.

Licensure Reference Number 175 NAC 12-006.09 (H). Based on record review and interview the facility failed to hold a blood pressure medication according to the prescribed blood pressure parameters for 1 (Resident 19) of 6 resident's sampled. The facility census was 80. The findings are:Record review of Resident 19's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-25-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person cognitively intact. - required extensive assistance with hygiene, and bed mobility.-required total assistance with dressing, toileting, bathing and transfers.-had a pressure ulcer. Record review of Resident 19's Medication Administration Record (MAR) for August 2025 revealed an order for Midodrine 5 milligram (mg) tablet take 1 tablet 3 times a day, hold if Systolic Blood Pressure (SBP: the top number of a blood pressure reading) was above 120. The following entries revealed a SBP of above 120.-08-15-2025 at 8:00 AM Blood Pressure (BP) was 127/79 and documented as administered.-08-25-2025 at 8:00 AM BP was 125/84 and documented as administered. Record review of Resident 19's MAR for September 2025 revealed an order for Midodrine 5 mg take 1 tablet 3 times a day, hold if SBP was above 120. The following entries revealed a SBP of above 120.-09-18-2025 at 8:00 AM BP was 133/82 and documented as administered.-09-21-2025 at 8:00AM BP was 122/69 and documented as administered.-09-12-2025 at 12:00 PM BP was 121/75 and documented as administered.-09-22-2025 at 12:00 PM BP was 127/72 and documented as administered-09-18-2025 at 5:00 PM BP was 133/82 and documented as administered.-09-22-2025 at 5:00 PM BP was 132/79 and documented as administered. An interview conducted on 09-25-2025 at 1:40 PM with Director of Nursing confirmed that Midodrine 5mg should have been held for the dates identified in August and September. Record review of the facility policy titled Following Physician's Orders dated 08-2025 revealed the purpose of this policy is to provide guidelines for following physician's and non-physician provider orders. If a physician order is present and is failed to be administered according to specific orders, it may result in a medication discrepancy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(a). Based on observation, interview and record review the facility failed to ensure ready to hang tube feeding was not in use beyond 24 hours for 1 (Resident 12) of 1 residents sampled. The facility census was 80. The findings are:Record review of the facility policy Gastric Tube Feeding Via Pump revealed the purpose of the policy is to provide nutritional support for residents who are unable to obtain nourishment orally. Furthermore, tube feeding and tubing can hang up to 24 hours.Record review of Resident 12's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS score was 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required extensive assistance with hygiene and bed mobility.-required total assistance with toileting, bathing, dressing and transfers.-had a feeding tube.Observation on 09-22-2025 at 9:00 AM revealed Resident 12 was in the room and tube feeding was disconnected from Resident 12 and the bottle and tubing were still hanging on the tube feeding pole. The bottle was Jevity 1.5 dated 09-22-2025 at 3:50 AM.Observation on 09-23-2025 at 9:30 AM revealed the tube feeding had been disconnected from Resident 12 and a bottle of Jevity 1.5 dated 09-22-2025 at 3:50 AM was still hanging on the tube feeding pole. An interview on 09-23-2025 at 2:15 PM with Registered Nurse (RN) E revealed the bottle of Jevity 1.5 dated 09-22-2025 at 3:50 AM was still running at 6:00 AM on 09-23-2025 and confirmed the bottle of Jevity 1.5 should have been changed at or before 3:50 AM on 09-23-2025. An interview with the Director of Nursing (DON) on 09-25-2025 at 10:55 AM confirmed ready to hang tube feeding should not be used beyond 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.18(B)
Licensure Reference Number 175 NAC 12.006.18(D)
Based on observation, interview, and record review, the facility failed to ensure the staff donned (put on) the correct personal protective equipment (PPE) in COVID-19 isolation rooms, doff (take off) gowns and gloves inside the resident's COVID-19 isolation rooms, ensure COVID-19 isolation residents room doors remained closed, and perform hand hygiene (cleaning) during glove changes to prevent cross contamination when performing peri-care on 2 (Residents 56 and 44) of 3 sampled residents. The facility census was 79.
Findings are:
A.
A record review of the facility's Infection Control Policy Coronavirus (COVID-19), February 2024 dated February 2024 revealed trash cans were to be near the exit inside any resident room to make it easy for employees to discard PPE.
A record review of the facility's undated Donning and Doffing Guideline and Audit revealed the purpose was to help prevent the spread of infection. Staff should have had a N-95 mask (a mask the filters out very small particles of bacteria) on at all times in COVID positive resident's isolation rooms.
An observation on 07/29/2024 at 9:03 PM revealed a Nursing Assistant (NA) exited COVID-19 isolation room [ROOM NUMBER] in gown, gloves, and eye protection and doffed the PPE in the 2nd floor hallway and placed in the dumpster in the hallway.
An observation on 07/29/2024 at 9:17 PM revealed Unit Manager (UM)-H exited COVID-19 isolation room [ROOM NUMBER] with a gown, gloves, and eye protection on, doffed in the 2nd floor hallway, and disposed of PPE in the dumpster in the hallway.
An observation on 07/30/2024 at 8:28 AM revealed NA-J entered COVID-19 isolation room with a surgical mask on, not a N-95 mask.
An observation on 07/30/2024 at 8:28 AM with UM-H revealed NA-J was in COVID-19 isolation room with a surgical mask on, not a N-95 mask, and was within 6 feet of a COVID-19 positive resident.
In an interview on 07/29/2024 at 9:23 PM, NA-J confirmed that there were trash cans in the COVID-19 isolation rooms and PPE should have been removed in the room.
In an interview on 07/30/2024 at 8:34 AM UM-H confirmed NA-J should not have been in COVID-19 isolation room without a N-95 mask on.
In an interview on 08/01/2024 at 7:23 AM, the Director of Nursing (DON) confirmed the staff should have removed PPE before exiting a positive for COVID-19 resident's room and not in the hallway.
B.
An observation on 07/29/2024 at 8:52 PM revealed a NA exited COVID-19 isolation room [ROOM NUMBER] and left the resident's door open.
An observation on 07/29/2024 at 9:03 PM revealed a NA exited COVID-19 isolation room [ROOM NUMBER] and left the room door open.
An observation on 07/30/2024 at 2:57 PM revealed the door to COVID-19 isolation room [ROOM NUMBER] was partially open and the resident was in the room taking a nebulizer treatment (a mist used to deliver medications to the lungs).
In an interview on 07/30/2024 at 3:05 PM, the facility's Administrator confirmed the staff was to keep the doors to COVID-19 isolation rooms closed when not entering or exiting.C.
Record review of Resident 44 Profile Face Sheet revealed an admission date of 4/17/2022. Resident 44 diagnosis include: Alzheimer's disease, unspecified dementia, cognitive communication deficit, and need for assistance with personal cares.
Record review of Resident 44's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 6/12/2024 revealed the resident was unable to participate in an interview for Brief Interview for Mental Status (BIMS, a brief screener to determine resident's cognition) as the resident is rarely/never understood. Staff assessment for Mental Status revealed the resident did not seem or appear to recall after 5 minutes nor did the resident seem or appear to recall the long past. Section GG revealed functional abilities of Resident 44 were eating-substantial/maximal assistance, toileting, bed mobility and transfers-total assistance. Section H revealed Resident 44 was always incontinent of bowel and bladder. Section O Special Treatments, Procedures, and Programs revealed the resident received hospice services while a resident.
Observation on 7/31/24 at 07:18 AM of Nursing Assistant (NA)-D and NA-E planned to performed peri-care on Resident 44 revealing NA-D explained to Resident 44 what the NA's were planned to do (peri-care). NA-D removed the tabs on the soiled brief and pushed it down between the resident's legs. NA-D using a clean washcloth wipe first under the abdominal fold, down each side of the groin and down the middle of the peri-area between the labia. NA-D removed the soiled gloves and without benefit of hand hygiene (HH) applied clean gloves and continued with peri-care. Both NA-D and NA-E roll the resident to the left side and removed the soiled brief. NA-D continued to do peri-care to the buttocks by wiping both buttock and then the anal area using a clean washcloth with each wipe. After the area was clean, NA-D removed the soiled gloves applied clean gloves without the benefit of HH. NA-D applied barrier cream to Resident 44's buttocks, removed the soiled gloves and applied clean gloves without benefit of HH.
Interview with NA-D on 7/31/24 at 8:05 AM confirmed HH should have been performed with each glove change.
Interview with Director of Nursing (DON) on 7/31/2024 at 12:05 PM confirmed HH should be performed with every glove change.
D.
Record review of Resident 56's Profile Face Sheet revealed the resident was admitted on [DATE]. Diagnosis listed: Cerebral Infarction (stroke), aphasia (doesn't speak), dysphagia (difficulty swallowing), chenille on dominant side (right), and contractures of right wrist.
Record review of Resident 56's MDS revealed the resident is rarely or never understood and was unable to perform the interview for mental status. The staff assessment of mental status revealed the resident does not seam or appear to recall after 5 minutes but does seem or appear to recall long past. Section GG/functional abilities revealed Resident 56 does not eat but receives his nutrition through a gastrointestinal tube (G-tube), dependent for toileting and transfers, and requires substantial/maximal assist with bed mobility. Section H revealed that Resident 56 is always incontinent of bowel and bladder.
Observation on 7/31/2024 at 11:24 AM of personal cares revealed NA-F and NA-G donned a gown and gloves in preparation of personal care for Resident 56. NA-F and NA G transferred Resident 56 from the wheelchair and into bed using a mechanical lift. Further observation on 7/31/2024 at 11:24 AM revealed NA-F and NA-G remove a sling from under residents 56, removed the gloves and donned another pair of gloves. NA-F and NA-G did not completed HH. NA-G removed the tabs on the adult brief and push the brief between Resident 56's legs. Further observation on 7/31/2024 at 11:24 AM revealed Resident 56 had a large lose bowel movement and was saturated. NA-G cleaned the front of the resident beginning of the groin, scrotum and penis. NA-G removed the soiled gloves applied clean gloves without HH. NA- F rolled Resident 56 on to the left side and NA-G removed the soiled brief. NA-G cleansed Resident 56's buttock, removed the soiled gloves and without completing HH,donned a clean pair of gloves.
Interview on 7/31/24 at 11:30 AM with NA-G confirmed HRH should have been performed with every glove change.
Interview on 7/31/24 at 12:05 PM with the DON confirmed HRH should have been performed with every glove change.
E.
Record review of Facility Policy Peri-care dated 01/2024 revealed the following:
-Purpose:
-The purpose of the guideline is to provide direction for proper peri-care.
-Knock and announce yourself upon entering the room.
-Identify resident and explain what you will be doing.
-Don appropriate Personal Protective Equipment (PPE), if indicated.
-Assemble equipment: Gather gloves, peri-wash, extra trash bags, and washcloths. Apply gloves prior to wetting the washcloths. Wet the washcloths thoroughly with warm water (do not allow the washcloths to touch the sink or the faucet) and place in plastic bag. Take to the bedside.
-Perineal cleanser may be pumped on to each individual cloth or washcloths in the plastic bag.
-Perform hand hygiene and put on gloves.
-Fold down bed linens, exposing only the peri area. Be sure to cover the resident's upper body with a towel or sheet to prevent the feeling of overexposure.
-If there is stool present, remove, and dispose of in toilet or trash bag. Remove gloves and perform hand hygiene.
-For a female resident: Separate the labia and wash around the urinary meats first, wiping downward from front to back and from inside toward outside. Never wash upward from the anal area. Be sure to use a clean washcloth for each wipe or anytime the washcloth becomes contaminated. Place dirty washcloths in an empty plastic bag. With a clean washcloth, continue to wash between and outside the labia using downward strokes alternating from side to side and moving outward toward the thighs. Pat area dry in the same direction used for washing.
-For male resident: If uncircumcised, pull foreskin back from head of penis. Use a washcloth to wash the urinary meats first, working down the penis, scrotum, and thighs. Be sure to wash all skin folds thoroughly, using a clean washcloth for each wipe. Place dirty washcloths in a plastic bag. Return the foreskin to the natural position if uncircumcised male. Pat area dry in the same direction used for washing.
-Take gloves off, perform hand hygiene, and apply new gloves.
-Keeping the resident covered, ask the resident to assist you in turning to side.
-With buttocks exposed. Wash the buttocks first and then the anal area, wiping front to back, using a different washcloth for each wipe. Place dirty washcloths in a plastic bag. Pat the skin dry with dry clean towel and dispose of it in plastic bag.
-Remove gloves and dispose into trash. Perform hand hygiene.
-If applying moisture barrier product. Perform hand hygiene. Apply clean gloves. Apply product using same technique as cleansing (front to back) Secure brief on resident, and re-dress resident.
-Position resident per their preference.
-Dispose of soiled supplies and perform hand hygiene.
-If PPE was used, remove, and perform hand hygiene.
-Report any unusual appearances in the resident's skin to charge nurse/supervisor.

Licensure Reference Number 175 NAC 12-006.09 (F)(iii)
Based on record review and interview, the facility failed to revise 1 (Resident 56) of 1 resident Care Plan related to NPO (nothing by mouth)status. The facility census was 79.
Findings are:
Record review of Resident 56's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/19/2024 revealed the resident's admission date was 2/21/2024. Resident 56's Brief Interview of Mental Status (BIMS, a brief screener to determine cognitive status) revealed Resident 56 was unable to complete the BIMS due to Resident 56 rarely to never being understood (Resident 56 does not speak). The staff assessment for Mental Status revealed short-term memory problem and appeared to recall long past. According to the MDS, Resident 56 had a stroke/Cardiovascular Accident (CVA) affecting his dominant side. Resident 56 also has diagnoses of aphasia (non-speaking) and dysphagia (difficulty swallowing) due to the CVA. His functional ability to eat-resident does not eat; Resident 56 gets nothing by mouth (NPO). Resident 56 is fed via a gastrointestinal tube (g-tube) for all nutrition and medications due to his dysphagia caused by the CVA.
Record review of Resident 56's Physician Orders dated 1/4/2022 revealed an order Jevity ( nutritional formula) 1.5 Cal via feeding pump at a rate of 65 milliliters (ml) per hour continuously for 24 hours for CVA, NPO.
Record review of Resident 56 Care Plan dated 5/8/2024 revealed Resident 56's care plan identified Resident 56's nutritional status was to remain stable with no significant weight loss and to tolerate tube feedings. The following interventions were identified: assist with meals as needed, monitor meal intake, and provide snacks and supplements as ordered (Resident 56 is NPO and would not be eating meals nor be given snacks or supplements).
Interview with Director of Nursing (DON) on 7/31/24 at 1:31 PM confirmed the interventions on the care plan dated 5/8/24 would be confusing as resident is NPO, does not eat meals, does not need assistance at mealtimes, and snacks and supplements would not be ordered. Resident is dependent upon the nursing staff to provide his nutrition 100% by g-tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.02(09(H)(v)
Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 30) of 1 sampled resident was placed on the Restorative Nursing Program (RNP)(a program to prevent or improve a resident's abilities) following discharge and recommendation from Occupational Therapy (OT) and Physical Therapy (PT). The facility census was 79.
Findings are:
A record review of the undated Florence Home Guideline Restorative Program revealed residents will be identified as candidates for the Restorative Nursing Program (RNP) based on therapy referrals and facility screenings. Residents identified as candidates would be placed on a RNP. The RNP would focus on range of motion, communication, ambulation, wheelchair mobility, splint application, use of adaptive devices, and restorative dining.
A record review of Resident 30's Profile Face Sheet dated 07/31/2024 revealed the resident was originally admitted to the facility on [DATE].
A record review of Resident 30's Med A (Medicare Part A) Resident Assessment dated 06/02/2024 revealed the resident had diagnoses of Encephalopathy (damage or disease that affects the brain), Parkinson's Disease With Dyskinesia (a progressive neuromuscular disorder), Epilepsy (a brain disorder that can cause seizures), Chronic Diastolic (congestive) Heart Failure. Chronic Kidney Disease, Stage 3, and Morbid Obesity (severely overweight).
A record review of Resident 30's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/12/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) 14 of 15 that indicated the resident was cognitively aware. The resident was dependent on staff with toileting, bathing, and dressing, needed partial/moderate assistance with eating and oral hygiene (cleaning), and substantial/maximal assistance with personal hygiene. Resident 30 had impairment on 1 side in range of motion (ROM) of the upper and lower extremities (arms and legs).
A record review of Resident 30's Care Plan dated of 06/01/2024 revealed the resident was on a restorative program to maintain the resident's flexibility. The resident had interventions to do the program 3-6 days per week for at least 15 minutes each category, Restorative nursing evaluations would be done monthly, the staff would document changes in activity tolerances, and cue and assist the resident as needed with grooming.
A record review of Resident 30's OT Discharge Summary dated 06/03/2024 revealed OT discharged the resident on 06/03/2024 with Restorative Programs, and they were established/trained.
A record review of Resident 30's PT Discharge Summary dated 06/03/2024 revealed PT discharged the resident on 06/03/2024 with a Restorative ROM Program. ROM Program was established/trained: the resident is currently able to move feet up and down, rotate the feet in and out, and rotate the legs inward and outward. The resident would be able to move feet up and down, move legs up and down, rotate feet in and out, and rotate legs in and out by performing the following Restorative Nursing interventions: encourage resident to assist with the ROM, encourage the resident to participate, never force the extremity ranging and passive motion.
A record review of Resident 30's Interdisciplinary (all staff) Notes dated 07/30/2024 did not reveal the resident was getting a RNP.
A record review of Resident 30's Electronic Medical Record and hard chart did not reveal the resident was getting a RNP.
An observation on 07/29/2024 at 8:51 PM revealed Resident 30 had difficulty moving both upper and lower extremities on both sides and demonstrated the challenge.
An observation on 07/30/2024 at 3:05 PM revealed Resident 30 had difficulty moving all extremities.
In an interview on 07/29/2024 at 8:51 PM, Resident 30 confirmed the resident had difficulty moving all extremities. Resident 30 confirmed the resident was not currently receiving OT, PT, or any staff assistance with exercising the resident's extremities. The resident confirmed the resident would do the exercises if offered.
In an interview on 07/30/2024 at 8:01 AM, the Director of Nursing confirmed Resident 30 did not get put on the RNP when OT and PT made the recommendations and he should have been placed on a RNP.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1)
Based on observation, interview, and record review, the facility staff failed to provide catheter care for 1 (Resident 5) of 3 sampled residents. The facility identified a census of 79.
Findings are:
A record review of Resident 5's face sheet revealed an admission date of 5/31/2024.
A record review of hospital records dated 05/13/2024 indicated that Resident 5 had an orthopedic surgery and was referred to a Skilled Nursing Facility for 24 hour care.
A record review of Resident 5's Minimum Date Set (MDS-a federally mandated comprehensive assessment tool dated 6/4/24 revealed the Resident was admitted to the facility with diagnoses of chronic kidney disease (CKD), Chronic Atrial Fibrillation (A-Fib), Diabetes Mellitus (DM), Spinal stenosis with prior spinal fusion, status post revision of T7-L3 laminectomy and fusion, and Chronic Diastolic Congestive Heart Failure. The MDS also indicated no indwelling catheter was in place and Resident 5 was always incontinent of bladder and bowel
A record review of lab results from Physician Laboratory Services the resident revealed a Urinary Tract Infection (UTI) on 07/01/2024 was identified. The culture and sensitivity report revealed the organism (a bacterium that normally lives inside human intestines, where it doesn't cause disease. If K. pneumoniae gets into other areas of the body, it can lead to a range of illnesses, including pneumonia, bloodstream infections, meningitis, and urinary tract infections.) to be Klebsiella pneumoniae.
A record review on the Resident's Physician Orders for 07/20/2024 revealed as of 07/04/2024 facility staff were to complete catheter cares twice daily.
A record review of Resident 5's Care Plan dated 07/07/2024 revealed staff were to perform Foley (catheter) cares per protocol.
A record review of progress notes revealed that Resident 5 has an appointment with the Urologist (A doctor that studies and treats conditions affecting the kidneys, ureters, bladder, and urethra). The appointment with the Urologist is on 08/13/2024 at 10:30 AM.
A record review of the Guidelines and Audit tool for Foley Care, dated 2024 revealed that during peri care the catheter should be cleansed and rinsed from insertion site to approximately 4 inches outward.
An observation on 7/29/24 at 7:30 PM revealed Resident 5 was sleeping with a catheter bag hanging from the bed.
An observation on 07/31/2024 at 7:14 AM with Licensed Practical Nurse (LPN)-C and a Nursing Assistant (NA)-B revealed they gathered the supplies to complete catheter cares. LPN-C had a gown on and washed hands before putting gloves on. The NA also had a gown on and placed gloves following hand washing. LPN-C announced to Resident 5 that LPN-C and NA-B were going to be completing catheter care. NA-B pulled the blankets back and began to unfasten Resident 5's brief. The LPN-C using wash cloths completed front peri care for Resident 5. Further observation on 07/31/2024 at 7:14 AM revealed LPN-C and NA-B completed providing personal care task without completing catheter care.
An interview on 7/31/24 7:7:23 AM was completed with LPN-C. During the interview LPN-C confirmed catheter care had not been completed for Resident 5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.11(E)
Based on observation, interview, and record review, the facility failed to ensure all food in the facility's refrigerators, freezers, and dry storage were sealed, labeled, and/or dated and failed to clean and maintain the kitchen's fixtures and equipment to prevent the potential for cross contamination and foodborne illness. This had the potential to affect 77 residents that consumed food from the kitchen. The facility census was 79.
Findings are:
A.
A record review of the facility's undated Food Storage (Dry, Refrigerated, and Frozen) Guideline & Procedure Manual revealed all food items would be labeled. The label must include the name of the food item and the date by which it should be sold, consumed, or discarded. Raw animal foods such as eggs should be wrapped properly. Never leave any food item uncovered and not labeled.
An observation on 07/29/2024 at 6:15 PM revealed the following:
The reach-in refrigerator in the dining room contained 7 chocolate covered cakes in clear plastic containers not labeled or dated.
The walk-in freezer contained:
-1 opened bag of mixed vegetables not labeled or dated
-1 bag of 2 breaded yellow items not labeled or dated
The walk-in refrigerator contained:
-26 small clear cups with lids that contained a white substance not labeled or dated
-1 steam pan of a yellow substance not labeled or dated
-1 steam pan of a green substance not labeled or dated
-1 steam pan of a white substance not labeled or dated
-1 steam pan of a red substance not labeled or dated
-The walk-in refrigerator on the back south wall contained
-1 bag of a shredded green substance not labeled or dated
-1 open bag of green chucks not labeled or dated
-2 steam pans covered with aluminum foil not labeled or dated on a cart
-1 open bag of a yellow shredded substance not labeled or dated
-1 bag of a white shredded substance not labeled or dated
-1 open clear container with yellow square slices not labeled or dated
-1 steam pan with 10 white ovals not labeled
-2 steam pans with a white cream not labeled
-1 opened gallon Hellmann's Real Mayonnaise without an open dated
-2 plastic containers of blue round items not dated
-1 gallon Sysco French Dressing without an open date
-1 green rectangular object in plastic wrap not labeled or dated
-1 clear container with a green lid not labeled or dated
-1 clear container with green round items not labeled or dated
-1 steam pan covered with plastic wrap not labeled
-1 open pack of meat slices not sealed or dated
-2 sandwiches not labeled or dated
-1 uncovered steam pan of white ovals, 1 broke oozing yellow not sealed not labeled or dated
-1 large clear plastic bin with an orange substance not labeled or dated
-2 small clear containers with small white chunky substances not labeled
-1 small clear covered container with an orange substance not labeled
-1 small clear covered container with a dark brown substance not labeled
The dry storage contained:
-1 open bag yellow crispy flakes not sealed, labeled, or dated
-1 bag of orange logs not labeled or dated
-1 large clear container of a yellow liquid substance not labeled or dated
In an interview on 07/31/2024 at 6:05 AM, the Dietary Manager (DM) confirmed that all items in the facility's refrigerators and freezers should have been sealed, labeled, and/or dated.
B.
A record review of the facility's undated Cooks Weekly Clean List revealed the cooks were to sweep and mop the storeroom daily, clean underneath shelves in the cooks area daily, delime the steam table as needed, clean the hot box once a week, clean the ovens and tops when needed, clean the range/grill/stove daily, and sweep and mop the kitchen daily.
A record review of the facility's undated Aide-PM Cleaning Checklist revealed the steam table was to be wiped down after each meal service, all carts were to be wiped down after each meal service, and sweep and mop the steamtable area daily.
An observation on 07/29/2024 at 6:15 PM revealed
-The ice maker had gray fuzzy substance on exterior vents above the door and a black slimy substance on interior surfaces in the front.
-The steam table had brown crusty substance between the warmer pans
-The toaster had light brown crumbs in and under it
-The walk-in freezer floor was sticky.
-The inside edge of the front of the hood had a gray fuzzy substance along the edge. The range/oven front vertical surfaces contained white and brown dried splatters and the oven handle was sticky.
-The [NAME] double ovens had brown food splatters on the front and inside the doors and the top had scattered black crusty substances
-The hot box vertical Flavor holding cart had white and brown dried on splatters down front and on inside lower warmer around door seal and bottom ledge.
-The vent on the hot box had a thick coating of a gray fuzzy substance
-The dry storage and kitchen floor had scattered crumbs and debris throughout and a black sticky substance around a floor electrical box under the prep table
An observation on 07/31/2024 at 6:05 AM with the DM revealed the items listed above had not been cleaned.
A record review of the Cooks Weekly Clean List dated July 2024 revealed the refrigerators sweep and mop had not been completed, the storeroom sweep and mop was only done 07/07/2024, the cleaning underneath shelves in cook's area was only done 07/03/2024 and 07/07/2024, delime the steam table had not been done, the hot box had not been cleaned, the ovens and tops had not been cleaned, the ice machine had not been cleaned, the range/grill/stove had not been cleaned, the daily floor sweep and mopping was only done 07/03/2024, 07/07/2024, and 07/21/2024.
In an interview on 07/31/2024 at 6:05 AM, the Dietary Manager (DM) confirmed that all items listed above were not clean and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to ensure its admission policy did not waive the potential liability for losses of a resident's personal property for Resident 2, 4, and 5. This had the potential to affect all residents in the facility. The facility census was 77.
Findings are:
Review of the facility, admission Agreement, revised 01/24, revealed the following:
-XIV. Personal Property: The Home shall not be liable for loss or damage to any personal property belonging to the resident and kept at the Home.
Review of the facility, Personal Property policy, updated 1/2024, revealed the following:
-[NAME] Home shall not be liable for loss or damage to any personal property belonging to the resident and kept at [NAME] Home, nor will [NAME] Home be responsible for replacing, lost, damaged or stolen items.
Review of Resident 2's admission Agreement, dated 9/18/09, revealed acknowledgement of the Personal Property agreement by Resident 2's resident representative.
Review of Resident 4's admission Agreement, dated 1/18/23, revealed acknowledgement of the Personal Property agreement by Resident 4.
Review of Resident 5's admission Agreement, dated 6/22/23, revealed acknowledgement of the Personal Property agreement by Resident 5's resident representative.
An interview on 2/21/24 at 9:27 AM, the Social Services confirmed that the facility's admission Agreement and Personal Property policy did waive the liability of the facility for losses of resident's personal property and that the agreement is signed upon admission by the resident or the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18
Based on observation and interview, the facility failed to maintain walls, safety stop strips, doors, fixtures, ceiling tiles and baseboards in good condition in 16 ( Rooms 202, 203, 206, 207, 208, 210, 211, 212, 213, 214, 215, 217, 221, 225, 232 and 233) of 31 occupied resident rooms on the second floor of the facility. The facility had a total of 52 occupied resident rooms. The facility census was 78.
Findings are:
Observation on 6/8/23 between 9:00 AM and 10:00 AM with the facility Administrator and the [NAME] President of Facilities Management (VPFM) during an environmental tour of the facility revealed the following environmental concerns:
- Scratches / gouges on several walls in resident rooms and bathrooms: rooms 202, 203, 211, 215, 217, 221, 225, and 233.
- Stop strips pulled away from the floor in front of the toilet in the bathroom and bed in room [ROOM NUMBER].
- Greenish colored corrosion around the water faucets in resident bathrooms in rooms [ROOM NUMBER].
- Scratches / gouges on the exterior room doors in rooms 202, 208, 210, 213, 214, 217 and 221.
- Cracked and brown stained caulking surrounding the base of toilets in resident bathrooms in rooms 207, 217, 225, and 232.
- Caulking between the sink and the wall cracked and pulled away from the wall in the resident bathroom in room [ROOM NUMBER].
- Ceiling tiles broken in resident bathrooms in rooms [ROOM NUMBERS].
- Ceiling tile had brown water stains present in resident bathroom in room [ROOM NUMBER].
- Linoleum baseboard loose and pulled away from the wall in resident bathroom room [ROOM NUMBER].
Interview on 6/8/23 at 10:05 AM with the VPFM confirmed the issues identified with walls, stop strips for safety, faucets, doors, caulking around the base of toilets and sinks, ceiling tiles and baseboards.
Interview on 6/8/23 at 10:56 AM with the VPFM confirmed that there were no work orders for the concerns identified during the environmental tour and that those concerns had not been identified by facility staff prior to the environmental tour of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C3a(6)
Based on observation, interview, and record review, the facility failed to notify the physician of a change in daily weights for 1 (Resident 24) of 1 resident reviewed. The facility had a total census of 78 residents.
Findings are:
Record review of Resident 24's Face Sheet, printed 6/7/23, revealed Resident 24 was admitted to the facility on [DATE] and their diagnoses included Congestive Heart Failure (a chronic condition where the heart doesn't pump blood as well as it should - this can cause fluid buildup in the feet, arms, lungs, and other organs) and Chronic Kidney Disease (a condition where the kidneys are damaged and cannot filter blood as well as they should - this can cause excess fluid and waste from the blood to remain in the body).
Observation on 6/8/23 at 9:23 AM revealed Resident 24 was dressed and lying on their bed. Further observation at this time revealed Resident 24's bilateral lower legs were very edematous (swollen).
Record review of Resident 24's May 2023 MAR (Medication Administration Record) revealed an order to document Resident 24's weight daily, with a start date of 5/26/23. The following weights were recorded for May 2023:
-5/26/23 - 183.9 lbs (pounds)
-5/27/23 - no weight recorded
-5/28/23 - no weight recorded
-5/29/23 - 174.7 lbs
-5/30/23 - 178.8 lbs
-5/31/23 - 179.5 lbs
Record review of Resident 24's June 2023 MAR revealed an order to document Resident 24's weight daily. The following weights were recorded for June 2023:
-6/1/23 - 180.1 lbs
-6/2/23 - no weight recorded
-6/3/23 - 180.7 lbs
-6/4/23 - 182.2 lbs
-6/5/23 - 184.6 lbs
-6/6/23 - 185.7 lbs
-6/7/23 - no weight recorded
Record review of Resident 24's Interdisciplinary Notes revealed the following:
-5/26/23 - Resident 24 was noted to have increased swelling in bilateral lower legs. Resident 24's physician was notified, and new orders were received.
-5/29/23 - Resident 24's physician was sent an update regarding Resident 24's weights and new orders were received.
Record review of Resident 24's Weight Tracking Record printed 6/8/23 revealed Resident 24 weighed 174.7 lbs on 5/29/23 and 185.7 lbs on 6/6/23, for a total weight gain of 11 lbs in 8 days' time.
Record review of Resident 24's electronic medical record on 6/8/23 did not reveal Resident 24's physician was updated regarding Resident 24's weight gain from 5/29/23 - 6/6/23.
Interview on 6/8/23 at 2:13 PM, the DON (Director of Nursing) confirmed Resident 24's physician had not been updated since 5/29/23 regarding Resident 24's weight gain. The DON also confirmed when the order for daily weights was written, parameters were not established for when to notify Resident 24's physician. The DON reported the standard the facility generally used for daily weight monitoring was to notify the provider if a weight gain of 3 pounds or more was noted in 24 hours or if a weight gain of 5 pounds or more was noted in 7 days. The DON further reported they had reached out to Resident 24's physician and confirmed that was the parameter Resident 24's physician wanted to implement for Resident 24's daily weight monitoring.