Arbor Care Centers - Ord, Llc

Licensure Reference Number 175 NAC 12-006.05(B) Based on interview and record review, the facility staff failed to provide documentation that a written notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) for 3 (Residents 25, 28, and 46) of 3 sampled residents when their Medicare A services ended. The facility census was 39. Findings are: A record review of Centers for Medicare and Medicaid Services (CMS) Guidelines with the Admin on notification of non-coverage (NOMNC, SNF ABN, ABN, DENC) undated revealed the following: Purpose: to comply with CMS regulations on proper notification of coverage termination to Medicare beneficiary and to release facility from financial responsibility. Standard: Timely and proper completion of CMS forms by facility as it related to CMS guidelines. Advance Beneficiary Notice provides written notice to beneficiary that therapy services may not be covered by Medicare. Allows the beneficiary to make an informed decision about whether to get the item or service that is not covered and accept financial responsibility if Medicare does not pay. Should be provided to Beneficiary when an item or service is not considered reasonable and necessary under Medicare Program Standards. A record review of the Entrance Conference Worksheet Beneficiary Notice-Residents discharged in the Last 6 Months received from the Administrator (Admin) revealed Resident 25, Resident 28, and Resident 46 were listed as having been discharged from Medicare A services with Medicare A days remaining. A.A record review of the SNF Beneficiary Notification Review for Resident 25 revealed the Medicare Part A Skilled Services Episode Start Date was 02/28/2025 and the last covered day of Part A Service was 3/31/2025. The Medicare Part A Service Termination/Discharge determined was listed as: the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The SNF ABN was not provided with the reason being listed as Resident had Med A days left, facility error. Resident 25 remained in the facility after their Medicare A services ended. B.A record review of the SNF Beneficiary Notification Review for Resident 28 revealed the Medicare Part A Skilled Services Episode Start Date was 06/03/2025 and the last covered day of Part A Service was 07/25/2025. The Medicare Part A Service Termination/Discharge determined was listed as: the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The SNF ABN was not provided with the reason being listed as Resident had Med A days left, facility error. Resident 28 discharged from the facility to home when Medicare A services ended. C.A record review of the SNF Beneficiary Notification Review for Resident 46 revealed the Medicare Part A Skilled Services Episode Start Date was 05/07/2025 and the Last covered day of Part A Service was 06/20/2025. The Medicare Part A Service Termination/Discharge determined was listed as: the Resident initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The SNF ABN was not provided with the reason being listed as Resident had Med A days left, facility error. Resident 46 discharged from the facility to home after their Medicare A services ended. Interview with the Administrator (Admin) on 09/23/2025 at 10:40 AM revealed this was a facility error in not providing this information to the resident when revealed they had not issued the SNF ABN to Residents 25, 28, and 46.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.19Based on record review, interviews and observations, the facility failed to ensure cleanliness in the dining room; failed to ensure that room wall fans/ventilation were clean; and failed to ensure that the bath house was cleaned thoroughly to remove the buildup on the tub handles and the exhaust fans were free of dust. This had the potential to affect all facility residents. The facility census was 39. Findings are:A.Observation on 9/22/2025 at 9:55 AM in the 400-hallway bath house revealed the exhaust vent was covered with fuzzy, grey-colored particulates. The bathtub had a buildup on the knobs that was white in color, looked like soap scum or build-up of hard water deposits, and could be easily scraped off when scratched. Interview with Bath Aide (BA)-F on 9/22/2025 at 9:55 AM revealed that the bath house was cleaned between residents with the tub being sanitized for 10 to 15 minutes or more between residents. At the end of each day the entire bath house is to have a terminal (final thorough clean) daily by housekeeping. BA-F agreed that there were fuzzy particles on the exhaust fan in the 400 bath house. BA-F also agreed that there was a white build up on the plastic handles of the tub where the water is turned on and off. Interview with the Admin and Maint while touring the 400 hall bathhouse on 09/23/2025 at 9:45 AM confirmed that there was a white build up on the bathtub handles and the exhaust fan was not clean and had grey fuzzy particles on it. B.Observation in the dining room on 09/22/2025 at 12:25 PM revealed the windowsills were covered in a dusty and oily feeling build-up with dead bugs on the windowsill. Observation in the dining room on 09/23/2025 at 8:20 AM revealed the windowsills in the dining room continued to have a dusty, oily like residue on the windowsills and the dead bugs remained on the windowsills. Interview on 09/23/2025 at 9:27 AM with the Facility Administrator (Admin) who confirmed the windowsills in the dining area do have dusty residue and there are some dead bugs in the windowsills. C.Observation on 09/22/2025 at 10:30 AM of the ventilation fan covers in the hallway revealed there was a dusty and fuzzy build up in the hallway vent covers near the north and south outside emergency exits beside room [ROOM NUMBER]. Observation on 09/22/2025 at 10:40 AM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:10 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:12 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:15 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:30 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:40 PM of the room ventilation cover in room [ROOM NUMBER] revealed the ventilation fan in the bathroom had fuzzy dust like build up on the exhaust vent.

Licensure Reference Number 175 NAC 12-006.11(E) Based on record review, interviews, and observations; the facility failed to store and prepare food in safe and sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen. The facility census was 39.Findings Are: A.Record review of an undated facility policy titled Food Safety Requirements revealed food safety practices shall be followed throughout the facility's entire food handling process. Food will be stored in a manner that helps prevent deterioration or contamination of the food. Record review of an undated facility policy titled Defrosting Freezers revealed freezers that are opened and closed frequently, or are located in humid environments, may need to be defrosted every 3 to 6 months. In an observation completed on 09/22/2025 at 10:00 AM an upright single door standard freezer was present in the facility dry food storage area. The interior of the freezer was observed to have a 3-4-inch layer of frost present to the inner top of the freezer. All items visible in the freezer were observed to have a thin opaque white layer of frost present covering their exposed packaging. In an interview completed on 09/22/2025 at 10:15 AM with the facility Dietary Manager (DM), the DM confirmed the layer of frost present on the single door standard freezer. The DM stated knowledge of it needing to be defrosted and cleaned stating had not been completed due to inability to store items while it was being defrosted. The DM confirmed that there should not be a buildup of frost on the interior of the freezer or the packaged items being stored in it and there was. B.Record review of an undated facility policy titled Food Safety Requirements revealed when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards. Record review of a facility policy titled Hand Hygiene and dated September 2024 revealed all staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene technique when using soap and water rub hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. In an observation completed on 09/25/2025 at 9:25 AM of meal preparation [NAME] C placed a white piece of rectangle wax paper on the stainless-steel table they were using to prepare the afternoon meal. The cook used a white handled scoop to scoop out solid/frozen peach-colored cubes from a clear plastic bag. The cook placed these cubes in a clear plastic container to be weighed. The cook then placed the scoop that was used opening down on the piece of wax paper setting on the stainless-steel table. The cook then moved the scoop from one area of the wax paper to the other side. The cook removed their gloves and disposed of them in the trash. The cook returned to the stainless-steel table and placed their unwashed bare hand on the wax paper where the scoop had been lying. The cook then removed the clear plastic container from the scale and emptied the peach cubes into a rectangular baking pan. The cook then placed the pan into the convection oven. The cook then walked over to the sink and completed hand hygiene using soap and water for 10 seconds. In an interview completed on 09/25/2025 at 9:50 AM with [NAME] C, [NAME] C confirmed that the peach cubes were frozen raw chicken pieces. The cook confirmed that they did not complete hand hygiene after removing their gloves and placed their hand on the wax paper where the scoop had been placed potentially contaminating their hand with raw chicken and did not complete hand hygiene. The cook confirmed that hand hygiene with soap and water should include rubbing the hands with soap for at least 20 seconds. The cook confirmed that when they completed hand hygiene with soap and water they did not rug their hands for at least 20 seconds with soap. In an interview completed on 09/25/2025 at 9:55 AM with the DM, the DM confirmed that the cook should have washed their hands after removing their gloves and after touching the wax paper where the scoop used on frozen raw chicken had been placed and did not. The DM confirmed when [NAME] C did complete hand hygiene with soap and water they did not rub their hands with soap for at least 20 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(A)(iii)(3)Based on interview and record review, the facility failed to follow the facility policy and complete criminal background checks, and [NAME] (Sex Offender Registry) checks for 1 of 5 personnel files reviewed. This had the potential to affect all of the facility residents. The facility census was 39. Findings are: A record review of an active employee roster dated 09/12/2025 revealed Medication Aide (MA)-A had a current status of active. Record review of personnel files for MA-A revealed a date of hire of 10/28/2024. Further review of MA-A personnel file revealed no evidence of a criminal background check or [NAME] checks. An interview with the Administrator (Admin) on 9/23/2025 at 4:30 PM revealed the criminal background check and [NAME] check for MA-A had not been completed. An interview with the Admin on 9/24/2025 at 9:45 AM revealed corporate staff had not completed background check or [NAME] checks for MA-A prior to hire and/or working with facility residents. A review of the facility policy titled, Abuse-Neglect-and-Exploitation Policy dated September 2024 revealed a policy statement of It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This included:Screening:-Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property.-Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students, students affiliated with academic institutions, volunteers, and consultants.-Screening may be conducted by the facility itself, third party agency or academic institution.-The facility will maintain documentation of proof that the screening occurred.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview the facility failed to report incidents and/or accidents as required to the regulatory agency for 1 resident (Resident 38) of 2 sampled residents. The facility census was 39. Findings are:A record review of a facility policy titled Incidents and Accidents revealed the purpose of incident reporting includes meting regulatory requirements for the reporting of incidents and accidents. A record review of a facility policy titled Abuse revealed the facility will report all alleged violations to the state agency, adult protective services and to all other required agencies with in specified time frames. A record review of an admission Record revealed the facility admitted Resident 38 on 12/12/2022 with a diagnosis of quadriplegia, which is a form of paralysis that affects all for limbs and the torso often resulting from a spinal cord injury in the neck region. A record review of Resident 38's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 07/10/2025 revealed Resident 38 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, indicating the resident was cognitively intact. The resident was dependent on staff assistance with bed mobility, transfers, and toilet use. A record review of Resident 38's Progress Notes for the month of September 2025 revealed documentation that on 09/17/2025 the resident was observed to have a red raised area to the dorsal surface of their right hand. The resident informed staff they had fallen asleep with their blow dryer on and the blow dryer caused the burn on their hand. Record review of a facility supplied document titled Incidents and Accidents revealed documentation of a incident report being completed on 09/17/2025 consistent with the documentation present in the progress notes. In an interview completed on 09/25/2025 at 11:00 AM with the facility Administrator (Admin), the Admin confirmed that Resident 38 had a self inflected burn to their right hand on 09/17/2025. The Admin confirmed that this incident was not reported to the necessary regulatory agencies as outlined in the facility abuse policy. The Admin confirmed that this incident should have been reported per the facility policy and was not.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(2) Based on interview and record review the facility failed to provide activities in accordance with the residents expressed interests for 1 (Resident 1) of 2 sampled residents. The facility census was 39. Findings are:A record review of a facility policy titled Activities and not dated revealed it is the policy of the facility to provide and ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. A record review of an admission Record revealed the facility admitted Resident 1 on 02/21/2025 with diagnoses of Type 2 Diabetes Mellitus (a condition where the body does not produce enough insulin for the body to utilize sugar in the blood stream), hypertension (High blood pressure), and generalized muscle weakness. A record review of Resident 1's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 08/28/2025 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, indicating the resident was cognitively intact. The resident utilized a wheelchair for mobility and was dependent on staff assistance propelling the wheelchair throughout the facility. A record review of Resident 1 Care Plan revealed a focus of personalized care with an intervention listed of participating in religious services to be very important to the resident. In an interview completed on 09/22/2025 at 1:45 PM with Resident 1, Resident 1 stated that they wished the facility offered religious services other than Catholic Mass. The resident stated they really missed going to church and would enjoy attending church services. Record review of the facility supplied activities calendar for the month of July 2025 revealed Catholic Communion being offered every Sunday. No other religious services or activity offerings were listed on the calendar for the month. Record review of the facility supplied activities calendar for the month of August 2025 revealed Catholic Mass being offered every Sunday and Bible Study to be offered every Tuesday. No other religious services or activity offerings were listed on the calendar for the month. Record review of the facility supplied activities calendar for the month of September 2025 revealed Catholic Communion being offered every Sunday and Bible Study was offered on the last Tuesday of the month. No other religious services or activity offerings were listed on the calendar for the month. In an interview completed on 09/25/2025 at 1:45 PM with the facility Administrator (Admin), confirmed the only religious services offered in the facility for the last 3 months was Catholic Mass or Communion and Bible Study.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on record review, observation, and interview, the facility failed to ensure that reusable respiratory equipment was labeled, cleaned, and stored per facility policy after use to prevent the potential for infection. This affected one (Resident 5) of one resident sampled. The facility census was 39. Findings are: Record review of the facility policy Infection Prevention and Control Program dated February 2025 stated this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted [NAME] standards and guidelines. On page 3 of 5, subsection Equipment Protocol, the policy stated: All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with out current procedures governing the cleaning and sterilization or soiled or contaminated equipment. Reusable items potentially contaminated with infections materials shall be placed in an impervious clear plastic bag. Observation in the room of Resident 5 on 9/22/2025 at 10:00 AM revealed a nebulizer (A device used to deliver aerosolized respiratory medications) that had been used for a medication treatment sitting on top of the nebulizer machine. The nebulizer was not labeled, had been used and was not clean, and was not in a plastic bag. Interview with the Infection Control Preventionist (IP) on 09/23/2025 at 2:45 PM confirmed that nebulizers and all oxygen equipment and tubing were to be labeled and dated, cleaned after use, and then stored per the facility policy. Interview on 09/23/2025 at 7:53 PM with the Facility Administrator (Admin) confirmed the nebulizer should have labeled, cleaned, then put into a plastic bag after use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12 Based on record review, observations, and interviews; the facility failed to ensure medications were ordered, available, and administered as ordered by a physician for 1 (Resident 17) of 1 sampled resident. The facility census was 39. Findings are: Record review of the Medical Diagnoses for Resident 17 revealed Resident 17 had a diagnosis of multiple myeloma (a type of cancer that develops in the plasma cells, which are white blood cells that produce antibodies to fight infections), not yet in remission. Record review of Resident 17's Physician Telemed visit with their oncologist (physician who specializes in cancers and blood disorders) dated 08/16/2024 revealed Resident 17 started lenalidomide (a specialized medication used to treat multiple myeloma) for multiple myeloma during the month of 07/2023. This medication was ordered to be given on a 28-day cycle where Resident 17 received lenalidomide 10 mg capsule oral daily for 21 days and then had 7 days with no medication before starting another 28-day cycle. Record review of the September 2024 Medication Administration Record (MAR) revealed that the medication was ordered to be given on a 28 day cycle with Resident 17 receiving 21 days of the medication and then having 7 days off before beginning a new cycle. The order stated: Revlimid Oral Capsule 10 MG (lenalidomide) give 1 capsule orally one time a day related to Multiple Myeloma not having achieved remission (C90.00) for 21 days. The order had a start date of 09/12/2024 and no end date. Resident 17 started a 28 day cycle on Thursday, 09/12/2024. A record review of the October 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days ended on Wednesday, 10/02/2024. There was to be a 7-day break with no medication and then medication was ordered to restart on Thursday, 10/09/2024. The October MAR revealed this medication did not restart until Tuesday, 10/22/2024, 13 days past the date that the medication should have started and continued through the end of the month. A record review of the November 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days was on the MAR and the medication administration ended on Monday, 11/11/2024. This was to be followed by 7 days with no medication administration and then restarted on Monday, November 18, 2024. The lenalidomide was not restarted in the month of November 2024. A record review of Resident 17's Physician Orders revealed no evidence of an order to stop the administration of the lenalidomide. A record review of the December 2024 MAR revealed that Resident 17 did not receive any of the lenalidomide during this period. A record review of the January 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Thursday, 01/03/2025 and ended on Wednesday, 01/23/2025. The medication should have been restarted on 01/30/2025, but the medication was not restarted in the month of January. A record review of the February 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Saturday, 02/01/2025, and should have been started on 01/30/2025. A record review of the March 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Saturday, 03/01/2025. The medication was stopped on Friday, 03/21/2025. The next 28-day cycle started on Sunday, 03/30/2025. A record review of Resident 17's April 2025 MAR revealed the order for lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR. The 21 day cycle started on March 30, 2025 and stopped on April 19, 2025.The medication was not given on 04/15, 04/16, or 04/17. The nurses noted revealed the medication was unavailable. Record review of a medication error report dated 04/14/2025, was sent to Resident 17's primary care physician and revealed that there was an order for the medication lenalidomide that was to be given in 28-day cycles for Resident 17's multiple myeloma, not in remission. The errors started in the month of October 2024 and continued throughout the month of December 2024. This significant medication error stated: Concerning Revlimid take 21 days of (off) 7 days regimen. Medication should have started the 10th of October for a 21 day cycle supply but was started on the 22nd of October and completed on 11/11/2024. Revlimid 10 mg should have been restarted on 11/19/2024 and went through until 12/9 off until 12/16 restarted on 12/17 given for 21 days which would have been until 12/28 stop 12/29 and restarted on 1/4/2025. Was restarted on 1/3/2025 off 1/22 and restarted on 1/30/25 but was restarted 2/1/25. Has been on track regimen since 2/1/25. Staff has been educated and medication regimen in computer until [DATE] finishing on 10/10 with an alert if medication is continued to input order after 10/10/2025. A record review of Resident 17's medical records revealed no evidence of the resident's oncologist being notified of the medication errors. Interview on 09/23/2025 at 10:30 AM with Infection Control and Preventionist (IP) revealed that Resident 17 took this medication for 21 days, then had a rest period for 7 days, then the cycle started again. The medication and rest cycle was a 28-day cycle. There was no order to stop the medication at any point. IP confirmed the facility made a mistake by not getting the lenalidomide back on the MAR as the facility could only put about 3 or 4 months into the medication order system to show up on the MAR and then fell off. The facility would then have to manually input that order back into the system. IP stated this medication only came from one source, a specialty pharmacy, and the facility had to call to have it delivered for each cycle. IP stated the facility could not order it in advance, as in 2 or 3 months at a time, the facility had to order it as each cycle ended and the next cycle was about to begin. IP confirmed Resident 17 missed a couple of 28-day cycles. Interview on 09/23/2025 at 4:40 PM with the IP confirmed that the medication is ordered from only one pharmacy, a specialty pharmacy, and that 21 pills at a time are delivered prior to each 28-day cycle. IP receives an email from the specialty pharmacy that states it is time to reorder the medication. However the IP does not keep these emails after the medication is delivered. These medications can only be ordered one cycle at a time and must be ordered just before starting a cycle. Interview on 09/23/2025 at 5:15 PM with a representative of the specialty pharmacy in the office of the IP with the IP in the room. This interview was conducted with the phone on speaker. The pharmacy representative stated medications had been ordered and delivered on the following dates, 21 pills at a time, each order was enough to complete one 28-day cycle (Also included are the dates when medications were documented but there were no deliveries from the pharmacy.);-08/29/2024 delivered (for the cycle administered 09/12/2024 to 10/10/2024-No medication delivered during the month of September 2024-No medication delivered for the cycle documented as administered from 10/22/2024 to 11/11/2024-No medication delivered during the month of October 2024-No medication delivered during the month of November 2024-12/24/2024 delivered (for the cycle administered 01/03/2025 to 01/23/2025)-01/16/2025 delivered (for the cycle administered 02/01/2025 to 02/21/2025)-No medication delivered during the month of February 2025.-No medication delivered during the month of March 2025-No medication delivered for the cycle documented as administered from 03/01/2025 to 03/21/2025-No medication delivered for the cycle documented as administered from 03/30/2025 to 04/19/2025-04/20/2025 delivered (for the cycle administered 04/27/2025 to 05/17/2025)-05/15/2025 delivered (for the cycle administered 05/26/2025 to 06/15/2025)-06/06/2025 delivered (for the cycle administered 06/24/2025 to 07/14/2025)-07/15/2025 delivered (for the cycle administered 07/23/2025 to 08/12/2025)-08/142025 delivered (for the cycle administered 08/21/2025 to 09/10/2025)-09/17/2025 delivered (for the cycle administered 09/19/2025 to be completed on 10/10/2025)The pharmacy representative confirmed that no medications had been ordered or sent to the facility during the months of September 2024, October 2024, November 2024, February 2025, or March 2025. Interview with on 09/23/2025 which started at 4:40 PM with the IP continued following the phone call with the pharmacy representative. The IP could not state when or where the medications for the medications were obtained for the months the pharmacy representative stated there were no deliveries. The IP was unable to show medication receipts to show that these medications were ordered or received. Interview on 9/25/2025 at 11:10 AM with Registered Nurse (RN) H stated knowing there were times when there was no medication available for Resident 17. Interview with RN-H on 9/25/2025 at 4:45 PM confirmed that the medication only comes one bottle at a time and that there are only 21 pills that are sent for each cycle. RN-H had never seen any extra medication in the medication cart at any time. Interview on 9/25/2025 at 5:15 PM with Medication Aide (MA) B who stated a couple of months ago, unsure of the dates but only that it was a couple of months ago, there was an extra bottle of medication in the medication cart. That extra medication was kept in a baggy in the back of the top drawer of the medication cart for Resident 17. There was a second bottle that was at that time being used and was only about 1/2 full we were in the middle of a 28-day cycle of the lenalidomide.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review, observation, and interview; the facility failed to ensure the medication administration error rate was 5% or less. Of the 25 medication administration opportunities, there were 13 errors and the error rate was 52%. This affected 2 (Residents 31 and 16) of 4 sampled residents. The facility census was 39.Findings are: Record review of the facility policy Medication Administration dated September 2024 revealed that within the policy explanation and compliance guidelines the following:Ensure the six rights of medication administration are followed:-Right resident-Right drug-Right dosage-Right route-Right time-Right documentationReview the Medication Administration Record (MAR) to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. A.Record review of the September 2025 Medication Administration Record (MAR) for Resident 31 revealed that medications were due for administration at 8:00 AM. The medications due at 8:00 AM were aspirin 31 milligrams (mg), Qulipta (a medication to prevent migraines) 60 mg, baclofen (a muscle relaxant and antispasmodic) 10 mg, Vitamin B-12 250 micrograms (MCG), ferrous sulfate 325 mg, fluoxetine (an antidepressant) 30 mg, gabapentin (an anticonvulsant medication) 100 mg, lamotrigine (a medication for epilepsy) 100 mg, pantoprazole (decreases stomach acid) 40 mg, Xarelto (prevents blood clots) 10 mg, senna docusate (for constipation) 8.6-50 mg oral 2 tablets, and Vitamin D3 1000 unit capsules 2 capsules. Observation on 09/24/2025 beginning at 9:27 AM of Licensed Practical Nurse (LPN)- T who prepared and administered medications the above listed medications to Resident 31. Interview on 9/24/2025 at 9:48 AM with LPN-T confirmed that the medications given to Resident 31 at 9:43 AM were all administered late and at the wrong time. B.Record review of the September 2025 MAR for Resident 16 revealed a medication order for Voltaren cream 4 grams to be administered twice a day topically and twice a day as needed 4 grams topically. Observation on 09/25/2025 at 8:15 AM of Medication Aide (MA) B who took the tube of Voltaren cream, squirted approximately a quarter sized dollop of the medication into MA-B's gloved hand, then applied the medication to the back of the neck of Resident 16. After rubbing the medication onto Resident 16, MA-B removed both gloves, performed hand hygiene, and then charted the medication. Interview on 09/25/2025 at 8:20 AM with MA-B who stated it was the experience of MA-B that about a quarter-sized dollop of the medication was approximately 4 grams. MA-B stated the medication did come with a medication measuring card but MA-B did not know where that card was located. MA-B confirmed the order for Resident 16 did read that there was to be 4 grams applied and without the use of the medication card to measure the medication it was unknown if the resident had received 4 grams. MA-B confirmed this was a medication error due to the wrong dose being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number175 NAC 12-006.10(D) Based on record review, interviews, and observations, the facility failed to ensure that there were no significant medication errors. This affected one (Resident 17) of 7 sampled residents. The facility census was 39.Findings are: Record review of the Medical Diagnoses for Resident 17 revealed Resident 17 had a diagnosis of multiple myeloma (a type of cancer that develops in the plasma cells, which are white blood cells that produce antibodies to fight infections), not yet in remission. Record review of Resident 17's Physician Telemed visit with their oncologist (physician who specializes in cancers and blood disorders) dated 08/16/2024 revealed Resident 17 started lenalidomide (a specialized medication used to treat multiple myeloma)for multiple myeloma during the month of 07/2023. This medication was ordered to be given on a 28-day cycle where Resident 17 received lenalidomide 10 mg capsule oral daily for 21 days and then had 7 days with no medication before starting another 28-day cycle. Record review of the Medication Administration Record (MAR) revealed that the medication was ordered to be given on a 28 day cycle with Resident 17 receiving 21 days of the medication and then having 7 days off before beginning a new cycle. The order stated: Revlimid Oral Capsule 10 MG (lenalidomide) give 1 capsule orally one time a day related to Multiple Myeloma not having achieved remission (C90.00) for 21 days. The order had a start date of 09/12/2024 and no end date. Resident 17 started a 28 day cycle on Thursday, 09/12/2024. A record review of the October 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days ended on Wednesday, 10/02/2024. There was to be a 7-day break with no medication and then medication was ordered to restart on Thursday, 10/09/2024. The October MAR revealed this medication did not restart until Tuesday, 10/22/2024, 13 days past the date that the medication should have started, and continued through the end of the month. A record review of the November 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days was on the MAR and the medication administration ended on Monday, 11/11/2024. This was to be followed by 7 days with no medication administration and then restarted on Monday, November 18, 2024. The lenalidomide was not restarted in the month of November 2024. A record review of Resident 17's Physician Orders revealed no evidence of an order to stop the administration of the lenalidomide. A record review of the December 2024 MAR revealed that Resident 17 did not receive any of the lenalidomide during this period. A record review of the January 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Thursday, 01/03/2025 and ended on Wednesday, 01/23/2025. The medication should have been restarted on 01/30/2025, but the medication was not restarted in the month of January. A record review of the February 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Saturday, 02/01/2025, and should have been started on 01/30/2025. Record review of a medication error report dated 04/14/2025, was sent to Resident 17's primary care physician and revealed that there was an order for the medication lenalidomide that was to be given in 28-day cycles for Resident 17's multiple myeloma, not in remission. The errors started in the month of October 2024 and continued throughout the month of December 2024. This significant medication error stated: Concerning Revlimid take 21 days of (off) 7 days regimen. Medication should have started the 10th of October for a 21 day cycle supply but was started on the 22nd of October and completed on 11/11/2024. Revlimid 10 mg should have been restarted on 11/19/2024 and went through until 12/9 off until 12/16 restarted on 12/17 given for 21 days which would have been until 12/28 stop 12/29 and restarted on 1/4/2025. Was restarted on 1/3/2025 off 1/22 and restarted on 1/30/25 but was restarted 2/1/25. Has been on track regimen since 2/1/25. Staff has been educated and medication regimen in computer until [DATE] finishing on 10/10 with an alert if medication is continued to input order after 10/10/2025. A record review of Resident 17's medical records revealed no evidence of the resident's oncologist being notified of the medication errors. A record review of Resident 17's April 2025 MAR revealed the order for lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR. The 21 day cycle started on March 30, 2025 and stopped on April 19, 2025.The medication was not given on 04/15, 04/16, or 04/17. The nurses noted revealed the medication was unavailable. Interview on 09/23/2025 at 10:30 AM with Infection Control and Preventionist (IP) revealed that Resident 17 took this medication for 21 days, then had a rest period for 7 days, then the cycle started again. The medication and rest cycle was a 28-day cycle. There was no order to stop the medication at any point. IP confirmed the facility made a mistake by not getting the lenalidomide back on the MAR as the facility could only put about 3 or 4 months into the medication order system to show up on the MAR and then fell off. The facility would then have to manually input that order back into the system. IP stated this medication only came from one source and the facility had to call to have it delivered for each cycle. IP stated the facility could not order it in advance, as in 2 or 3 months at a time, the facility had to order it as each cycle ended and the next cycle was about to begin. IP confirmed the facility had an issue realizing that the medication had slipped off of the MAR and that there were several doses that were missed during the months of November and December 2024. Interview on 09/23/2025 at 2:45 PM with IP confirmed that there had been many doses not given and significant medication errors were made with the medication administration of lenalidomide for Resident 17.

Licensure Reference Number 175 NAC12-006.04(H)(ii) Based on record review and interview, the facility failed to employ a Director of Food and Nutrition Services that met the regulatory educational requirements. This had the potential to affect all of the residents receiving meals from the kitchen. The facility census was 39. Findings are:A record review of a facility supplied document titled Department Heads revealed an employee name listed as the Dietary Manager (DM). A record review of facility supplied documents revealed no evidence of the DM having received the required education and no evidence of a qualified dietitian being employed full time. In an interview completed on 09/22/2025 at 10:15 AM with the DM, the DM confirmed they had not completed an educational program that met regulatory requirements. The DM also confirmed that the Registered Dietitian was not employed full time and completed facility visits and resident reviews on a monthly basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.04(D) Based on observation and interview, the facility failed to ensure that that exhaust fans in the resident rooms on the 400 hallway were in working order. This affected 12 (Residents 3, 5, 10, 14, 17, 18, 19, 30, 31, 39, 40, and 45) of 12 sampled residents. The facility census was 39. Findings are: A.Observation on 09/22/2025 at 10:15 AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. B.Observation on 09/22/2025 at 10:35 AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. C.Observation on 09/22/2025 at 10:40 AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. D.Observation on 09/22/2025 at 12:10 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. E.Observation on 09/22/2025 at 12:12 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. F.Observation on 09/22/2025 at 12:15 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. G.Observation on 09/22/2025 at 12:30 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. H.Observation on 09/22/2025 at 12:40 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. I.Observation on 09/22/2025 at 1:10 PM AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. Interview on 09/23/2025 at 9:25 AM with the Maintenance Supervisor (Maint) who revealed they were not aware that the vents in these rooms were not working as required. Interview on 09/23/2025 at 9:27 AM with the Facility Administrator who confirmed not knowing the ventilation fans were not working in the 400 hallway.

Licensure Reference Number 175 NAC 12-006.01(G)&(H) Based on record review and interview, the facility failed to notify the State Agency within 5 working days when there was a change in Administrator position. This had the potential to affect all facility residents. The facility census was 39. Findings are:A record review of the facility's undated Change of Administrator or Director of Nursing Notification Form revealed the facility had a change in administrator on 11/19/2025-11/20/2024. An interview on 9/24/2025 at 4:25 PM with the administrator and the facility owner (via telephone) confirmed the change in administrator form for the change that occurred on 11/19/2025-11/20/2024 was not sent to the State Agency until 12/16/2025. The owner confirmed this was outside of the required timeframe. A record review of the facility's undated Change of Administrator or Director of Nursing Notification Form revealed the facility had a change in administrator on 6/10/2025-6/11/2025. An interview on 9/24/2025 at 4:30 PM with the administrator and the facility owner (via telephone) confirmed the change in administrator form for the change that occurred on 6/10/2025-6/11/2025 was not sent to the State Agency until 7/12/2025. The owner confirmed this was outside of the required timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.19
Based on observation and interviews; the facility failed to maintain flooring that was stain free, ceiling tiles that are stain free, lighting fixtures that are bug and/or pest free, and thresholds that are free of trip hazards for 4 (Halls 300, 400, 500, and 700) of 5 sampled hallways. The facility census was 33.
Findings are:
In an observation completed on [DATE] from 7:25 PM to 8:20 PM the following was observed:
A.
In the 300 Hall in front of the door labeled Dining the carpet in front of the door is black and shiny in color from the threshold of the doorway extending 5 to 6 inches into the hallway where it fades to a gray color and then into the brown cream coloring of the carpeting squares.
In the 300 Hall the carpeting between room [ROOM NUMBER] and 311 a large dark colored ring extending from the wall to the middle of the hallway.
In the commons area in front of the nurse's station gray black circular discolored areas.
B.
In the 400 Hall on the exit side of the fire doors the ceiling tiles stained black, red fading into brown circles with the stained discolored area protruding down from the flat surface of the other ceiling tiles. The area is 3 ceiling tiles long and 2 ceiling tiles wide.
In the 400 Hall first light fixture in the ceiling entering the hall is a black multi legged deceased bug approximately the size of a quarter.
In the 400 Hall in front of room [ROOM NUMBER] a large dark gray black colored circular area extending from the threshold of the entry to the room approximately 4 inches into the hallway.
In the 400 Hall the thresholds of Rooms 400, 402, 403, 406, 408, and 409 the carpet is loose, and the laminate flooring is loose from the underlayment beneath creating a trip hazard for residents.
C.
In the 500 Hall on the exit side of the fire doors the ceiling tiles are stained orange fading into a red brown color. The area is 2 ceiling tiles long and 4 ceiling tiles wide.
In front of room [ROOM NUMBER] the ceiling tiles are yellow brown in color extending from the entrance to the room across 3 sections of ceiling tile.
D.
In the 700 Hall rooms [ROOM NUMBERS] the flooring of the threshold is carpet going to tile. The carpet is loose in the inner corner coming up from being secured to the floor. The tile is chipped and cracked exposing the sub floor underneath creating an uneven area where black, thick brown substance has collected and built up.
In an interview on [DATE] at 9:56 AM with the Maintenance Manager (MM) the MM confirmed that the ceiling tiles were warped and stained and needed replaced. The MM stated that a water leak had been repaired but the ceiling tiles had not been replaced yet. The MM stated that the carpets are cleaned twice a year by an outside company and the facility does not perform any carpet cleaning in between these cleanings. The MM confirmed that the carpet throughout the facility had different degrees of staining present and needed cleaned more frequently. The MM confirmed the bug present in the 400-hall light fixture and that the carpeting and tile were cracked and coming loose on the thresholds of some of the doorways of the resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09
Based on observation, record review, and interviews; the facility failed to ensure the provider was notified of abnormal laboratory results affecting 1 Resident (Resident 21) of 5 sampled residents, and failed to notify a physican of blood pressures that were out of range per the physcian order for 2 Residents (Resident 24 and Resident 4) of 3 sampled residents. The facility census was 33.
Findings are:
A.
Review of an admission Record revealed the facility admitted Resident 21 on 12/01/2022 with diagnoses that included type two diabetes (which is when the body has trouble controlling blood sugar and using it for energy).
Review of Resident 21 Physician Orders revealed an order for the facility to obtain a Hemoglobin A1C (HbA1C, a blood test that measures the average amount of glucose(sugar) in the blood over the past three months) every 3 months to be performed on the 5th of the month with a start date of 03/05/2024.
Review of Resident 21's medical health record revealed a laboratory value for a HbA1C of 9.10 with a collection date of 06/07/2024. The normal reference range for this laboratory value was documented as 4.80-6.00. The result of 9.10 was indicated on the document as an abnormal value listed as High. The document provided no indication of provider review or acknowledgment of the abnormal laboratory value.
Review or Resident 21's progress notes for the month of June 2024 revealed no documentation of the provider being notified of the abnormal HbA1C level or the provider reviewing the abnormal HbA1C level.
In an interview completed on 08/21/2024 at 3:45 PM with the facility Medical Records (MEDR), the MEDR confirmed there was no documentation indicating the provider had been notified of the abnormal HbA1C lab value.
In an interview completed on 08/21/2024 at 4:43 PM with the facility Director of Nursing (DNS), the DNS confirmed that Resident 21's HbA1C was an abnormal laboratory value, and the provider should have been notified of the abnormal value and reviewed the abnormal laboratory value indicating further directions for treatment or not to the facility. The DNS confirmed that this was not present in the resident's medical health record.
B.
Record review of Resident 24's admission Record dated 08/19/2024 revealed the resident admitted on [DATE]. The admission record also reveals an admission and primary diagnosis of Parkinson's Disease (a progressive brain disorder that affects the nervous system and causes unintended or uncontrollable movements).
Record review of Resident 24's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 08/18/2024 revealed the resident takes and anti-Parkinson medication. The care plan goals and interventions revealed:
-The resident will be free of any discomfort or adverse side effects of anti-Parkinson therapy,
-will remain free of signs and symptoms (s/s),
-administer medications per physician orders,
-monitor/document/report as needed (PRN) adverse reactions of anti-Parkinson therapy: increased risk of low BP on rising and falls; significant confusion, restlessness, delirium, difficulty walking/moving, nausea, dizziness, hallucinations, and agitation.
Record review of Resident 24's physician orders revealed the following orders:
-Carbidopa-Levodopa oral tablet 25-250 milligram (MG) give 1 tablet by mouth 3 times a day related to Parkinson's Disease: order date 02/15/2024.
-Notify doctor if systolic blood pressure is greater than (>)150 or less than (<)100, heart rate >110 or <50, respiratory rate >24 or <12, oxygen saturation <90%. temperature > 100.5 Fahrenheit (F) or <95.8 F: order date 03/07/2024.
Record review of Resident 24's Blood Pressure Summary report revealed the systolic blood pressure >150 or less than <100 were found on dates:
-08/14/2024: 99/54
-08/05/2024: 99/54
-07/22/2024: 99/60
-04/22/2024: 89/45
Record review of Progress Notes and medical records of physician notification of blood pressure summaries or notification of systolic blood pressure >150 or less than <100 revealed no documentation that the physician was notified.
C.
Record review of Resident 4's admission Record dated 08/20/2024 revealed the resident admitted on [DATE]. The admission record also reveals an admission and primary diagnosis of an injury of the cervical spinal cord, quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down) and hypertensive heart disease (heart problems that occurred due to high blood pressure).
Record review of Resident 4's Care Plan revealed the high-risk medications the resident takes are a hypertension (a condition where the pressure in your blood vessels is consistently too high) medication, and an anticoagulant (a blood thinner medication used to prevent the formation of blood clots) medication. An intervention listed for taking the medications are to notify the physician if systolic blood pressure is greater than (>)150 or less than (<)100.
Record review of Resident 4's physician orders revealed the following orders:
-Notify the physician if: systolic blood pressure is >150 or less than <100: order date 03/13/2024.
Record review of Resident 4's Blood Pressure Summary report revealed the systolic blood pressure >150 or less than <100 found on dates:
-08/20/2024: 98/54
-07/25/2024: 99/54
-07/11/2024: 94/55
-07/04/2024: 94/58
-05/30/2024: 97/70
-04/11/2024: 90/58
-03/28/2024: 96/69
-03/27/2024: 93/53
-03/26/2024: 98/68
-03/16/2024: 96/58
-03/15/2024: 88/54
-03/13/2024: 98/54
Record review of Progress Notes and medical records of physician notification of blood pressure summaries or notification of systolic blood pressure >150 or less than <100, revealed no documentation that the physician was notified.
During an interview with Registered Nurse-E (RN-E) on 08/21/2024 at 4:21 PM revealed when an out-of-range vital sign is noted, and an order to notify is present, the physician's office is either called, or a fax to the physician's office is sent. Once that is completed a progress note is completed.
The DNS was interviewed on 08/21/2024 at 4:40 PM confirmed there was no documentation that a physican was notified of Resident 24 and Resident 4's blood pressures out side of paramters on the listed dates. The DNS also revealed the expectation of the nurse or the charge nurse on duty is to contact the physician's office on the out-of-range vital signs. The information is then documented in the progress notes.

Licensure Reference Number 175NAC 12-006.(I)
Licensure Reference Number 175NAC 12-006.(I)(i)(3)
Based on observation, record review, and interviews; the facility failed to implement fall prevention interventions to prevent falls for 1 resident (Resident 25) and failed to ensure the mattress was secured to the bedframe to prevent the potential for entrapment or falls for 1 resident (Resident 25). The facility census was 33.
Findings are:
A.
Record review of the facility policy Fall Prevention and Fall Leaf Program dated 2/2020 revealed that the purpose is to ensure fall risks are identified and interventions are implemented in an effort to prevent falls, as possible, and to maintain a safe environment for each resident of the facility. The section titled Falls revealed that if a resident incurred a fall, a Fall Incident and Investigation report is completed. The Fall Incident and Investigation report will be reviewed at the next Department Clinical Meeting for interdisciplinary review of the fall, interventions, and determination of need for additional interventions or revision of current interventions.
Record review of the admission Record dated 8/19/24 for Resident 25 revealed that Resident 25 admitted into the facility on 6/22/23 wiht diagnoses of: anxiety, unsteadiness on feet, muscle weakness, and history of falling.
Observation on 8/19/24 at 4:13 PM in the hall between the atrium and the sunshine room revealed that Resident 28 pushed Resident 25 in a wheelchair. Resident 25 held onto a walker to the right side of the wheelchair. Resident 25 steered the walker alongside the wheelchair with their right hand. Resident 28 continued to push Resident 25 in the wheelchair through the sunshine room. Nurse Aide-A (NA-A) approached Residents 28 and 25. NA-A took the walker from Resident 25 and took the walker to the resident's room. Resident 28 continued to push Resident 25 in the wheelchair towards the resident room.
Record review of the Progress Note dated 3/20/24 at 3:38 AM for Resident 25 revealed that at 3:00 AM Resident 25 called out to their spouse/roommate (Resident 28) for help. The unidentified nurse arrived at the resident room and found Resident 25 and Resident 28 on the floor. Resident 25 was bleeding from the left front of their head. Emergency Medical Technicians arrived at 3:30 AM and left Resident 25 at 4:00 AM.
Record review of the Progress Note dated 8/19/24 at 8:35 PM for Resident 25 revealed that Resident 25 was found lying on the floor with their spouse/roommate (Resident 28) in the resident's room. Resident 25 could not recall why they fell. Resident 28 stated that Resident 28 tried to get Resident 25 to the toilet. During transfer, Resident 28 lost their balance, and both fell to the floor. Resident 25 complaint of a headache and soreness to the back of the head. Resident 25 got more confused and started telling staff that they were running into a wall. 911 was called. Emergency Medical Services transported Resident 25 to the emergency room at 9:15 PM.
Record review of the Care Plan for Resident 25 dated 8/21/24 revealed a care focus for falls. The care plan revealed that on 3/20/24 Resident 25 called for their spouse/roommate (Resident 28) to help in the bathroom. Resident 25 fell with Resident 28 to the floor. 8/19/24 Resident 28 attempted to transfer Resident 25 to the bathroom. Resident 28 lost their balance and both Resident 28 and Resident 25 fell to the floor. Intervention for the fall on 3/20/24 revealed only that Resident 25 was sent to the emergency room and returned the same day with no acute fractures. No fall intervention to prevent future falls was developed for the 3/20/24 fall. Intervention added to the care plan on 8/19/24 for the fall on 8/19/24 revealed that staff are to place Resident 25 in a chair at meals, and staff to assist Resident 25 back to the room from meals and do cares right then so the spouse/roommate (Resident 28) is not tempted to transfer Resident 25. The intervention was dated 8/19/24.
Observation on 8/21/24 at 7:33 AM in the facility dining room revealed that Resident 25 sat in a wheelchair at the dining room table.
Observation on 8/21/24 at 8:07 AM in the facility dining room revealed that Resident 25 remained in the wheelchair at the dining room table feeding themselves breakfast.
Observation on 8/21/24 at 8:30 AM in the facility dining room revealed that Resident 25 sat in the wheelchair at the dining room table.
Observation on 8/21/24 at 8:33 AM at the nurse's station revealed that Resident 28 pushed Resident 25 in the wheelchair from the dining room through the sunshine room to the resident's room. Resident 28 pushed the wheelchair into the bathroom in the resident's room. Resident 25 stood from the wheelchair and Resident 28 backed the wheelchair out of the bathroom. An alarm was beeping at a low volume. The facility Infection Coordinator (IC) came to the room at a fast pace. IC entered the room and closed the door at 8:35 AM.
Observation on 8/21/24 at 11:33 AM at the room of Resident 25 revealed that Medication Aide-H (MA-H) transferred Resident 25 from the resident's room in a wheelchair. MA-H transferred Resident 25 into the dining room and positioned Resident 25 in the wheelchair up to the dining room table. Resident 25 thanked MA-H and then asked where their spouse (Resident 28) was. MA-H told Resident 25 that they were coming. MA-H exited the dining room. Resident 28 entered the dining room at 11:34 AM and sat down in a chair at the table. Resident 28 sat to the right of Resident 25.
Interview on 8/21/24 at 1:56 PM with Medication Aide-G (MA-G) confirmed that Resident 25 is at increased risk of falls. MA-G revealed that interventions to prevent falls are used to keep residents safe from falls. MA-G revealed that the charge nurse or the stand up meeting team develops new or revised fall prevention interventions after a resident has a fall. MA-G revealed that new or revised interventions are communicated to staff through the computer. MA-G revealed that when the staff log onto the computer the dashboard page displays with new messages including new fall interventions. MA-G revealed that staff usually just glance at it and move on to chart cares. MA-G revealed that staff don't have time to read it. MA-G offered to show this surveyor what the page looks like on the computer. MA-G logged onto a computer. The dashboard page was displayed. The dashboard contained no information regarding the fall of Resident 25 and contained no updated fall prevention measures.
Observation on 8/21/24 at 4:50 PM in the facility dining room revealed that Resident 25 sat in a wheelchair at the table.
Interview on 8/22/24 at 7:28 PM with the facility Director of Nursing Services (DNS) confirmed that new or revised interventions are expected to be developed for fall prevention after a resident has a fall. The DNS confirmed that staff are expected to follow fall interventions to try to prevent resident falls and injuries.
Observation on 8/22/24 at 7:38 AM in the facility dining room revealed that Resident 25 sat at the dining room table in a wheelchair. Resident 28 was seated in a chair to the right of Resident 25.
Interview on 8/22/24 at 7:55 AM with Director of Nursing Services (DNS) confirmed observation at the facility dining room that Resident 25 was seated in a wheelchair at the dining room table eating breakfast. The DNS confirmed that Resident 25 is to be placed in a regular chair at the table for the new fall prevention intervention after the resident fall on 8/19/24. The DNS confirmed that the new intervention had not been implemented.
B.
Record review of the facility admission Agreement dated 10/2019 revealed that the facility must not charge a resident for room/bed maintenance services. The section titled Safe Environment revealed that the resident has a right to a safe, homelike environment. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes independence and does not pose a safety risk.
Record review of the admission Record dated 8/19/24 for Resident 25 revealed that Resident 25 admitted into the facility on 6/22/23 with diagnoses of: anxiety, unsteadiness on feet, altered mental status, and history of falling.
Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 8/8/24 for Resident 25 revealed that Resident 25 is independent with rolling from their back to their right and their left when lying in bed. The MDS revealed that Resident 25 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 7 (a score of 0-7 indicates severe cognitive impairment).
Observation on 8/18/24 at 7:40 PM in the room of Resident 25 revealed that Resident 25 was in bed. Resident 25 was lying on their back.
Observation on 8/19/24 at 8:29 AM in the room of Resident 25 revealed that the mattress on the bed of Resident 25 was not secured to the bedframe. The mattress slid over approximately 14 inches from the bedframe from side to side. This created a gap for potential entrapment on the side of the bed against the wall. This created a fall hazard on the side of the bed away from the wall.
Interview on 8/21/24 at 1:34 PM with facility Maintenance Manager (MM) revealed that the facility does not check to see if resident mattresses are secured to the bedframe. MM confirmed that the mattress on the bed of Resident 25 was not secured to the bedframe. MM was unaware of devices to secure mattresses to the frame. MM confirmed that MM was not aware that the mattress had to be secured to the bedframe.

Licensure Reference Number 175NAC 12-006.09(H)
Based on observation, record review, and interviews; the facility failed to manage pain for 2 Residents (Resident 18 and Resident 21) of 2 sampled residents. The facility census was 33.
Findings are:
Review of a facility policy titled Pain Management dated 02/2020 revealed in order to help a resident attain or maintain their highest practicable level of well-being and to prevent or manage pain the facility manages or prevents pain consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified.
Review of a document titled Determining mild, moderate, and serve pain equivalency across pain intensity tools in nursing home residents by the Journal of Rehabilitation Research and Development dated 11/02/2007 revealed responses to pain rating of 1 through 4 on a 0 though 10 scale indicated mild pain, responses of 5 though 6 for moderate pain, and 7 though 10 for severe pain.
A.
A review of an admission Record dated 08/18/2024 revealed the facility admitted Resident 18 on 04/10/2024 with diagnoses that of preprhial vascular disease (which is a chronic disorder that causes blood vessels to narrow reducing blood flow to the organs they supply), restless leg syndrome (which is a disorder that causes uncontrollable urge to move the legs and is often accompanied by an unpleasant sensation), polyneuropathy (which the simultaneous malfunction of many peripheral nerves throughout the body), fibromyalgia (which a chronic disorder that causes widespread pain and tenderness in the body), rheumatoid arthritis (which is a chronic disease that causes inflammation and pin in the joints), and pressure related wound (which is a wound caused by pressure) of the buttock.
The Quarterly Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) with the Assessment Reference Date (ARD), of 07/11/2024 revealed Resident 18 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 13 indicating the resident was cognitively intact. The resident received both routine and as needed pain medication during the last 5 days prior to the ARD. The resident stated they frequently had pain that interfered with sleep, therapy activities, and day to day activities. The resident rated the pain on a descriptor scale as Moderate.
Review of Resident 18's Comprehensive Care plan (a written interdisciplinary comprehensive plan to meet the resident's needs that are identified in the resident's comprehensive assessment), dated 08/19/2024, revealed a focus of Pain with a tolerable pain level stated as Mild. The goal was listed as the resident will have pain at a tolerable level for them of Mild. An intervention was listed if the resident was receiving frequent as needed pain medication for breakthrough pain, to visit with the provider about getting a different medication or stronger medication to get the residents pain to a tolerable level.
In an interview with Resident 18 on 08/19/2024 at 9:35 AM, Resident 18 stated they are often uncomfortable and in pain. Resident 18 stated [gender] is to get up for one hour and get into their recliner two times a day but often refuses to do this due to level of pain. Resident 18 stated staff will administer an as needed pain medication when the resident requests it but by the time the medication takes effect it is to late to get up and into the recliner so just stays in bed.
Review of Resident 18's Medication Administration Record for the Month of August 2024 revealed the resident was monitored for pain every shift. 20 of the 37 pain ratings obtained from the resident were of a pain level of 5 or higher on a 1 to 10 scale indicating pain at a moderate to severe level of pain.
Review of Resident 18's Medication Administration Record for the Month of August 2024 revealed Resident 18 received as needed Acetaminophen (a mild pain medication) 5 times for pain ratings of 6 or greater on a 1 to 10 scale.
Review of Resident 18's Medication Administration Record for the Month of August 2024 revealed Resident 18 received as needed Oxycodone (a narcotic strong pain medication) 17 times for pain ratings of 8 or greater on a 1 to 10 scale.
In an interview conducted on 08/21/2024 at 11:00 AM with Registered Nurse E (RN-E), RN-E confirmed that Resident 18 often refused to get up out of bed due to pain. RN-E denies offering Resident 18 pain medication prior to offering to get the resident out of bed stated the medication is administered when the resident requests it. RN-E stated the resident's provider had not been notified about the frequent use of the as needed pain medication to maintain the residents comfort level for adjustments in the resident's routine pain medication for better coverage and less breakthrough pain for Resident 18.
In an interview conducted on 08/21/2024 at 12:20 PM with the Director of Nursing (DNS), the DNS confirmed that Resident 18 pain was not controlled, and the provider should be notified for a change in the resident's routine pain medication to decrease break through pain.
B.
A review of an admission Record dated 08/18/2024 revealed the facility admitted Resident 21 on 12/01/2022 with diagnoses of multiple myeloma (which is a type of bone marrow cancer), chronic gout (which is repeated episodes of pain and inflammation of joints), and neuralgia and neuritis (which is server sharp often shock like pain that follows the path of a nerve with inflammation of the nerve).
The Quarterly MDS with the ARD, of 07/18/2024 revealed Resident 21 had a BIMS score of 15 indicating the resident was cognitively intact. The resident received both routine and as needed pain medication during the last 5 days prior to the ARD. The resident stated they frequently had pain that interfered with sleep and day to day activities. The resident rated the pain on a descriptor scale as Moderate.
Review of Resident 21's Comprehensive Care plan, dated 08/19/2024, revealed a focus of Pain with a tolerable pain level stated as Mild. The goal was listed as the resident will have pain at a tolerable level for them of Mild. An intervention was listed to observe for effectiveness of pain mediation and to keep the provider informed.
In an interview conducted on 08/19/2024 at 1:30 PM with Resident 21 revealed [gender] often suffered from pain during the early morning hours and would have to request to be gotten out of bed early in the morning to be able to change position to try and alleviate some of the discomfort they were experiencing. The resident stated they received pain medication when they requested it and on a routine basis but felt like their pain was never at a tolerable level.
Review of Resident 21's Medication Administration Record for the Month of August 2024 revealed the resident was monitored for pain every shift. 30 of the 37 pain ratings obtained from the resident were of a pain level of 5 or higher on a 1 to 10 scale indicating pain at a moderate to severe level of pain.
Review of Resident 21's Medication Administration Record for the Month of August 2024 revealed Resident 21 received as needed Acetaminophen (a mild pain medication) once for pain ratings of 10 on a 1 to 10 scale.
Review of Resident 21's Medication Administration Record for the Month of August 2024 revealed Resident 21 received as needed Tramadol (a narcotic pain medication) 7 times for pain ratings of 7 or greater on a 1 to 10 scale.
In an interview conducted on 08/21/2024 at 11:15 AM with Registered Nurse E (RN-E), RN-E confirmed that Resident 21 often awoke in the early morning hours and requested as needed pain medication and to get up out of bed to alleviate pain and discomfort. RN-E confirmed that the residents last dose of scheduled analgesics was administered at bed time and the provider had not been contacted about the frequent as needed pain medication use to adjust time of dosing of medication.
In an interview conducted on 08/21/2024 at 12:25 PM with the Director of Nursing (DNS), the DNS confirmed that Resident 21's pain was not controlled, and the provider should be notified for a change in the resident's routine pain medication in efforts to decrease break through pain.

Licensure Reference Number 175NAC 12-006.09(H)
Based on record review and interview; the facility failed to ensure that PRN (as needed) psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) were limited to 14 days as required for 1 resident (Resident 135) of 5 residents reviewed. The facility census was 33.
Findings are:
Record review of the facility policy titled Use of Psychotropic Drugs dated 2/2020 revealed that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (such as 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN use.
Record review of the admission Record dated 8/19/24 for Resident 135 revealed that Resident 135 admitted into the facility on 8/5/24.
Record review of the Order Summary (a listing of all physician's orders for a resident) dated 8/19/24 for Resident 135 revealed that Resident 135 had an order for Lorazepam 0.5 milligrams (a psychotropic medication used to treat anxiety) every 12 hours as needed for anxiety or agitation. The Lorazepam order had a start date of 8/5/24. The order had no end date as required.
Record review of the medication administration record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) dated 8/20/24 for Resident 135 revealed that Resident 135 received the as needed Lorazepam on 8/4/24, 8/5/24, 8/12/24, 8/14/24 and 8/20/24 (the 15th day after the original order).
Record review of the Pharmacy Note for Resident 135 dated 8/17/24 at 8:25 AM revealed that the consultant pharmacist completed a medication review for Resident 135. The Consultant Pharmacist noted that Resident 135 had an order for a PRN psychotropic medication that did not have a 14 day stop date.
Interview on 8/21/24 at 8:14 AM with the facility Infection Control Coordinator (IC) confirmed that orders for psychotropic medications are limited to 14 days unless re-evaluated for necessity and re-ordered by the physician. IC revealed that IC was unaware of the note from the Consultant Pharmacist for the PRN 14 day Lorazepam for Resident 135. IC then located an email from the consultant pharmacist and printed the recommendation note.
Record review of the Note to Attending Physician/Prescriber dated 8/17/24 for Resident 135 revealed that PRN orders for psychotropic medications are limited to 14 days. If therapy is desired past a 14 day period, a patient specific rationale and duration must be documented in the resident's medical record by the attending physician or prescribing practitioner. The PRN Lorazepam 0.25 milligrams will be automatically discontinued after 14 days of the original order date; or request to continue the PRN order for less than 1 year with clinical rationale.
Interview on 8/21/824 at 8:22 AM with the facility IC confirmed that the Note to Attending Physician/Prescriber dated 8/17/24 for Resident 135's Lorazepam PRN limited to 14 days had not been sent to Resident 135's physician for review and should have been sent.

Licensure Reference Number 175NAC 12-006.12(D)(vi)
Based on observation, record review, and interview; the facility failed to ensure medications were labeled clearly and accurately for 2 Residents (Resident 18 and Resident 29) of 5 sampled residents. The facility census was 33.
Findings are:
Review of a facility policy titled Labeling of Medications and Biologicals dated 02/2020 revealed All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Medication labels bust be always legible. Any medication label that is soiled, incomplete, illegible, worn, or makeshift must be returned and replaced by the issuing pharmacy.
A.
Review of an admission Record dated 08/19/2024 revealed the facility admitted Resident 18 on 04/10/2024 with diagnoses of type two diabetes mellitus, (which is when the body has trouble controlling blood sugar and using it for energy).
Review of Resident 18's Treatment Administration Record for the month of August 2024 revealed Resident 18 received Humalog Insulin (which is a medication that helps to regulate blood sugar levels), injections per a sliding scale (which is a varied dose based on blood sugar levels) schedule before meals and at bedtime.
In an observation of medication administration completed on 08/20/2024 at 7:35 AM, Registered Nurse F (RN-F) was observed to prepare to administer an injection to Resident 18 using an insulin pen. The label attached to the insulin pen was observed to have black smeared ink over one side of the label making the residents name and directions for sliding scale administration illegible.
In an interview completed on 08/202/2024 at 7:35 AM with RN-F, RN-F confirmed that the label on the insulin pen was illegible and the full directions for administering Resident 18 insulin was not visible on the label.
In an interview completed on 08/21/2024 at 1:35 PM with the Director of Nursing (DNS), the DNS confirmed that the label on Resident 18 insulin pen was illegible and needed to be replaced by the pharmacy.
B.
Review of an admission Record dated 08/19/2024 revealed the facility admitted Resident 29 on 10/25/2023 with diagnoses of hypertensive heart disease (which is high blood pressure).
Review of Resident 29 Medication Administration Record for the month of August 2024 revealed Resident 29 had physician orders to receive Potassium Chloride (which is a mineral supplement) ER (Extended Release), 20 Milliequivalents (MEQ) tablet one time every day.
In an observation of medication administration completed on 08/20/2024 at 7:45 AM, RN-F was observed preparing Resident 29 medications. RN-F removed an oblong cream granular in appearance tablet from a medication card labeled with Resident 29 name and Potassium Chloride 20 MEQ tablet. RN-F placed the tablet in a clear medication cup with other medications and took the cup to Resident 29. Resident 29 using the medication cup and a drink of water swallowed all the medications in the cup. RN-F then returned to the medication cart.
In an interview with RN-F completed on 08/20/2024 at 7:50 AM, RN-F confirmed the label on the medication card read Resident 29 name and Potassium Chloride 20 MEQ and the order in Resident 29 Medication Administration Record read Potassium Chloride ER 20 MEQ. RN-F confirmed that the label on the medication package and the order in the Medication Administration Record did not match.
In an interview with the DNS completed on 08/21/2024 at 1:35 PM, the DNS confirmed that the label on Resident 29 Potassium Chloride medication and the order in the Medication Administration Record did not match. The DNS confirmed the order needed verified and clarified with the provider and the pharmacy.

Licensure Reference Number: 175 NAC 12-006.11(E)
Based on observations, record review, and interviews; the facility failed to store food under sanitary conditions as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32.
Findings are:
Source: Nebraska Food Code, effective date 07/21/2016 revealed section:
3-305.11: Food Storage: A. Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:
-In a clean, dry location;
-Where it is not exposed to splash, dust, or other contamination; and
-At least 15 cm (6 inches) above the floor.
A review of the facility policy titled; Dietary Sanitation Policy Statement revealed: All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.
Observation on 08/19/2024 at 8:35 AM revelaed the Food Services Supervisor (FSS) directed surveyor towards the back of the facility where a kitchen was presented with a dry storage on the east of the kitchen, dishwashing machine, stoves, and ovens. The dry storage had items labeled, and stored off of the floor. Underneath the dry storage was a 4-inch gap between the shelving and the floor, where visible were individual food packs of cookies, condiments and 4 wooden snap mouse traps. The FSS then lead the surveyor towards the main storage area that contained a refrigerator, 5 stand alone freezers and 2 large dry food storage wire shelving units that held dry food items, and another large shelving unit that held canned food items. The floors of the area were observed to have dried pasta, corn kernels and a buildup of dark soiling. Also observed were mouse droppings littered all over the floor with a concentration of droppings in specified areas of the storage room. There is a two-door entryway for deliveries where sticky mouse traps were present by the door and a cluster of mouse droppings.
On 08/19/2024 at 2:12 PM Cook-I is observed to be retrieving food items from the food storage area of dry goods and refrigerated items. The items are placed on a rolling cart and brought to the kitchen where food is prepared. After the food is prepared, the food is kept hot in the oven. Once food is ready to be served, the food is then moved to the serving kitchen/dining room, where the food is then placed into a steam table and served to the residents.
The FSS was interviewed on 08/19/2024 at 2:26 PM. The FSS revealed they were aware of the mouse droppings and stated they did not have the live mouse traps available to the kitchen. The FSS also revealed more cleaning needs to be done.

D.
Record review of the facility policy titled Enhanced Barrier Precautions dated 4/1/24 revealed that it is the policy of the facility to implement enhanced barrier precautions for the prevention of the transmission of multidrug-resistant organisms. The definition for Enhanced Barrier Precautions (EBP) revealed that EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy revealed that all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. High contact resident care activities include: Dressing, Bathing, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Wound care: any skin opening requiring a dressing. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of an indwelling medical device.
Record review of the admission Record dated 8/19/24 for Resident 11 revealed that Resident 11 admitted into the facility on 7/24/24.
Record review of the Care Plan dated 8/19/24 for Resident 11 revealed that Resident 11 had a surgery for fracture of the left elbow. Resident 11 had an incision on the left arm to be observed for signs and symptoms of infection.
Record review of the Treatment Administration Record (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) dated 8/20/24 for Resident 11 revealed that Resident 11 had an order for dry dressing with ace wrap changed daily. Monitor incision site for signs and symptoms of infection.
Observation on 8/19/24 at 8:59 AM in the room of Resident 11 revealed that Nurse Aide-A (NA-A) transferred Resident 11 into the room in a wheelchair. Resident 11 had an ace wrap around their left elbow. A sign on the wall between the bathroom door and closet in the resident's room revealed ENHANCED BARRIER PRECAUTIONS. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device Care or use: Central Line, Urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. A holder with gowns and gloves hung from the back of the room door. NA-A did not put on a gown or gloves. NA-A applied a gait belt (a belt device placed around a resident's abdominal area used to aid in the safe movement of a resident with mobility problems) around the abdomen of Resident 11 with the bare hands. NA-A's arms were in contact with the arms of Resident 11 as the gait belt was applied. NA-A assisted Resident 11 to stand from the wheelchair. Resident 11 held onto a walker. NA-A assisted Resident 11 to step towards the recliner as NA-A held onto the gait belt with their right hand and held onto the left arm of Resident 11 with the left hand. Resident 11 complained that NA-A was putting pressure leaning on Resident 11's left arm during the transfer. Resident 11 complained that their left arm is sore.
Observation on 8/19/24 at 9:34 AM in the room of Resident 11 revealed that Physical Therapy Assistant (PTA) entered the room of Resident 11. PTA did not put on a gown or gloves. PTA put shoes on Resident 11 with the bare hands. PTA put a gait belt around the abdomen of Resident 11 and assisted Resident 11 to stand from the recliner. PTA rubbed against Resident 11 as Resident 11 stood up with the assistance. Resident 11 held onto the walker. PTA held onto the gait belt and walked with Resident 11 from the resident room to the therapy gym.
Observation on 8/20/24 at 9:04 AM in the room of Resident 11 revealed that Nurse Aide-B (NA-B) did not put on a gown or gloves. Resident 11 sat in the wheelchair. NA-B placed a gait belt around the abdomen of Resident 11 with the bare hands. NA-B's bare arms rubbed against the arms and torso of Resident 11 as the gait belt was applied. NA-B held onto the gait belt and the resident's left arm pit as Resident 11 was assisted to stand. Resident 11 used the walker to transfer to the recliner. Resident 11 was assisted into the recliner as NA-B held onto the resident. Resident 11 tilted the recliner back and elevated their feet.
Interview on 8/20/24 at 2:35 PM with NA-B revealed that this surveyor asked NA-B what the sign Enhanced Barrier Precautions meant. NA-B reviewed the sign and stated that it was for bathing the resident and for residents with catheters that staff have to wear gown and gloves. NA-B was unaware that gown and gloves were required for any high contact care including transfers for residents on Enhanced Barrier Precautions.
Observation on 8/20/24 at 11:06 AM in the therapy gym revealed that Physical Therapist (PT) reached across the back of Resident 11 with the left hand and held onto the back of the gait belt. PT's arm was holding against the back of Resident 11. PT placed their right hand on the upper arm of Resident 11 with the right hand. PT assisted Resident 11 to sit in a chair. PT did not wear a gown or gloves.
Observation on 8/20/24 at 11:09 AM in the therapy gym revealed that PTA sat down next to Resident 11. PTA told Resident 11 that the oxygen nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) needed to be adjusted. PTA grabbed the nasal cannula on the left and right of Resident 11's nose with the bare hands and adjusted the prongs into the nostrils of Resident 11. PTA tightened the cannula to hold it in place.
Observation on 8/20/24 at 12:44 PM revealed that Nurse Aide-B (NA-B) transferred Resident 11 in the wheelchair from the dining room into the resident's room. NA-B did not put on a gown or gloves. NA-B pushed the wheelchair into the bathroom. NA-B put on gloves and placed a gait belt around the abdomen of Resident 11. NA-B assisted Resident 11 to stand up from the wheelchair using the gait belt. Resident 11 grabbed onto the grab bar on the wall to assist with standing. NA-B pulled down the pants of Resident 11 and then pulled down Resident 11's brief. NA-B assisted Resident 11 to sit down on the toilet. NA-B removed and discarded the gloves. NA-B asked Resident 11 to use the call light to let staff know when the resident was finished in the bathroom. NA-B exited the resident's room.
Observation on 8/20/24 at 12:54 PM at the room of Resident 11 revealed that Medication Aide-C (MA-C) entered the room of Resident 11. MA-C did not perform hand sanitization. MA-C did not put on a gown or gloves. MA-C entered the resident's bathroom and asked Resident 11 if they were finished. Resident 11 responded yes. MA-C put on gloves and used a wipe to wipe the bowel movement (BM) from the resident's anal area. MA-C obtained a second wipe and wiped the resident's anal area. MA-C obtained a third wipe and wiped the resident's anal area. MA-C removed and discarded the gloves. MA-C did not perform hand sanitization. MA-C used the bare hands to assist Resident 11 to a standing position in front of the toilet. MA-C used the bare hands to pull up Resident 11's brief and pants. MA-C assisted Resident 11 to sit in the wheelchair. MA-C transferred Resident 11 out of the bathroom to near the recliner. MA-C moved the recliner as requested by Resident 11. MA-C used the bare hands to move the over bed table on the left side of the recliner towards the rear of the recliner as requested by Resident 11. MA-C positioned the wheelchair in front of the recliner. MA-C used the bare right hand to hold onto the gait belt in back of Resident 11 while draping the left arm underneath the left arm of Resident 11. MA-C held onto the front of the gait belt with the bare left hand and assisted Resident 11 to stand from the wheelchair. MA-C's uniform was touching Resident 11 as MA-C pivoted Resident 11 into the recliner. MA-C placed their bare hands on their sides touching their uniform. MA-C used the bare hands to pick up the nasal cannula from the bed and placed the nasal cannula on the face of Resident 11. MA-C used the bare hands to operate the control on the recliner to elevate Resident 11's feet and tilt the back of the chair backwards. MA-C used the bare hands to place a pillow behind Resident 11. MA-C used the bare hands to place a pillow underneath the left arm of Resident 11. MA-C entered the bathroom and performed hand washing. Resident 11 stated that the pain in their left arm was a 6 on a scale of 0-10. Resident 11 stated that they were supposed to place an ice pack to help with the pain. MA-C told Resident 11 they would get an ice pack. MA-C exited the room of Resident 11.
Observation on 8/20/24 at 1:06 PM in the room of Resident 11 revealed that MA-C returned to the room with an ice pack. MA-C did not put on a gown or gloves. MA-C used the bare hands and lifted the left arm of Resident 11 and placed the ice pack under the left elbow and forearm of the resident. An ace wrap was in place on the left elbow of Resident 11. MA-C exited the resident room.
Interview on 8/20/24 at 4:30 PM with Medication Aide-C (MA-C) revealed that the Enhanced Barrier Precautions means you have to gown up and wear gloves if doing anything with a resident's wounds. MA-C was not aware that gown and gloves were required for transferring and toileting residents on Enhanced Barrier Precautions.
Observation on 8/21/24 at 9:57 AM in the room of Resident 11 revealed that Registered Nurse-E (RN-E) performed hand sanitization and entered the resident room after reviewing the order for the incision on Resident 11's left elbow. The incision along the bottom of the left elbow had 6 steri strips (strips of tape put across an incision for wound closure) over it. The area around the incision was a light brown along the length of the incision. The incision contained a scabbed area below the elbow measuring approximately 3 centimeters (cm) long and 1 cm wide and a scabbed area above the elbow measuring approximately 2 cm long and 1cm wide. Resident 11's left arm had a moderate amount of swelling into the fingers and was light reddish in color.
Interview on 8/22/24 at 7:28 AM with the facility Director of Nursing Services (DNS) confirmed that residents on Enhanced Barrier Precautions (EBP) are to have an EBP poster sign posted to identify the resident is on EBP. The DNS confirmed that staff are expected to follow the Enhanced Barrier Precautions and wear gown and gloves for resident transfers, toileting, and wound care. The DNS revealed that the facility training to ensure staff are educated needs revised.
E.
Record review of the admission Record for Resident 8 dated 8/19/24 revealed that Resident 8 admitted into the facility on 1/10/24. Resident 8 had a chronic ulcer (open wound) of the left lower leg.
Record review of the Care Plan dated 8/19/24 for Resident 8 revealed that staff are to observe open areas for signs and symptoms of infection. See Treatment Administration Record (TAR) for treatments. The care plan contained a care focus for Enhanced Barrier Precautions. The Care Plan revealed that Resident 8 has an open pressure wound (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) and vascular wounds (wounds on your skin that develop because of problems with blood circulation) receiving treatments. Put on gown and gloves for cares at all times in the resident's room. In room care: Provide EBP care during dressing, bathing, transferring, providing hygiene care, changing bed linens, changing briefs or assisting with toileting.
Observation on 8/20/24 at 2:35 PM at the room of Resident 8 revealed that a sign on the outside of the door to the room of Resident 8 read ENHANCED BARRIER PRECAUTIONS. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device Care or use: Central Line, Urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person.
Interview on 8/20/24 at 2:35 PM with Nurse Aide-B (NA-B) revealed that this surveyor asked NA-B what the sign Enhanced Barrier Precautions on the door of Resident 8 meant. NA-B reviewed the sign and stated that it was for bathing the resident and for residents with catheters. NA-B stated that NA-B was unsure if it was even applicable to Resident 8 anymore. NA-B revealed that Resident 8 may have had an infection at one time.
Observation on 8/21/24 at 7:37 AM in the room of Resident 8 revealed that Medication Aide-D (MA-D) and Nurse Aide-A (NA-A) were in the bathroom with Resident 8. Resident 8 was in the wheelchair. MA-D put on gloves and stood in front of the wheelchair beside the toilet. MA-D did not wear a gown. NA-A stood behind the wheelchair just inside the bathroom doorway. NA-A did not wear a gown or gloves. NA-A placed a gait belt around the lower abdomen of Resident 8. MA-D and NA-A each held onto the gait belt with one hand and supported the resident's arms with their other hand. MA-D and NA-A assisted Resident 8 to stand up from the wheelchair. MA-D removed the resident's brief. Resident 8 was assisted to sit on the toilet.
Observation on 8/21/24 at 9:22 AM at the room of Resident 8 revealed that Registered Nurse -E (RN-E) reviewed the dressing change order. RN-E performed hand sanitization and put on gown, gloves, and face shield. RN-E revealed that Resident 8 had received a bath so the wound on the top of the foot was open to air. An open wound on the top of Resident 8's left foot measured approximately 8 cm long, 5 cm wide, and 0.5 cm deep. The wound bed was bright red and approximately 70% covered with a thick dark yellow-brown exudate (wound drainage). RN-E completed the wound treatment and applied the silicone foam border dressing over the wound.
Observation on 8/21/24 at 10:25 AM in the room of Resident 8 revealed that Resident 8 was in bed lying on their left side. RN-E reviewed the dressing change order for the pressure ulcer on the resident's coccyx (the bony lower portion of the spine). RN-E performed hand sanitization and put on a gown, gloves, and face shield. RN-E pulled down the resident's pants and brief to just below the buttocks. An open wound was visible on the resident's coccyx. The wound measured approximately 3 cm long and 2.5 cm wide and was light red in color. An approximately 1 cm long, 0.5 cm wide, and 1 cm deep open area inside the wound near the top of the wound area was present. RN-E completed the wound treatment and applied a silicone foam dressing over the wound.
Interview on 8/22/24 at 7:28 AM with the facility Director of Nursing Services (DNS) confirmed that residents on Enhanced Barrier Precautions (EBP) are to have an EBP poster sign posted to identify the resident is on EBP. The DNS confirmed that staff are expected to follow the Enhanced Barrier Precautions and wear gown and gloves for resident transfers, toileting, and wound care. The DNS revealed that the facility training to ensure staff are educated needs revised.
Licensure Reference Number 175NAC 1-005.06(E)
Licensure Reference Number 175NAC 12-006.18(B)
Based on record review and interview the facility failed to complete and review pre-employment health histories for 4 of 4 sampled staff. Based on observation, record review, and interview the facility failed to perform hand sanitization during medication administration to 3 or 5 sampled residents (Resident 17, 28, and 18), sanitize blood glucose glucometer after use for 1 of 1 sampled resident (Resident 18), and failed to follow Enhanced Barrier Precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism and residents at increased risk) to prevent the potential spread of multidrug-resistant infection for 2 residents (Residents 11 and 8). The facility census was 33.
Findings are:
A.
Review of a facility supplied documents titled Employee Heath History Screen revealed the following:
-Document for Housekeeper J (HSK-J) not completed in its entirety. No primary physician past medical history or allergies listed. The form is signed by HSK-J and dated 06/18/2024. There is no signature or date of the form being reviewed by other facility staff.
-Document for Medication Aide K (MA-K) not completed in its entirety. No immunization record present. The form is signed by MA-K and dated 06/19/2024. There is no signature or date of the form being reviewed by other facility staff.
-Document for Dietary Aide L (DA-L) completed, signed by DA-L and dated 07/30/2024. There is no signature or date of the form being reviewed by other facility staff.
-Document for Maintenance Manager (MM) not completed in its entirety. No employee name listed on the form no position title emergency contact primary physician or immunization history completed. The form is signed by MM and dated 05/24/2023. There is no signature or date of the form being reviewed by other facility staff.
In an interview on 08/21/2024 at 10:35 AM with the facility Business Office Manager (BOM), the BOM confirmed they are the individual responsible for ensuring all new hire documentation is completed and present in the employees file. The BOM confirmed that the Employee Health History Screen forms for HSK-J, MA-K, and MM were not completed entirely. The BOM confirmed that the forms were not reviewed to ensure that the individuals were free of communicable diseases prior to working with or in the direct vicinity of residents.
B.
Review of a facility policy titled Hand Hygiene and dated 2021 revealed hand hygiene is indicated and will be performed under the conditions listed in but not limited to the hand hygiene table. The Hand Hygiene Table lists hand hygiene is to be performed between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before preparing or handling medications.
In an observation of medication administration by Registered Nurse F (RN-F), completed on 08/20/2024 from 7:20 AM to 8:20 AM the following was observed:
RN-F knocked and entered Resident 17's room. RN-F gave the medications to Resident 17 in a clear plastic cup and Resident 17 then took the medications and swallowed them, and handed the clear up back to RN-F. RN-F thanked the resident and exited the room returning to the medication cart located in the hall outside of the room. RN-F threw the clear plastic cup in the trash can on the cart and placed the syringe in a clear plastic sleeve in the medication cart. RN-F then signed out the medication administration in the computer and removed the next residents' medications from the medication cart. RN-F did not complete hand sanitization/hygiene between administering Resident 17's medications and preparing the next residents' medications. Then RN-F prepared Resident 28's medications at the medication cart in the hallway located outside of Resident 28's room. RN-F knocked and entered the resident's room and handed the resident a cup containing clear liquid and a clear medication cup containing multiple medications. The resident emptied the cup containing the medications in their mouth and handed the cup back to RN-F. RN-F then returned to the medication cart in the hall signed out the medications administered in the computer. RN-F then locked the medication cart and proceeded down the hall to the nurse's station where another medication cart was located. The RN unlocked this cart and obtained a clear blue plastic pencil box from the cart. The RN did not complete hand sanitization/hygiene after administering Resident 28's medications and going to the other medication cart to get the clear blue plastic pencil box. Next RN-F entered Resident 18's room and obtained a paper towel and placed it on the resident's bed side stand. RN-F then set down a clear blue plastic pencil box on the paper towel. RN-F then applied gloves to both hands and performed the procedure of obtaining resident 18's blood sugar. After completion of the procedure RN-F removed their gloves from their hands and placed the items used back into the clear blue plastic pencil box. RN-F then picked up the box exited the resident's room and returned the box to the medication cart located at the nurse's station. RN-F did not complete hand sanitization/hygiene after removing their gloves post procedure.
In an interview on 08/20/2024 at 8:25 AM completed with RN-F, RN-F confirmed hand sanitization/hygiene should have been completed after administering Resident 17 and Resident 28's medications. RN-F confirmed that hand sanitization/hygiene should have been completed after [gender] removed their gloves.
C.
Review of a facility policy titled Blood Glucose Monitoring dated 2021 revealed the nurse or med aide will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions.
Review of a document titled Assure Platinum Reference Manual and dated 03/2014 revealed the glucometer should be cleaned and disinfected after each use.
Review of a document titled General guidelines for use Super Sani-Cloth and dated 2021 revealed to allow the treated surface to remain wet for two minutes then let air dry.
In an observation completed on 08/20/2024 at 7:45 AM RN-F used a glucometer to obtain Resident 18's blood sugar at the bedside. RN-F then placed the glucometer into a clear blue plastic pencil box and returned to the medication cart located down the hall by the nurse's station. RN-F placed the clear blue plastic box on the medication cart and obtained a disposable wipe from a container labeled Super Sani-Cloth located on top of the medication cart. RN-F wiped the glucometer with the disposable wipe for approximately 30 seconds. RN-F disposed of the wipe in the trash can and then placed the glucometer back into the clear blue plastic pencil box and placed it into the medication cart.
In an interview on 08/20/2024 at 8:25 AM with RN-F, RN-F stated [gender] did not know the contact time or how long the surface had to remain wet for proper cleaning technique of the glucometer per the disposable wipes manufacturer recommendations. Review of the label on the container labeled Super Sani-Cloth revealed a time of 2 minutes the item being cleansed with the cloth should remain wet. RN-F confirmed this instruction was written on the label.
In an interview on 08/21/2024 at 1:35 PM with the facility Director of Nursing (DNS), the DNS confirmed that the glucometer is to remain wet for 2 minutes for proper cleaning technique when using the Super Sani-Cloth disposable wipes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-007.04(D)
Based on observation, and interview; the facility failed to ensure the bathroom ventilation system could pull up a square of single ply tissue in 3 rooms, (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), of 16 sampled rooms. The facility census was 33.
Findings are:
In an observation completed on 08/22/2024 at 9:30 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue.
In an observation completed on 08/22/2024 at 9:31 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue.
In an observation completed on 08/22/2024 at 9:32 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue.
In an interview completed on 08/22/2024 at 9:56 AM with the Maintenance Manager (MM), confirmed that the vents located in the ceilings of the bathrooms in room [ROOM NUMBER], 307, and 311 could not pull up a single ply of tissue. The MM confirmed that the vents should be able to pull up a single ply of tissue and that the ventilation system was not working properly.

Licensure Reference Number: 175 NAC 1-009.01(C)
Based on observations, record review and interviews, the facility failed to maintain an effective pest control program as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32.
Findings are:
A review of an undated facility policy titled Pest Control, indicates the facility shall maintain an effective pest control program. The policy further implements that the facility will maintain an on-going pest control program to ensure that the building is kept free of insects and rodents.
Observation on 08/19/2024 at 8:35 AM the Food Services Supervisor (FSS) directed the surveyor towards the back of the facility towards a kitchen with a dry storage on the east side of the kitchen. Under the dry storage was a 4-inch gap, that had food items and 4 wooden snap mouse traps. The FSS then lead the suerveyor towards the main storage area that contained a refrigerator, 5 stand alone freezers, 2 large dry food storage wire shelving units that held dry food items, and another large shelving unit that held canned food items. The floors of the area were observed to have dried pasta, corn kernels and a buildup of dark soiling present. Also observed were mouse droppings littered all over the floor with a concentration of droppings in specified areas of the storage room. There is a two-door entryway for deliveries where sticky mouse traps caught with dead bugs were present by the doors and a cluster of additional mouse droppings.
The FSS was interviewed on 08/19/2024 at 2:26 PM. The FSS revealed they were aware of the mouse droppings and stated they did not have the live mouse traps available to the kitchen as they typically did in other areas of the facility. The FSS stated they cleaned it up, however more cleaning needs to be done.
An interview with the Facility Administrator (FA) on 08/19/2024 at 5:05 PM revealed they were unaware of the rodent droppings in the dry food storage area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.
A review of Resident 279's admission Record revealed an initial admission date of 7/25/23 and an admitting diagnosis of Retropharyngeal and Parapharyngeal Abscess (a collection of pus within the tissues of the back wall of the throat and the tissues surrounding the throat.)
A review of Resident 279's Progress Notes revealed that the resident was admitted to the hospital on [DATE] after an MRI (Magnetic Resonance Imaging - a non-invasive technique that produces detailed images of the internal structures of the body) of the neck and an appointment with their Primary Care Provider.
Further review of the Progress Notes from 8/2/23 revealed no documentation that the resident or resident's representative was notified in writing regarding the resident's transfer to the hospital.
An interview with the FA on 8/23/23 at 3:40 confirmed that a Written Notice of Transfer had not been given to Resident 279 or their representative on transfer of the resident to the hospital.
An interview with the DCO on 8/23/23 at 3:56 PM confirmed that Written Notice of Transfer was not given on Resident 279 for the discharge/transfer to the hospital.
A review of the facility's Transfer and Discharge Policy dated September 2022 revealed the following:
The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.
Based on record review and interviews the facility failed to provide written notice to the resident or their representative regarding discharge or transfer to the hospital for 2 residents (Residents 3 and 279) of 2 residents reviewed. The facility census was 27.
Findings are:
A.
Record review of the EHR (electronic health record) progress notes dated 4/9/23 revealed that Resident 3 was admitted to the hospital from the ER (Emergency Room) due to an elevated white blood cell count and a UTI (urinary tract infection). The resident was treated with IV (intravenous) antibiotics.
Record review of Resident 3's EHR progress notes revealed no documentation that the resident or resident's representative was notified in writing regarding the hospital transfer or discharge.
Interview with FA (Facility Administrator) on 8/23/23 at 3:40 PM confirmed that the facility did not provided written notice to Resident 3 or the personal representative regarding the discharge to the hospital.
Interview with DOO (Director of Operations) on 8/23/23 at 1:30 PM confirmed that the facility should be sending a written notice of transfer or discharge to the resident and resident representatives on a transfer or discharge.
Interview with DCO (Director of Clinical Operations) on 8/23/23 at 3:56 PM confirmed that the written notice of transfer was not provided to Resident 3 or the resident's personal representative for the transfer or discharge to the hospital.

Licensure Reference Number 175NAC 12-006.02(8)
Based on record review and interview the facility failed to ensure that notification of potential abuse and neglect occurred within the required timeframe for 1 resident (Resident 20) of 2 residents reviewed. The facility census was 27.
Findings are:
Record review of the facility policy titled Abuse, Neglect, and Exploitation dated September 2022 revealed that an immediate investigation is warranted when suspicion of abuse, or reports of abuse occur. The facility will report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes. Reporting is made immediately, but not later than 2 hours after the allegation is made if the events that caused the allegation involve abuse.
Record review of the admission Record for Resident 20 dated 8/23/23 revealed that Resident 20 admitted into the facility on 4/20/23. Diagnoses included Parkinson's Disease, anxiety disorder, and chronic pain.
Record review of the progress note dated 7/9/23 at 11:26 AM for Resident 20 revealed that Resident 20 was noted to have a 1 centimeter by 1.5 centimeter bruise on the index finger of the right hand.
Interview on 8/24/23 at 10:17 AM with the Facility Administrator (FA) revealed that on 7/5/23 Resident 20 reported to the bath aide that a staff member was rough with the resident and threw them around. The FA revealed that the FA was notified of the allegation on 7/13/23. This was 8 days after the resident reported the abuse to facility staff. The FA confirmed that the report to adult protective services was not within the required timeframe.