Clarkson Community Care Center Inc

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(8)Based on record review and interview; the facility failed to investigate and submit a completed investigation report related to abuse and neglect to the State Agency within the required time frame for Residents 1 and 2. The sample size was 3 and the facility census was 29.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i) Based on record review and interview; the facility failed to identify causal factors of falls and to revise and/or develop interventions based on those factors to prevent ongoing falls for Residents 1 and 3. The sample size was 3 and the facility census was 29.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.04D(i) Based on record reviews and interviews; the facility failed to provide full time hours for the designated Director of Nursing (DON) who was working as a Charge Nurse. This failure had the potential for affecting nursing care to all the residents. The total sample size was 15 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility fails to obtain informed consent for the use of psychotropic (medications that effect the brain and alter mental processes, emotions, and behavior) medications for Residents 12,16, 17, and 29. The sample size was 5 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview; the facility failed to review and revise Care Plans to accurately reflect Residents 5 and 6's Enhanced Barrier Precautions (EBP-an infection control strategy that involves the use of gown and gloves during high contact resident care activities to reduce the spread of drug resistant organisms in settings such as nursing homes) and Residents 7, 12, 16, and 24's fall interventions. The sample size was 12 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)Based on interview and record review; the facility failed to review for causal factors and implement measures to prevent ongoing falls for Resident's 12, 16, 7, and 24. The sample size was 4 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report a fall with injury for Resident 24 and an injury of unknown origin for Resident 7 as potential allegations of abuse and/or neglect. The sample size was 2 and the facility census was 30.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on interview and record review; the facility failed to investigate and to submit the results of the investigation to the State Agency within the required time frame a fall with significant injury for Resident 24 and an injury of unknown origin for Resident 7. The sample size was 2 and the facility census was 30.

Inspectors wroteNumber of residents sampled: 1Number of residents cited: 1Based on record review and interview; the facility failed to ensure a comprehensive discharge summary for completed for Resident 35. Licensure Reference Number NAC 175-12 006.09(G)(i)7Based on record review and interview; the facility failed to document a recapitulation (a complete summary of the residents stay in nursing facility from admittance to discharge) for a resident-initiated discharge for 1 (Resident 35) of 1 sampled resident. The facility identified a census of 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(C)(ii)Based on record review and interview; the facility failed to ensure a Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) was completed for Resident 12 for a hospice admission. The sample size was 12 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B)(iv)Based on record review and interview; the facility failed to ensure Resident 2's MDS (Minimum Data Set-federally mandated comprehensive assessment used to develop resident care plans) was coded accurately to reflect which type of medications were being administered. The sample size was 12 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09ABased on record review and interview: the facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) screen was completed accurately for 1 (Resident 6) of 1 sampled residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E)Based on record review and interview; the facility failed to ensure Resident 2's Care Plan was comprehensive and accurately reflected the residents diagnoses and high-risk medication use. The sample size was 12 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to complete an assessment for Resident 6 for potential adverse effects from antipsychotic ( a type of medication that alters the chemicals in the brain to effect change in behavior, mood and emotion). The sample size was 5 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B)Based on observation, record review, and interview; the facility failed to ensure hand hygiene was completed at appropriate intervals during wound care for Resident 16 to prevent potential cross-contamination. The sample size was 12 and the facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.9 Based on observations, interviews, and record reviews; the facility failed to follow Resident 1's physician orders regarding fluid consistency. The sample size was 3. The facility census was 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interviews; the facility failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination during the provision of care for 3 (Residents 2,11, and 14) of 12 residents sampled. The facility also failed to develop and implement policies and procedures to prevent and protect residents from an onset of the communicable disease Legionella (a bacteria that thrives in water, that has the potential to cause Legionnaires Disease, a type of pneumonia). This had the potential to affect all the residents. The facility failed to prevent the potential for cross contamination for staff testing for Covid. The facility census was 33. Findings Are. A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04D Based on observations and interviews; the facility failed to ensure bathroom ventilation systems were functioning, preventing lingering odors from permeating for 11 (rooms 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214) of 12 rooms sampled. The facility census was 33.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09B Based on observation, interview, and record review; the facility failed to code the Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment to reflect the behavior of 1 (Resident 21) of 5 sampled residents. The facility census was 33 at the time of survey.

Inspectors wroteLicensure Reference Number NAC 12-006.090D Based on record reviews and interviews; the facility failed to obtain physician discharge orders, failed to prepare the resident and document plans for discharge, and failed to complete the discharge summary for 1 (Residnet 28) of 1 sampled resident prior to discharging the resident. The facility census was 33 at the time of survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04B1 Based on record reviews and interviews, the facility failed to ensure new employees were trained on abuse for 7 (DA-A, NA-B, DA-C, DA-D, NA-E, NA-H DA-I ) of 9 sampled employees. The facility census was 28.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09B Based on record review and interview, the facility failed to complete a quarterly Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) within the regulatory time frame for 7 (Residents 1, 3, 6, 16, 18, 22, and 29) of 9 residents reviewed. The facility census was 37.

Inspectors wroteLicensure reference number 175 NAC 12-006.04C3a Based on record review, observations, and interviews, the facility failed to notify the physician of change in condition for 1 (Resident #10) of 1 resident sampled. The facility staff have identified the census to be 37.

Inspectors wroteLicensure Reference Number 175NAC 12-006.05(5) Based on record review and interview, the facility failed to provide a written notice of transfer to the resident and/or resident representative upon transfer to the hospital for 1 (Resident 18) of 1 sampled resident. The facility census was 37.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09B1(1) Licensure Reference Number 175NAC 12-006.09B1(3) Based on record review and interview, the facility failed to ensure that an admission Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) for 1 (Resident 20) and an annual MDS was completed within the regulatory time frame for 2 (Residents 3 and 21) of 9 residents reviewed. The facility census was 37.

Inspectors wroteLicensure reference number 175 NAC 12-006.17A Based on record review, observations and interviews, the facility failed to maintain transmission-based precautionjs to prevent the spread of Covid-19 for 1 (Resident #10) of 1 sampled resident. The facility staff have identified the census to be 37.