Highland Manor Of Elko

F-F880

50210

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 On 07/17/2024 at 3:31 PM, during an interview with the DON and in the presence of the Regional Nurse Consultant, the DON verbalized the DON was not familiar with the facility's fall protocol to include the Level of Harm - Minimal harm or reference to interdisciplinary team minutes and did not know where to look to find them. The DON left the potential for actual harm interview to ask the Assistant DON.

Residents Affected - Some Upon return, the DON verbalized being unsure how to access a resident's MAR. Once the MAR was accessed, the DON was not sure how to interpret a checkmark on a resident's MAR for side effect monitoring. The DON confirmed being unable to see whether side effects were exhibited for the resident per

the MAR but did not know where to look for documentation of the side effects. The DON left to ask the Assistant DON.

Upon return, the DON explained the DON's EMR training was informal and minimal.

The facility's DON job description signed by the DON on 06/21/2024, documented the DON was accountable for directing all clinical services of the facility and overseeing nursing staff training upon hire and ongoing in-service education programs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 50210 minimal harm Based on observation and interview, the facility failed to ensure nursing hours were posted in the facility's Residents Affected - Some secured memory care unit to be readily accessible to visitors and residents. This restricted access to nursing hours had the potential to affect 27 residents.

Findings include:

On 07/17/2024 at 9:19 AM, the secured memory care unit lacked nursing hours posted.

On 07/17/2024 at 9:19 AM, a Registered Nurse (RN) in the memory care unit verbalized nursing hours were not posted in the facility's secured memory care unit.

On 07/18/2024 at 8:50 AM, the Administrator verbalized visitors could use the entrance to the secured memory care unit.

On 07/18/2024 at 10:07 AM, the Administrator verbalized the nursing hours were not posted in the facility's secured memory care unit and confirmed the residents in the secured memory care unit did not have access to the nursing hours posted outside the memory care unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49557 Residents Affected - Few Based on observation, interview, and document review the facility failed to ensure expired medications were not kept in a medication cart for 1 of 2 medication carts reviewed for medication storage.

Findings include:

On 07/17/2024 at 12:36 PM, during a review of a medication cart in the 600 hall and in the presence of a Registered Nurse (RN), the following items were found:

-A bottle containing Fish Oil 1200 milligrams (mg) (360 mg Omega-3) capsules. The expiration date on the bottle was January 2024.

-A bubble pack containing 25 tablets of Tramadol 50 mg. The expiration date on the bubble pack was 05/14/2024.

On 07/17/2024 at 12:41 PM, the RN explained facility staff did a monthly check of the medication cart for expired medications. The RN explained the importance of removing expired medications from a medication cart was residents could get sick if an expired medication was administered.

On 07/17/2024 at 2:22 PM, the Director of Nursing (DON) explained failure to remove expired medications from a medication cart could result in a medication error and expired medications, if administered to a resident, may not have the same effect as prescribed.

The facility policy titled Pharmaceutical Procedures, revised 01/31/2024, documented all expired medications were to be returned to the pharmacy for proper disposition and crediting considerations. The only exception was for controlled drugs, which would be disposed of on the premises by two licensed staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 35601

Residents Affected - Many Based on observation, interview and document review the facility failed to ensure hand washing was performed between the passing of resident beverages, touching residents and in between assisting two residents with eating.

Findings include:

On 07/15/2024 at 4:55 PM, in preparation for dinner in the 600 hall dining room, a Certified Nursing Assistant (CNA) completed the following sequential tasks without performing hand hygiene between tasks:

-The CNA assisted a resident to a dining room seat, patted the seat, and touched the resident's oxygen tubing to reposition the tubing.

-Retrieved three glasses and filled with ice and water then served to residents.

-Pushed a resident in a wheel chair to a table.

-Touched a resident's shoulder.

-Entered the satellite pantry, retrieved a coffee pot and mug, poured the cup of coffee, served it to the resident and put the coffee pot back in the satellite pantry.

-Retrieved six glasses and filled them with ice and then water. Served water glasses to residents, embraced

a resident with a full hug.

-Poured two more glasses of water, served, retrieved towels and began placing on residents as bibs.

-Put left arm around a resident while talking to the resident.

-Placed a right hand on a resident's chest while talking to the resident.

-Put a towel bib on a resident.

-Retrieved residents from the television area and pushed one resident in a wheel chair to a dining table.

-Embraced a resident with a full hug.

-Retrieved mugs and placed two mugs in front of two residents, entered the satellite pantry, retrieved a coffee pot and poured for two residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -Reentered the satellite pantry, retrieved a pitcher of a milky beverage and poured for two residents.

Level of Harm - Minimal harm or -Reentered the satellite pantry, retrieved juice from fridge and placed pitchers of juice on the counter. potential for actual harm -Readjusted a resident's towel bib, repositioned the resident's glasses on their face and placed CNA's right Residents Affected - Many hand on the left knee of the resident.

-Touched a resident's right arm and back with the CNA's left hand.

On 07/15/2024 at 5:16 PM, the CNA washed their hands.

On 07/15/2024 at 5:16 PM, the CNA recalled using hand sanitizer before assisting residents to the dining room, serving residents, and assisting residents with set-up. The CNA confirmed the CNA did not perform hand hygiene to include hand sanitizer between touching each resident. The CNA verbalized the CNA did not have to wash hands when touching residents, such as giving hugs. The CNA verbalized the CNA's preference was to wash hands when handling the cups.

On 07/15/2024 at 5:24 PM, the CNA explained the CNA double checked and confirmed the CNA can use only hand sanitizer when serving cups up to a handful of times to include filling ice and water cups and touching residents.

49557

On 07/15/2024 at 5:49 PM, while seating between two residents in the 400 hall dining room, a CNA2 completed the following sequential tasks without performing hand hygiene between tasks:

-Provided feeding assistance to a resident.

-Assisted a second resident with cleaning up a small amount of food the resident dropped on the table and

on the resident's clothing, then provided feeding assistance to the same resident.

-Provided feeding assistance to the first resident.

-Provided feeding assistance to the second resident.

On 07/15/2024 at 5:58 PM, the CNA2 confirmed the CNA2 did not perform hand hygiene between assisting each resident with eating. The CNA2 explained hand hygiene was required to be performed prior to providing feeding assistance for residents and in between each resident.

On 07/18/2024 at 9:06 AM, the Director of Nursing (DON) explained hand hygiene was required to be performed by staff prior to any initiation of resident care. The DON confirmed hand hygiene was required to be performed prior to and after meals or contact with each resident.

The facility policy titled Infection Control, revised 01/31/2024, documented hand washing was the foundation of controlling infectious disease. Staff were to perform hand washing when between residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The facility policy titled Handwashing Procedure, adopted 08/2019, documented when to wash hands: every time you enter the satellite pantry, after touching clothes, face, body or hair, after handling soiled equipment, Level of Harm - Minimal harm or and after engaging in any activity which would contaminate hands. Hand antiseptic may be used after potential for actual harm washing hands and was not to be used as a substitute for handwashing.

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50210

Residents Affected - Few Based on interview, document review, and clinical record review, the facility failed to ensure treatment administered, side effect monitoring, pain monitoring, COVID-19 symptom monitoring, and behavior monitoring was documented for 1 of 18 sampled residents (Resident #20).

Findings include:

Resident #20

Resident #20 was admitted to the facility on [DATE REDACTED], with diagnoses including unspecified dementia unspecified severity with mood disturbance, Alzheimer's Disease with late onset, anxiety disorder unspecified, and major depressive disorder recurrent unspecified.

Treatment

A physician's order dated 04/17/2024, documented to apply lotion on shower days every day shift on Wednesdays and Saturdays.

Resident #20's June 2024 Treatment Administration Record (TAR) lotion administration had blank spaces on Saturday 06/15/2024.

Resident #20's progress notes lacked documented evidence lotion was administered on 06/15/2024.

Side Effect Monitoring

Resident #20's physician's orders dated 04/17/2024, documented the following:

-Monitor antidepressant Amitriptyline common side effects two times a day. indicate letter if observed and document in Electronic Medical Record (EMR) if needed: A. sedation, B. drowsiness, C. dry mouth, D. constipation, E. blurred vision, F. extrapyramidal reaction, G. excess weight gain, H. edema, I. postural hypotension, J. sweating, K. loss of appetite, L. urinary retention, M. nausea and vomiting, N. confusion, O. anxiety, P. other.

-Monitor antipsychotic Seroquel common side effects two times a day. Indicate letter if observed and document in EMR if needed: A. sedation, B. drowsiness, C. dry mouth, D. constipation, E. blurred vision, F. extrapyramidal reaction, G. excess weight gain, H. edema, I. postural hypotension, J. sweating, K. loss of appetite, L. urinary retention, M. other.

Resident #20's June 2024 TAR documented the following:

-Amitriptyline side effect monitoring had blank spaces on 06/06/2024, 06/14/2024, and 06/22/2024. The other dates of the month documented a check for confirmation of side effect monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -Seroquel side effect monitoring had blank spaces on 06/06/2024, 06/14/2024, and 06/22/2024. The other dates of the month documented a check for confirmation of side effect monitoring. Level of Harm - Minimal harm or potential for actual harm Resident #20's progress notes lacked documented evidence of antidepressant or antipsychotic side effect monitoring on 06/06/2024, 06/14/2024, and 06/22/2024. Residents Affected - Few Pain Monitoring

A physician's order dated 04/17/2024, documented to assess pain every shift using a 0-10 scale or verbal descriptor scale for pain monitoring related to pain in the right hip and other chronic pain.

Resident #20's June 2024 TAR had a blank space for pain monitoring on the day shift of 06/15/2024.

Resident #20's progress notes lacked documented evidence of pain monitoring on 06/15/2024.

COVID-19 Symptom Monitoring

A physician's order dated 04/17/2024, documented COVID-19 monitoring to include assessing for fever, cough, sore throat, shortness of breath, headache, chills, vomiting, diarrhea, new loss of taste or smell, muscle pain, and diarrhea. Document N for no symptoms present and Y for symptoms present. Notify the doctor and document symptoms in progress note every shift for COVID-19 screening.

Resident #20's June 2024 TAR lacked documented evidence COVID-19 symptoms were monitored during

the day shift on 06/15/2024.

Resident #20's progress notes lacked documented evidence of COVID-19 symptom monitoring on 06/15/2024.

Behavior Monitoring

Resident #20's physician's orders dated 04/17/2024, documented the following:

- Monitor for target behaviors r/t amitriptyline use. Target Behaviors: 1. yelling out for help, 2. verbal behaviors toward others, 3. physical behaviors toward others, 4) refusal of cares

-Monitor for target behaviors related to antipsychotic use two times a day. 1. Refusals of care, 2. verbal behaviors toward others, 3. disruptive behaviors in the dining hall

Resident #20's June 2024 TAR documented the following:

-Amitriptyline behavior monitoring had blank spaces at 3:00 PM on 06/06/2024, 06/14/2024, and 06/22/2024.

The other dates of the month document a check for confirmation of side effect monitoring.

-Seroquel behavior monitoring had blank spaces at 3:00 PM on 06/06/2024, 06/14/2024, and 06/22/2024.

The other dates of the month document a check for confirmation of side effect monitoring.

Resident #20's progress notes lacked documented evidence of antidepressant or antipsychotic behavior monitoring on 06/06/2024, 06/14/2024, and 06/22/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 On 07/17/2024 at 2:07 PM, a Registered Nurse (RN) verbalized a blank space in the TAR would mean the administering nurse did not document in the EMR. If monitoring was not completed, an indication should be Level of Harm - Minimal harm or documented using the key on the TAR. The RN explained progress notes could be linked with further potential for actual harm descriptions if the monitoring had not occurred. The RN confirmed blank spaces on Resident #20's June 2024 TAR for treatment, side effect monitoring, pain monitoring, COVID-19 symptom monitoring, and Residents Affected - Few behavior monitoring on the days and times mentioned above.

On 07/17/2024 at 2:33 PM, a Licensed Practical Nurse (LPN) explained a blank space on the TAR could mean the time frame for administration passed. For monitoring, administering nurses had the whole shift to observe and document. The LPN verbalized even if the resident was not available or outside of the facility,

the administering nurse should indicate it on the TAR.

On 07/17/2024 at 4:06 PM, the Director of Nursing (DON) confirmed blank spaces on the TAR for treatment, side effect monitoring, pain monitoring, COVID-19 symptom monitoring, and behavior monitoring on the days and times mentioned above. The DON explained those blank spaces meant the administering nurses forgot to document on those days and times.

The facility policy titled Psychoactive Medication Use, Intervention and Monitoring, revised 12/2016, documented if the resident was treated for altered behavior, the interdisciplinary team would document any improvements or worsening in the individual's behavior, mood, and function. If the resident used psychoactive medications, the psychotropic committee would monitor for side effects and complications related to those medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311 potential for actual harm Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) Residents Affected - Many Enhanced Barrier Precautions (EBP) were implemented for 2 of 7 sampled residents (Resident #58 and #69), 2) the facility peformed active infection surveillance for July 2024, 3) a Licensed Practical Nurse (LPN) performed hand hygiene between residents while administering medications and 4) a resident on contact precautions did not share a room with another resident who did not have the same infection with the same microorganism, did not have meals in a shared dining room, and staff understood the Personal Protective Equipment (PPE) requirements when entering a room with contact precuation signage in place for 1 of 18 sampled residents (Resident #40).

Findings include:

Enhanced Barrier Precautions

Resident #58

Resident #58 was admitted to the facility on [DATE REDACTED], with diagnoses including chronic obstructive pulmonary disease, unspecified, type II diabetes mellitus without complications, benign prostatic hyperplasia without lower urinary tract symptoms, and acute on chronic respiratory failure with hypoxia.

A physician order dated 04/25/2024, documented 16 French 10 cubic centimeters (cc) Foley catheter as needed related to neuromuscular dysfunction of bladder, unspecified.

Resident #69

Resident #69 was admitted to the facility on [DATE REDACTED], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, apraxia, dysarthria and anarthria, and pressure ulcer of sacral region, Stage III.

A physician order dated 07/10/2024, documented the following for wound treatment:

-cleanse coccyx with wound cleaner, pat dry, apply hydrogel to wound bed and cover with foam dressing. Monitor for any signs or symptoms of infection, notify provider with any concerns. Every day shift Monday, Wednesday, Saturday related to pressure ulcer of sacral region, Stage III.

Resident #69's Care Plan, last reviewed 06/03/2024, documented the resident's care was to be provided using EBP protocol.

On 07/15/2024 at 5:35 PM, during a facility tour, Resident #69 and Resident #58's rooms did not have an EBP sign on the resident's room door or on the wall outside of each door. Both rooms lacked a PPE cart outside the room doors.

On 07/16/2024 at 1:54 PM, the IP/ADON explained any resident receiving wound care should have EBP and confirmed Resident #69 received wound care three times weekly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/16/2024 at 2:42 PM, Resident #69 and #58's rooms did not have EBP signage on the room door or a PPE cart outside the rooms. Level of Harm - Minimal harm or potential for actual harm On 07/16/2024 at 2:47 PM, the IP/ADON explained each resident on EBP should have a sign on the door indicating EBP in use and what PPE to wear. The IP/ADON verbalized all residents with an indwelling Residents Affected - Many catheter would be placed on EBP and confirmed Resident #58 had an indwelling catheter.

On 07/16/2024 at 3:15 PM, the IP/ADON communicated the facility used the Centers for Disease Control (CDC) signage for resident precautions. EBP would include residents with a Foley catheter, an ostomy, and

a wound requiring a dressing change. The IP/ADON explained the purpose of using the EBP was to protect

the resident from possible transmission of infection and to protect staff from carrying the infection on staff clothing.

On 07/16/2024 at 5:07 PM, the Director of Nursing (DON) explained infection precautions were based on the provider's recommendations and the CDC recommendations for EBP, PPE, and isolation. The DON communicated the infection control program was intended to prevent the spread of infection and prevent cross-contamination between the staff and residents and the IP was responsible for the program. The DON expected staff to don/doff gowns and gloves during care of resident's on EBP.

On 07/18/2024 at 8:39 AM, the IP/ADON confirmed the facility followed the CDC guidance for infection control. The IP/ADON confirmed the facility did not follow CDC standards with the lack of EBP signage and PPE carts at the point of care for Resident #58 and #69.

The facility policy titled Infection Control, revised 01/31/2024, documented all residents with known or suspected infectious conditions would be cared for using the most appropriate nursing care for the benefit and safety of the resident concerned, the other residents in the facility, and employee safety.

A Centers for Medicare and Medicaid memo titled Quality, Safety, and Oversight (QSO)-24-08-Nursing Homes (NH), dated 03/20/2024, documented EBP recommendations included the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of

the multidrug-resistant organism status, in addition to residents who had an infection or colonization with a CDC-targeted other epidemiologically important [NAME] Drug Restistant Organisms (MDROs). Staff should be aware of which residents require the use of EBP prior to providing high-contact care. It was critical to ensure staff had awareness of the facility's expectations about hand hygiene and gown/glove use and access to appropriate supplies. This was accomplished by the following:

Surveillance

On 07/16/2024 at 1:58 PM, the Antibiotic Stewardship binder did not include infections, antibiotic use, tracking, room mapping, or trending for July 2024. The IP/ADON could not produce a Monthly Antibiotic/Infection Control Log for July 2024 and confirmed the IP/ADON had not yet performed infection trending or tracking for the month of July because the IP had been on vacation. The IP/ADON explained the IP/ADON kept track of infections in handwritten notebooks throughout the month and confirmed the IP/ADON had not yet started an infection notebook for July 2024 and could not produce the June 2024 notebook.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/16/2024 at 3:01 PM, the IP/ADON explained the facility used Point Click Care (PCC) as the facility's electronic documentation system. PCC included a screening tool completed by nursing staff when an Level of Harm - Minimal harm or infection was suspected. The IP/ADON would see the information on the dash board in PCC, discuss the potential for actual harm resident in the daily clinical meeting, would document the discussion in the handwritten notebook, and transfer the information to the Monthly Antibiotic/Infection Control Log at the end of each month. Residents Affected - Many

An infection map was used to locate each type of infection by resident room and was completed monthly.

The IP/ADON confirmed a map for July 2024 had not yet been created and would only include residents who were taking an antibiotic, omitting residents with infections not currently treated with antibiotics, including a wound infection of Methicillin Resistant Staphylococcus Aureus (MRSA). The IP/ADON explained the IP/ADON would not know if an infection was currently contained or spreading throughout the facility as there was not a current infection map for July 2024.

On 07/18/2024 at 9:10 AM, the Administrator confirmed the IP/ADON was responsible for oversight and execution of the Infection Control and Prevention Program and the Antibiotic Stewardship program.

A job description titled Assistant Director of Nursing, documented the primary responsibilities of the ADON included supervision of the infection control and antibiotic stewardship program. Specific duties included completion of the weekly Infection Control Report, review numbers of infections and isolations to determine areas of concern, monitor completion of weekly measurements and documentation of wounds, and monitor/ensure compliance of standard precautions, the vaccine program, bloodborne pathogens, and CDC guidelines for isolation/treatment of infections.

49557

Hand Hygiene During Medication Pass

On 07/17/2024, during the medication pass from 4:11 PM through 4:24 PM, an LPN administered medications to five residents and did not perform hand hygiene prior to preparing medication for each resident, prior to administering medication to each resident, or after administering medication to each resident.

On 07/17/2024 at 4:25 PM, the Licensed Practical Nurse (LPN) confirmed the LPN did not perform hand hygiene prior to medication preparation and administration or after medication administration. The LPN explained hand hygiene was required to be performed between each resident.

On 07/18/2024 at 9:06 AM, the DON explained hand hygiene was required to be performed by staff prior to any initiation of care with a resident. The DON confirmed hand hygiene was required to be performed during medication pass, prior to and after each resident interaction.

The facility policy titled Infection Control, revised 01/31/2024, documented hand washing was the foundation of controlling infectious disease. Personnel were to wash hands when between residents.

Contact Precautions

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/15/2024 at 1:12 PM, room [ROOM NUMBER] had a sign on the door indicating contact precautions were in place. The sign stated everyone must perform hand hygiene before entering and when leaving the Level of Harm - Minimal harm or room, providers/staff must put on gloves and a gown before entering the room. A PPE cart was located potential for actual harm outside the door, in the hallway. The placard on the wall outside the room indicated the room belonged to Resident #40 and Resident #26. Residents Affected - Many Resident #26

Resident #26 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic kidney disease, stage five and type two diabetes mellitus with diabetic chronic kidney disease.

Resident #40

Resident #40 was admitted to the facility on [DATE REDACTED], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and pressure ulcer of right buttock, unstageable.

On 07/16/2024 at 8:31 AM, Resident #26 explained the contact precaution sign on the resident's door was intended for Resident #40 due to wounds on Resident #40's legs. Resident #26 denied staff regularly wore a gown or gloves while providing care to Resident #26.

On 07/16/2024 at 9:16 AM, a Certified Nursing Assistant (CNA)1 entered room [ROOM NUMBER]. The CNA1 was not wearing a gown or gloves.

On 07/16/2024 at 9:48 AM, a CNA2 explained the sign on the door of room [ROOM NUMBER] was in place because Resident #40 had a wound on the resident's hip. The CNA2 further explained the sign was intended to notify staff to don a gown when providing care to Resident #40 if the care required physical contact with

the resident. The CNA2 verbalized a gown was not required when providing care to Resident #26.

On 07/16/2024 at 1:30 PM, an LPN explained staff received infection control training quarterly. The LPN confirmed the training covered the topics of EBP and transmission-based precautions (TBP). The LPN explained staff knew a resident was on EBP or TBP by a sign on the resident's door. The LPN verbalized the sign would instruct staff on what PPE was required and when staff was required to wear it.

The LPN explained Resident #40 was on contact precautions due to a wound cultured and positive for Methicillin-Resistant Staphylococcus Aureus (MRSA). The sign meant staff were required to don a gown and gloves for hands on care for Resident #40 such as showers, transfers, and changing the resident's clothing.

A gown and gloves were not required when staff were only walking in the room. The LPN explained the intent of using a gown and gloves when providing care to Resident #40 was to prevent the transfer of MRSA onto staff clothing which could then be transferred to other residents.

An Antimicrobial Susceptibility and Organism Identification Report with a collection date of 06/19/2024, and a reported date of 06/22/2024, documented a culture from Resident #40's right gluteal was positive for MRSA.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident #40's Care Plan included a focus of MRSA: The resident had MRSA to a stage four pressure injury to right gluteal. The date initiated was 07/01/2024, and was revised on 07/15/2024. Interventions included: Level of Harm - Minimal harm or potential for actual harm -Contact Precautions. Wear gown and masks when changing contaminated linens. Place soiled linens in marked biohazard. Bag linens and close bag tightly before taking to laundry. Residents Affected - Many -Mask/face shield to be worn during procedures with risk of splashes or droplet contamination of bodily fluids.

-Observe standard precautions for infection control.

-Open wounds should be kept covered, rather than open to air.

-Resident areas to be thoroughly cleaned using disinfectants.

-Resident care equipment to be appropriately cleaned, disinfected or sterilized according to facility protocol.

A progress note dated 06/23/2024, documented Resident #40's dressing on the resident's right glute was saturated and coming off.

A progress note dated 06/27/2024, documented Resident #40's dressing on the resident's right gluteal was saturated and coming off.

A progress note dated 07/01/2024, documented Resident #40 was on MRSA precautions.

A progress note dated 07/01/2024, documented Resident #40's wound culture came back positive for MRSA.

A progress note dated 07/04/2024, documented Resident #40's dressing on the resident's right glute was saturated and falling off.

A progress note dated 07/05/2024, documented Resident #40's dressing on the resident's right glute was saturated and falling off.

A progress note dated 07/11/2024, documented Resident #40's dressing on the resident's right glute was coming off.

Progress notes dated from 06/23/2024 through 07/14/2024, documented Resident #40 was in the shared dining room for meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/16/2024 at 3:01 PM, the Minimum Data Set (MDS) Coordinator explained the MDS Coordinator updated residents' care plans based on interviews with the residents, meetings held with the interdisciplinary Level of Harm - Minimal harm or team (IDT), and clinical record review. The MDS Coordinator confirmed Resident #40's care plan included an potential for actual harm intervention for contact precautions due to MRSA. The MDS Coordinator explained this intervention was added to Resident #40's care plan by the MDS Coordinator after the MDS Coordinator read a progress note Residents Affected - Many in the resident's clinical record. The progress note indicated a lab result came back showing the resident was positive for MRSA. The MDS Coordinator explained adding the intervention to the care plan would give floor staff access to see the resident was positive for MRSA and the interventions needing to be implemented.

The MDS Coordinator then verbalized the IP/ADON would be responsible to place precaution signage on the resident's door and a PPE cart in the hall.

On 07/16/2024 at 3:15 PM, the IP/ADON explained the IP/ADON and/or the physician were able to make decisions on when to place residents on TBP or EBP. The IP/ADON used resident symptoms to guide the decision on which precautions were appropriate and if a resident had a wound the facility was culturing it would be more of a contact thing. The IP/ADON verbalized the facility used and followed CDC signage when placing a resident on TBP. The IP/ADON explained contact precautions were used when contact was how a possible contaminant was spread, staff were to wear a gown and gloves when providing care. The IP/ADON explained if a resident was on contact precautions due to a wound, and the wound was covered with a dressing, staff were not required to wear PPE if the care being provided did not include contact with the resident.

The IP/ADON explained examples of when EBP was used were when residents had ostomies, catheters, and any wound requiring a dressing change. EBP was used to protect residents from possible transmission of infection and protected staff so the infection was not carried on clothing. With EBP, care such as showering, transfers, and anything with close contact required staff to wear a gown and gloves.

The IP/ADON verbalized contact precautions and EBP were similar and it depended on if the infected area was covered or not. The IP/ADON explained the facility had one resident on contact precautions and the resident was allowed to come out of the resident's room and eat meals in the shared dining room because

the resident's wound was covered. The IP/ADON confirmed the resident the IP/ADON was referring to was Resident #40.

On 07/16/2024 at 3:21 PM, the IP/ADON retrieved a copy of the CDC signage the facility used for EBP and contact precautions and placed them side by side. The IP/ADON confirmed the sign for EBP instructed staff to don a gown and gloves prior to high-contact care activities. The IP/ADON confirmed the contact precautions sign instructed staff to don a gown and gloves prior to room entry and the sign did not specify PPE was only required for direct contact with the resident.

The IP/ADON explained Resident #40 was previously on EBP. The resident was later placed on contact precautions after a culture of the resident's wound was positive for MRSA. The IP/ADON believed the wound culture result was received on 06/29/2024. The intent of placing Resident #40 on contact precautions was so staff would know the resident had an infection with the potential to spread.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/16/2024 at 3:35 PM, the IP/ADON provided a copy of the facility's TBP policy. The IP/ADON confirmed the policy stated residents on contact precautions were to be placed in a private room. The Level of Harm - Minimal harm or IP/ADON confirmed Resident #40 was not in a private room. The IP/ADON confirmed Resident #40's potential for actual harm roommate, Resident #26, had a dialysis port in the resident's right upper chest. The IP/ADON confirmed placing Resident #26 in a shared room with Resident #40 put Resident #26 at an increased risk of Residents Affected - Many contracting an MDRO.

On 07/16/2024 at 5:07 PM, during an interview with the DON and in the presence of the IP/ADON, the DON confirmed the DON provided oversight of the IP/ADON. The DON confirmed MRSA was an MDRO. The DON explained the intent of TBP was to prevent the spread of infections. The facility followed CDC and physician recommendations when deciding to place residents on TBP. The DON verbalized it was the DON's understanding if staff entered a resident's room with contact precautions in place, and did not come into contact with the resident, staff would not be required to don PPE. The DON verbalized the DON knew MRSA could be detrimental to immunocompromised residents.

The DON verbalized it was questionable whether a resident on contact precautions should be in a shared room. The DON confirmed the facility's policy stated to place a resident on contact precautions in a private room or with a resident with the same infection with the same microorganism. The DON confirmed Resident #40 had dressings described as saturated prior to 07/15/2024.

On 07/17/2024 at 7:07 AM, Resident #26 was observed to have been moved to another room. Resident #40 remained in room [ROOM NUMBER], a CDC contact precautions sign remained on the door, and a PPE cart remained in the hall near the resident's doorway.

The facility policy titled Infection Control, revised 01/31/2024, documented residents who were diagnosed as having an infectious disease or condition which did not warrant strict isolation procedures were to be restricted to the residents' rooms if the infection could not be contained. Activities were to be controlled such as going to the dining room and visitors to the room were to be limited. The purpose of isolation techniques was to protect the resident and personnel from infection and to halt the spread of infectious agents.

The facility policy titled Categories of Transmission-Based Precautions, revised 01/2024, documented it was

the policy of the facility to follow nationally recognized standards and guidelines for transmission-based (isolation) precautions. Transmission-based precautions would be implemented, in addition to standard precautions, and were based upon the means of transmission in order to prevent or control infections. Contact precautions were implemented for residents known to be infected or colonized with organisms which could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring contact precautions included but were not limited to skin or wound infections or colonization with MDROs. Residents were to be placed in a private room or placed with a resident with the same infection with the same microorganism. Gloves were to be worn upon entering the room if contact with the resident or potentially contaminated surfaces was possible. Staff were to wear a gown when entering the room if it was anticipated staff would have substantial contact with the resident, the resident's environment, or items in the resident's room. Gowns were required if the resident had wound drainage not contained by a dressing.

The facility policy did not follow CDC guidance regarding gown and glove usage when entering resident rooms with contact precautions in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The CDC document titled Management of Multidrug-Resistant Organisms in Healthcare Settings (2006), updated 10/2022, documented recommendations for MDRO prevention in long-term care facilities included Level of Harm - Minimal harm or using contact precautions in addition to standard precautions for those residents whose infected secretions potential for actual harm or drainage could not be contained. Contact precautions were intended to prevent transmission of infectious agents which were transmitted by direct or indirect contact with the resident or the resident's environment. Residents Affected - Many Recommendations for resident placement included placing residents with MDROs in single-resident rooms or cohorting residents with the same MDRO when a single room was not available. A single resident room was preferred for residents who require contact precautions. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for all interactions which may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning a gown and gloves upon room entry and discarding before exiting the resident room was done to contain pathogens.

The CDC document titled Transmission-Based Precautions, dated 04/03/2024, documented contact precautions were to be used for residents with known or suspected infections which represented an increased risk for contact transmission. Transport and movement of residents outside of the resident's room was to be limited to medically-necessary purposes. When transport or movement was necessary, infected or colonized areas of the resident's body were to be covered and staff were to don clean PPE to handle the resident at the transport location.

A CDC document titled Implementation of PPE Use in Nursing Homes to Prevent Spread of MDROs, dated 07/12/2022, described EBP as an infection control intervention designed to reduce transmission of MDROs

in nursing homes. EBP involved gown and glove use during high contact resident care areas for residents known to be colonized or infected with an MDRO, as well as those at increased risk of acquiring MDROs, such as residents with wounds or indwelling medical devices. Effective EBP implementation required staff training on PPE and the availability of PPE and hand hygiene supplies at the point of care.

Cross reference with tag

F-F882

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311

Residents Affected - Some Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure

the Infection Preventionist (IP) had the education and competency to demonstrate the tracking and trending of infections was accurately completed and monitored with the potential to affect the facility's entire resident census of 79, 2) retain education and training when the Infection Preventionist did not demonstrate competency in the implementation of the Antibiotic Stewardship Program (ASP) and infection surveillance (lack of competency in medication differentiation, inaccurate infection control log, lack of infection surveillance), and 3) demonstrate understanding of contact precautions and following of the Center for Disease Control (CDC) guidance related to the implementation of contact precautions for 1 of 18 sampled residents (Resident #40).

Findings include:

Education/Competency

On 07/16/2024 at 1:58 PM, the Antibiotic Stewardship binder did not include infections, antibiotic use, tracking, room mapping, or trending for July 2024. The Infection Preventionist (IP)/Assistant Director of Nursing (ADON) could not produce a Monthly Antibiotic/Infection Control Log for July and confirmed the IP/ADON had not yet performed infection trending or tracking for the month of July 2024, because the IP/ADON had been on vacation for three days in July. The IP/ADON explained the IP/ADON usually kept track of infections in handwritten notebooks throughout the month and confirmed the IP/ADON had not yet started an infection notebook for July 2024.

On 07/16/2024 at 3:01 PM, the IP/ADON explained an infection map was to be used to locate each type of infection by resident room and was to be completed monthly to identify trends. The IP/ADON explained the infection tracking and mapping occurred at the end of the month and would not have a current infection or antibiotic resident list. The IP/ADON confirmed a map for July 2024, had not yet been created and would only include residents who were taking an antibiotic, thus omitting residents with infections not currently treated with antibiotics.

ASP

On 07/16/2024, the Antibiotic Stewardship binder lacked identification of infections, antibiotic use, tracking, room mapping, and trending for July 2024.

On 07/16/2024, in the afternoon, the IP/ADON was asked to produce a list of all residents currently on antibiotics.

On 07/16/2024 at 2:37 PM, the IP/ADON produced an Order Listing Report dated 07/16/2024 and printed at 2:06 PM, which was generated from the facility's electronic documentation system. The report listed five residents who were supposed to be prescribed antibiotics, however only two of the residents were on an antibiotic, two residents were on an antifungal medication, and one resident was on an anti-viral medication.

The IP/ADON confirmed the provided list was accurate and complete to include all residents currently on an antibiotic.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 The IP/ADON lacked the understanding of the difference between an antibiotic medication, an antifungal medication, and an antiviral medication. Level of Harm - Minimal harm or potential for actual harm On 07/16/2024 at 3:01 PM, the IP/ADON verbalized the IP/ADON had not been tracking infections not associated with an antibiotic prescription and did not include those infections on the facility mapping to trend Residents Affected - Some infection spread. The IP/ADON explained the IP/ADON would not know if an infection was currently contained or spreading throughout the facility as there was not a current infection map for July 2024.

The IP/ADON explained the daily stand up meeting members would discuss any new infections or suspected infections but did not document the data or map the rooms to ascertain infection spread throughout the facility. The IP/ADON confirmed the lack of surveillance of infections and antibiotics for July 2024.

On 07/18/2024 at 9:10 AM, the Administrator confirmed the IP was responsible for the execution of the Infection Control and Prevention Program and the Antibiotic Stewardship program. The Administrator confirmed the lack of an IP job description and explained the role was considered a nursing role of the ADON.

A job description titled Assistant Director of Nursing, documented the primary responsibilities of the ADON included supervision of the infection control and antibiotic stewardship program. Specific duties included completion of the weekly Infection Control Report, reviewed numbers of infections and isolations to determine areas of concern, monitor completion of weekly measurements and documentation of wounds, and monitor/ensure compliance of standard precautions, the vaccine program, bloodborne pathogens, and CDC guidelines for isolation/treatment of infections.

The facility policy titled Antibiotic Stewardship, revised 01/31/2024, documented the facility would follow an Antibiotic Stewardship program which included the core elements as outlined by the CDC. The Infection Preventionist was the designated coordinator of the Infection Prevention and Control Program. The facility would track antibiotic use daily and would monitor for all adverse reactions/outcomes related to antibiotic therapy.

A CDC document titled Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/2024, documented the seven core elements of the ASP was as follows:

-Leadership Commitment: Demonstrate and support safe and appropriate antibiotic use.

-Accountability: Identify nursing, physician, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship.

-Drug expertise: establish access to individuals with experience or training in antibiotic stewardship.

-Action: Implement at least policy or practice to improve antibiotic use.

-Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 -Reporting: Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff. Level of Harm - Minimal harm or potential for actual harm Cross-reference with tag

F-F883

Residents Affected - Some 49557

Contact Precautions

On 07/15/2024 at 1:12 PM, room [ROOM NUMBER] had a CDC sign on the door indicating contact precautions were in place. The sign stated everyone must perform hand hygiene before entering and when leaving the room, providers/staff must put on gloves and a gown before entering the room. A Personal Protective Equipment (PPE) cart was located outside the door, in the hallway. The placard on the wall outside the room indicated the room belonged to Resident #40 and Resident #26.

Resident #40

Resident #40 was admitted to the facility on [DATE REDACTED], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and pressure ulcer of right buttock, unstageable.

Resident #26

Resident #26 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic kidney disease, stage five and type two diabetes mellitus with diabetic chronic kidney disease.

On 07/16/2024 at 8:31 AM, Resident #26 explained the contact precaution sign on the resident's door was intended for Resident #40 due to wounds on Resident #40's legs. Resident #26 denied staff regularly wore a gown or gloves while providing care to Resident #26.

On 07/16/2024 at 3:15 PM, the IP/ADON explained the IP/ADON and/or the physician were able to make decisions on when to place residents on TBP or EBP. The IP used resident symptoms to guide the decision

on which precautions were appropriate and if a resident had a wound the facility was culturing it would be more of a contact thing. The IP/ADON verbalized the facility used and followed CDC signage when placing a resident on TBP. The IP/ADON explained if a resident was on contact precautions due to a wound, and the wound was covered with a dressing, staff were not required to wear PPE if the care being provided did not include contact with the resident. The IP/ADON verbalized contact precautions and EBP were similar and it depended on if the infected area was covered or not.

On 07/16/2024 at 3:21 PM, the IP/ADON retrieved a copy of the CDC signage the facility used for EBP and contact precautions and placed them side by side. The IP/ADON confirmed the sign for EBP instructed staff to don a gown and gloves prior to high-contact care activities. The IP/ADON confirmed the contact precautions sign instructed staff to don a gown and gloves prior to room entering the room and sign did not specify PPE was only required for direct contact with the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 The IP/ADON explained Resident #40 was previously on EBP and was later placed on contact precautions when a culture of the resident's wound was positive for MRSA. The IP/ADON believed the culture result was Level of Harm - Minimal harm or received on 06/29/2024, and the intent of placing Resident #40 on contact precautions was so staff would potential for actual harm know the resident had an infection with the potential to spread.

Residents Affected - Some On 07/16/2024 at 3:35 PM, the IP/ADON provided a copy of the facility's TBP policy. The IP/ADON confirmed the policy stated residents on contact precautions were to be placed in a private room. The IP/ADON confirmed Resident #40 was not in a private room.

A Job Description: Assistant Director of Nursing, signed and dated by the IP/ADON on 06/26/2023, documented the IP/ADON was responsible to monitor and ensure compliance with CDC guidelines for isolation/treatment of infections.

The facility policy titled Categories of Transmission-Based Precautions, revised 01/2024, documented it was

the policy of the facility to follow nationally recognized standards and guidelines for transmission-based (isolation) precautions. Transmission-based precautions would be implemented, in addition to standard precautions, and were based upon the means of transmission in order to prevent or control infections. Contact precautions were implemented for residents known to be infected or colonized with organisms which could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring contact precautions included but were not limited to skin or wound infections or colonization with MDROs. Residents were to be placed in a private room or placed with a resident with the same infection with the same microorganism.

The CDC document titled Management of Multidrug-Resistant Organisms in Healthcare Settings (2006), updated 10/2022, documented recommendations for MDRO prevention in long-term care facilities included using contact precautions in addition to standard precautions for those residents whose infected secretions or drainage could not be contained. Recommendations for resident placement included placing residents with MDROs in single-resident rooms or cohorting residents with the same MDRO when a single room was not available. A single resident room was preferred for residents who require contact precautions. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for all interactions which may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning a gown and gloves upon room entry and discarding before exiting the resident room was done to contain pathogens.

The CDC document titled Transmission-Based Precautions, dated 04/03/2024, documented contact precautions were to be used for residents with known or suspected infections which represented an increased risk for contact transmission.

The CDC document titled Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes, dated 06/28/2024, documented EBP differed from contact precautions as contact precautions required the use of a gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311 potential for actual harm Based on clinical record review, interview, and document review the facility failed to ensure a resident was Residents Affected - Few screened for eligibility to receive the influenza and pneumococcal vaccinations for 1 of 5 residents sampled for vaccinations (Resident #26).

Findings include:

Resident #26

Resident #26 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with a diagnoses including chronic kidney disease, Stage IV, type II diabetes mellitus with diabetic chronic kidney disease, dependence

on renal dialysis, and acute and chronic respiratory failure with hypoxia.

A facility document titled Influenza Vaccine Immunization Assessment/Consent, signed 05/02/2023, documented the following:

-Risk Assessment: blank

-Assessment for contraindications to pneumococcal vaccine: blank

-Consent for immunization: signed by resident and documented the influenza vaccine was administered on 05/02/2023.

A facility document titled Pneumococcal Vaccine Immunization Assessment/Consent, signed 05/02/2023, documented the following:

-Assessment of pneumococcal immunization status: blank

-Assessment for Contraindications: blank

-Consent for immunization: signed by resident on 05/02/2023.

Resident #26's clinical record lacked documented evidence the resident was screened for eligibility to receive the influenza and pneumococcal vaccines.

On 07/18/2024 at 8:45 AM, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) communicated the expectation was for all residents to be screened for eligibility of the pneumococcal and influenza vaccines to ensure it was safe to administer the vaccinations to the residents. The IP/ADON confirmed Resident #26 had signed the consent and received the vaccinations but was not screened for eligibility of the influenza and pneumococcal vaccines prior to administration.

On 07/18/2024 at 9:10 AM, the Administrator confirmed the IP was responsible for the execution of the Infection Control and Prevention Program and the Antibiotic Stewardship program. The Administrator confirmed the lack of an IP job description and explained the role was considered a nursing role of the ADON.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 295078 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295078 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Manor of Elko Rehabilitation LLC 2850 Ruby Vista Drive Elko, NV 89801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The facility policy titled Influenza Vaccination, revised on 01/31/2024, documented a resident's immunization status was assessed annually and were screened for contraindication prior to administering the vaccine. Level of Harm - Minimal harm or potential for actual harm The facility policy titled Pneumococcal Vaccination, revised on 01/31/2024, documented all residents aged [AGE] years or more and all residents determined to be at high risk would be offered the pneumococcal Residents Affected - Few vaccine as recommended by the CDC. The resident would be screened for contraindications prior to administering the pneumococcal vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 295078