South Lyon Medical Center

F-F880

The facility policy titled Quality Management Program, last revised 11/2017, documented the QAPI committee, with the support and approval of the Governing Body, had the responsibility for monitoring every aspect of resident care and service from the time the resident entered the facility, through diagnosis, treatment, recovery, and discharge in order to identify and resolve any breakdowns with the potential to result in sub-optimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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** 43310 potential for actual harm Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) Residents Affected - Some the Infection Control and Prevention Plan (IPCP) policy was reviewed annually, and 2) enhance barrier precautions (EBP) were being implemented for 2 of 2 residents with indwelling medical devices (Resident #1 and #4).

Findings include:

Infection Control and Prevention Plan

The facility's IPCP policy documented the policy was last reviewed by the facility on 10/2022. The facility was not able to provide evidence the policy had been reviewed and/or revised after 10/2022. The policy referred to IPCP as the hospital's IPCP, referenced duties for hospital staff, and did not include language indicating

the policy included the Long Term Care facility.

The IPCP lacked the following elements:

-a list of reportable communicable diseases and a process for reporting to the appropriate state agencies.

-prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease.

-a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, multi-drug resistant organisms (MDRO)status, special instructions or precautions including transmission based precautions (TBP), medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable.

-a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type.

The IPCP policy referenced an additional policy titled List of Nationally Notifiable Diseases, last revised 06/2020. The policy did not list the reportable diseases but provided two links to the most current nationally notifiable diseases. The links were dated 2020 and neither of the links were active. At the bottom of the policy, under references, an active link was provided. The policy did not include guidance for prohibition of employees with communicable diseases or a process for reporting to the appropriate agencies.

On 07/18/24 at 8:00 AM, the DON confirmed the IPCP lacked the following elements:

-a list of reportable communicable diseases and a process for reporting to the appropriate state agencies.

-prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 -a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, MDRO status, special instructions or precautions including TBPs, medications, lab work, other diagnostics, Level of Harm - Minimal harm or test results, treatments, and discharge summary if applicable. potential for actual harm -a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other Residents Affected - Some facility type.

On 07/18/2024 at 8:45 AM, the Director of Nursing (DON) confirmed the IPCP provided was the policy used by the facility.

The facility policy titled Infection Prevention and Control Program, revised 10/2022, documented the IPCP was conducted in accordance with all applicable federal and state rules and regulations. The IPCP was evaluated annually and whenever risk had significantly changed. Revisions were made as appropriate.

Enhanced Barrier Precautions

Resident #1

Resident #1 was admitted to the facility on [DATE REDACTED], and last readmitted to the facility on [DATE REDACTED], with diagnoses including quadriplegia, unspecified, calculus of kidney, and other artificial openings of urinary tract status.

Resident #1's Comprehensive Care Plan documented Resident #1 had a urostomy related to complications of quadriplegia.

Resident #4

Resident #4 was admitted to the facility on [DATE REDACTED], with a diagnosis of multiple sclerosis, neuromuscular dysfunction of bladder, retention of urine, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms.

Resident #4's Comprehensive Care Plan documented Resident #4 had a suprapubic catheter related to urinary retention, possibly related to the inhibition of the reflex arc, secondary to multiple sclerosis.

On 07/15/2024 at 8:03 AM, the DON confirmed Resident #1 and #4 both had indwelling medical devices and should have had Enhanced Barrier Precautions (EBP) in place. The DON confirmed EBP had not been initiated and/or implemented for Resident #1 and #4.

On 07/15/2024 at 9:48 AM, during an inspection of the facility, TBP including EBP, were not in place for any of the resident rooms, including Resident #1 and #4.

On 07/18/2024 at 8:18 AM, the DON verbalized diagnostic testing and symptoms were used to determine if a resident needed to be placed in TBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 A facility policy titled Enhanced Barrier Precautions, last revised 07/2024, with an effective date of 01/2024, documented the facility ensured staff used EBPs while caring for residents with wounds and indwelling Level of Harm - Minimal harm or medical devices. Effective implementation of EBP included staff training on the proper use of personal potential for actual harm protective equipment (PPE) and the availability of PPE and hand hygiene products at the point of care. Clear signage was to be posted outside of the resident room indicating the type of PPE required and to define the Residents Affected - Some high risk patient care activities. Gowns, gloves and alcohol-based hand rub were available outside of the residents room. A trash can was made available for the disposal of PPE for each room. EBPs were continued for the duration of the resident's stay.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 43310 potential for actual harm Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) Residents Affected - Many the facility's Antibiotic Stewardship Program (ASP) policy was reviewed annually, 2) education regarding the ASP/antibiotic use was provided to staff and residents, #3) a process was in place to ensure the Infection Preventionist (IP) was made aware when a resident had a new infection and an antimicrobial medication was prescribed, 4) an antibiotic time out was performed to ensure the best treatment was being provided to residents, and 5) the IP had a process in place related to communicating infection, treatment, and prescribing concerns to prescribing providers.

Findings include:

Antibiotic Stewardship Policy

A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, lacked the following components:

-Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics

-A process for periodic review of antibiotic use by prescribing practitioners such as: review of labs and med orders, progress notes and medication administration records to determine if an infection or communicable disease was documented and whether an appropriate antibiotic was used for the recommended length of time.

-A process for reviewing antibiotic use when a resident is newly admitted , returns, or is transferred from another facility/hospital.

-Protocols to ensure the proper antibiotics are prescribed.

-A system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners.

The policy documented the ASP program included the following components, but failed to document how each element was accomplished and/or the guidelines used.

-Formal programs for tracking, auditing, and reporting antimicrobial use.

-Clinician and patient education on antimicrobial use.

-Use of nationally recognized antimicrobial use guidelines.

-A standardized process for outcome measurement.

On 07/18/2024 at 8:00 AM, the Director of Nursing (DON) confirmed the facility's ASP policy lacked the following components:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0881 -Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics Level of Harm - Minimal harm or potential for actual harm -A process for periodic review of antibiotic use by prescribing practitioners such as: review of labs and med orders, progress notes and medication administration records to determine if an infection or communicable Residents Affected - Many disease was documented and whether an appropriate antibiotic was used for the recommended length of time.

-A process for reviewing antibiotic use when a resident is newly admitted , returns, or is transferred from another facility/hospital.

-Protocols to ensure the proper antibiotics are prescribed.

-A system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners.

Antibiotic Stewardship Education

On 07/18/2024 at 9:20 AM, the facility was not able to provide documented evidence education related to the ASP was provided to staff and residents.

On 07/18/2024 at 9:22 AM, the IP confirmed the facility had not provided education related to the ASP to staff or residents.

On 07/18/24 at 10:17 AM, the IP confirmed the IP did not provide education related to the ASP to staff or residents because the IP was not clinical.

A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented staff and residents were provided education related to antimicrobial medications.

Antibiotic Stewardship Process

On 07/18/2024 at 9:25 AM, the IP verbalized the IP did not review resident's antibiotic use upon admit and explained the review was completed by the pharmacist. The IP confirmed the pharmacist only came to the facility on e time per month.

On 07/18/2024 at 9:30 AM, the IP explained a form titled The Four Moments of Antibiotic Decision Making as completed by nurses when a new onset of infection was suspected. The form was used to guide antibiotic selection, antibiotic duration, ensure cultures were completed, and ensure follow up after 24 hours. The IP verbalized the IP did not use the form and the form was not forwarded to the IP after it was completed by nursing. The IP verbalized when lab results were returned for a resident, the resident's nurse contacted the provider to confirm the resident was receiving the correct antibiotic. The IP explained when a resident had an infection, the IP was notified the resident had an infection when the resident's lab work result came back.

After receiving the lab results, the IP looked to see if the correct antibiotic was being administered. Next the IP notified the pharmacist and documented the data onto a spreadsheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0881 A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented the ASP proactively monitored the use of antimicrobial prescriptions with real time feedback and advised clinicians Level of Harm - Minimal harm or regarding the appropriate antimicrobial use in patients. The facility followed the Four Moments of Antibiotic potential for actual harm Decision Making for every antibiotic order.

Residents Affected - Many Antibiotic Time Out

On 07/18/2024 at 10:12 AM, the IP explained when nurses sent a culture to the lab, the nurse did not always tell the IP and most of the time the IP was not aware a culture had been sent until the results came back.

The IP confirmed an antibiotic time out was not completed at any time during a resident's course of antibiotics.

A Centers for Disease Control and Prevention document titled The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/2024, documented broad interventions to improve antibiotic use and standardize the practices which should be applied during the care of any resident suspected of an infection.

The practices included improving the evaluation and communication of clinical signs and symptoms when a resident was first suspected of having an infection. The use of diagnostic testing was optimized when an antibiotic review process known as an antibiotic time out was implemented for all antibiotics prescribed in the facility. Antibiotic reviews provided clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture was clearer, and more information was available.

A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented the resource for

the policy was the Centers for Disease Control and Prvention (CDC) Core Elements of Antibiotic Stewardship Program.

Communication with Prescribing Providers

On 07/18/2024 at 10:17 AM, the IP verbalized the IP did not communicate with the physician regarding antibiotics including prescribing habits and antibiotic usage because the IP was not clinical. The IP confirmed

the IP was not involved with the decision process for selecting the type of transmission based precautions (TBP) a resident may need and explained the decision was made and implemented by nursing staff. The IP confirmed the IP never communicated with the physician regarding any of the concerns of the ASP.

A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, lacked guidance related to a system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 43310

Residents Affected - Many Based on observation, clinical record review, interview, and document review the facility failed to ensure the Infection Preventionist ( IP) 1) completed a specialized IP training course, 2) provided education related to

the Antibiotic Stewardship Program (ASP) to staff 3) understood and conducted an antibiotic time out (an active reassessment conducted of an antimicrobial prescription 48-72 hours after the first administration), 4) had a process in place to ensure residents and staff were offered vaccines (see tag

F-F881

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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** 43310 potential for actual harm Based on observation, clinical record review, interview, and document review the facility failed to ensure 26 Residents Affected - Many of 27 residents residing at the facility were screened for eligibility to receive immunization with an influenza (flu) vaccine and/or a pneumonia (PNA) vaccine and failed to ensure education related to the vaccines was provided resulting in substandard quality of care (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8).

Findings include:

Resident #4

Resident #4 was admitted to the facility on [DATE REDACTED], with a diagnosis of multiple sclerosis. The resident was [AGE] years of age (YOA).

Resident #27

Resident #27 was admitted to the facility on [DATE REDACTED], with diagnoses including heart failure, unspecified, chronic obstructive pulmonary disease (COPD), unspecified, and unspecified asthma, uncomplicated. The resident was 95 YOA.

Resident #16

Resident #16 was admitted to the facility on [DATE REDACTED], with diagnoses including COPD, chronic respiratory failure with hypoxia, fibromyalgia, and adult failure to thrive. The resident was 78 YOA.

Resident #10

Resident #10 was admitted to the facility on [DATE REDACTED], with diagnoses including vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and disease of pancreas, unspecified. The resident was 86 YOA.

Resident #24

Resident #24 was admitted to the facility on [DATE REDACTED], with diagnoses including alcoholic hepatic failure without coma, alcoholic cirrhosis of liver with ascites, and unspecified protein calorie malnutrition. The resident was 63 YOA.

Resident #11

Resident #11 was admitted to the facility on [DATE REDACTED], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, adult failure to thrive, heart failure, unspecified, and hypothyroidism. The resident was 76 YOA.

Resident #15

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 Resident #15 was admitted to the facility on [DATE REDACTED], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and Level of Harm - Minimal harm or nutritional anemia, unspecified. The resident was 81 YOA. potential for actual harm Resident #14 Residents Affected - Many Resident #14 was admitted to the facility on [DATE REDACTED], with diagnoses including cerebral infarction, unspecified, and hypertensive heart disease with heart failure. The resident was 79 YOA.

Resident #19

Resident #19 was admitted to the facility on [DATE REDACTED], with diagnoses including type II diabetes mellitus with diabetic chronic kidney disease and diabetic polyneuropathy, hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease, or unspecified chronic kidney disease, and anemia in chronic kidney disease. The resident was 56 YOA.

Resident #6

Resident #6 was admitted to the facility on [DATE REDACTED], with diagnoses including cerebral infarction, unspecified, vascular dementia, moderate with agitation, and post COVID-19 condition, unspecified. The resident was 74 YOA.

Resident #13

Resident #13 was admitted to the facility on [DATE REDACTED], with diagnoses including Alzheimer's disease, unspecified, post COVID-19 condition, unspecified, and acute kidney failure, unspecified. The resident was 88 YOA.

Resident #5

Resident #5 was admitted to the facility on [DATE REDACTED], with diagnoses including Alzheimer's disease, unspecified, disease of pancreas, unspecified, and other nonspecific abnormal finding of lung field. The resident was 93 YOA.

Resident #23

Resident #23 was admitted to the facility on [DATE REDACTED], with diagnoses including COPD, adult failure to thrive, pulmonary hypertension, unspecified, and unspecified dementia, unspecified severity, with mood disturbance. The resident was 84 YOA.

Resident #2

Resident #2 was admitted to the facility on [DATE REDACTED], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety, heart failure, unspecified, and unspecified atrial fibrillation. The resident was 93 YOA.

Resident #1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 Resident #1 was admitted to the facility on [DATE REDACTED], and last readmitted to the facility on [DATE REDACTED], with diagnoses including quadriplegia, unspecified, hydrocephalus, epilepsy, unspecified, not intractable, without Level of Harm - Minimal harm or status epilepticus, unspecified asthma, uncomplicated, respiratory failure, unspecified, unspecified whether potential for actual harm with hypoxia or hypercapnia, unspecified severe protein calorie malnutrition, calculus of kidney, other artificial openings of urinary tract status, other postprocedural cardiac functional disturbances following Residents Affected - Many cardiac surgery, and adult failure to thrive. The resident was 41 YOA.

Resident #3

Resident #3 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type II diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease, or unspecified chronic kidney disease, nonrheumatic aortic (valve) stenosis with insufficiency, chronic atrial fibrillation, unspecified, anemia in chronic kidney disease, coagulation defect, unspecified, and Guillain-Barre syndrome. The resident was 81 YOA.

Resident #22

Resident #22 was admitted to the facility on [DATE REDACTED], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified severe protein-calorie malnutrition, and COPD. The resident was 84 YOA.

Resident #21

Resident #21 was admitted to the facility on [DATE REDACTED], with diagnoses including Alzheimer's disease with late onset, atherosclerotic heart disease of native coronary artery without angina pectoris, and personal history of pulmonary embolism. The resident was 73 YOA.

Resident #9

Resident #9 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including hemiplegia, unspecified affecting right dominant side, and vascular dementia, unspecified severity, with other behavioral disturbance. The resident was 86 YOA.

Resident #7

Resident #7 was admitted to the facility on [DATE REDACTED], with diagnoses including COPD, unspecified, type II diabetes mellitus without complications, and other specified hypothyroidism. The resident was 76 YOA.

Resident #20

Resident #20 was admitted to the facility on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED], with diagnosed including endocarditis, valve unspecified, primary pulmonary hypertension, nonrheumatic tricuspid (valve) insufficiency, hypothyroidism, and obstructive sleep apnea (adult) (pediatric). The resident was 86 YOA.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 Resident #18

Level of Harm - Minimal harm or Resident #18 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including potential for actual harm type II diabetes mellitus with diabetic polyneuropathy, long term (current) use of insulin, COPD, unspecified, and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood Residents Affected - Many disturbance, and anxiety. The resident was 80 YOA.

Resident #12

Resident #12 was admitted to the hospital on 04/22/2024, with diagnoses including unspecified disorder of circulatory system, encephalopathy, unspecified, adult failure to thrive, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified convulsions. The resident was 64 YOA.

Resident #26

Resident #26 was admitted to the facility on [DATE REDACTED], with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, status unknown, subsequent encounter, and unspecified dementia, unspecified severity, with other behavioral disturbance. The resident was 79 YOA.

Resident #17

Resident #17 was admitted to the facility on [DATE REDACTED], with diagnoses including transient cerebral ischemic attack, unspecified, unspecified atrial fibrillation, and myasthenia gravis without (acute) exacerbation. The resident was 89 YOA.

Resident #8

Resident #8 was admitted to the facility on [DATE REDACTED], with diagnoses including COPD, unspecified, other forms of dyspnea, hypoxemia, and hypothyroidism, unspecified. The resident was 95 YOA.

Influenza Vaccine

The facility lacked documented evidence 23 of 26 residents eligible or potentially eligible to receive a flu vaccine were screened for eligibility to receive a flu vaccine and lacked documented evidence education related to the 2023/2024 flu vaccines was provided to the resident or the resident's representative (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8). The facility administered flu vaccines to the residents as follows:

-8 of 26 residents eligible to receive a flu vaccine declined vaccination (Resident #11, #19, #13, #23, #3, #9, #18, and #12). The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine and the residents and/or residents' representatives were provided education regarding the 2023/2024 flu vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 -5 of 26 residents' (Resident #24, #22, #7, #17 and #8) clinical records lacked documented evidence the residents were screened to determine eligibility to receive a flu vaccine and were provided education Level of Harm - Minimal harm or regarding the 2023/2024 flu vaccines prior to signing consents and prior to the administration of a 2023/2024 potential for actual harm flu vaccine. This failure resulted in the residents not having the opportunity to make an informed decision prior to being administered a 2023/2024 flu vaccine and put residents at risk of having adverse reactions to Residents Affected - Many the flu vaccine related to risk factors identified during the screening process.

-3 of 26 residents' (Resident #16, #20 and #26) clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine, education regarding the 2023/2024 flu vaccine was provided, and consent was given by the resident or the residents representative prior to administering a flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process.

-6 of 26 residents' (Resident #10, #15, #6, #5, #1 and #21) clinical records documented consents were signed to receive a flu vaccine during the 2022/2023 flu season. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive vaccination with a 2023/2024 flu vaccine, the resident or the resident's representative were provided education regarding the 2023/2024 flu vaccines, and consent for vaccination with the 2023/2024 flu vaccine was obtained prior to administering a 2023/2024 flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process.

-1 of 26 residents (Resident #4) was screened for eligibility to receive a flu vaccine with a hospital consent form. The screening/consent form included a section with an acknowledgement of receipt of a Vaccination Information Sheet (VIS) and an acknowledgement the resident reviewed the information on the back of the form. The form documented the VIS provided to the resident was dated 08/06/2021. The form documented

the vaccine administered to Resident #4, Fluad manufactured by Seqirus, was to be given to individuals 65 and older only !!!! and Resident #4 was 61 YOA.

The hospital consent form instructed to initial on the line next to each acknowledgement and to sign the line below the acknowledgement to give consent for vaccination. A check mark was entered into the provided line

in front of each acknowledgement and were not initialed by the resident or a resident representative. The signature line for consent documented verbal consent and did not document who gave the consent.

This failure resulted in Resident #4 not having the opportunity to make an informed decision prior to being administered a 2023/2024 flu vaccine and put residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 On 07/18/24 at 8:29 AM, the Director of Nursing (DON) confirmed the facility did not have a process in place for screening residents for eligibility to receive a flu vaccine and did not provide education related to flu Level of Harm - Minimal harm or vaccines to the residents. The DON confirmed consents were signed at admit and new consents were not potential for actual harm signed prior to each new flu vaccine administered.

Residents Affected - Many On 07/18/2024 at 8:36 AM, the DON confirmed the facility did not have a screening tool or an algorithm to assist in determining eligibility and/or the recommended PNA vaccine for a resident. The DON confirmed the facility was not using the VIS educational documents to provide education related to flu and PNA vaccines to residents or the resident's representative/guardian.

A Food and Drug Administration (FDA) package insert titled Fluad Quadrivalent - Seqirus Incorporated, dated March 2023, documented the Fluad vaccine was approved for use in individuals [AGE] years of age or older and was not approved by the FDA for people under the age of 65.

The facility policy titled Influenza Vaccination, revised 12/2023, documented influenza vaccination was the primary method for preventing influenza and it's severe complications. Therefore, vaccination against influenza was offered to residents. Upon admission residents were assessed for recent and past flu vaccination, and flu vaccines were administered to residents annually thereafter. The healthcare professional administering the vaccine obtained a signed consent from the resident or resident representative at the time of admission or prior to the next flu season. Residents were routinely vaccinated, unless contraindicated, at one time, annually, before the influenza season. Residents and/or the resident representatives were provided a copy of the most current VIS regarding the flu vaccine the resident was to be given. Residents were screened for history of Guillain-Barre Syndrome, and for severe allergic reaction to a previous dose, vaccine component, and egg protein. A flu vaccine was not to be administered to residents exhibiting signs and symptoms of moderate or severe acute illness, with or without fever. The facility referred to current Advisory Committee on Immunization Practices (ACIP) recommendations for special circumstances such as immunosuppression, immunodeficiencies, corticosteroid therapy and organ transplantation.

The licensed nurse administered flu vaccines according to the manufacturer's instructions and followed the Six Rights of Drug Administration.

Pneumonia Vaccine

The facility lacked documented evidence 26 of 26 residents eligible or potentially eligible to receive a PNA vaccine were screened for eligibility to receive a PNA vaccine and lacked documented evidence education regarding the PNA vaccine the resident was eligible to receive was provided to the resident or the resident's representative (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8). The facility administered PNA vaccines to the residents as follows:

-13 of 26 residents (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8) eligible or potentially eligible to receive a PNA vaccine declined vaccination.

The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a PNA vaccine and the residents and/or residents' representatives were provided education regarding the PNA vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 -7 of 26 residents' clinical record included a signed consent requesting to receive vaccination with a PNA vaccine (Resident #2, #21, #8, #7, #22, #24, and #10). The residents' clinical record lacked documented Level of Harm - Minimal harm or evidence the resident was screened for eligibility to receive a PNA vaccine, education was provided related potential for actual harm to the PNA vaccine the resident was eligible to receive, and the PNA vaccine was administered to the resident. Residents Affected - Many Resident #14's clinical record lacked documented evidence the resident was screened for eligibility to received a PNA vaccine, education regarding PNA vaccines was provided, a consent or declination to receive a PNA vaccine was obtained, and the resident was provided with a PNA vaccine based on eligibility for the vaccine and the resident's desire to be vaccinated. The Centers for Disease Control and Prevention (CDC) app PneumoRecs VaxAdvisor (VaxAdvisor) recommendation for Resident #14 was to receive one dose of Pneumococcal conjugate vaccine (PCV)15 or PCV20. If PCV20 was administered, the resident's vaccinations were considered complete. If PCV15 was administered the recommendation was for Resident #14 to receive one dose of pneumococcal polysaccharide vaccine (PPSV) 23 after one year.

Resident #4's clinical record included a consent signed by the resident on 10/11/2014, requesting to receive

a PNA vaccine. Resident #4's clinical record documented the resident received one dose of PPSV23 on 11/07/2017, approximately three years after consenting/requesting to receive a PNA vaccine. Resident #4's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the recommended dose to give the resident, and lacked documented evidence education regarding PNA vaccines was provided. The resident's clinical record lacked documented evidence

the resident was screened for eligibility to receive any additional doses of a PNA vaccine.

Resident #15's clinical record included a consent to receive a PNA vaccine signed by the resident's guardian

on 02/10/2023. One dose of PPSV23 was administered to the resident on 02/13/2023. Resident #15's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the recommended PNA vaccine to administer prior to administering a PNA vaccine. Resident #15's clinical record lacked documented evidence the resident and/or the resident's guardian were provided education related to the vaccine administered to Resident #15.

Resident #6's clinical record included a consent to receive a PNA vaccine, the consent was verbal consent from the resident dated 09/09/2022. Resident #6's clinical record documented the resident received one dose of PPSV23 on 11/09/2022. Resident #6's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the CDC recommended PNA vaccine to administer. The residents clinical record lacked documented evidence the resident was provided education related to PPSV23. Resident #6's clinical record lacked documented evidence the resident was screened for eligibility to receive any additional subsequent doses of a PNA vaccine.

Resident #5's clinical record included a consent to receive a PNA vaccine signed by the residents guardian

on 08/31/2011. Resident #5's clinical record documented the resident received one dose of PPSV23 on 12/04/2017, approximately six years after consenting/requesting to receive a PNA vaccine. Resident #4's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the recommended dose to give the resident, and lacked documented evidence education regarding PNA vaccines was provided to the resident or the resident's guardian. The resident's clinical record lacked documented evidence the resident was screened for eligibility to receive any additional doses of a PNA vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 Resident #20's clinical record documented the resident was administered one dose of PPSV23 on 11/08/2022. Resident #20's clinical record did not include a signed consent to receive the vaccine, evidence Level of Harm - Minimal harm or the resident was screened for eligibility to receive a PNA vaccine and to determine which PNA vaccine to potential for actual harm administer. Resident #20's clinical record lacked documented evidence the resident or the resident's representative were provided education regarding PNA vaccines. The CDC's VaxAdvisor recommended to Residents Affected - Many administer one dose of PCV15 or PCV20 at least one year after the last dose of PPSV23 in order for the resident's PNA vaccinations to be complete.

The failure to screen residents for eligibility to receive a PNA vaccine and determine the correct PNA vaccine to administer to each resident, placed residents at risk of being vaccinated with the wrong PNA vaccine for

the resident, or not receiving additional needed doses of a PNA vaccine. The lack of education related to the PNA vaccine a resident was eligible to receive resulted in the residents not having the opportunity to make

an informed decision and consent prior to being administered the vaccine. The failure to administer a PNA vaccine to eligible residents put the residents at risk of developing PNA with the potential to result in complications associated with PNA.

On 07/16/24 at 4:22 PM, the DON confirmed the facility did not have a screening process in place related to PNA vaccines and did not provide education related to PNA vaccines to residents or the resident's representative. The DON confirmed none of the facility's 27 residents had been screened for vaccination with

a PNA vaccine and education related to PNA vaccines was not provided to the residents.

The facility policy titled Pneumococcal Polysaccharide Vaccination, last revised 10/2017, documented because pneumococcal disease was known to lead to serious infections in the resident population and was proving to be resistant to antibiotics, the facility provided vaccination against pneumococcal disease to prevent the spread of infection. PPSV protected against multiple types of pneumococcal bacteria and was offered to the resident population. Residents were screened for severe allergic reactions after a previous dose of PPSV and consent was obtained from the resident or the resident's representative/guardian. Residents or the resident's representative/guardian were provided with information regarding potential reactions and a copy of the most current VIS. Copies of the VIS were obtained from the CDC website. Documentation in the residents clinical record included the date of administration, amount and dosage given, reactions to the vaccine.

The policy was last revised in 2017, and documented the sole reference was titled CDC, Morbidity and Mortality Weekly Report (MMWR), Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), volume 46/No. RR-8, dated 04/04/1997. The reference included a weblink, but the link indicated the page could no longer be found. The guidance in the policy was outdated and did not include the CDC's most recent guidance regarding the selection and administration of pneumococcal vaccines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 43310

Residents Affected - Few Based on observation, clinical record review, interview, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 (COVID) booster vaccine, education regarding the vaccine was provided and the CNA had an opportunity to make an informed decision to receive or decline the vaccination, and 2) 1 of 6 residents reviewed for immunization with a COVID booster vaccine were screened for eligibility to receive the vaccine, education regarding the vaccine was provided to the resident or the resident's representative, and the resident or the resident representative had the opportunity to make an informed decision to receive or decline the vaccine.

Findings include:

CNA

The facility lacked documented evidence a CNA with the hire date of 10/25/2020, was screened for eligibility to receive a COVID booster vaccine, education regarding the vaccine was provided and the CNA had an opportunity to make an informed decision to receive or decline the vaccination. The CNAs state immunization record documented the CNA recieved a dose of a COVID vaccine on 10/13/2021 and 02/03/2021.

On 07/16/2024 at 12:13 PM, the Director of Nursing (DON) confirmed the facility did not have documented evidence the CNA had been provided education regarding updated COVID vaccines, was screened for eligibility and had either been provided the vaccine or completed a declination for the vaccine. The facility was not able to provide documented evidence the vaccine was provided by a third party provider. The DON confirmed the facility was no longer tracking COVID vaccination status for staff.

On 07/18/2024 at 9:10 AM, the DON verbalized education related to COVID vaccines was only provided when new vaccines were available or when a vaccination clinic was held. The DON confirmed education related to COVID vaccines was not being provided to residents or staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 46301

Residents Affected - Few Based on personnel record review, interview and document review, the facility failed to ensure communications training was completed by staff for 1 of 20 sampled employees (Employee #4).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record lacked documented evidence of communication training.

On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Communication training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Communication training.

The facility policy titled Communication Training, effective 04/2022, documented employees were to complete Communication training at a minimum of annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0942 Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Level of Harm - Minimal harm or potential for actual harm 46301

Residents Affected - Few Based on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 1 of 20 sampled employees (Employee #4).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record lacked documented evidence of resident rights training.

On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Resident Rights training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Resident Rights training.

The facility policy titled Resident Rights Training, effective 08/2022, documented employees were to complete Resident Rights education at a minimum of annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 46301

Residents Affected - Few Based on personnel record review, interview and document review, the facility failed to ensure elder abuse training was completed timely for 7 of 20 sampled employees (Employee #4, #7, #10, #11, #17, #19, and #20).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record documented elder abuse training completed 10/06/2022, however lacked documented evidence elder abuse training was completed in 2023.

Employee #7

Employee #7 was hired as a Certified Nursing Assistant (CNA) on 04/01/2023.

Employee #7's personnel record documented elder abuse training completed 10/29/2023, however was completed more then 30 days after hire.

Employee #10

Employee #10 was hired as a Licensed Practical Nurse on 06/06/2024.

Employee #10's personnel record lacked initial elder abuse training completed prior to starting work on the floor.

Employee #11

Employee #11 was hired as a Registered Nurse (RN) on 01/22/2024.

Employee #11's personnel record documented elder abuse training completed 06/12/2024,however was completed more then 30 days after hire.

Employee #17

Employee #17 was hired as a CNA on 11/13/2023.

Employee #17s personnel record lacked initial elder abuse training completed prior to starting work on the floor.

Employee #19

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0943 Employee #19 was hired as a Hospitality Aide on 04/19/2024.

Level of Harm - Minimal harm or Employee #19's personnel record lacked initial elder abuse training completed prior to starting work on the potential for actual harm floor.

Residents Affected - Few Employee #20

Employee #20 was hired as a Housekeeper on 11/09/2023.

Employee #20's personnel record documented elder abuse training completed 12/27/2023, however was completed more then 30 days after hire.

On 07/17/2024 at 11:04 AM, the Human Resources Supervisor verbalized all staff were required to complete elder abuse training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employees #4, #7, #10, #11, #17, #19, and #20 lacked timely elder abuse training.

The facility policy titled Abuse Prevention, revised 05/2023, documented all staff would be in serviced annually on the facility abuse prohibition policy.

The facility abuse policy lacked the requirement to complete abuse training upon orientation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 46301

Residents Affected - Few Based on interview and document review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) training had been completed to include objectives of resident care needs for 1 of 20 sampled employees (Employee #4).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record lacked documented evidence of QAPI training.

On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete QAPI training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have QAPI training.

The facility policy titled Quality Management Program, revised 11/2017, documented all staff shall receive annual training on the facility's QAPI program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 46301

Residents Affected - Few Based on interview and document review, the facility failed to provide timely infection control training to all staff to ensure proper procedures and standards of the program for 1 of 20 sampled employees (#4).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record lacked documented evidence infection control training had been completed.

On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete infection control training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have infection control training.

The facility policy titled Infection Control Training, effective 01/2021, documented education and training would be provided to all healthcare personnel annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 46301 potential for actual harm Based on interview and document review, the facility failed to ensure compliance and ethics training was Residents Affected - Few completed timely for 1 of 20 sampled employees (#4).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record lacked documented evidence of compliance and ethics training.

On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Compliance and Ethics training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have compliance and ethics training.

The facility policy titled Compliance and Ethics Training, Effective 10/2022, documented all employees complete Compliance and Ethics continuing education. Education and training shall be provided to all staff annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or 46301 potential for actual harm Based on interview and document review, the facility failed to ensure behavioral health training was Residents Affected - Few completed timely for 1 of 20 sampled employees (Employee #4).

Findings include:

Employee #4

Employee #4 was hired as the Registered Dietician on 09/11/2003.

Employee #4's personnel record lacked documented evidence of behavioral health training.

On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Behavioral Health training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Behavioral Health training.

The facility policy titled Behavioral Health Care Training, effective 07/2022, documented employees were to complete Behavioral Health Care training at a minimum of annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 47 295011

F-F882

Infection Control and Prevention Plan Policy

The facility's IPCP policy documented the policy was last reviewed by the facility on 10/2022. The facility was not able to provide evidence the policy had been reviewed and/or revised after 10/2022. The policy referred to IPCP as the hospital's IPCP and the referenced duties for hospital staff did not include language indicating

the policy included the Long-Term Care facility.

The IPCP lacked the following elements:

-a list of reportable communicable diseases and a process for reporting to the appropriate state agencies.

-prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease.

-a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, multi-drug resistant organisms (MDRO)status, special instructions or precautions including transmission-based precautions (TBP), medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable.

-a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type.

The IPCP policy referenced an additional policy titled List of Nationally Notifiable Diseases, last revised 06/2020. The policy did not list the reportable diseases but provided two links to the most current nationally notifiable diseases. The links were dated 2020 and neither of the links were active. At the bottom of the policy, under references, an active link was provided. The policy did not include guidance for prohibition of employees with communicable diseases or a process for reporting to the appropriate agencies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 0865 On 07/18/24 at 8:45 AM, the Director of Nursing (DON) confirmed the IPCP provided was the policy used by

the facility. Level of Harm - Minimal harm or potential for actual harm On 07/18/24 at 8:00 AM, the DON confirmed the IPCP lacked the following elements:

Residents Affected - Few -a list of reportable communicable diseases and a process for reporting to the appropriate state agencies.

-prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease.

-a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, MDRO status, special instructions or precautions including TBPs, medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable.

-a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type.

Cross reference with Tag

F-F883

Communication with Prescribing Providers

On 07/18/2024 at 10:12 AM, the IP never communicated with physicians/providers and explained the IP was not clinical.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 A facility policy titled Infection Prevention and Control Program, last revised 10/2022, documented the Infection Control Professional (IP), collaborated with all staff regarding infection prevention and control Level of Harm - Minimal harm or processes. The IP communicated to staff, including medical staff, concerns related to infection control potential for actual harm processes.

Residents Affected - Many Cross reference with

F-F887), and 5)

the IP communicated with providers regarding prescribing trends, needs, and outcomes, with the potential to effect the facility's entire census of 27 residents.

Findings include:

Specialized Training

A facility document titled Payroll Status Form, dated 10/13/2022, documented the facility's IP had a hire and status (role) date of 10/13/2022. The role was documented as Infection Preventionist.

On 07/16/2024 at 7:39 AM, the IP verbalized the IP had completed the Centers for Disease Control and Prevention (CDC) Infection Preventionist Training Course and provided a certificate documenting the IP had participated in an educational activity and was awarded two Continuing Education Units (CEUs). The certificate did not document the 19.75 CEU hours required for course completion. The IP provided a copy of

the IP's Nursing Home Infection Preventionist Training Course transcript. The transcript documented the IP had completed 15 of the IP training course modules and one course was still required. The section of the transcript titled Completion for Nursing Home Infection Preventionist Training Course, was marked as not started. The IP confirmed the IP did not have any further documented evidence of course completion.

On 07/16/2024 at 3:11 PM, the Director of Nursing (DON) confirmed the Infection Preventionist Training Course Transcript provided by the IP lacked documented evidence the IP had completed the IP training course. The DON verbalized the IP training course needed to be completed prior to an individual assuming

the role of IP and confirmed the IP had been working in the role of IP without having completed an approved IP specialized training course.

A facility document titled Infection Control Preventionist - Job Description, signed and dated by the IP on 04/04/2022, documented the IP was required to have knowledge of state and federal regulations regarding infection control. The Job Description failed to address the requirements related to the completion of specialized training in infection control.

Antibiotic Stewardship Education

On 07/18/2024 at 9:12 AM, the facility was not able to provide documented evidence the facility provided education related to the ASP to the facility's staff. The DON confirmed the facility did not have documented evidence education related to the ASP was provided to staff and confirmed the education was not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 47 295011 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 295011 B. Wing 07/23/2024

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

South Lyon Medical Center 213 Whitacre St Yerington, NV 89447

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 A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented staff and residents were provided education related to antimicrobial medications. Level of Harm - Minimal harm or potential for actual harm A facility policy titled Infection Prevention and Control Program, last revised 10/2022, documented the Infection Control Professional (IP) was responsible for providing education to residents, visitors, and staff. Residents Affected - Many

A facility document titled Infection Control Preventionist - Job Description, signed and dated by the IP on 04/04/2022, documented the IP was responsible for teaching principles and practical application on infection prevention and control to all levels of healthcare staff. The IP promoted the ASP.

Cross reference with