Licensure Reference Number 175NAC 12-006.09(H)(iv)(5) Based on record review and interviews; the facility failed to follow physician orders on bowel protocols for 1 (Resident 31) of 1 sampled residents. Facility census was 32. Findings are: A record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 04/05/2024 revealed: -The resident has impaired cognitive function/dementia or impaired though process related to cognitive decline evidenced by a diagnosis of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities.). -The resident has an activity of daily living (ADLs) (basic everyday tasks including bathing, eating, dressing, getting in and out of bed, and toileting) self-care performance deficit related to confusion evidenced by a diagnosis of dementia. A record review of the assessment Functional abilities dated 07/08/24 revealed the following: -Resident 31 is independent/supervision/touch assistance for all mobility activities. -Resident 31 is a setup or clean up assistance for- toilet hygiene, upper and lower body dressing, and personal hygiene, Further record review of the undated Standing Orders list revealed the following medications for bowel regimen: -Dulcolax suppository 10 milligrams (mg) rectally as needed for constipation, give daily as needed. Contact provider if there are three days without a significant bowel movement (BM), -Fleet Enema 7-19 gram (gm)/118milliliter (mL)-insert rectally as needed for constipation one time daily as needed Contact provider if there are three days without a significant BM, -Milk of Magnesia Suspension 400 MG/5ML give 30ml by mouth as needed for constipation give daily as needed. Contact provider/practitioner if there are 3 days without a significant BM, contraindicated for residents with renal impairment, -Senna-S Tablet 8.6-50MG give 2 tablets by mouth as needed for constipation give up to twice daily as needed, hold for loose stool. Contact provider if there are three days without a significant BM. Record review of Resident 31's EMR revealed a signed physician order for the standing orders. Record review of Point of Care charting (the recording and documenting of patient information directly at the bedside or point of care) on a 30 day look back period from 06/24/2024-07/23/2024 for questions on toileting revealed the resident did not have a bowel movement for 3 or more days from 06/24/2024 through 06/29/2024, 07/11/2024 through 07/15/2024. Review of Resident 31's Medication Administration Record (MAR) summary for the month of June 2024 and July of 2024 revealed no medication being administered from the standing order list for bowel regimen. Review of Resident 31's Progress Notes for the month of June 2024 and July of 2024 revealed no communication from the facility to the physician regarding three or more days without a significant BM. Record review of Resident 31's EMR did not reveal a fax communication contacting the provider regarding three or more days without a significant BM. An interview on 07/23/2024 at 1:09 PM with Medication Aide-A (MA-A) revealed that the Nursing Assistant (NA) will chart in the electronic medical record (EMR, digital collection of medical information about a person that is stored on a computer) when a resident has a bowel movement. If a resident is independent, the NA will need to ask the resident about their bowel movement to chart accurately. The resident is asked several times a day for charting purposes. If the charting reveals the resident does not have a bowel movement for 2 days and/or more days consecutively, the nurse will get an alert in the EMR and the resident is offered a medication from the physician standing orders list named Standing Orders that is physician approved. An interview on 07/23/2024 at 1:30 PM the Director of Nursing confirmed that no medication was given to Resident 31 for having three or more days without a significant BM and that the physician was not notified.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on interviews and record reviews, the facility failed to ensure that the monthly medication drug reviews were received and reviewed by facility staff to identify priority irregularities which needed addressed. This affected 1 resident (Resident 6) of 3 sampled residents. The facility census was 32. Findings are: A record review of the facility policy titled Medication Drug Regimen Review (MRR) dated 2/28/2024 stated the review is done to prevent medication errors that could cause harm to a resident, result in resident hospitalization, and to identify potential adverse events. The Pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed, complete the MRR Summary, and give a copy to the Director of Nursing (DON) upon completion of the monthly MRR. These reports must be shared with the Medical director and the attending physician and the reports must be acted upon. If the consulting pharmacist detects a potential or actual problem that requires urgent action to protect the resident, the pharmacist will promptly alert the direct care nurse for immediate action. A record review of the Pharmacy Consultation report dated 6/30/2024 for Resident 6 revealed the report was time sensitive and had a prescriber response and facility action requirement of July 1, 2024 by 11:59 PM per the Federal Impact Act. This was a warning for potentially duplicate orders for the ropinirole (a medication that is used for restless leg syndrome) that Resident 6 was prescribed as there were three different orders in the medication administration record. A record review of the Monthly MRR's for Resident 6 revealed that the reviews were done monthly, however the results for June 2024 were missing. An interview on 7/22/2024 at 4:30 PM with the Director of Nurses (DON) revealed that the June 2024 MRR had been done by a consulting pharmacist. The DON revealed that the facility didn't get a copy of any of the consultation reports for June 2024. The DON assured the surveyors the reports would be available the following day. An interview on 7/23/2024 at 9:20 AM with the DON. Consulting Pharmacist June 2024 MRR paperwork was made available for review. The DON stated the Medical Director would be in the facility the following day and be able to review all of the reports and address them at that time. None of the paperwork from the June reports had been seen by the physician and the physician wouldn't see them until the following day. An interview on 7/23/2024 at 2:45 PM with the Consulting Pharmacist (CP). The CP always fills out the consultation reports from the monthly MRR's and sends them to the DON and the Facility Adminstrator (FA) either the same day or the day after the MRR has been completed. However, during the month of June the CP was not at the facility and another pharmacist had done the MRR. An interview on 7/23/2024 at 3:40 PM with Registered Pharmacist (RP-C) who had completed the MRR on June 30, 2024. RP-C stated that once the MRR had been completed, the MRR reports were sent to the facility on the same date. The email was sent to the DON and cc'd to the Administrator. At this point, the RP-C checked the sent box of email and stated it was indeed sent from RP-C's to the facility DON. RP-C had called the facility to notify a nurse (could not recall the name of the nurse) to let that nurse know that there was an order that needed to be addressed as soon as possible. An interview on 7/23/2024 at 4:00 PM with DON. The DON confirms that the consultation reports were not reviewed for the month of June 2024 as the DON had not received them. Today was the first time that (the DON) saw them. The physician won't see them until tomorrow. Tomorrow is a routine for the physician to be here (in the facility).

Licensure Reference Number 175NAC 12-006.09(H) Based on record review and interviews, the facility failed to implement AIMS monitoring for 1 (Resident 21) of 5 sampled residents, to identify potential adverse effects of antipsychotic medications. Facility census was 32. Findings are: A review of a facility policy dated 12/06/2023 titled Psychotropic Medications revealed: -The resident will be free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. -Each resident's drug regimen must be free from unnecessary drugs. An Unnecessary drug is any drug when used without adequate monitoring and without adequate indications for use. -Before administration of non-emergency psychotropic medications, the following must be completed: If the physician prescribes an antipsychotic for the resident, a registered nurse must complete the Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in the electronic medical record (EMR) (digital collection of medical information about a person that is stored on a computer). -Throughout the administration of the psychotropic medications, the following must be completed: If the resident is on an antipsychotic, a registered nurse must complete the Abnormal Involuntary Movement Scale (AIMS) in the EMR every 6 months. If there is a change in the results of the AIMS in EMR (electronic medical record), the physician and family/legal representative must be notified, and this notification must be documented in the medical record. A record review of Resident 21's most recent Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated April 27, 2024, revealed resident is taking an antipsychotic on a routine basis. A record review of Resident 21's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 11/14/2022 with a revision date of 4/16/2024 reveals: -The resident is on an antipsychotic medication related to dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities) with behavioral symptoms. -The resident has a behavior symptom related to dementia with behaviors being argumentative, striking out at staff, exit seeking, raising her voice, being disruptive, demanding large sums of money. -The resident uses psychopharmacological medications related to dementia with behaviors. A record review of Resident 21's Medication Administration Record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) revealed, an order for Geodon (antipsychotic medication) 40 milligram (mg), 1 capsule by mouth 2 times a day with date initated 11/01/2022. A record review of Resident 21's assessments revealed no Abnormal Involuntary Movement Scale (AIMS) monitoring (an assessment used to assess for abnormal irregular, involuntary movements most commonly in areas of the face, around the eyes, and of the mouth, including the jaw, tongue, and lips) for the antipsychotic medication. On 7/22/2024 at 3:14 PM an interview with the Minimum Data Set Coordinator (MDSC, a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) revealed that the AIMS assessment should be triggered to be completed for all residents receiving an antipsychotic medication. The MDSC confirmed that for Resident 21, it had not been initiated or completed during the duration of the prescribed antipsychotic.

Licensure Reference Number 175 NAC 12-006.12D(vi) Based on observation, record review, and interviews; the facility failed to ensure that resident medications had labels that matched the physician's order for 2 (Residents 20 and 15) of 5 residents observed. This had the potential for risk to resident safety related to medication administration. The facility census was 32. Findings are: A. A record review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides dated 3/29/23 revealed the purpose of the policy was to administer medications correctly and in a timely manner. The section titled Procedure revealed the instruction to review the Medication Administration Record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) for medications due. Follow the Six Rights: Right medication, right dose, right resident, right route, right time, and right documentation. Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup, and just before administering the medication. An observation on 7/18/24 at 8:39 AM at the medication cart just outside the facility dining room revealed that Medication Aide-A (MA-A) began medication set up for Resident 20. MA-A reviewed the MAR for Resident 20. The MAR for Resident 20 revealed that Venlafaxine HCl ER (a medication used to treat depression and anxiety) Oral Tablet Extended Release 24 Hour 150 milligrams (mg) (Venlafaxine HCl) Give 150 mg by mouth two times a day was due to be administered. MA-A removed the medication container of Venlafaxine from within the medication cart and looked briefly at the label on the medication container for the Venlafaxine. This surveyor reviewed the label on the medication container. The label read Venlafaxine 75mg and instructed to give 75mg orally daily; take with 150mg dose for total of 225mg every day. The label did not match the current physician order for Resident 20 to receive 150mg twice a day (a total of 300mg daily). Further observation on 7/18/24 at 8:39 AM at the medication cart just outside the facility dining room revealed that MA-A reviewed the MAR for Resident 20. The MAR for Resident 20 revealed that Fluticasone Propionate Suspension (a medication sprayed into the nose for relief of allergy symptoms) 50 micrograms (mcg) 1 spray in both nostrils 1 time a day was due to be administered. MA-A removed the clear plastic bag containing the Fluticasone bottle from within the medication cart. MA-A looked at the pharmacy label on the clear plastic bag. This surveyor reviewed the pharmacy label on the plastic bag for the bottle of Fluticasone spray. The label read Fluticasone Propionate 120 metered sprays 50mcg 2 sprays intranasally (into the nostril) daily. The label did not match the physician's order to administer 1 spray into each nostril. A record review of the Order Summary dated 7/18/24 for Resident 20 revealed the current physician order for Venlafaxine HCL ER 150mg. Give 150mg by mouth two times a day for anxiety due to depression. Monitor for adverse effects peripheral edema (swelling in the legs, ankles, or feet from excess fluid), headache, constipation, nausea, vomiting, and back pain. The order start date was 4/15/24. A record review of the Order Summary dated 7/18/24 for Resident 20 revealed the current physician order for Fluticasone Propionate Suspension 50mcg 1 spray in both nostrils one time a day for allergy. The order start date was 9/11/22. An interview on 7/18/24 at 10:23 AM with the facility Director of Nursing (DON) confirmed that the label for Resident 20's Venlafaxine 75mg instructed to give 75mg orally daily; take with 150mg dose for total of 225mg every day. The DON confirmed that the label did not match the current physician's order for Venlafaxine 150 mg by mouth two times a day for a total of 300mg. The DON revealed that they would notify the pharmacy of the label discrepancy. The DON confirmed that the label for Resident 20's Fluticasone Propionate Suspension 50 mcg instructed to give 2 sprays intranasally daily. The DON confirmed that the label did not match the current physician's order for Fluticasone Propionate Suspension 50 MCG 1 spray in each nostril 1 time a day. The DON revealed that the DON would notify the pharmacy of the label discrepancy. The DON confirmed that the expectation is that the pharmacy labels for medications match the physician's order for the medication so that staff administer the medications as ordered. B. An observation on 7/18/24 at 8:55 AM at the medication cart just outside the facility dining room revealed that Medication Aide-B (MA-B) began medication set up for Resident 15. MA-B reviewed the MAR for Resident 15. The MAR for Resident 15 revealed that Albuterol Sulfate 108mcg (a medication inhaled into the lungs to treat breathing difficulty) 2 puffs inhale orally two times a day was due to be administered. MA-B opened the medication cart drawer and removed the Albuterol Sulfate inhaler for Resident 15. The inhaler was not in a labeled plastic bag or any other container. This surveyor reviewed the inhaler. The inhaler had a label applied to it containing the name of the resident and the name of the medication Albuterol Sulfate. The label had no instructions containing the physician's order instructions for administration. This surveyor asked MA-B where the label for the Albuterol inhaler was located. MA-B revealed that the label is normally located on a plastic bag that the inhaler is stored in. MA-B revealed that the plastic bag for the Albuterol inhaler for Resident 15 was missing. MA-B had no label containing the physician's administration order for the Albuterol inhaler to compare with the MAR as required. A record review of the Order Summary dated 7/18/24 for Resident 15 revealed the current physician order for Albuterol Sulfate Inhalation Aerosol 108mcg 2 puffs inhale orally two times a day. An interview on 7/18/24 at 11:29 AM with the facility DON confirmed that the facility did not have a pharmacy label with instructions for Resident 15's Albuterol inhaler. The DON confirmed that the expectation was for the Albuterol inhaler to have a pharmacy label with instructions for use matching the physician's order so that staff administered the medication as ordered.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(3) Based on interview and record review, the facility failed to ensure Resident 8's POA (Power of attorney who can make decisions for Resident if Resident is unable)/or their personal representative was informed of the risks and alternate treatment available before initiating antipsychotic medication (medication used to treat psychotic/behavior disorders). This affected 1 of 5 sampled residents. The facility identified a census of 35 at the time of survey. Findings are: A. Record review of Resident 8's admission record revealed that the resident was admitted to facility on 11/01/2018 with diagnoses of impaired cognitive function/dementia or impaired thought process. Record review of Resident 8's admission Record dated 6/21/2023 revealed that Resident 8 had a POA for healthcare. Record Review of Resident 8's Medication Orders from Primary Care Physician revealed that Resident 8 was prescribed Seroquel 50 mg (an antipsychotic, medication used to treat behavior disorders, with potential adverse side effects), on 10/19/22. Record review of Resident 8's Nursing Notes for 10/19/22 through 6/20/23 revealed there was no documentation the POA of Resident 8 was informed of the antipsychotic medication prescription, side effects or risks, and was not given alternative options for treatment. Interview with the facility DON (Director of Nursing) on 6/20/23 at 10:00 AM revealed that the POA was not notified of Resident 8's prescribed treatment of Seroquel's side effects, or risks, and was not given alternative options for treatment. The DON revealed notification to the POA was expected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.05-4 Based on interview and record review, the facility failed to ensure the facility residents had the opportunity to formulate an advance directive. This affected 2 of 3 residents sampled, Residents 34 and 12. Census was 35. Findings are: A. Record review of admission Record dated June 15,2023 revealed that Resident 12 was admitted on [DATE]. Record review of the medical record revealed the absence of any documentation of an advance directive for Resident 12. Record review of the undated care plan revealed that there was no code status or advance directive care planned for Resident 12. B. Record review of admission Record dated June 15,2023 revealed that Resident 34 was admitted on [DATE]. Record review of the medical record revealed the absence of any documentation of an advance directive for Resident 34. Record review of the undated care plan revealed that there was no code status care or advance directive planned for Resident 34. Interview with the SSD (Social Services Director) on 6/15/23 at 9:15 AM revealed that there was not an advance directive on file for Resident 12 and Resident 34. The facility's process was to ask any resident that comes in without an advance directive what their wishes were and then to send that information over to the physician's office for an order. The SSD revealed there was no other paperwork that got filled out and put on the chart, including documentation the residents were informed of the advance directive options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Observation on June 21,2023 at 11:37 AM revealed RN (Registered Nurse)-B was changing and cleaning a pressure ulcer dressing for Resident 34. After preparing the materials needed for changing and cleaning the wound and dressing the RN washed hands for 10 seconds total with soap and water. The RN proceeded with the wound cleaning and dressing change and then washed with soap and water for a total of 15 seconds. C. Observation of medication pass on 6/21/2023 at 9:00 AM with RN-B revealed that the RN washed hands with soap and water in the sink for a total of 15 seconds before the medications pass then administered medications to Resident 25 by handling the medication containers and medication cup. Licensure Reference 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to ensure hand hygiene was completed per expectation during a dressing change which affected 1 of 2 sampled residents, Resident 34, before starting medication administration which affected 1 of 3 residents observed, Resident 25; and during the distribution of water which affected 8 of 9 residents, Resident 15, 14, 27, 23, 21, 18, 1, and 8. The facility identified a census of 35 at the time of survey. Findings are: A. Observation of unit 3 on 6/14/23 from 9:47 AM to 9:53 AM revealed MA-A (Medication Aide) pushed a 3 tiered cart that had pitchers of ice water on the top shelf from the kitchen down the hall. MA-A had disposable gloves on. MA-A took a clean pitcher off the cart and took it into Resident 13's room. MA-A sat the new pitcher of ice water down and picked up the pitcher that was sitting on the stand and picked it up by the handle and brought it out and put it on the 2nd shelf of the cart. MA-A picked up a new pitcher off the top shelf by the handle with the same gloved hands and took a pitcher in to Resident 15's room, sat it down on the table, then picked up the pitcher that was already sitting on the table by the handle and took it out of the room and placed it onto the 2nd shelf of the cart. Using the same gloved hands, MA-A repeated the process for Resident 14, Resident 27, Resident 23, Resident 21, Resident 18, Resident 1, and Resident 8. MA-A wore the same pair of gloves to handle the clean pitchers and the dirty pitchers. MA-A then pushed the cart back to the kitchen after MA-A passed the clean pitchers and picked up the dirty ones. Interview with the IP (Infection Preventionist) on 6/21/23 at 1:49 PM revealed the facility staff were expected to wash hands for 2 minutes before each med pass and in between residents. Interview with the DON (Director of Nursing) on 6/21/23 at 1:50 PM revealed the staff were to sing the ABC song to themselves twice during the hand washing process to ensure they were washing their hands long enough. Staff were also expected to gel in gel out (apply hand sanitizer when they enter a room and when they exit a resident room) and scrub with the hand sanitizer until their hands were dry. If they had dirty gloves on they were expected to remove them and do hand hygiene before they put new gloves on. The DON confirmed the pitchers on the top of the cart were the clean ones and the staff were expected to do hand hygiene in between the clean and dirty pitchers and not wear the same pair of gloves during the process. If the staff performed a dirty task, they were expected make sure they were washing hands or gel in gel out. Review of the facility policy Hand Hygiene dated 3/29/2022 revealed the following: All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. All employees in patient care areas will adhere to the 4 moments of Hand Hygiene and 2 Zones of Hand Hygiene: 1. Entering room [ROOM NUMBER]. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting room [ROOM NUMBER]. Zones: patient zone and health-care zones. Gloves are a protective barrier for the HCW (Health Care Worker) according to standard precautions. 1. Gloves are never to be reused or sanitized. 2. Hand hygiene should be performed after glove removal. Procedure: HCW will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: when entering patient room; before preparing or administering medications, if gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves; after removing gloves regardless of task completed; after contact with a patient's non-intact skin, wound dressings, secretions, excretions, mucous membranes, as long as hands are not visibly soiled; when moving from contaminated body site to a clean body site during patient care; when entering healthcare zone; when exiting patient room. Using alcohol-based hand sanitizer: apply adequate amount of product to palm of one hand and rub hands together covering all surfaces of hand and fingers until hands are dry which should take 15-20 seconds. Washing with soap and water/liquid antiseptic and water: wet hands first with tepid water, apply amount of soap to hands as recommended by the manufacturer. Rub hands together briskly for at least 15-20 seconds covering all surfaces of the hands, fingers and wrists. Rinse hands with water and dry thoroughly with a disposable towel or warm-air hand dryer if disposable towel not available. Use towel to turn off the faucet. Change gloves when moving from a dirty to a clean or sterile activity performing hand hygiene in between changing gloves. Gloves are single use and should not be washed or sanitized for reuse. Hand hygiene must be performed after removal regardless of task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on interview and record review, the facility staff failed to complete a SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) when Resident 6 was admitted to Hospice (a program designed to give supportive care to people in the final phase of a terminal illness). This affected 1 of 16 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 32 at the time of survey. Findings are: Review of Resident 6's quarterly MDS dated [DATE] revealed an admission date of 11/26/2018. Review of Resident 6's Census listed on the EHR (Electronic Health Record) revealed Resident 6 was admitted to hospice on 1/14/2022. Review of Resident 6's MDS schedule in the EHR revealed a quarterly MDS was in progress for Resident 6 as of 3/23/2022 and a quarterly was completed 9/22/2021. There was no documentation a SCSA MDS was completed for Resident 6 after hospice care was initiated. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed the following: An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). Interview with the FA (Facility Administrator) on 4/12/22 at 10:21 AM confirmed the SCSA MDS should have been completed for Resident 6. Review of the facility policy Assessment (MDS)-Rehab/Skilled dated 1/25/2022 revealed the following: Purpose: To ensure resident assessments are completed and coordinated in compliance with appropriate regulations. Review of assessment will be done no later than 92 days from last assessment, and with a significant change as defined in the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review; the facility staff failed to complete a Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) at least every 3 months for 2 of 16 sampled residents, Resident 2 and Resident 4. This affected 2 of 16 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 32 at the time of survey. Findings are: A. Review of Resident 2's SCSA (Significant Change in Status) MDS dated [DATE] revealed an admission date of 5/19/2020. Review of Resident 2's MDS Schedule in the EHR (Electronic Health Record) on 4/12/22 revealed Resident 2's quarterly MDS with an ARD (Assessment Reference Date) of 3/9/2022 was in progress. There was no documentation it had been completed, locked, and transmitted. B. Review of Resident 4's admission MDS dated [DATE] revealed an admission date of 12/16/2021. Review of Resident 4's MDS Schedule in the EHR on 4/12/2022 revealed Resident 4's quarterly MDS with an ARD of 3/16/2022 was in progress and there was no documentation it had been completed, locked, and transmitted. Interview with the FA (Facility Administrator) on 4/12/22 at 10:21 AM confirmed the MDS assessments had not been completed and they should have been as they were late. Review of the facility policy Assessment (MDS)-Rehab/Skilled dated 1/25/2022 revealed the following: Purpose: To ensure resident assessments are completed and coordinated in compliance with appropriate regulations. Review of assessment will be done no later than 92 days from last assessment and with a significant change as defined in the RAI (Resident Assessment Instrument) manual. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed the following: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, SCQA, or Annual assessment + 92 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09D4 Based on observation, record review, and interview; the facility failed to ensure that the restorative nursing care plan (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their possible highest level of well-being) was followed for 1 resident (Resident 24). The facility census was 32. Findings are: Record review of the facility policy titled Restorative: Nursing Care Implementation and Screening dated 4/12/22 revealed that each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as defined in nursing assessments. This restorative care will be outlined in the resident's nursing care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident). Residents are provided appropriate treatment and services to attain/maintain functional abilities in activities of daily living (ADLs)(basic everyday tasks including bathing, eating, dressing, getting in and out of bed, and toileting). Any resident who is unable to carry out independent activities of daily living will receive necessary services to prevent further diminishing of independent abilities. Record review of the admission Record for Resident 24 revealed that Resident 24 admitted into the facility on 3/21/18. Record review of the Minimum Data Set Assessment (MDS) (a mandatory comprehensive resident assessment used for care planning) dated 2/16/22 for Resident 24 revealed that Resident 24 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 8 (a score of 8 indicates moderately impaired cognition). The MDS revealed that Resident 24 required extensive assistance (staff providing weight bearing support to the resident) with transfers (moving between surfaces including from the chair, bed, and to a standing position), walking in the resident's room, for personal hygiene, and for using the toilet. Record review of the care plan for Resident 24 revealed that Resident 24 had a need for restorative interventions due to an activities of daily living (ADLs) self-care deficit. The restorative interventions for Resident 24 included active range of motion (using your muscles) with the NuStep (an exercise bike that simulates the motion of walking to improve strength) 3 times a week for 15-20 minutes. The intervention had been revised on 2/1/22. Record review of the care plan for Resident 24 revealed the intervention to keep the walker within reach of the resident for safety. Record review of the Task Record (a report that documents the assistance that staff provided to the resident for activities of daily living including eating, bathing, and mobility) for Resident 24 for April 2022 revealed no task for staff to perform and document assisting the resident to use the NuStep. Interview on 4/6/22 at 11:00 AM with the family member of Resident 24 revealed that the resident used to exercise on the NuStep bike. The family member revealed that the resident had not been able to exercise on the NuStep for a while possibly due to Covid. The family member revealed that the staff walked the resident to and from the bathroom and were to work on walking Resident 24 to the dining room. Observation on 4/11/22 at 9:58 AM in the room of Resident 24 revealed that Resident 24 sat in the recliner. The foot of the recliner was down and Resident 24's feet were on the floor. A front wheeled walker was positioned by the window approximately 8 feet away from the resident. Observation on 4/11/22 at 1:35 PM in the room of Resident 24 revealed that Resident 24 sat in the recliner with the feet elevated. A front wheeled walker was positioned by the window approximately 8 feet away from the resident. Observation on 4/11/22 at 1:38 PM in the facility therapy room revealed that the NuStep was not in use. Observation on 4/11/22 at 3:06 PM in the room of Resident 24 revealed that Resident 24 sat in the recliner with the feet elevated. A front wheeled walker was positioned by the window approximately 8 feet away from the resident. Observation on 4/12/22 at 8:10 AM in the facility dining room revealed that Resident 24 sat in a wheelchair at a dining room table. The resident was looking over the menu. No walker was observed in the area. Observation on 4/12/22 at 8:12 AM in the room of Resident 24 revealed that a front wheeled walker was positioned against the heating unit by the window. Observation on 4/12/22 at 10:28 AM in the facility therapy room revealed that the NuStep was not in use. Interview on 4/12/22 at 10:28 AM with Physical Therapist-G (PT-G) confirmed that the therapy room is open for residents to use the NuStep exercise bike assisted by staff. Observation on 4/13/22 at 1:02 PM in the room of Resident 24 revealed that a front wheeled walker was positioned by the dresser across the room from the resident's recliner. Observation on 4/13/22 at 1:04 PM in the facility dining room revealed that Resident 24 sat in a wheelchair at the table eating lunch. No walker was observed in the area. Interview on 4/13/22 at 1:04 PM with Nursing Assistant-K (NA-K) confirmed that Resident 24 did not walk to the dining room today. Record review of the progress note for Resident 24 dated 12/3/2021 at 10:16 PM revealed that Resident 24 has had a decline in ADL's, requiring more assistance with transfers, mobility, bed mobility and eating. Record review of the MDS assessment dated [DATE] for Resident 24 revealed that no physical therapy, occupational therapy, or speech therapy had been provided to Resident 24. The MDS revealed that Resident 24 received no restorative nursing programs for range of motion. The MDS revealed that Resident 24 received restorative nursing for walking on all 7 days of the assessment lookback period. Record review of the Restorative Nursing Documentation assessment dated [DATE] for Resident 24 revealed that the type of restorative nursing program for Resident 24 was to assist the resident to attain/improve function. The restorative nursing program was to help the resident maintain current function and prevent or slow decline. The evaluation section documented that Resident 24 was currently on a restorative program and to update the care plan if needed. The reason selected to identify why Resident 24 needed a restorative program was for the resident to maintain their functional status. The additional notes and comments section revealed that Resident 24 participates in active range of motion using the NuStep 3 times a week ranging from 10-17 minutes depending on their attention span. Staff walk the resident to or from meals depending on the resident's mental status each day. Record review of the MDS assessment dated [DATE] for Resident 24 revealed that no physical therapy, occupational therapy, or speech therapy had been provided to Resident 24. The MDS revealed that Resident 24 received no restorative nursing programs for range of motion. The MDS revealed that Resident 24 received restorative nursing for walking on 2 days of the 7 day assessment lookback period. Record review of the Restorative Nursing Documentation assessment dated [DATE] for Resident 24 revealed that the type of restorative nursing program for Resident 24 was to assist the resident to attain/improve function. The restorative nursing program was to help the resident maintain current function and prevent or slow decline. The evaluation section documented that Resident 24 was currently on a restorative program and to update the care plan if needed. The reason selected to identify why Resident 24 needed a restorative program was for the resident to maintain their functional status. The additional notes and comments section revealed that Resident 24 continued the restorative exercise program using the NuStep 3 times a week and walking to meals. Record review of the MDS assessment dated [DATE] for Resident 24 revealed that no physical therapy, occupational therapy, or speech therapy had been provided to Resident 24. The MDS revealed that Resident 24 received no restorative nursing programs for range of motion. The MDS revealed that Resident 24 received restorative nursing for walking on 3 days of the 7 day assessment lookback period. Record review of the MDS assessment dated [DATE] for Resident 24 revealed that no physical therapy, occupational therapy, or speech therapy had been provided to Resident 24. The MDS revealed that Resident 24 received no restorative nursing programs for range of motion or for walking during the 7 day assessment lookback period. Record review of the Restorative Nursing Documentation assessment dated [DATE] for Resident 24 revealed that the type of restorative nursing program for Resident 24 was to assist the resident to attain/improve function. The restorative nursing program was to help the resident maintain current function and prevent or slow decline. The restorative program review section documented that Resident 24 was currently on a restorative program that needed to be reviewed. The evaluation section revealed that Resident 24 needed a restorative program and did not need referral for a therapy evaluation. The assessment revealed that Resident 24 had an intervention for a restorative exercise program using the NuStep 3 times a week and walking to and from meals. Record review of the MDS assessment dated [DATE] for Resident 24 revealed that no physical therapy, occupational therapy, or speech therapy had been provided to Resident 24. The MDS revealed that Resident 24 received no restorative nursing programs for range of motion or for walking during the 7 day assessment lookback period. Record review of the Restorative Nursing Documentation assessment dated [DATE] for Resident 24 revealed that the resident is on a restorative nursing program but they have been unable to provide the NuStep. The restorative program review section documented that Resident 24 was currently on a restorative program that needed to be reviewed. The restorative nursing MDS data section revealed that walking did not occur for Resident 24. The restorative nursing MDS data section revealed that Resident 24 had a functional limitation in range of motion of both lower extremities (legs). The evaluation section revealed that Resident 24 was currently on a restorative program and to update the care plan if needed. The section revealed that Resident 24 did not need referral for a therapy evaluation. The assessment revealed that Resident 24 had an intervention for a restorative exercise program using the NuStep 3 times a week and walking to and from meals and activities. Interview on 4/12/22 at 12:10 PM with Medication Aide-B (MA-B) revealed that the facility does not have a restorative nurse to oversee the resident restorative program. MA-B revealed that the facility does not have a restorative aide to assist the residents with their restorative programs. MA-B revealed that the staff try to do the restorative exercises with the residents but don't usually have time. Interview on 4/12/22 at 2:55 PM with Nursing Assistant-J (NA-J) revealed that the only restorative therapy for Resident 24 is to try to get the resident to walk. NA-J revealed that Resident 24 did use the NuStep in the past when the facility had a restorative aide. NA-J revealed that the facility does not have a restorative nurse. NA-J revealed that the facility used to have a restorative aide assigned to do the restorative programs with the residents. NA-J revealed that since Covid the facility has not had a restorative aide assigned to assist the residents. Interview on 4/12/22 at 3:52 PM with the facility Director of Nursing (DON) confirmed that the facility does not currently have a restorative nurse to oversee the restorative nursing program. The DON confirmed that the facility does not have a designated restorative aide to perform the resident's restorative nursing program. The DON revealed that when residents come off of therapy services the DON has been putting the resident's restorative program on the resident's care plan. The DON revealed that the restorative program exercises for each resident are in the Point of Care electronic charting as a task for staff to perform and document the performance of the restorative program exercises. Interview on 4/13/22 at 2:51 PM with the Facility Administrator (FA) confirmed that the facility Restorative nursing policy directs that the restorative plan of care is to be included in the resident's care plan. The FA confirmed that the expectation is for the facility to provide the assistance to the residents and to perform the restorative exercises in the resident's care plan. The FA confirmed that the restorative plan of care was to be followed. The FA confirmed that the facility currently had no restorative nurse to oversee the facility's restorative nursing program. The FA confirmed that the facility currently had no designated restorative aide. The FA revealed that the facility did not have a restorative aide since sometime in the last year. The FA revealed that the expectation was for each aide to participate in assisting the resident in performing the resident's restorative care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09D9 Based on observation, record review, and interview; the facility failed to ensure that residents received assistance with hydration (providing adequate amounts of liquids) for 2 residents (Residents 22 and 16) to prevent the potential for dehydration. The facility census was 32. Findings are: A. Record review of the facility policy titled Nutrition and Hydration dated 5/3/21 revealed that nutritional status includes both nutrition and hydration status. The policy revealed that the facility ensures that each resident maintains acceptable parameters of nutritional status. The policy revealed that the facility offers sufficient fluid intake to maintain proper hydration and health. The policy revealed that the facility will monitor to determine whether the resident is consuming adequate food and fluid for their needs. Fluid includes beverages, foods that are liquid at room temperature, and fluid in foods. The section of the policy titled Hydration revealed that the facility will offer sufficient fluid intake to maintain proper hydration and health. Employees will monitor resident's intake of drinks and other fluids at meals through observation, offer alternative fluids, and make changes as necessary. The policy revealed that fresh water will be available to the residents at bedside unless contraindicated. Record review of the admission Record for Resident 16 revealed that Resident 16 admitted into the facility on 1/20/14. Resident 16 had a diagnosis of dementia. Record review of the Minimum Data Set Assessment (MDS) (a mandatory comprehensive resident assessment used for care planning) dated 1/19/22 for Resident 16 revealed that Resident 16 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 0 (a score of 0 indicates severe cognitive impairment). The MDS revealed that Resident 16 required extensive assistance of staff for eating and drinking. The MDS revealed that Resident 16 had no swallowing disorders. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 16 revealed that Resident 16 had a potential for fluid deficit (inadequate intake of fluids). The care plan contained the goal that Resident 16 would drink a minimum of 1000 cubic centimeters (cc) each 24 hour period. The care plan included the intervention to offer drinks to Resident 16 during resident interactions. The care plan included the intervention to monitor Resident 16 for signs and symptoms for dehydration including sunken eyes, dry mouth, changes in mental status, and fever. Record review of the Dietitian assessment dated [DATE] revealed that the daily fluid intake requirement for Resident 16 was 1466 cc. Observation on 4/7/22 at 2:46 PM in the room of Resident 16 revealed that the resident was in bed. A clear water cup with a lid and a straw sat on the dresser next to the bed. The water cup was full with the water level in line with the bottom of the lid. Observation on 4/7/22 at 3:57 PM in the room of Resident 16 revealed that the resident remained in bed with the eyes closed. The level of water in the clear cup remained in line with the bottom of the lid. Observation on 4/11/22 at 11:15 AM in the room of Resident 16 revealed that the resident sat in a wheelchair near the head of the bed. A clear water cup sat on the 3 drawer dresser across the room out of reach of the resident. The clear cup of water was full. Observation on 4/11/22 at 1:35 PM in the room of Resident 16 revealed that the resident was supine in bed. The clear cup of water remained on the top of the 3 drawer dresser. The clear cup of water was full. Observation on 4/11/22 at 3:06 PM in the room of Resident 16 revealed that the resident was in bed. The resident's eyes were closed. The clear cup of water remained on the top of the 3 drawer dresser across the room from the resident. The clear cup of water was full. Observation on 4/11/22 at 4:01 PM in the room of Resident 16 revealed that the resident was in bed. The clear cup of water remained on the top of the 3 drawer dresser. The clear cup of water was full. Record review of the Documentation Report for April 2022 for Resident 16 revealed that the staff documented that Resident 16 drank a total of 260 cc of water outside of meals during the 24 hour period on 4/11/22. The staff documented that Resident 16 received a total of 420 cc of fluids with meals during the 24 hour period on 4/11/22. This was a total of 680 cc of fluids for Resident 16 over the 24 hour period. The amount of fluids received by Resident 16 was less than the care plan goal of 1000 cc and the dietitian requirement of 1466 cc of fluids. Observation on 4/12/22 at 8:11 AM in the room of Resident 16 revealed that a clear cup of ice water sat on the 3 drawer dresser. Condensation was observed on the outside of the cup. A small amount of ice was in the cup. The clear cup was noted to be full. A straw stuck out of the lid. Observation on 4/12/22 at 8:12 AM on the 200 hall just outside of the room of Resident 16 revealed that 4 clear cups full of ice water sat on the 3 shelf cart in the hallway. Condensation was observed on the outside of the cups. Observation on 4/12/22 at 10:24 AM in the room of Resident 16 revealed that the clear cup of water remained on the 3 drawer dresser. The clear cup and the straw remained in the same position. The clear cup remained full of water. Observation on 4/12/22 at 12:07 PM in the room of Resident 16 revealed that the clear cup of water remained on the 3 drawer dresser. The clear cup and the straw remained in the same position. The clear cup remained full of water. Observation on 4/12/22 at 1:17 PM in the room of Resident 16 revealed that the resident was in the bed. The clear cup of water remained on the 3 drawer dresser across the room from the resident. The position of the clear cup and the straw remained unchanged. The clear cup of water remained full. No ice or condensation was observed. Observation on 4/12/22 at 2:55 PM in the room of Resident 16 revealed that the clear cup of water remained on the 3 drawer dresser across the room from the resident. The clear cup of water was full. Record review of the Documentation Report for April 2022 for Resident 16 revealed that on 4/12/22 at 2:21 PM the staff documented that Resident 16 drank 60 cc of water during the shift. The amount of water in the clear cup had remained unchanged with the clear cup full of water at all observations on 4/12/22 between 8:11 AM and 2:55 PM. Record review of the Documentation Report for April 2022 for Resident 16 revealed that the staff documented that Resident 16 drank a total of 330 cc of water outside of meals during the 24 hour period on 4/12/22. The staff documented that Resident 16 received a total of 160 cc of fluids with meals during the 24 hour period on 4/12/22. This was a total of 490 cc of fluids for Resident 16 over the 24 hour period. The amount of fluids received by Resident 16 was less than the care plan goal of 1000 cc and the dietitian requirement of 1466 cc of fluids. Interview on 4/12/22 at 1:20 PM on with Medication Aide-B (MA-B) revealed that to prevent dehydration staff offer fluids to the resident when they are in the resident's room. MA-B revealed that the amount of fluids that the resident takes is recorded in the Point of Care electronic charting for every shift. MA-B revealed that Resident 16 is 100% dependent on staff for assistance with drinking. Interview on 4/12/22 at 2:55 PM with Nursing Assistant-J (NA-J) revealed that Resident 16 is totally dependent on staff for assistance with drinking. NA-J revealed that staff make sure that the residents have fresh water to prevent dehydration and check to see that the residents are drinking. NA-J revealed that the amount of fluid taken by the residents are documented every shift. Observation on 4/13/22 at 9:31 AM in the room of Resident 16 revealed that the resident sat in a wheelchair at the side of the bed. A full clear cup of water sat on the over bed table behind the wheelchair. Dry flaky skin was noted on the back of Resident 16's hands. Dry skin flakes were noted on Resident 16's cheek. Interview on 4/13/22 at 2:51 PM with the Facility Administrator (FA) confirmed that the expectation is for the staff to ensure that the residents receive fluids throughout the day to meet the individual resident's needs and goals for hydration and fluid intake. The FA confirmed that the expectation is for staff to offer a drink to dependent resident's during each resident interaction. The FA confirmed that the expectation is for the staff to encourage residents to drink and to provide assistance to residents that are unable to drink on their own. The FA confirmed that the expectation is that the drink should be in reach of the resident in the resident's room. B. Record review of the admission Record for Resident 22 revealed that Resident 22 admitted into the facility on 1/30/17. Resident 22 had a diagnosis of dementia. Record review of the MDS assessment for Resident 22 dated 2/16/22 revealed that Resident 22 had a BIMS score of 9 (a score of 9 indicates moderate cognitive impairment). The MDS revealed that Resident 22 required extensive assistance of staff for eating and drinking. The MDS revealed that Resident 22 had no swallowing disorders. Record review of the care plan for Resident 22 revealed that Resident 22 had a potential for fluid deficit (inadequate intake of fluids). The care plan contained the goal that Resident 22 would drink a minimum of 1000 cubic centimeters (cc) each 24 hour period. The care plan included the intervention to monitor Resident 22 for signs and symptoms of dehydration including sunken eyes, dry mouth, changes in mental status, and fever. Record review of the Dietitian assessment dated [DATE] revealed that the daily fluid intake requirement for Resident 22 was 2045 cc. Observation on 4/11/22 at 11:15 AM in the room of Resident 22 revealed that the resident sat in a wheelchair towards the head of the bed. The over bed table sat next to the resident's left side. A clear water cup with a lid and a straw sat on the over bed table. The water cup was full with the water level in line with the bottom of the lid. Observation on 4/11/22 at 1:35 PM in the room of Resident 22 revealed that the resident was seated in the wheelchair in the middle of the resident's side of the room. The clear cup of water remained on the over bed table to the left of the resident. The clear cup of water was full. Observation on 4/11/22 at 3:06 PM in the room of Resident 22 revealed that the clear cup of water remained on the over bed table. The clear cup of water was full. Observation on 4/11/22 at 4:01 PM in the room of Resident 22 revealed that the resident sat in the wheelchair in the middle of the resident's side of the room. The clear cup of water remained on the over bed table to the left of Resident 22. The clear cup of water was full. Record review of the Documentation Report for April 2022 for Resident 22 revealed that the staff documented that Resident 22 drank a total of 340 cc of water outside of meals during the 24 hour period on 4/11/22. The staff documented that Resident 22 received a total of 980 cc of fluids with meals during the 24 hour period on 4/11/22. This was a total of 1320 cc of fluids for Resident 22 over the 24 hour period. The amount of fluids received by Resident 22 was less than the care plan goal of 1000 cc and the dietitian requirement of 2045 cc of fluids. Observation on 4/12/22 at 8:11 AM revealed that a clear cup of ice water sat on the over bed table in the room of Resident 22. Condensation was observed on the outside of the cup. The clear cup was noted to be full. A straw stuck out of the lid of the cup. Observation on 4/12/22 at 10:24 AM in the room of Resident 22 revealed that the clear cup of water remained on the over bed table. The over bed table was against the wall and situated between the dresser with the TV and the 3 drawer dresser of Resident 16 (the roommate of Resident 22). The small clear cup and the straw remained in the same position. The clear cup remained full of water. Observation on 4/12/22 at 12:07 PM in the room of Resident 22 revealed that the clear cup of water remained on the over bed table up against the wall. The small clear cup and the straw remained in the same position. The clear cup remained full of water. Observation on 4/12/22 at 1:17 PM in the room of Resident 22 revealed that the resident sat in the wheelchair near the bed. The clear cup of water remained on the over bed table against the opposite wall between the TV and the 3 drawer dresser of Resident 16. The table and the clear cup were out of the resident's reach. The clear cup remained full. Observation on 4/12/22 at 2:55 PM in the room of Resident 22 revealed that the clear cup of water remained on the over bed table across the room from the resident. The clear cup of water was full. Record review of the Documentation Report for April 2022 for Resident 22 revealed that on 4/12/22 at 2:20 PM the staff documented that Resident 22 drank 60 cc of water during the shift. The amount of water in the clear cup had remained unchanged with the clear cup full of water at all observations on 4/12/22 between 8:11 AM and 2:55 PM. Record review of the Documentation Report for April 2022 for Resident 22 revealed that the staff documented that Resident 22 drank a total of 205 cc of water outside of meals during the 24 hour period on 4/12/22. The staff documented that Resident 22 received a total of 240 cc of fluids with meals during the 24 hour period on 4/12/22. This was a total of 445 cc of fluids for Resident 22 over the 24 hour period. The amount of fluids received by Resident 22 was less than the care plan goal of 1000 cc and the dietitian requirement of 2045 cc of fluids. Interview on 4/12/22 at 1:20 PM on with Medication Aide-B (MA-B) revealed that to prevent dehydration staff offer fluids to the resident when they are in the resident's room. MA-B revealed that the amount of fluids that the resident takes is recorded in the Point of Care electronic charting for every shift. MA-B confirmed that Resident 22 requires assistance with drinking. Interview on 4/12/22 at 2:55 PM with Nursing Assistant-J (NA-J) revealed that the staff make sure that the residents have fresh water to prevent dehydration and check to see that the residents are drinking. NA-J revealed that the amount of fluid taken by the residents are documented every shift. NA-J confirmed that Resident 22 is dependent on staff for assistance with drinking. Interview on 4/13/22 at 2:51 PM with the Facility Administrator (FA) confirmed that the expectation is for the staff to ensure that the residents receive fluids throughout the day to meet the individual resident's needs and goals for hydration and fluid intake. The FA confirmed that the expectation is for staff to offer a drink to dependent resident's during each resident interaction. The FA confirmed that the expectation is for the staff to encourage residents to drink and to provide assistance to residents that are unable to drink on their own. The FA confirmed that the expectation is that the drink should be in reach of the resident in the resident's room.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on observation, interview, and record review; the facility failed to ensure medications were administered within the required time frame for 4 of 4 residents observed, Residents 134, 24, 30, and 19. The facility identified a census of 32 at the time of survey. Findings are: A. Observation of Resident 134 on 4/11/22 at 9:20 AM revealed LPN-A (Licensed Practical Nurse) administered 2 units of Humalog insulin injection to Resident 134. At 9:30 AM LPN-A administered Levothyroxine (thyroid medication) 25 mcg (micrograms) per GT (Gastrostomy Tube); diltiazem 30 mg (milligram) per GT; cholecalciferol (Vitamin D3) liquid 1 tsp (teaspoon) per GT; famotidine 20 mg per GT; metoprolol 25 mg 1/2 tab per GT; venlafaxine 37.5 mg per GT; Banatrol plus 1 packet in 120 cc (cubic centimeters) water per GT and finasteride 5 mg per GT to Resident 134. Review of Resident 134's MAR (Medication Administration Record) for April 2022 revealed the levothyroxine was scheduled at 0700 (7:00 AM) and the Humalog was scheduled at 0730. The diltiazem was scheduled at 0800. The cholecalciferol, famotidine, metoprolol, venlafaxine, Banatrol, and finasteride were scheduled for AM Pass. Review of Resident 134's Medication Admin Audit Report dated 4/11/2022 revealed the following: Levothyroxine schedule date 07:00. Administration time 9:50 AM by LPN-A. Metoprolol, Banatrol, Famotidine, Cholecalciferol, Finasteride schedule date 07:15. Administration time 9:58 AM by LPN-A. Venlafaxine schedule date 07:15. Administration time 10:00 AM by LPN-A. Humalog schedule date 07:30 AM. Administration time 9:51 AM by LPN-A. B. Observation of Resident 24 on 4/11/22 at 9:46 AM revealed MA-B (Medication Aide) administered Synthroid 75 mcg 1 tab PO (by mouth), KCL (potassium chloride) 20 mEq PO, Sodium Chloride 1 gm (gram) tablet PO, and Colace 1 tablet PO to Resident 24. Review of Resident 24's MAR for April 2022 revealed the Synthroid and sodium chloride were scheduled to be administered at 0730. The Colace and KCL was scheduled for AM Pass. Review of Resident 24's Medication Admin Audit Report dated 4/11/2022 revealed the following: Synthroid and sodium chloride schedule date was 07:30; Potassium Chloride Packet and Colace schedule date was 07:15. Administration time for all was 09:50 AM documented by MA-B. C. Observation of Resident 19 on 4/11/22 at 9:51 AM revealed MA-B administered the medications Vitamin C 500 mg PO, calcium 500 mg with D 1 PO, stool softener 1 PO, Celecoxib 200 mg 1 PO, and Tolterodine ER (Extended Release) 4 mg 1 PO to Resident 19. Review of Resident 19's MAR for April 2022 revealed the Vitamin C 500 mg PO, calcium 500 mg with D 1 PO, stool softener 1 PO, Celecoxib 200 mg 1 PO, and Tolterodine ER 4 mg 1 PO were scheduled for the AM Pass. Review of Resident 19's Medication Admin Audit Report dated 4/11/2022 revealed the schedule date for the stool softener, Vitamin C, Celecoxib, Tolterodine ER, and Calcium with D was 07:15. The administration time was 9:54 AM by MA-B. D. Observation of Resident 30 on 4/11/22 at 9:56 AM revealed MA-B administered the medications omeprazole 20 mg 1 PO; ASA (aspirin) 81 mg PO; furosemide 40 mg 1 PO; lisinopril 20 mg 1 PO; metoprolol succinate 100 mg ER 1 PO; multivitamin with minerals 1 PO; potassium chloride 10 mEq ER 2 tabs (20 MEQ) PO; sodium chloride 1 GM PO; Tylenol Arthritis 650 mg PO, and Vitamin C 500 mg 1 PO to Resident 30. Review of Resident 30's MAR for April 2022 revealed the omeprazole was scheduled at 0730. The ASA, furosemide, lisinopril, metoprolol, multivitamin, potassium chloride, sodium chloride, Tylenol Arthritis, and Vitamin C were scheduled for AM Pass. Review of Resident 30's Medication Admin Audit Report dated 4/11/2022 revealed the schedule date for the lisinopril, sodium chloride, Tylenol Arthritis, multivitamin, potassium chloride, metoprolol, ASA, furosemide, and vitamin C was 07:15 AM. The administration time was 09:59 AM by MA-B. The schedule date for the omeprazole was 07:30 give 30 minutes prior to breakfast. The administration time was 9:59 AM by MA-B. Review of the facility document Schedule of Medication Administration times received 4/6/2022 revealed AM Pass was from 0715 AM to 0915 AM. Interview with the DON (Director of Nursing) on 4/11/22 at 3:16 PM confirmed the medications should have been given within the time frame and as ordered. Review of the facility policy Medication Administration Including Scheduling and Medication Aides-Rehab/Skilled dated 3/29/2022 revealed the following: Purpose: To administer medications correctly and in a timely manner. Medications are administered to the resident according to the Six Rights. Procedure: Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review; the facility failed to maintain a medication error rate below 5% with 4 errors out of 28 opportunities which resulted in a medication error rate of 14.29%. This affected 3 of 4 residents observed, Residents 134, 24, and 30. The facility identified a census of 32 at the time of survey. Findings are: A. Observation of Resident 134 on 4/11/22 at 9:20 AM revealed LPN-A (Licensed Practical Nurse) administered 2 units of Humalog insulin injection to Resident 134. At 9:30 AM LPN-A administered Levothyroxine (thyroid medication) 25 mcg (micrograms) per GT (Gastrostomy Tube); diltiazem 30 mg (milligram) per GT; cholecalciferol (Vitamin D3) liquid 1 tsp (teaspoon) per GT; famotidine 20 mg per GT; metoprolol 25 mg 1/2 tab per GT; venlafaxine 37.5 mg per GT; Banatrol plus 1 packet in 120 cc (cubic centimeters) water per GT and finasteride 5 mg per GT to Resident 134. Review of Resident 134's Order Summary Report dated 4/11/2022 revealed an active order for Levothyroxine Sodium Tablet 25 MCG Give 25 mcg via G-Tube one time a day for Hypothyroidism. No vitamins, minerals or antacids within two hours. Review of Resident 134's MAR (Medication Administration Record) for April 2022 revealed the levothyroxine was scheduled at 0700 (7:00 AM) and the Humalog was scheduled at 0730. The diltiazem was scheduled at 0800. The cholecalciferol, famotidine, metoprolol, venlafaxine, Banatrol, and finasteride were scheduled for AM Pass. Resident 134 was also scheduled to receive a multivitamin which was not administered which resulted in 1 error. The levothyroxine was scheduled to be administered with no vitamins, minerals or antacids within two hours which resulted in 1 error as the levothyroxine was administered with the cholecalciferol (a vitamin) and famotidine (an antacid). Review of Resident 134's Medication Admin Audit Report dated 4/11/2022 revealed the levothyroxine schedule date was 07:00. The administration time was 9:50 AM by LPN-A. The metoprolol, Banatrol, famotidine, cholecalciferol, and finasteride schedule date was 07:15. The administration time was 9:58 AM by LPN-A. B. Observation of Resident 24 (Medication Aide) on 4/11/22 at 9:46 AM revealed MA-B administered Synthroid 75 mcg 1 tab PO (by mouth), KCL (potassium chloride) 20 mEq (milliequivalents) PO, Sodium Chloride 1 gm tablet PO, and Colace 1 tablet PO to Resident 24. Review of Resident 24's MAR for April 2022 revealed the Synthroid and sodium chloride were scheduled to be administered at 0730. The Colace and KCL was scheduled for AM Pass. Review of Resident 24's Medication Admin Audit Report dated 4/11/2022 revealed the following: Synthroid and sodium chloride schedule date was 07:30; Potassium Chloride Packet and Colace schedule date was 07:15. Administration time for all was 09:50 AM documented by MA-B which resulted in 1 error for the Synthroid not being administered before the breakfast meal. Review of the Nursing2018 drug hand book revealed the following administration instructions for Synthroid: give drug at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. D. Observation of Resident 30 on 4/11/22 at 9:56 AM revealed MA-B administered the medications omeprazole 20 mg 1 PO; ASA (aspirin) 81 mg PO; furosemide 40 mg 1 PO; lisinopril 20 mg 1 PO; metoprolol succinate 100 mg ER 1 PO; multivitamin with minerals 1 PO; potassium chloride 10 mEq ER 2 tabs (20 MEQ) PO; sodium chloride 1 GM PO; Tylenol Arthritis 650 mg PO, and Vitamin C 500 mg 1 PO to Resident 30. Review of Resident 30's MAR for April 2022 revealed the omeprazole was scheduled at 0730. The ASA, furosemide, lisinopril, metoprolol, multivitamin, potassium chloride, sodium chloride, Tylenol Arthritis, and Vitamin C were scheduled for AM Pass. Review of Resident 30's Medication Admin Audit Report dated 4/11/2022 revealed the schedule date for the omeprazole was 07:30 with the directions to give 30 minutes prior to breakfast. The administration time was 9:59 AM by MA-B which resulted in 1 error for the omeprazole being administered after breakfast. Interview with DC-M (Dietary Cook) on 4/11/22 at 3:02 PM confirmed Residents 24 and 30 had eaten breakfast in the dining room and the residents had been served by 8:40 AM. Interview with the DON (Director of Nursing) on 4/11/22 at 3:16 PM confirmed the medications should have been given within the time frame and as ordered, including without food other medications. Review of the facility policy Medication Administration Including Scheduling and Medication Aides-Rehab/Skilled dated 3/29/2022 revealed the following: Purpose: To administer medications correctly and in a timely manner. Medications are administered to the resident according to the Six Rights. Procedure: Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation.

Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure that staff delivered resident meals to prevent the potential for food borne illness for 12 residents (Residents 3, 8, 17, 13, 30, 28, 29, 27, 2, 25, 24, and 31). The facility census was 32. Findings are: Record review of the facility policy titled Safe Handling of Personal Food dated 5/19/20 revealed that staff are to use safe food handling practices at all times. Record review of the facility policy titled Dining Service Standards dated 2/24/22 revealed that employees will follow procedures for prevention of foodborne illness when serving meals. Never touch ready to eat foods with the bare hands. Never touch the eating surface of utensils and dishware. Observation on 4/6/22 at 12:31 PM in the facility dining room revealed that Dietary Aide-F (DA-F) picked up a plate of food from the meal service counter with the bare thumb of the left hand on the top surface of the plate touching the bread stick. DA-F picked up a bowl of cake from the meal service counter with the bare thumb of the right hand inside of the bowl next to the cake. DA-F sat the plate on the table in front of Resident 3 and then sat the bowl on the table in front of Resident 3. The hands of DA-F touched the table in front of the unmasked resident. DA-F returned to the meal service counter and picked up a plate of food with the thumb of the bare left hand on the top surface of the plate next to the bread stick. DA-F picked up a bowl of cake with the bare thumb of the right hand inside of the bowl next to the cake. DA-F sat the plate and the bowl on the table in front of Resident 8. The hands of DA-F touched the table in front of the unmasked resident. DA-F returned to the meal service counter and picked up a plate of food with the bare thumb on the top surface of the plate with the thumb of the bare left hand next to the food on the plate. DA-F picked up a blue bowl containing puree bread stick. DA-F sat the plate and the bowl on the table in front of Resident 17. The bare hands touched the table in front of the unmasked resident. DA-F returned to the meal service counter and picked up a plate of food with the thumb of the bare left hand on the top surface of the plate next to the food. DA-F picked up a bowl with a slice of pie in it with the bare right hand. The thumb of the bare right hand was on the inside of the bowl against the pie as DA-F carried it. DA-F sat the plate and the bowl on the table in front of Resident 13. The bare hands of DA-F touched the table in front of the unmasked resident. The time was now 12:37 PM. DA-F returned to the meal service counter and picked up a plate of food with the thumb of the bare right hand on the top surface of the plate next to the food. DA-F picked up a bowl with the left hand. DA-F sat the bowl on the table in front of Resident 30. DA-F grabbed the plate of food with the left hand and used both hands to rotate the position of the plate. The thumb of the bare right hand and the thumb of the bare left hand were both on the top surface of the plate. The bare left thumb was in contact with the breadstick. DA-F sat the plate on the table in front of Resident 30. The bare hands touched the table in front of the unmasked resident. DA-F returned to the meal service counter. DA-F picked up a plate of food at the meal service counter. The thumb of the bare left hand was on top of the plate next to the food. DA-F grabbed a bowl of cake with the thumb of the bare right hand on the inside of the bowl next to the cake. DA-F sat the plate and the bowl on the table in front of Resident 28. The hands of DA-F touched the table in front of the unmasked resident. DA-F returned to the meal service counter. DA-F picked up a plate of food with the thumb of the bare left hand on the top of the plate next to the food. DA-F picked up a bowl of food with the right hand. DA-F sat the plate and the bowl on the table in front of Resident 29. The bare hands of DA-F touched the table in front of the unmasked resident. DA-F went to the sink in the dining room and washed the hands. DA-F scrubbed the hands with soap for 41 seconds and then rinsed and dried the hands. DA-F went to the meal service counter. DA-F picked up a plate of food. The thumb of the bare left hand was next to the food on the top surface of the plate. DA-F picked up a bowl of jello with the right hand. DA-F carried the bowl with the hand underneath the bowl. DA-F sat the plate of food and the bowl on the table in front of Resident 27. The bare hands of DA-F touched the table in front of the unmasked resident. DA-F returned to the meal service counter. DA-F picked up a plate of food. The thumb of the bare left hand was on the top of the plate next to the food on the top surface of the plate. DA-F picked up a bowl with the right hand underneath the bowl. DA-F sat the plate of food and the bowl on the table in front of Resident 2. Observation on 4/7/22 at 12:33 PM in the facility dining room revealed that the Dietary Manager (DM) went to the meal service counter. DM picked up a plate of food with the bare left hand. The thumb of the left hand was on the top surface of the plate next to the food. DM sat the plate on the table in front of Resident 13. DM returned to the meal service counter. DM picked up a plate of food with the bare left hand. The thumb of the left hand was on the top surface of the plate next to the food. DM sat the plate on the table in front of Resident 25. DM picked up a plate of food from the meal service counter. DM picked the plate up with the bare right hand. The thumb of the right hand was on the top surface of the plate next to the food. DM sat the plate on the table in front of Resident 24. Observation on 4/7/22 at 12:45 PM in the facility dining room revealed that DA-F picked up a plate of food from the meal service counter. DA-F picked up the plate with the bare left hand. The thumb of the left hand was on the top surface of the plate next to the food. DA-F sat the plate on the table in front if Resident 31. DA-F went to the counter and picked up a carafe of coffee. DA-F carried the carafe to the table of Resident 28. DA-F grabbed Resident 28's coffee cup with the bare hand and refilled the coffee cup. DA-F returned to the counter and sat the carafe on the counter. DA-F did not perform hand hygiene. DA-F returned to the meal service counter. DA-F picked up a plate of food with the bare left hand. The thumb of the left hand was on the top surface of the plate against the roast beef and cheese sandwich on a bun. DA-F sat the plate on the table in front of Resident 29. Interview on 4/13/22 at 2:51 PM with the Facility Administrator (FA) confirmed that the expectation is that the staff handle plates and bowls to ensure that the thumbs and hands do not touch the food surface or the food with the bare hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC-12-006.12E6 Based on observation, interview, and record review; the facility failed to ensure the emergency medication boxes were locked, secured, and monitored to ensure they had not been tampered with and the medications were protected from diversion. This had the potential to affect all of the facility residents. The facility identified a census of 32 at the time of survey. Findings are: Observation of the facility medication room on 4/12/22 at 8:18 AM with RN-L (Registered Nurse) revealed the facility had 3 emergency drug boxes; 1 for IV (Intravenous) medications, 1 for controlled substances/narcotics, and 1 for general use medications. The general use medication drug box was in the cupboard in the medication room. It was unlocked and open. Interview with RN-L at this time confirmed the drug box was supposed to be locked with one of the plastic sequentially numbered locks that was in the top of the drug box. RN-L revealed the night shift nurse was expected to check the locks on the drug boxes every night shift. Interview with the DON (Director of Nursing) on 4/12/2022 at 8:20 AM revealed the medication box was expected to be locked at all times and it was to be checked by a nurse every day. The DON opened the book that was laying on the medication room counter with the Daily Emergency Box Verification sheets and there were no sheets for March and April 2022. The sheet for February had 3 entries on it for February 4, 5, and 6. The entries for the other dates the drug box was to be checked were blank. The sheet had entries on it for the lock number to be entered on each drug box so the staff could verify if the lock was intact and had not been removed or tampered with. Interview with the DON at this [NAME] confirmed there was no documentation the drug boxes were being checked to ensure they had not been tampered with and no diversion had occurred. Review of the Daily Emergency Box Verification dated February 2022 revealed documentation the drug boxes were checked on February 4, 5, and 6. There was no other documentation the drug boxes were checked. Review of the Ekit Contents sheet for the IV Ekit box revealed the exchange date by the pharmacy was 4/1/2022. The narcotic Ekit box exchange date by the pharmacy was 4/11/2022. The general Ekit box exchange date was 3/28/2022 which was the last documented date the boxes were checked by anyone including the pharmacist. There were 9 items listed on the narcotic Ekit including alprazolam, fentanyl, hydrocodone (2 different strengths), lorazepam, morphine, oxycodone (2 different strengths), and tramadol. There were 49 items listed on the IV drug Ekit box, and there were 60 items listed on the general Ekit including psychotropic medications (medications used to alter mood and behavior). Review of the facility policy Emergency Drug Boxes-Rehab/Skilled dated 9/13/2021 revealed the following: Purpose: To ensure a system is in place for use of the emergency drug box. Policy/Procedure: Emergency drug boxes are an extension of the providing pharmacist's store and will be kept in the med room, accessible to licensed nurses and medication aides. Record keeping will be in accordance with the state pharmacy system.

C. Observation on 4/6/22 at 12:31 PM in the facility dining room revealed that Dietary Aide-F (DA-F) picked up a plate of food from the meal service counter with the bare thumb of the left hand on the top surface of the plate touching the bread stick. DA-F picked up a bowl of cake from the meal service counter with the bare thumb of the right hand inside of the bowl next to the cake. DA-F sat the plate on the table in front of Resident 3 and then sat the bowl on the table in front of Resident 3. The hands of DA-F touched the table in front of the unmasked resident. DA-F did not perform hand hygiene. DA-F returned to the meal service counter and picked up a plate of food with the thumb of the bare left hand on the top surface of the plate next to the bread stick. DA-F picked up a bowl of cake with the bare thumb of the right hand inside of the bowl next to the cake. DA-F sat the plate and the bowl on the table in front of Resident 8. The hands of DA-F touched the table in front of the unmasked resident. DA-F did not perform hand hygiene. DA-F returned to the meal service counter and picked up a plate of food with the bare thumb on the top surface of the plate with the thumb of the bare left hand next to the food on the plate. DA-F picked up a blue bowl containing puree bread stick. DA-F sat the plate and the bowl on the table in front of Resident 17. The bare hands touched the table in front of the unmasked resident. DA-F did not perform hand hygiene. DA-F returned to the meal service counter and picked up a plate of food with the thumb of the bare left hand on the top surface of the plate next to the food. DA-F picked up a bowl with a slice of pie in it with the bare right hand. The thumb of the bare right hand was on the inside of the bowl against the pie as DA-F carried it. DA-F sat the plate and the bowl on the table in front of Resident 13. The bare hands of DA-F touched the table in front of the unmasked resident. DA-F did not perform hand hygiene. The time was now 12:37 PM. DA-F returned to the meal service counter and picked up a plate of food with the thumb of the bare right hand on the top surface of the plate next to the food. DA-F picked up a bowl with the left hand. DA-F sat the bowl on the table in front of Resident 30. DA-F grabbed the plate of food with the left hand and used both hands to rotate the position of the plate. The thumb of the bare right hand and the thumb of the bare left hand were both on the top surface of the plate. The bare left thumb was in contact with the breadstick. DA-F sat the plate on the table in front of Resident 30. The bare hands touched the table in front of the unmasked resident. DA-F did not perform hand hygiene. DA-F returned to the meal service counter. DA-F picked up a plate of food at the meal service counter. The thumb of the bare left hand was on top of the plate next to the food. DA-F grabbed a bowl of cake with the thumb of the bare right hand on the inside of the bowl next to the cake. DA-F sat the plate and the bowl on the table in front of Resident 28. The hands of DA-F touched the table in front of the unmasked resident. DA-F did not perform hand hygiene. DA-F returned to the meal service counter. DA-F picked up a plate of food with the thumb of the bare left hand on the top of the plate next to the food. DA-F picked up a bowl of food with the right hand. DA-F sat the plate and the bowl on the table in front of Resident 29. The bare hands of DA-F touched the table in front of the unmasked resident. DA-F went to the sink in the dining room and washed the hands. DA-F scrubbed the hands with soap for 41 seconds and then rinsed and dried the hands. DA-F went to the meal service counter. DA-F picked up a plate of food. The thumb of the bare left hand was next to the food on the top surface of the plate. DA-F picked up a bowl of jello with the right hand. DA-F carried the bowl with the hand underneath the bowl. DA-F sat the plate of food and the bowl on the table in front of Resident 27. The bare hands of DA-F touched the table in front of the unmasked resident. DA-F returned to the meal service counter. DA-F picked up a plate of food. The thumb of the bare left hand was on the top of the plate next to the food on the top surface of the plate. DA-F picked up a bowl with the right hand underneath the bowl. DA-F sat the plate of food and the bowl on the table in front of Resident 2. D. Observation on 4/6/22 at 12:16 PM in the facility dining room revealed that Medication Aide-N (MA-N) used a spoon to feed bites of sherbet to Resident 16. MA-N wore a surgical mask with the mask down below MA-N's nose. MA-N wore goggles. MA-N was seated at the corner of the table between Residents 16 and 6. MA-N sat to the left of Resident 16. MA-N joined the residents and staff in the dining room in singing happy birthday. MA-N leaned in towards the head of Resident 16 while singing. The face of MA-N was within 6 inches of the face of Resident 16 per visual measurement. E. Record review of the facility policy titled Catheter Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen dated 5/27/21 revealed that urinary catheters (a flexible rubber like tube inserted into the bladder to drain urine from the bladder) are always properly secured, connected and maintained using a sterile closed drainage system. Catheter tubing should never be allowed to touch the floor. The section titled Emptying the Catheter Drainage Bag (a flexible plastic bag connected to the urinary catheter to collect and store the urine drained from the bladder) revealed that staff are to make sure that the drainage bag and tubing are appropriately placed. Do not store the measuring container on the floor. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 29 dated 2/23/22 revealed that Resident 29 recently admitted into the facility on 1/14/22. The MDS documented that Resident 29 had a urinary catheter. Observation on 4/11/22 at 3:08 PM in the room of Resident 29 revealed that the resident was on their back in the bed. The urinary catheter tubing contained clear light yellow urine. The urinary catheter bag hung from the bottom bed frame and sat on the floor. Observation on 4/12/22 at 2:45 PM in the room of Resident 29 revealed that Nursing Assistant-J (NA-J) entered the resident's room. NA-J told the resident that NA-J was going to empty the urine from the catheter bag. The catheter bag was lying on the floor on the right side of the bed. The catheter bag was hanging from the bottom of the bed frame. Approximately 6 inches of the catheter bag were in contact with the floor per visual measurement. Interview on 4/13/22 at 2:51 PM with the Facility Administrator (FA) confirmed that the expectation was for staff to secure urinary catheter bags to keep them from touching the floor. LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility staff failed to prevent the potential spread of Covid-19 by failing to ensure staff wore a face covering/masks in resident care areas of the facility which had the potential to affect all of the facility residents; failed to perform hand hygiene to prevent cross contamination during meal service in the dining room which had the potential to affect the 31 residents who received food from the facility kitchen/dining room; and failed to store a urinary catheter drainage bag in a manner to prevent potential cross contamination for 1 of 1 sampled residents, Resident 29. The facility identified a census of 32 at the time of survey. Findings are: A. Observation of the facility dining room on 04/06/22 at 12:35 PM revealed the following: DA-F (Dietary Aide) picked up Resident 15's coffee cup by the handle and refilled it with coffee. Resident 15 had been observed drinking from the cup and handling it by the handle. DA-F put the cup back down in front of Resident 15, put the coffee carafe on the counter and went to the service window and took a plate of food and bowl of dessert to Resident 13. Resident 13 was then observed eating off of the plate and bowl. DA-F did not do any hand hygiene after handling Resident 15's coffee mug. At 12:38 PM DA-F took a plate of food to Resident 30. DA-F did not do any hand hygiene. Resident 30 was observed eating off the plate of food. DA-F then went to the freezer and opened the freezer door and took out 4 cups of ice cream and placed them on the counter in a tub of ice. At 12:39 PM DA-F took a plate and bowl to Resident 135. DA-F did not do hand hygiene. Resident 135 was observed eating from the items. At 12:40 PM, DA-F handled a diet card from the holder on the counter and handed it to the cook. DA-F had not done any hand hygiene after handling Resident 15's cup. At 12:40 PM DA-F took a plate of food to Resident 28. DA-F then took the ice cream cups out of the tub of ice on the counter and took them to Resident 3; Resident 22, and Resident 24. DA-F handled the ice cream containers and opened the lids before placing the containers of ice cream in front of the residents. All 3 of the residents were then observed eating the ice cream by picking up the containers and holding them. At 12:41 PM DA-F took a plate and bowl of food to Resident 29 who was then observed eating from the items. At 12:44 PM DA-F took the other ice cream cup they had handled to Resident 2 who then handled the container while eating it. At 12:46 PM DA-F did not do hand hygiene after handling the ice cream containers they had handled without doing hand hygiene after handling Resident 15's coffee mug and prepared a room tray for Resident 19 by handling the plate, bowl, silverware, cups/glasses. Another staff person then took the tray to Resident 19's room and Resident 19 proceeded to eat the food from the items on the tray DA-F had handled. Residents who were observed in the dining room were Residents 13, 3, 29, 18, 16, 28, 27, 6, 30, 24, 33, 17, 26, 10, 7, 21, 135, 32, 14, 8, 25, 1, 15, 22, 11, and 2. Review of the facility policy Hand Hygiene and Handwashing-Rehab/Skilled Senior Living dated 4/6/2021 revealed the following: Purpose: To ensure appropriate hand hygiene technique for clinical use. Food service: The goal is to protect all residents from foodborne illness by never touching their food with bare hands or contaminated gloves. Proper handwashing and appropriate use of gloves protects residents against foodborne illness from improperly handled time/temperature control for safety foods. Review of the facility policy Dining Service Standards-Food and Nutrition Services dated 2/24/2022 revealed the following: Employees will follow procedures for prevention of foodborne illness when serving meals (e.g. never touch ready-to-eat food with bare hands; never touch the eating surface of utensils and dishware). Review of the facility policy Hand Washing and Glove Use-Food Nutrition Services dated 4/11/2022 revealed the following: Employees wash their hands as required and wear gloves only when appropriate to protect any food from contamination they may be present on hands. When to wash hands: before, between and after resident contact. After touching any contaminated object (face, hair body or clothing garbage or dirty utensils, dirty dishes, phone, linen or money). Interview with FA (Facility Administrator) on 4/13/22 at 3:07 PM revealed the facility staff were expected to wash their hands after handling resident items. B. Observation of the facility on 4/06/22 at 12:55 PM revealed LPN-A (Licensed Practical Nurse) walked from the old DON (Director of Nursing) office on the 300 unit, around the corner through the living room/lounge/milieu to the medication room that was located in the living room area. LPN-A was not wearing a face covering. There were residents observed sitting in the area, Resident 22 and Resident 16. Resident 21 then drove through the area with their power wheelchair on the way down the hall that Resident 21 resided on. At 1:00 PM LPN-A walked across the 300 hall from the old DON office to the galley and got a supplement and applesauce out of the refrigerator and walked back across the hall to the old DON office. The treatment cart was observed sitting in that office. LPN-A did not have a face covering on. The Resident 22 and Resident 16 were observed sitting in the living room adjacent to the office. Observation of the facility on 4/13/22 at 3:00 PM revealed MA-C (Medication Aide) was observed standing in the living room talking to MA-I who was sitting in a chair in the living room with 3 residents in the area. MA-C's surgical mask was down under their chin and their nose and mouth were uncovered. MA-C was standing within 6 feet of Resident 16, and was facing Resident 16 as MA-C was talking to MA-I. Resident 16 was sitting in their wheelchair with no face mask on. Resident 6 was asleep in their wheelchair sitting next to Resident 16 and Resident 26 was sitting in their wheelchair in the living room next to Resident 26. Review of the list of residents and their Covid-19 vaccination status received from the FA revealed Resident 17 and Resident 134 were not vaccinated for Covid-19. Review of the staff Covid-19 vaccination matrix reveled 12 facility staff were not vaccinated for Covid-19. Interview with the FA 4/13/22 at 2:49 PM revealed the facility staff were expected to wear masks in the facility in the resident care areas including the living room and the halls. Review of the Facility Masking Policy updated February 23, 2022 revealed the following: All employees mask in all patient-facing and/or public areas; continue self-screening prior to your shift. Skilled nursing and assisted living should continue to mask in all areas.

Based on observation, interview, and record review; the facility to ensure the unvaccinated staff followed mitigation to prevent the potential spread of Covid-19 in the facility by following the testing requirements for unvaccinated staff. This had the potential to affect all of the facility residents. The facility identified a census of 32 at the time of survey. Findings are: Interview with the DON (Director of Nursing) on 4/13/22 at 10:54 AM revealed the mitigation for staff who were unvaccinated was the unvaccinated staff were expected to test for Covid-19 twice a week. Observation of the facility on 4/6, 4/7, 4/11, 4/12, and 4/13 revealed all of the staff were observed working in the facility wearing surgical masks including the unvaccinated staff. No other type of mask was worn by the unvaccinated staff such as an N95 or KN95 which indicated no other mitigation was in place to prevent the spread of Covid-19 to the residents other than the twice weekly Covid-19 testing for unvaccinated staff. Review of the staff Covid-19 Vaccination Matrix dated 4/6/2022 revealed DA-D (Dietary Aide) and DA-E were unvaccinated for Covid-19. Review of the facility Covid-19 Testing logs for February, March, and April 2022 revealed no documentation DA-E had been tested for Covid-19. There was documentation DA-D had been tested for Covid-19 on 2/2, 2/9, 2/12, 2/16, 2/19 and 3/19/22. There was no documentation DA-D had been tested for Covid-19 between 2/19/22 and 3/19/22, or after 3/19/22. Review of the POC (Point of Care)Test Result Reporting for DA-D dated 4/13/2022 revealed documentation DA-D tested for Covid-19 on 2/2, 2/9, 2/12, 2/16, 2/19, an 3/19/22. Review of the untitled dietary staff schedules for February, March, April 2022 revealed DA-D was scheduled to work February 2, 5, 6, 9, 12, 16, 18, 19, 20, 23, 26, 27; March 2, 5, 6, 9, 12, 13, 19, 20, 27; and April 2, 3, 9, 10, 16. DA-E was scheduled to work April 1, 4, 5, 7, 9, 10, 12, and 13. Review of the Hours Worked for DA-D for 1/30/2022 to 4/9/2022 revealed documentation DA-D worked 1/30; 2/2, 2/3, 2/4, 2/5, 2/6, 2/9, 2/12, 2/16, 2/18, 2/19, 2/20, 2/23, 2/26, 2/27, 3/5, 3/6, 3/9, 3/12, 3/13, 3/19, 3/20, 3/24, 3/25, 3/27, 4/3, 4/5 4/7, and 4/8. Review of the Pay Distributions (Daily Hours) for DA-E for April 2022 revealed documentation DA-E worked in the facility April 1, 4, 5, 7, and 12. Interview with the DM (Dietary Manager) on 4/13/22 at 1:35 PM confirmed DA-D and DA-E were working in the facility and served food to the facility residents. The DM revealed DA-E had started working in the kitchen on April 1 and DA-D worked in February, March, and April 2022. The DM revealed the unvaccinated staff had been trained and were expected to test for Covid-19 when they were working in the facility Interview with the FA (Facility Administrator) on 4/13/22 at 1:39 PM confirmed there was no documentation DA-E had been tested for Covid-19 at all and there was no documentation DA-D was tested for Covid-19 twice a week as required. Review of the facility policy Covid-19 Immunization, Employee-Enterprise dated 2/16/2022 revealed the following: Covid-19 vaccinations shall be required for all employees, medical residents, students, volunteers contingent workers, and vendors unless exempt for medical or religious purposes as outlined below or otherwise prohibited by applicable state law. Any person who is exempt from the Covid-19 vaccination for a medical or religious exemption shall be required to wear source control covering the nose and mouth at all times, submit to mandatory surveillance testing, or other agreed upon reasonable accommodation (s) (such as periodic testing) as determined on a case-by-case basis in accordance with the Reasonable Accommodations/ADAAA-Enterprise policy. Any employee who has an approved exemption from the Covid-19 vaccination and who fails to comply with the masking or other required mitigation strategies at any time following the Enforcement Date shall be suspended and removed from the work schedule until such time when the employee receives the Covid-19 vaccination; provided, however, that prior to any suspension, the employee shall first receive a verbal reminder, a written reminder and a final written reminder. Interview with the FA on 4/13/22 at 2:02 PM confirmed DA-D and DA-E both worked in the facility during the time frames they did not test for Covid-19. Review of the untitled list of residents and their Covid-19 vaccination status received from the FA (Facility Administrator) revealed Resident 17 and Resident 134 were not vaccinated for Covid 19.