**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview; the facility failed to code the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment to reflect the resident's status for 1 (Resident 18) of 5 sampled residents. The facility census was 38. Findings are: A record review of Resident 18's August 2024 Medication Administration Record (MAR) revealed that Resident 18 was receiving clopidogrel (an antiplatelet medication used to prevent blood from forming a clot) 75 milligrams (mg) daily. A record review of Resident 18's MDS dated [DATE], revealed the use of antiplatelet medication was coded No. A record review of the MDS 3.0 RAI (Resident Assessment Instrument) User's Manual v1.18.11, dated October 2023, revealed the following guidance: -Antiplatelet: check if an antiplatelet medication (e.g. clopidogrel) was taken by the resident at any time during the 7-day observation period. In an interview on 10/02/24 at 1:02 PM, the MDS nurse confirmed that Resident 18 did have an order for an antiplatelet medication and that the medication was received as ordered in August 2024. The MDS nurse further confirmed that the use of the antiplatelet medication was not coded correctly on the MDS and should have been marked Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference number 175 NAC 12-006.17 Based on observation, interviews, and record review; the facility failed to ensure that staff washed their hands with soap and water for at least 20 seconds to prevent the potential for cross contamination during wound care for 1 (Resident 8) of 1 sampled resident. The facility census was 38. Findings are: Record review of Resident 8's Face Sheet dated 10/1/24 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of non-pressure chronic ulcer of skin or other sites with unspecified severity. Record review of Resident 8's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 7/18/24 revealed in: Section C: a Brief Interview for Mental Status (BIMS) score of (-) indicating that the resident was rarely/never understood. Section GG: the resident required maximum assistance with rolling left and right (The ability to roll from lying on back to left and right side and return to lying on back on the bed). Section M: the resident was at risk for pressure ulcers and had one Stage 1 pressure ulcer (an observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence) and one unstageable deep tissue injury. Record review of Resident 8's physician orders dated 10/1/24 revealed an order for the following treatment to their bilateral [NAME] hip ulcers: wash with soap and water, apply Flagyl powder and Xeroform to black areas then cover with Mepilex. The order stated to change the wound dressing three times per week to reduce the smell and promote comfort. An observation on 10/2/24 at 8:34 AM of Resident 8's wound cares with Licensed Practical Nurse (LPN). LPN stated Resident 8 had received pain medication prior to the dressing change. LPN performed hand hygiene with soap and water for 20 seconds and donned gloves. LPN removed the left hip dressing, which revealed a brownish drainage on the dressing and a strong odor was noted. LPN placed the old dressing in a red trash bag and removed their gloves. LPN performed hand hygiene with ABHR gel and donned new gloves. LPN cleansed the wound with antibacterial soap, rinsed and dried. LPN sprinkled [NAME] powder onto the wound, then the xeroform dressing was applied and the wound was covered with a Mepilex dressing. LPN removed their gloves and performed hand hygiene by washing their hands with soap and water for 12 seconds, then donned new gloves. LPN repositioned Resident 8 and then removed the right hip dressing, which had brownish drainage and odor present and placed the dressing into the red trash bag. LPN then removed their gloves and performed hand hygiene with ABHR gel and donned new gloves. LPN cleansed the right hip wound with antibacterial soap, rinsed and dried. LPN sprinkled [NAME] powder onto wound, then the xeroform dressing was applied and the wound was covered with a Mepilex dressing. LPN removed their gloves, repositioned Resident 8 again, and placed a blanket on the resident. LPN performed hand hygiene with soap and water for 7 seconds, donned new gloves and removed the trash from the room. An interview on 10/2/24 at 8:55 AM with LPN revealed that [gender] should have washed [gender] hands for 20 seconds when using soap and water. An interview on 10/2/24 at 10:47 AM with the DON confirmed that hand washing with soap and water should be done for 20 seconds. Record review of the facility's undated Handwashing policy revealed the purpose of the policy was to prevent the spread of infection. The policy also contained guidance to perform the following tasks: 3. Apply soap and work into lather, 4. Rub all surfaces of the hands, between fingers, under nails and 2 of the wrists together continuously for 20 seconds. (2 minutes at the beginning of the shift and end of each shift).

License Reference Number 175 NAC 12-006.04(H)(ii)(1) Based on record reviews and interviews, the facility failed to ensure the DS (Dietary Supervisor) had the required credentials. This had the potential to affect 38 residents who ate food prepared in the kitchen. The facility had a census of 38. Findings are: An interview on 9/30/24 at 12:25 PM with DS revealed [gender] had not taken classes for their CDM (Certified Dietary Manager) and that the administrator was going to set up the classes. An interview with the Administrator on 10/1/24 at 7:26 AM revealed DS was not a CDM and the RD was not currently employed full time at the facility. An interview with the RD on 10/1/24 at 10:00 AM revealed the RD works in the facility 8 hours a week and remotely to equal 25-30 total hours a week. The RD oversaw the dietary supervisor. A record review of the facility's undated Dietary Manager Job Description revealed a Performance Requirement stating the Dietary Manager was to have completed the requirements for education as outlined in State and Federal guidelines and was to participate in ongoing continuing education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09B Based on observations, record reviews, and interviews, the facility failed to code the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment for the use of a restraint for 1 resident (Resident 12). Facility census was 36. Findings are: Record review of Resident 12's History and Physical completed 6/14/2022 revealed the resident was admitted to the facility in 2016. Among the medical diagnoses listed on the resident's record was an admitting diagnosis of TBI (Traumatic Brain Injury). Resident 12 was also identified as having contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand and left upper arm. Record review of Resident 12's Annual MDS dated [DATE] identified the resident as having no trunk restraint in place while in the chair. Observation of Resident 12 on 8/22/2022 at 10:23 AM revealed the resident was sitting in a tilted wheel chair with a seat belt clasped across the waist. Observation of the resident on 8/24/2022 at 10:20 AM revealed the resident had a seat belt clasped across the waist while sitting in the wheel chair. Interview with the DON (Director of Nursing) on 8/24/2022 at 10:35 AM revealed Resident 12 was not able to remove the waist belt without assistance. Interview with the MDS Coordinator on 8/24/2022 at 10:43 AM revealed Resident 12 was not able to remove the waist belt without assistance and the resident should have been coded as having a restraint in place. Record review of Resident 12's MDS section P related to restraints revealed the following, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observation, interview, and record review; the facility failed to ensure thickened fluids were available in the room for 1 resident (Resident 28). Findings are: Review of Resident 28's care plan dated 7/28/2022 revealed the resident had diagnosis of Cerebral Palsy (A congenital disorder of movement, muscle tone, or posture. Cerebral Palsy is due to abnormal brain development, often before birth). The resident was also identified as utilizing thickened fluids due to history of aspiration. Review of Resident 28's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment dated [DATE] revealed the resident required supervision and setup for drinking. Observation of Resident 28 on 8/22/2022 at 12:59 PM revealed the resident was sitting in the room watching television. No thickened fluids were present on Resident 28's side of the room. Observation of Resident 28 on 8/24/2022 at 11:00 AM revealed the resident was sitting in the wheel chair in the room. There was no drink observed on Resident 28's side of the room. Interview with NA-B (Nursing Assistant) on 8/24/2022 at 2:23 PM revealed the resident can drink without assistance and uses a lidded cup and liquid thickener. The resident has not had drinks available in the room for at least the past year. Interview with Resident 28 on 8/25/2022 at 9:58 AM revealed the resident shakes head yes when asked if the resident would like to have water available in the room. Interview with the MDS Coordinator on 8/24/2022 at 3:20 PM revealed the facility did not have drinks available in the room for residents on thickened fluids.

Based on record review and interview, the facility failed to ensure behavior monitoring was completed to indicate duplicate mood/behavior medications were necessary for Resident 21 and 31. The sample size was 5. The facility census was 36. FINDINGS ARE: A. A record review of the Active Orders report ran on 8/22/22 revealed Resident 21 to be taking the following medications that affect mood and behaviors: *olanzapine (an antipsychotic medication) tablet 2.5 mg (milligrams) Oral Twice a day. *sertraline (an antidepressant medication) tablet 50 mg Oral At bedtime. *temazepam (a sedative/hypnotic medication) capsule 15 mg Oral At bedtime. *lorazepam (used to treat anxiety) tablet 0.5 mg Oral Every 6hours as needed. A record review of the Progress Notes dated 6/23/22 through 8/23/22 revealed no documentation of any negative behaviors being displayed by Resident 21 over the last 60 days. A record review of the document titled Behavior Analysis Report (CareAssist only) dated 6/23/22 through 8/23/22 revealed no negative behaviors had been displayed. An interview on 8/24/22 at 10:23 AM with the facility Nurse Mentor, after review of the Behavior Analysis Report (CareAssist only) dated 6/23/22 through 8/23/22 confirmed that the behavior documentation did not reflect Resident 21's need for the use of 4 medications that affect mood and behavior with no dose reduction attempts. An interview with NA (Nurse Aide)-C on 8/24/22 at 12:15 PM confirmed that the options for negative behaviors to document were not specific to individual residents but were the same for all residents within the facility. B. A record review of the Active Orders report ran on 8/22/22 revealed Resident 31 to be taking the following medications that affect mood and behaviors: -alprazolam (an antianxiety medication) tablet 0.5 mg Oral Three times a day. -mirtazapine (an antidepressant medication) tablet 30 mg Oral At bedtime. -sertraline (an antidepressant medication) tablet 50 mg Oral Every day. A record review of the document titled Point of Care Mood Category Report (MDS 3.0) and dated 7/21/22 through 7/29/22 revealed a list of behaviors listed as follows; Little Interest/Pleasure Doing Things, Mood Symptom Presence, Appearing Down/Hopeless, Trouble Sleeping/Sleeping Too Much, Feeling Tired/Having Little Energy, Poor Appetite or Overeating, Feels Bad About Self, Trouble Concentrating, Moves Slow or Fidgety/Restless, Harms Self/Wants to Die, Short Tempered/Easily Annoyed which the NA's had documented a YES on one isolated entry and NO all remainder of the days for Resident 31. A record review of the Progress Notes for Resident 31 dated 8/18/22 through 8/23/22 revealed the nursing staff would document episodes of restlessness and anxiety which did not correlate with the behavior charting completed by the nursing assistants. An interview on 8/24/22 at 10:23 AM with the facility Nurse Mentor, after review of the NA behavior charting confirmed that the behavior documentation did not reflect Resident 31's display of behaviors, most likely due to staff accepting the behaviors as normal behavior for Resident 31. The interview confirmed that the documentation did not support the use of 3 medications that affect mood and behavior, and no dose reduction attempts. An interview with NA-D on 8/24/22 at 12:13 PM confirmed that the options for negative behaviors to document were not specific to individual residents but were the same for all residents within the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, interview, and record review; the facility failed to monitor the temperatures for the medication refrigerator on the east hallway. This had the potential to affect any resident with medication which required refrigeration on the east hallway. The facility census was 36. Findings are: Observation of the east medication refrigerator on 8/24/2022 at 2:30 PM revealed multiple medications were being stored in the refrigerator including insulin. Interview with RN-A (Registered Nurse) on 8/24/2022 at 2:30 PM revealed there were multiple days with no documentation of refrigerator temperatures on the log posted above the east hall medication refrigerator. Interview with the Administrator on 8/24/2022 at 3:03 PM revealed a discussion with staff had already occurred to ensure daily monitoring of medication temperatures was completed. Record review of the east hall refrigerator log revealed only 5 temperatures were documented for the month of June and 5 temperatures for the month of July. The 4 days in August prior to observation on 8/24/2022 were also not documented. Record review of an undated Policy and Procedure titled, Medication and Storage in The Facility. Heading k. of the document states, Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on record review and interview; the facility failed to prevent the possibility of the transmission of COVID 19 by not ensuring that visitor screening was completed. This has the potential to affect all residents. The facility identified a census of 36 at the time of survey. Findings are: A record review of an undated visitor screening log revealed there were blank entries. On 08/23/22 at 10:34 AM interview with the Medical Records Coordinator confirmed that the Medical Records Coordinator was to check the visitor screening sheets everyday while at work. The nurses check the sheets when visitors come in during the evening, on weekends and on holidays. When a visitor comes to visit the first time, they need to fill out a screening sheet. The Medical Records Coordinator confirmed the sheet was not dated and incomplete at times. The information was then transferred to a tracking form for each visitor. 08/24/22 10:29 AM Interview with the Infection Preventionist confirmed all the sign in sheets for the visitors should not have blanks on them. They should all be double checked. A record review of the Coronavirus Surveillance Policy, date Implemented 3/16/22: Screening for visitors and staff for signs and symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptom of coronavirus in the last 14 days, has had contact with someone with a confirmed diagnosis of COVID-19, suspected to have COVID-19, or is ill with respiratory illness. Visitors will be denied entry into the facility if they exhibit any of the criteria listed above. They may be directed to the Infection Preventionist, Director of Nursing, or nurse manager on duty if they have any questions.