Licensure Reference Number 175 NAC 12-006.09(H)(vi) Based on record review and interview; the facility failed to ensure that Resident 5 was free from use of unnecessary medications as a psychotropic medication (medication that affects the mind, emotions, and behavior) had been initiated without an indication for use. The sample size was 5 and the facility census was 32. Findings are: A. A record review of the facility policy Use of Psychotropic Drugs with a review date of 2/2020 revealed the following: -Residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the medical record, -the indication for initiating psychotropic medication's would be determined by the resident's actions and behaviors, -the indications for the use of psychotropic medications would be documented in the medical record, and -psychotropic medications would be initiated after admission after medical and physical causes had been identified and addressed. B. A record review of Nursing Progress Notes for Resident 5 revealed the following: -On 12/12/24 the resident was admitted from the assisted living facility and admitted with a psychotropic medication and an antidepressant. The resident's mood was pleasant, and no behaviors were witnessed. -On 12/14/24 at 11:52 PM nursing progress notes revealed that the resident's mood was pleasant with no behaviors. -On 12/18/24 a Social Services note revealed that the resident had confusion at times with a diagnosis of neurocognitive disorder with Lewy bodies (neurocognitive disorder that caused a gradual decline in mental abilities). -On 12/23/24 the psychotropic medication was discontinued. -From 12/24/24 to 1/7/25 nursing progress notes revealed that no behaviors had been documented. -On 1/7/25 a behavior meeting occurred with no change in medications. -From 1/7/25 to 1/27/25 nursing progress notes revealed that no behaviors had been documented. -On 1/27/25 the resident went to a neurology appointment with family and returned with an order for Seroquel (psychotropic medication) 12.5 milligrams (mg) at bedtime for 2 weeks then increase to 25mg at bedtime for diagnosis of Neurocognitive Disorder with Lewy Bodies. -On 1/31/25 at 10:20 AM nursing progress note revealed that staff had noted an increase in sleepiness in the morning, was difficult to awaken, and the neurologist had been notified. -On 1/31/25 at 1:19 PM nursing progress note revealed that the resident was showing more signs of confusion and wandering. A record review of Resident 5's Physician Visit/Communication Record dated 1/27/25 revealed Resident 5 went to a neurology appointment for a check-up. The Progress Notes section revealed Want to add Seroquel back. Start 12.5mg at bedtime x2 weeks, then increase to 25mg at bedtime. Do not remove unless directed by Neurology Clinic. This will be alongside to Celexa. The document did not include any evidence of an indication for the medication to be given to the resident. An interview on 1/29/25 at 9:45 AM with the Director of Nursing (DON) verified that the resident was admitted from an assisted living facility with a psychotropic medication, the resident did not have any documented behaviors and the psychotropic medication was stopped on 12/23/24. Further interview confirmed the psychotropic medication was restarted on 1/27/25 after a neurology appointment, the neurologist documented the medication could only be stopped by the neurology clinic and the resident was not exhibiting behaviors. The DON confirmed that the facility did not address stopping the psychotropic medication after 1/27/25 when the Resident 5 was not having behaviors or meeting the requirement for the medication prescribed.

Licensure Reference Number 175 NAC 12.006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure insulin pens were dated when opened for Residents 25 and 26. The sample size was 2 and the facility census was 32. Findings are: A record review of the undated facility policy Administering Medications revealed the following: -medications are administered in a safe and timely manner, and -when opening a multi-dose container, the date opened is recorded on the container. A. A record review of Resident 26's January 2025 medication administration record (MAR) revealed an order for Tresiba (a long-acting insulin) 6 units to be given 2 times daily. An observation on 1/30/25 at 7:30 AM with Registered Nurse (RN)-F revealed RN-F obtained Resident 26's Tresiba insulin pen out of the medication cart for administration. The Tresiba insulin pen had been opened and did not have an open date documented on it. B. A record review of Resident 25's January 2025 MAR revealed an order for Lantus (a long-acting insulin) 23 units to be given at bedtime. An observation of the medication cart on 1/30/25 at 7:35 AM revealed Resident 25's Lantus insulin pen had been opened and did not have an open date documented on it. An interview on 1/30/25 at 7:35 AM with RN-F confirmed that Resident 26's Tresiba pen and Resident 25's Lantus pen had been opened and had not been dated, but should have been. An interview on 1/30/25 at 10:30 AM with the Director of Nursing confirmed that the facility's expectation was for each resident's insulin pen to be dated when opened.

Licensure Reference Number: 175 NAC 12-006.04D2a Based on record review and interview; the facility failed to ensure the Dietary Manager (DM) had the credentialing to meet the requirements for the position. This had the potential to affect all residents who consumed food from the kitchen. The facility census was 33 with a total sample size of 15. Findings are: Review of the facility Job Description for the role of Dietary Service Manager revealed necessary qualifications included the completion of a Dietary Manager certification course. During an interview on 01/28/24 at 11:38 AM, the DM confirmed staff did not have the required training to meet the qualification for the DM position. The DM reported being enrolled in the DM course, however, has not completed the course.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff failed to: 1) utilize handwashing and gloving techniques to prevent potential food contamination during food service; and 2) clean and disinfect equipment between uses to assure food safety. These practices had the potential to affect all residents who consumed food from the kitchen. The facility census was 33 with a total sample size of 15. Findings are: A. Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-301.14 Food employees shall wash hands and exposed portions of their arms immediately before engaging in food preparation: -after handling soiled equipment; and -before donning gloves to work with food. -3-304.15 (A) Single use gloves shall be used for only one task and should be discarded when soiled or when interruptions occur in the operation. B. Review of the facility policy Dietary Employee Personal Hygiene (undated) revealed handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Gloves were to be worn and changed appropriately to reduce the spread of infection. C. Observations during the follow-up kitchen sanitation tour conducted on 1/28/24 from 11:10 AM to 12:35 PM revealed the following: -Dietary [NAME] (DC)-K used a digital thermometer probe to obtain food temperatures prior to the noon meal service. DC-K used the same thermometer to obtain the temperature of each of the following food items; baked beans, meatballs, fortified baked beans, puree baked beans, puree meatballs and mashed potatoes. DC-K failed to clean and/or sanitize the thermometer probe between uses; and -without washing hands, DC-K put on a pair of clean disposable gloves. DC-K used gloved hands and touched various kitchen surfaces including the resident's menu cards, dishes, serving utensils and opened a refrigerator. While continuing to wear the same pair of gloves, DC-K used gloved hands to open buns when preparing meatball sub sandwiches. This practice continued throughout the meal service. Interview with the Dietary Manager on 1/28/24 at 1:00 PM confirmed DC-K should have wash hands before donning clean gloves and a clean pair of gloves should be worn whenever touching ready to eat foods or a serving utensil should have been used. In addition, DC-K should have cleaned/sanitized the digital thermometer probe between each use.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to identify, investigate and to report allegations of potential staff to resident neglect involving an elopement for Resident 10. The sample size was 15 and the facility census was 27. Findings are: A. Review of the facility's policy Elopement and Wandering Residents with a revised date of May 2020 revealed the following: -the facility would ensure residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents; -an elopement occurs when a resident leaves the premises or a safe area without authorization and supervision; -the facility is equipped with door locks/alarms to help avoid elopements; -alarms are not a replacement for supervision and staff should respond in a timely manner; and -when a resident elopes, a report to the state agency shall be completed. B. Review of the facility's policy Abuse, Neglect and Exploitation dated September 2022 revealed the following: -the facility would ensure residents are protected from abuse, neglect, exploitation and misappropriation of personal property by preventing, identifying, investigating, and protecting residents from physical and mental harm; -alleged violations of abuse/neglect are defined as situations or occurrences that are observed or reported by staff, residents, relatives, visitors or others but has not yet been investigated; and -staff should report alleged violations of abuse/neglect to the administrator, state agency, adult protective services and other required agencies within 2 hours or no later than 24 hours from the time the incident occurred. C. Review of Resident 10's care plan with an initiated date of 11/20/2021, revealed the resident was identified at risk for elopement related to a diagnosis of dementia, intermittent confusion, attempts to leave the facility, looking for people who are not there and impulsive behaviors with a goal for the resident to not leave the building without an escort. The following interventions were identified; a wander guard (a device attached to a person that sounds an alarm or automatically locks a door to prevent leaving a facility) was attached the resident's right wrist, staff should encourage participation in activities, provide supervision while outside and redirect the resident when the wander guard sounds and [gender] is attempting to leave the building. Review of Resident 10's Elopement Risk Evaluation dated 7/21/22 revealed the following related to the resident's risk of elopement: -the resident had a history of elopement or an attempted elopement while at home; -the resident had a history of attempting to leave the facility without informing staff; -the resident verbalized a desire to go home, packed belongings or stayed near an exit door; -the resident wandered; and -the wandering behavior was likely to affect the safety or well-being of self/others. Review of Resident 10's Nursing Progress Note dated 8/14/22 at 2:47 PM, revealed the resident spent the majority of the shift wandering and pacing in the hallways. Further review indicated the resident had set off the wander guard alarm and was observed outside the facility, at the edge of the front porch near the parking lot. Staff re-directed the resident back into the building. During an interview with the Director of Nurses (DON) on 12/21/22 at 11:55 am, the DON confirmed the incident that was documented in Resident 10's medical record on 8/14/22 at 2:47 PM was an elopement and should have been reported to the DON, administrator and state agency and was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D8b Based on record review and interview, the facility failed to implement recommended nutritional measures to prevent potential ongoing weight loss for Resident 24. The sample size was 15 and the facility census was 27. Findings are: Review of the facility policy Weight Monitoring with a review date of [DATE], revealed the following; -the facility would ensure that all residents maintained acceptable parameters of nutritional status, such as usual or desirable body weight and electrolyte balance, unless the resident's clinical condition or resident preference indicated otherwise, -weight loss was a useful indicator of nutritional status and unintended changes in weight could indicated a nutritional problem, -residents would be weighed weekly unless ordered less frequently, -the Registered Dietitian (RD) would be consulted to assist with interventions, and -the Physician would be consulted to assist with interventions, and -the interdisciplinary team would follow up with weight loss and track until stable. Review of Resident 24's Weight Summary from 11/3/22 through 12/19/22 revealed the following; -on 11/3/22 the resident's weight was 100 pounds -on 11/7/22 the resident's weight was 93 pounds -on 11/11/22 the resident's weight was 92 pounds -on 11/14/22 the resident's weight was 91 pounds -on 11/22/22 the resident's weight was 90 pounds -on 11/25/22 the resident's weight was 88 pounds -on 11/28/22 the resident's weight was 87 pounds (13% of total body weight in 5 weeks) -on 12/19/22 the resident's weight was 87 pounds Review of Resident 24's Minimum Data Set (MDS-federally mandated assessment use to develop the resident's Care Plan) dated 11/7/22 revealed the following; -diagnoses of high blood pressure, irritable bowel syndrome, kidney failure, and malnutrition, -body weight of 100 pounds with no significant weight loss or gain, and -the resident received minimal assistance with bed mobility, transfers, toileting and dressing and supervision with eating, Review of Resident 24's Care Plan with a revision date of 11/18/22 revealed the following; -the resident was at increased nutritional risk due to variable meal intakes, -staff were to encourage 100% consumption of fluids at meals, -offer alternatives to food or drinks refused, -alert the Dietitian and Physician or significant weight loss, and -reweigh for any weight change of greater than or equal to 3 pounds. Review of Resident 24's Progress Notes revealed the following; - on 12/7/22 the Dietitian noted the resident had lost 13.9 pounds since 10/31/22 and recommended switching from Ensure to Boost High Calorie supplement twice daily, and -on 12/19/22 the Dietitian noted the resident had lost 13.5 pound since 10/31/22 and again recommended switching from Ensure to Boost High Calorie supplement twice daily. Review of Resident 24's Medication Administration Record dated 11/22 and 12/22 revealed that Ensure 8 ounces was being given twice daily starting on 11/16/22 and the Boost High Protein supplement was initiated on 12/20/22- (13 days after the initial recommendation by the Dietitian). During an interview on 12/21/22 at 11:00 AM with the Director of Nursing confirmed that Resident 24 had lost 13.5 % total body weight and resident's physician did not respond to an initial request by the facility Dietitian to change supplements, and not until it was addressed again by the Dietitian (13 days later) did the recommended supplementation get implemented.