Licensure Reference Number 175 NAC 12-006.02(H)Based on interview and record review, the facility failed to complete a thorough investigation for an allegation of abuse for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Abuse, Neglect and Exploitation dated revised 01/2025 revealed: -A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -B. Written procedures for investigations include: -1. Identifying staff responsible for the investigation; -2. Exercising caution in handling evidence that could be used in a criminal investigation. -3. Investigating different types of alleged violations; -4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; -5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and -6. Providing complete and thorough documentation of the investigation.Record review of Resident 1's admission Record printed 9/22/2025 showed the facility admitted the resident on 3/15/2023.Record review of Resident 1's Medical Diagnosis printed 9/22/2025 revealed the resident had diagnoses of chronic obstructive pulmonary disease (pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), schizophrenia (a mental illness that is characterized by disturbances in thought, perception, and behavior, by a loss of emotional responsiveness and extreme apathy, and by noticeable deterioration in the level of functioning in everyday life), and age-related osteoporosis.Record review of Resident 1's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 7/10/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15. According to the MDS manual, a score of 13 indicated the resident was cognitively intact. Further review of the MDS revealed Resident 1 displayed verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others on one to three days during the review period.Record review of a facility reported investigation dated 12/5/2024 showed on 12/1/2024 Resident 1 reported pain under the right breast to the licensed nurse. The licensed nurse assessed the area which revealed no redness or change in skin condition. Resident 1 reported that someone hit [gender] there and that is why it hurt. Further review of the investigation showed that the report lacked staff and resident interviews.Interview on 9/22/2025 at 3:15 PM with the facility Administrator (ADM) confirmed that staff and resident interviews were not documented. The ADM further confirmed the investigation was not complete.

Based on record review and interview, the facility failed to provide federally required transfer documentation to the receiving health care institution for 2 (Resident 1 & 2) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Transfer and Discharge (including AMA) dated revised 2/2025 revealed: -8. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: -a. Contact information of the practitioner who was responsible for the care of the resident; -b. Resident representative information, including contact information; -c. Advance directive information; -d. All other information necessary to meet the resident's needs, which includes but may not be limited to: -i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; -ii. Diagnoses and allergies; -iii. Medications (including when last received); and -iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. -e. All special instructions and/or precautions for ongoing care, as appropriate such as: -i. Treatments and devices (oxygen, implants, IVs, tubes/catheters); -ii. Transmission-based precautions such as contact, droplet, or airborne; -iii. Special risks such as risk for falls, elopement, bleeding, pressure injury and/or aspiration precautions; -f. The resident's comprehensive care plan goals; -h. Additional information, if any, outlined in the transfer agreement with the acute care provider.A. Record review of Resident 1's admission Record revealed the facility admitted the resident on 3/15/2023.Record review of Resident 1's Progress Notes (PN) dated 8/26/2025 revealed Resident 1 sustained a fall and was transferred to the hospital for evaluation and treatment.Record review of Resident 1's Electronic Health Record (EHR) including progress notes, assessments, and scanned documents lacked evidence the facility sent federally required information to the hospital at the time of transfer.Interview on 9/22/2025 at 3:15 PM with the facility Administrator (ADM) confirmed there was no evidence that federally required transfer documentation was sent to the hospital and the facility should have.B. Record review of Resident 2's admission Record revealed the facility admitted the resident on 3/6/2024.Record review of Resident 2's PN dated 8/27/2025 revealed the resident had sustained a fall and was transferred to the hospital for evaluation and treatment.Record review of Resident 2's EHR including progress notes, assessments, and scanned documents lacked evidence the facility sent federally required information to the hospital at the time of transfer.Interview on 9/22/2025 at 3:15 PM with the ADM confirmed there was no evidence that federally required transfer documentation was sent to the hospital and the facility should have.

Licensure Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review, the facility failed to implement interventions to prevent potential falls for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Fall Prevention Program dated revised 7/2025 revealed: -Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -6. High Risk Protocols: -c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: -i. Assistive devices -ii. Increased frequency of rounds -iii. Sitter, if indicated -iv. Medication regimen review -v. Low bed -vi. Alternate call system access -vii. Scheduled ambulation or toileting assistance -viii. Family/caregiver or resident education -ix. Therapy services referral -8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. -a. Interventions will be monitored for effectiveness. -b. The plan of care will be revised as needed. -9. When any resident experiences a fall, the facility will: -a. Assess the resident. -b. Complete a post-fall assessment. -c. Complete an incident report. -d. Notify physician and family. -e. Review the resident's care plan and update as indicated. -f. Document all assessments and actions. -g. Obtain witness statements in the care of injury.Record review of Resident 2's admission Record printed 9/22/2025 revealed the facility admitted the resident on 3/6/2024.Record review of Resident 2's Medical Diagnosis printed 9/22/2025 revealed Resident 2 had diagnoses of Neurocognitive disorder with Lewy bodies (a form of dementia characterized by the presence of abnormal protein deposits called Lewy bodies in the brain), Parkinson's Disease (a progressive neurological disorder that affects movement. It occurs when nerve cells in the brain that produce dopamine are gradually damaged or die. Dopamine is a neurotransmitter that helps control movement, balance, and coordination), dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior)), history of falling, osteoarthritis of the right shoulder, and difficulty in walking.Record review of Resident 2's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 8/5/2025 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 5/15. According to the MDS manual, a score of 5 indicated the resident had severe cognitive impairment. Further review of the MDS revealed the resident required substantial assistance from staff for bed mobility and transfers, walked with supervision, and was independent with wheelchair mobility.Record review of Resident 2's Prestige-Fall Risk (PFR) dated 8/13/2025 showed the resident had a score of 19. According to the assessment, a score of 19 indicated the resident was at high risk for falls.Record review of Resident 2's PFR dated 8/27/2025 showed a score of 15. According to the assessment, a score of 15 indicated the resident was at high risk for falls.Record review of Resident 2's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed the following interventions to prevent falls: -3/6/2024 Encourage resident to ask for assistance when attempting to transfer. Provide a clutter-free environment. Provide a well-lit environment. -4/2/2024 Place sign visible to pt (patient) in room reminding him to call for assistance. -6/10/2024 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -12/19/2024 fall mat next to bed -1/22/2025 ensure resident is wearing non-skid socks and or footwear. -2/13/2025 resident to have flannel sheets on bed at all times. Bolster mattress placed by hospice. -5/19/2025 dycem (a brand of non-slip, reusable, and antimicrobial material available in mats, rolls, and netting, designed to provide stability and control contamination in both daily living and professional environments) placed in tilt w/c. -7/21/2025 assist to toilet after meals -7/29/2025 Non-skid strips in front of toilet and sink in bathroom -8/12/2025 Scheduled toileting before and after meals and at HS (bed time) -8/13/2025 15-minute checks x 14 days.Record review of 15-minute checks dated 8/27/2025 through 9/22/2025 revealed: -No 15-minute check sheet was located for 9/4/2025. -12:15 am through 5:45 pm checks were left blank for 9/5/2025. -No 15-minute check sheet was located for 9/7/2025. -12:15 am through 5:45 am checks were left blank for 9/12/2025. -All other dates had 15-minute checks completed in full.Observation on 9/22/2025 at 8:23 AM revealed Resident 2 was asleep in bed with the bed in low position and the call light within reach. A bolster mattress (a mattress with an integrated perimeter of soft foam designed to create a safe, defined edge around the mattress to prevent falls and entrapment without the use of restrictive side rails) was in place. There was no fall mat at the bedside.Observation on 9/22/2025 at 11:55 AM, Nurse Aide (NA)-A assisted Resident 2 to the bathroom after the noon meal. Resident 2 was wearing non-skid socks. Non-skid strips were noted in front of the toilet and sink in Resident 2's bathroom. An interview on 9/22/2025 at 11:58 AM with NA-A confirmed there was no fall mat at the resident's bedside. NA-A further confirmed there was no dycem in the seat of the wheelchair and there was no sign displayed in the room for the resident to call for assistance.An interview on 9/22/2025 at 3:15 PM with the facility Administrator confirmed interventions listed on the care plan are expected to be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1 Based on record review and interviews, the facility failed to initiate interventions to prevent further weight loss for 1 (Resident 193) of 1 sampled resident. The facility identified a census of 40. Findings are: Record review of Resident 193's admission record revealed the resident admitted on [DATE] with the following diagnoses: unspecified dementia, anxiety, muscle weakness, need for assistance with personal care, cognitive communication deficit, attention and concentration deficit. Record review of Resident 193's admission Minimum Data Set (MDS) (a federally mandated assessment used to determine cares for a resident) dated 8/28/2024 revealed under Section C, a Brief Interview for Mental Status (BIMS) (an interview used to determine a resident's cognition) a score of 3. A score of 3 indicated severe mental cognition impairment. Section K revealed no concerns with swallowing, nutrition, or an altered diet. Record review of Resident 193's Care Plan dated 8/21/2024 revealed a focus indicating that the resident will consume 50% of most meals and 75% of oral supplements through next review date. On 10/6/2024 a weight loss was added to the care plan, with no new interventions. An interview on 11/7/24 at 8:40 AM with the Power of Attorney (POA) for Resident 193 revealed that the resident admitted with a weight of 171 pounds on 8/21/2024. Resident 193's weight dropped to 166 within a few weeks and the resident's pants were loose. The POA asked the facility Social Worker (SW) to get an order for a supplement. The POA indicated that a week later, the supplement had not been ordered. The Resident continued to lose weight and on 10/13/2024 the POA asked a nurse if any supplement had been ordered, the nurse relayed to the POA that there was an order from 10/11/24 but it did not get put on the Electronic Medication Administration Record (EMAR), the nurse started it that day. Record review of Resident 193's weights in the medical record revealed the following weights: admission weight on 8/21/2024 was 171 pounds. -9/7/2024 weight was 168.5 pounds. -9/11/2024 weight was 166.5 pounds. -10/1/2024 weight was 158.5 pounds. -10/13/2024 weight was 155 pounds. Record review of Resident 193's Mini Nutritional Assessment that was completed by the Registered Dietician (RD) on 8/25/24 revealed a nutrition score of 9. According to the Mini Nutrition assessment a score of 8-11 indicated the resident was at risk of malnutrition. Record review of Resident 193's progress notes revealed an Interdisciplinary Team (IDT) note dated 10/2/2024 indicating a weight loss greater than 5% in 30 days. According to Resident 193's Progress Note (PN) dated 10/2/2024 the physician was notified of the change and gave an order for the Registered Dietician (RD) to evaluate and treat with the RD being notified of the order. Record review of Resident 193's Nutrition Consult note dated 10/6/2024 revealed a weight loss of 7.3% x 30 days with a recommended of starting 4 ounces mighty shake twice a day between meals. Record review of Resident 193's Nutrition Consult note revealed the physician signed it on 10/11/2024 with no follow up with the signed order until 10/13/2024. Record review of Resident 193's medical record revealed no labs were ordered during the duration of the residents stay in the facility. Record review of Resident 193's PN revealed a note entered by a nurse on 10/13/2024 with the following information: POA here this am, wanted to weight resident. Weight at 155.5. POA asking about the supplement and if they were ordered yet. The nurse found the order from 10/11/2024 for the mighty shakes, House Supplement. Order written and sent to MD for signature, then order put into the electronic medical record. Nurse advised the medication tech to give the mighty shake. Resident consumed 100%. Record review of the RD Nutrition Services Recommendations undate Spreadsheet revealed that on 10/8/2024 the RD sent a reminder to the facility regarding Resident 193's recommendation for the mighty shake as it was not in Point Click Care (PCC) (the facilities electronic charting system)yet. Record review of Resident 193's physicians orders revealed that the order for the mighty shake was not noted by a nurse until 10/16/2024, after the resident discharged to another facility. An interview on 11/12/24 at 9:00 AM with the Dietary Manager (DM) revealed the process for monitoring weights was that the nursing staff enter the weights into PCC, PCC then sends an alert to staff if the weight is off normal range. The DM looks at the weights with the dietician weekly but also in the clinical meeting with the IDT in the mornings. The DM indicated that either the DM or nursing staff notify the RD of the weight loss. The RD is available either via phone or email. The DM indicated that the RD would put the recommendations into a folder to be picked up whenever by the MD. The facility recently determined that this process was taking too long so now the process is that the recommendations are emailed to the MD immediately. An interview with the RD on 11/12/24 at 10:18 AM revealed that the RD comes into the facility monthly and reviews weights, the MDS and assessments weekly remotely. If there is a weight loss, the nursing staff notify the RD by email or phone and the RD tries to respond timely. The RD indicated that it used to be if the resident had an order for the RD to evaluate and treat, the RD would be able to put the recommendations in place immediately, but that process has changed. The RD indicated that they would follow up if the recommendations are not completed timely by the MD and will send reminders to the facility. An interview on 11/12/24 at 8:45 AM with the Director of Nursing (DON) revealed that the RD is responsible for writing recommendations regarding weight variances. PCC triggers a flag in the system for weight variances and it is reviewed every morning in clinical meeting. The team then notifies the RD via phone or email. The DON verbalized that the emails are not always addressed that same day. The DON confirmed that the order for the mighty shake was not noted off by a nurse until 10/16/2024, the date the resident discharged . An interview on 11/12/2024 at 12:11 PM with the Corporate Nurse (CN) revealed the physician wants the opportunity to review recommendations before interventions are being put into place. The CN revealed they are working on a new process and confirmed there was a delay in Resident 193 getting a supplement started. Record review of the facility Nutrition Policy last revised 6/2024, under #1 revealed the following: -The facility will provide nutritional care consistent with the resident's comprehensive assessment. #2 will maintain usual body weight or desirable body weight - #5 The physician will be responsible for ordering the appropriate enteral feeding or may designate the RD to order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on observation, record review and interview, the facility failed to provide a trauma-based assessment for 2 (Resident 24 and 34) of 2 sampled residents who were diagnosed with Post Traumatic Stress Disorder. The facility had a census of 40. Findings are: A. A record review of Resident 24's Electronic Health Record revealed the Resident was admitted to the facility on [DATE]. A record review of Resident 24's Minimum Data Set (MDS - a federally mandated assessment tool used in nursing homes to evaluate the health of residents) dated 8/19/2024, revealed the resident had a Brief Interview for Mental Status (BIMS - a mandatory tool used to identify cognitive impairment in long-term care residents) of 3, indicating the resident had severe cognitive impairment (had problems with the ability to think, learn, remember, use judgement and made decisions). A record review of Resident 24's Medical Diagnosis sheet revealed Resident 24 had a diagnosis Post-Traumatic Stress Disorder (PTSD - a mental health condition that can develop after someone experiences or witnesses a traumatic event) dated 4/12/2022. A record review of Resident 24's MDS dated [DATE] revealed Resident 24 had an active diagnosis of Post Traumatic Stress Disorder. An interview on 11/13/2024 at 8:16 AM with the Corporate Nurse (CN) confirmed they were unable to find a PTSD/trauma assessment (a screening or evaluation that helps identify whether someone may have post-traumatic stress disorder) for Resident 24. An interview on 11/13/2024 at 8:15 AM with the Social Service Director (SSD) revealed the facility did not have a PTSD/Trauma Assessment on Resident 24. B. A record review of Resident 34's admission Record revealed the resident admitted to the facility on [DATE] with a diagnosis of PTSD. A record review of Resident 34's Care Plan, last revised on 8/16/2024 did not contain any information related to PTSD. A record review of Resident 34's MDS dated [DATE] confirmed Resident 34 had a diagnosis of PTSD. A record review of Resident 34's Medication Administration Record (MAR) revealed Resident received Venlafaxine Capsule total 225 milligrams(mg) daily for PTSD and Benztropine tabled 1 mg tablet twice a day. A record review of a physicians' Progress Note dated 9/30/24 and electronically signed by the facility's Medical Director, confirmed Resident 34 had a past medical history of PTSD. A record review of Resident 34's Trauma Informed Care assessment dated [DATE] conducted by SS confirmed Resident 34 had PTSD. An interview on 11/13/2024 at 1:15 PM with the SSD confirmed Resident 34 did not have a Trauma Informed Care Assessment in the facility prior to 11/13/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, doors, carpets, bathroom ceiling ventilation covers in 17 (rooms 104, 106, 108, 110, 111, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 319 and 324) of 28 occupied resident rooms in the facility. The facility census was 40. Findings are: Observation on 11/06/24 between 8:00 AM and 4:00 PM, during the initial pool observations of resident rooms, revealed the following environmental concerns: - The caulking surrounding the base of the toilet was cracked and broken in resident bathrooms for rooms 104, 106, 108,110, 111, 217, 219, and 319. - There were scrapes present in the drywall on walls in resident bathrooms in rooms [ROOM NUMBER]. - There were stained, brown areas present around the base of the toilet in resident bathrooms and on the linoleum in rooms 108, 110, 214, 216, 217, 218, 219, 220, 221, 222 and 319. - The baseboard was pulled away from the wall in the bathroom in resident rooms 214, 216, 217, 219 and in the hall of the secured care unit by the janitor closet. - There were scraped areas in the wood of bathroom and closet doors in resident rooms [ROOM NUMBER] - The ventilation system covers in resident bathrooms were coated with a gray fuzzy substance that resembled dust in resident rooms 104, 106, 108, 110, 111, 221, 222, 220, 213, 214, 215, 217, 218, 219, 216, and 319. - The bathroom door in room [ROOM NUMBER] would not close. - The carpets were stained with dark areas in the center of the room in rooms [ROOM NUMBERS]. - The caulking between the sink to the wall was cracked and broken and the sink was pulled away from the wall in rooms 104, 111, 213, 214, 215, 216, 218, and 220. - Fall stop strips were pulled away from the floor which created a non cleanable surface in rooms 104, 106, 110, 214, and 216. - There is a hole in the brick around the electrical outlet in room [ROOM NUMBER]. -The transition strip between the bathroom and the room was pulled loose from the floor and had blue duct tape over the transition strip in room [ROOM NUMBER]. Observation on 11/12/24 between 7:30 AM and 8:20 AM with the Maintenance Director [MD], during the environmental tour, revealed the following concerns: - The caulking surrounding the base of the toilet was cracked and broken in resident bathrooms for rooms 104, 106, 108,110, 111, 217, 219, and 319. - There were scrapes present in the drywall on walls in resident bathrooms in rooms [ROOM NUMBER]. - There were stained, brown areas present around the base of the toilet in resident bathrooms and on the linoleum in rooms 108, 110, 214, 216, 217, 218, 219, 220, 221, 222 and 319. - The baseboard was pulled away from the wall in the bathroom in resident rooms 214, 216, 217, 219 and in the hall of the secured care unit by the janitor closet. - There were scraped areas in the wood of bathroom and closet doors in resident rooms [ROOM NUMBER] - The ventilation system covers in resident bathrooms were coated with a gray fuzzy substance that resembled dust in resident rooms 104, 106, 108, 110, 111, 221, 222, 220, 213, 214, 215, 217, 218, 219, 216, and 319. - The bathroom door in room [ROOM NUMBER] would not close. - The carpets were stained with dark areas in the center of the room in rooms [ROOM NUMBERS]. - The caulking between the sink to the wall was cracked and broken and the sink was pulled away from the wall in rooms 104, 111, 213, 214, 215, 216, 218, and 220. - Fall stop strips were pulled away from the floor which created a non cleanable surface in rooms 104, 106, 110, 214, and 216. - There was a hole in the brick around the electrical outlet in room [ROOM NUMBER]. -The transition strip between the bathroom and the room was pulled loose from the floor and had blue duct tape over the transition strip in room [ROOM NUMBER]. Interview on 11/12/24 at 8:45 AM with the MD confirmed the observed concerns and confirmed that these concerns needed to be cleaned and fixed. The MD confirmed that there were no active work orders for the concerns identified during the environmental tour. Record review of the Facility Assessment Section 3/8 dated 11/24 revealed the following: - All rooms are inspected by the Maintenance Director monthly and fixed as needed. If staff has concerns with equipment or equipment has broken, it is reported to maintenance verbally, on a form, or in the TELS system [electronic maintenance system to identify work orders] thru PCC [Point Click Care, electronic medical record system]. Items are then replaced or repaired before being put back into service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interview, the facility staff failed to notify the practitioner of a change in condition and to update the practitioner as ordered for 1 [Resident 3] of 3 sampled residents. Facility had a total census of 46 residents. Findings are: A. A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure [a chronic condition in which the heart is unable to pump blood efficiently enough to meet the body's needs]. A review of Resident 3's admission orders dated 7/31/24 revealed an order for daily weights. A review of Resident 3's Care Plan revealed a focus area identifying Resident 3 had congestive heart failure dated 8/14/24 with the following interventions: -Encourage adequate nutrition and offer small frequent feedings -Give cardiac medications as ordered -Monitor lab work including potassium, sodium, blood urea nitrogen, and creatinine -Monitor/document/report as needed any signs/symptoms of congestive heart failure -Weight monitoring daily A review of Resident 3's electronic medical record weight report revealed Resident 3 weighed 314.5 lbs. on 8/7/24 and 320.5 lbs. on 8/11/24 which reflected a weight gain of 6 lbs. A review of Resident 3's electronic medical record, 8/2024 Medication Administration Record (MAR) and 8/2024 Treatment Administration Record (TAR) did not reveal any weights recorded for 8/8/24, 8/9/24, and 8/10/24. A review of Resident 3's Progress Notes did not reveal any documentation of Resident 3's practitioner being notified of 6 lbs. weight increase between 8/7/24 and 8/11/24. A review of communication with Resident 3's practitioners on the HUCO application [an application used by the facility to communicate with Resident 3's providers] revealed a communication dated 8/9/24 requesting updates tomorrow [8/10/24] and Sunday [8/11/24]. A review of communication with Resident 3's practitioners on the HUCO application revealed a note from practitioner dated 8/12/24 that stated no update was received on Saturday or Sunday as requested and requested that update be given that day. In an interview on 9/10/24 at 12:13 PM, the Administrator confirmed that the Administrator would have expected Resident 3's practitioner be notified of a 6 lbs. weight gain and that Resident 3's practitioner should have been updated on Resident 3's condition on 8/10/24 and 8/11/24 in accordance with request on 8/9/24. In further interview on 9/10/24 at 1:52 PM, the Administrator identified an expectation that a physician be notified of any weight increase of over 5 lbs. B. A review of facility policy titled Notification of Changes revised 3/2024 revealed the following circumstances requiring notification of resident's physician: -2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. -3. Circumstances that require a need to alter treatment. This may include: a. New treatment b. Discontinuation of current treatment due to: i. Adverse consequences ii. Acute condition iii. Exacerbation of a chronic condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09 D7a Based on observation, record review and interview, the facility failed to ensure that chemicals were secured and not accessible to 2 (Residents 23 and 43) residents that were independent with ambulation, exhibited wandering behaviors [movement with no purpose or safety awareness], had poor safety awareness, and resided on the secured unit of the facility. The facility had 10 residents that resided on the secured unit of the facility. The facility census was 48. Findings are: A. Record review of a facility policy entitled Environmental Services Safety Procedures dated 5/23 revealed the following guidelines: - 3. Staff will ensure equipment (e.g., chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locking closet, cabinet, or storage area for safety. B. Continuous observation on the ACU [secured unit] unit on 09/12/23 between 8:45 AM and 1:00 PM revealed an unlocked bathhouse door with 3 spray bottles (each were 1/4 full) and 1 refill bottle (1/4 full) of liquid substances in an unlocked cabinet under the sink. The door was closed to the cabinet. The products included: QC 33 Floor Finish Restorer, Peroxide Multi Surface Cleaner and Disinfectant, Lemon [NAME] Cleaning Product, and a spray bottle, 1/4 full, of an unknown, unlabeled substance. During the observation, no residents were observed to be wandering or walking in the hallways of the secured unit. All residents were in the supervised dining room or their resident rooms. Observation during those times revealed that facility staff were in constant eyesight of the hallway, resident room doors, the doorway to the bathhouse and the dining room to provide supervision. Observation on 09/12/23 at 12:30 PM with Licensed Practical Nurse [LPN] A confirmed that the bathhouse was unlocked and accessible. LPN A confirmed that the cabinet in the bath house near the sink contained 3 spray bottles (1/4 full) and 1 refill bottle (1/4 full) of labeled and unlabeled chemicals. LPN A confirmed the products included: QC 33 floor finish restorer, Peroxide Multi surface cleaner and Disinfectant, Lemon [NAME] Cleaning product and a spray bottle 1/4 full of an unknown, unlabeled substance. LPN A confirmed that there were residents in the secured unit that walked around the unit independently and resided in the secured unit due to poor safety awareness. Observation on 09/12/23 at 1:03 PM with the Director of Nursing [DON] confirmed there were 4 bottles of chemicals in an unlocked cabinet in the unlocked bath house on the secured care unit. The DON removed the chemicals to a secure location off of the unit. C. Interview on 09/12/23 at 1:03 PM with the DON confirmed that the chemicals were accessible to residents and should have been locked up and secured in the housekeeping cart and that the door to the bathhouse should be always locked. The DON confirmed that the chemicals were hazardous and could cause physical harm if ingested. Interview on 09/12/23 at 1:12 PM with the DON identified 2 residents (Residents 23 and 43) as independently ambulatory without assist and both exhibited wandering behaviors within the unit. The DON confirmed that the bathhouse and the cabinet would be accessible to those residents. The DON confirmed that 10 residents resided on the secured unit of the facility. D. Record review of Resident # 23's Face Sheet [A document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning] revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses that included: Delusional Disorder [fixed false beliefs], Cognitive Decline, Cognitive Communication Deficit and other symptoms and signs involving cognitive functions and awareness. Record review of Resident # 23's Quarterly Minimum Data Set [MDS, a mandatory comprehensive assessment tool used for care planning) dated 7/21/23 revealed a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 00 which indicated severe cognitive impairment with no behaviors exhibited and was independent with ambulation on the unit and in the resident's room. Record review of a Physician order dated 7/24/23 revealed that Resident # 23 was to be moved to the secured unit of the facility. Record review of Elopement Risk Assessments [an assessment to identify risk for leaving the facility without staff knowledge] dated 10/19/22 on admission and 11/7/22 identified that Resident # 23 was ambulatory, was cognitively impaired with decreased safety awareness, exhibited a disturbance in judgement and exhibited wandering behaviors. Record review of Resident 23's Comprehensive Care Plan [CCP, a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 10/20/22 identified that Resident # 23 had been admitted long term in the ACU (secured care unit) and liked to wander through the hallways. The Care Plan dated 2/14/23 indicated that Resident # 23 had behavior issues as evidenced by wandering/pacing to point of exhaustion related to Dementia. The Care Plan identified that Resident # 23 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, due to the disease process and impaired cognitive function/dementia. Resident # 23 had impaired thought processes related to difficulty making decisions and neurological symptoms. Record review of Resident # 23's Nursing Progress Notes on the following dates identified the following wandering behaviors: - 9/5/2023 10:47 While writer was in a different resident's room trying to provide care resident walked into room, writer redirected resident and effective at that time, will continue to monitor. - 8/24/2023 00:00 Anxious and wandering. Checked and changed. Resting in bed at this time. Will observe. - 8/18/2023 15:02 resident attempted to get into linen closet, redirected. resident observed wandering into corridor of rooms that is not hers, continue to redirect and monitor with all safety maintained. - 8/17/2023 13:57 resident following staff into other residents' rooms, resident redirected. E. Record review of Resident # 43's Face Sheet revealed that Resident #43 was admitted to the facility on [DATE] with diagnoses that included: Delusional Disorder, Psychosis not due to substance abuse, Anxiety Disorder and Conduct Disorder. Record review of Resident # 43's Quarterly MDS' dated 7/21/23 revealed a BIMS score of 00 which indicated severe cognitive impairment, no behaviors were exhibited, and the resident was independent with ambulation on the unit and in the resident's room. Record review of Resident 43's CCP dated 8/17/23 identified that Resident #43 was at risk for elopement related to dementia/confusion, resided in the ACU unit, and wandered throughout the halls, had impaired cognitive function/dementia or impaired thought processes, was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits of Dementia and had a history of going into other resident's rooms and laying in other peoples beds. Record review of Resident 43's Nursing Progress Notes on the following dates identified the following wandering behaviors: - 9/10/2023 09:39 resident wandering in other resident's rooms. writer reminded resident that those are other resident's rooms and it's an invasion of privacy, resident just looked at writer and picking at hands at same time and said OK. writer then asked if there was something she was looking for or needed and resident attempted to communicate however having a hard time articulating what it is she needed. writer then asked if she could show her where her room is, and resident agreed. resident currently in bed resting at this time with call light within reach and all safety maintained. - 9/6/2023 23:41 Critical charting for recent med changes and behaviors. Mood and affect flat. Resident wandering in hallway and no skin picking noted at this time. Able to redirect and reorient as needed. Will observe. - 9/2/2023 12:35 Resident continues to tolerate recent medication changes of increased Zoloft [ antidepressant medication] and return to Seroquel [ antipsychotic medication]. Resident paces in hallways at times this shift. Resident eats well. Resident continues to pick at face and chest. - 9/1/2023 14:55 resident pacing in halls this AM and afternoon for a little period of time and going in and out of corridors of other resident's rooms, resident easily redirected and effective for short time. resident also observed picking at hands/face/neck/chest on and off throughout shift, multiple interventions attempted and not effective to help decrease picking, will continue to monitor with all safety maintained. - 8/28/2023 09:24 resident got self-up this AM came down hall and ate breakfast in dining area, now resident continues to pace hall and enter corridor or other resident's rooms and then leaves when writer asked if resident had to use restroom resident stated no. writer, then asked if there was something she could help resident with, and resident stated no while continuing to pick at skin on hands. resident is not easily redirected will continue to monitor. - 8/27/2023 13:54 pt wanders hall during this shift. eats breakfast and lunch meal in DR. tolerates med admin. no c/o pain or discomfort. pleasant to staff and other pts in facility. pt continues to pick at face/neck area, redirection unsuccessful. F. Record review of the Material Safety Data Sheet [MSDS, a product information sheet that identifies the hazardous properties and warnings associated with the use of chemicals] for Peroxide Multi Surface Cleaner and Disinfectant revealed that the product was a disinfectant, was a danger and would be harmful if swallowed or in contact with skin. The product could cause severe skin burns and eye damage, could cause an allergic skin reaction and was toxic if inhaled. The MSDS sheet recommended that the product be stored in a well-ventilated space with the container tightly closed and should be stored locked up. Record review of the MSDS sheet for Lemon-[NAME] revealed that the product was a cleaning product, was a danger and could cause severe skin burns and eye damage. It recommended that the product be stored locked up. Record review of the MSDS sheet for QC 33 Floor Finish Restorer revealed that the product was a floor care product and could cause serious eye irritation. It was to be stored in accordance with local regulations.

Licensure Reference Number 12-006-18 B Based on observation, interview and record review; the facility failed to maintain the cleanliness and condition of ventilation systems, fixtures and floors in 7 resident bathrooms (rooms 316, 317, 318, 320, 321, 322 and 325) of 10 occupied resident rooms on the secured unit of the facility. The facility census was 48. Findings are: Observation on 09/13/23 between 1:00 PM and 1:30 PM with the facility Director of Maintenance [DM] revealed the following concerns with the facility environment: - The surface and interior of the ventilation systems in resident bathrooms in rooms 316, 317, 318, 320, 321, 322 and 325, on the secured unit of the facility, were heavily coated with a gray fuzzy substance that resembled dust. - The surrounding base of the toilets and the linoleum in resident bathrooms in rooms 316, 317, 318, 321 and 325, on the secured unit of the facility, had a brown, greasy substance that corroded the base of the toilets. The linoleum that surrounded the base of the toilets' was gray and spongy from water damage and was pulled away from the wall in some areas in the bathrooms. Record review of a Council Concern / Recommendation Form dated 5/10/23 did not include the cleaning of the ventilation systems and did not specify the cleaning of the base of toilets or floors in the resident rooms. The staff response identified what days of the week specific halls were cleaned but not specifically what items were included in the cleaning. Interview on 09/13/23 at 1:35 PM with the DM confirmed that a gray fuzzy substance coated the ventilation systems in rooms 316, 317, 318, 320, 321, 322 and 325 and confirmed that the cleaning of the ventilation system had not been included in the cleaning schedules. The DM agreed that the buildup of the fuzzy substance was heavy as though they had not been wiped out recently. The DM confirmed that the base of the toilets were soiled with a brown greasy substance, the linoleum was spongy and stained gray from water damage and was pulled away from the walls in some areas in resident bathrooms in rooms 316, 317, 318, 321 and 325 on the secured unit of the facility. The DM confirmed that the facility did not have a policy related to the specific cleaning of ventilation systems, toilets or floors. Record review of the Facility Bed Count form revealed that there were 10 occupied resident rooms on the 300 hall in the facility identified as secured unit in the facility.

Licensure Reference Number NAC 12-006.04C2 Based on record review and interview, the facility failed to ensure a Registered Nurse was present in the facility for a continuous period of 8 hours a day, 7 days a week. This had the potential to affect all residents who reside in the facility. The facility had a census of 48. Findings are: An interview on 9/13/2023 at 11:41 AM with the Human Resources/Scheduler (HR/S) confirmed (gender) is responsible for filling out the 24hour staffing sheets. HR/S confirmed there are no RNs (Registered Nurse) in the building on the weekends. An interview on 9/13/2023 at 2:45 PM with the HR/S confirmed the HR/S was aware of the requirement for an RN to be in the facility for 8 consecutive hours, 7 days a week. An interview on 9/13/2023 at 12:02 PM with the Administrator confirmed that there is not an RN on site on the weekends. The Administrator confirmed an RN is on call during the weekends and the RN on call responsibility is rotated between the Administrator and the Director of Nursing. An interview on 9/13/2023 at 2:35 PM with the Administrator confirmed the Administrator was not aware of the requirement for an RN to be in the facility for 8 consecutive hours each day, 7 days a week. A record review of the Payroll Based Journal (PBJ) Staffing data for the Fiscal Year 2nd Quarter 2023 (January 1 - March 31) confirmed there were 4 or more days within the Quarter with no RN hours. The dates triggered were 2/23 (Friday), 2/25 (Saturday), 3/10 (Friday), 3/17(Friday), 3/25(Saturday), 3/26 (Sunday), 3/27 (Monday), 3/31 (Friday). A record review of the nursing staffing schedule from August 11, 2023 to September 11, 2023 confirmed there were no RNs scheduled on 8/12(Saturday), 8/13(Sunday), 8/19(Saturday), 8/20 (Sunday), 8/26(Saturday), 8/27(Sunday), 9/2(Saturday), 9/3 (Sunday), 9/4 (Monday) (Labor Day), 9/9 (Friday), and 9/10(Sunday). A record review of the individualy dated facility nurse staffing sheets from March 1, 2023 to August 31, 2003 confirmed there were no RN hours during that time. A record review of the facility's Nursing Services and Sufficient Staff Policy dated 4/2019 and reviewed 8/2023 revealed the following: Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. (If RN is not in the building RN must be on-call and within 20 min from facility for any emergency needs).

Licensure Reference Number 12-006-11 E Based on observations, interviews and record reviews; the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent foodborne illness. This had the potential to affect all residents in the facility who eat food from the kitchen. The facility census was 48. Findings are: Record Review of Prestige Healthcare Management Food Safety Requirements Revised on 8/23 revealed the following information: -Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. -Policy Explanation and Compliance Guidelines: -Section 1. Food safety practices shall be followed throughout the facility's entire food handling process. -This process begins when food is received from the vendor and ends with delivery of food to the resident. -Section 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. -Staff shall wash hands according to facility procedures. Record Review Prestige Healthcare Management- Handwashing Guidelines for Dietary Employees- Reviewed and revised on 08/23 revealed the following information: -Policy: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. -Compliance Guidelines under section 6: -Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: -a. every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. -b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. -c. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). -d. After coughing, sneezing, or blowing your nose, using tobacco products, eating or drinking. -e. After handling chemicals and before beginning to work with food. -f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. -g. When switching between working with raw food and working with ready to eat food. -h. Before donning gloves for working with food. -i. After caring for or handling service animals or aquatic animals. -j. After engaging in any activity that may contaminate the hands. -Compliance Guidelines under section 7: -Handwashing procedure: -Turn on water to a comfortable warm temperature. -Moisten hands/exposed portions of arms with water and apply the amount of soap recommended by manufacturer. -Cover with soap well beyond the area of contamination. -Rub together vigorously for at least 20 seconds. -Pay attention to areas between fingers, around nail beds and under nails (nails should be kept short). -Create friction on the surfaces of the hands and arms, fingertips and areas between the fingers. -Rinse thoroughly under clean, running warm water; avoid contact with the sink during rinsing. -Thoroughly dry and turn water off with paper towels touching the faucet handles. -Dispose of paper towels in a pedal opening trash can (do not touch the can lid with clean hands). Observation on 09/12/23 between 10:55 AM and 11:10 AM of the facility's main kitchen revealed [NAME] A applied oven mitts and removed beef tips from oven. [NAME] A took the temperature of the beef tips at 167.9 degrees Fahrheit (F) then wiped the temperature probe with alcohol wipe and went to the handwashing sink and performed hand hygiene for 15 seconds with soap and water. Then [NAME] A used the commercial blender to make puree beef tips. Two scoops of beef tips were placed in the blender and pureed. [NAME] A scooped out blender with spatula and put puree beef in a pan donned oven mitts and placed beef tips and beef tip puree in oven. [NAME] A went to the handwashing sink and performed hand hygiene with soap and water for 8 seconds and tapped both hands on the inside of the sink rim to remove excess water and then dried hands with a paper towel. [NAME] A donned oven mitts and removed rice from oven and stirred the rice with a slotted spoon, stated the rice isn't done and placed the pan of rice back into the oven. [NAME] A removed oven mitts and performed hand hygiene at the handwashing sink with soap and water for 10 seconds. Observation on 09/12/23 between 11:30 AM and 12:22 PM of the facility's main kitchen revealed [NAME] A used a 4 oz scoop and puts 2 scoops of beans with an unmeasured amount of butter into the commercial blender, blended then stopped and stirred with spatula, until the beans were pureed. [NAME] A scraped beans with a spatula into a pan and placed it into the oven. [NAME] A wiped down the blender with detergent water then sanitizer water then performed hand hygiene at handwashing sink for 10 seconds with soap and water. Then [NAME] A went to the steam table and dished out 2 scoops of rice and placed it into the blender receptacle and pureed the rice.When finished [NAME] A wiped down blender with detergent water then sanitizer water and then went to handwashing sink and performed hand hygiene for 6 seconds with soap and water. [NAME] A then went to the steam table and began to temp the food. After the temperatures were completed [NAME] A went to the handwashing sink and performed hand hygiene for 10 seconds with soap and water. [NAME] A then began to serve the residents in the dining room. After all the tables were served in the dining room [NAME] A performed hand hygiene with soap and water for 15 seconds. The CDM (certified dietary manager) performed hand hygiene for 9 seconds at hand washing sink and then helped cover bread on plates with clear wrap, while [NAME] A prepared 5 room trays. After the room trays were prepared, [NAME] A performed hand hygiene with soap and water for 3 seconds. Observation of breakfast service on 09/13/23 between 07:25 AM and 7:45 AM in the ACU (secure unit) revealed [NAME] A and the CDM brought the steam cart to the dining room and set up the steam cart in the kitchen area of the unit. [NAME] A dished up a plate and served it to Resident #29, then performed hand hygiene for 4 seconds with soap and water. [NAME] A then dished up another plate and took it to Resident #8 and performed hand hygiene for 3 seconds with soap and water. [NAME] A then dished up the next plate which was a room tray for Resident #38. The CDM had left the unit to get utensils and arrived back to the unit with a ladle. CDM performed hand hygiene for 12 seconds with soap and water. Resident #23 ambulated into dining room and the CDM with bare hands took both of Resident # 23's hands and guided her to the dining table. The CDM performed hand hygiene for 6 seconds with soap and water and then dished up Resident # 42's tray and then Resident # 39's tray and then performed hand hygiene for 11 seconds with soap and water.Cook A performed hand hygiene for 8 seconds with soap and water and then dished up the room trays. [NAME] A dished up the last room tray and performed hand hygiene for 7 seconds with soap and water and placed the room trays into the refrigerator on the unit. Observation on 09/13/23 between 12:10 PM and 12:30 PM of the kitchen accompanied by CDM revealed [NAME] B entered the main kitchen at 12:20 PM and performed hand hygiene for 3 seconds using soap and water. At 12:30 PM [NAME] A entered the kithcen and performed hand hygiene for 6 seconds. The CDM confirmed the hand hygiene performed by [NAME] B and [NAME] A was not long enough.

Based on record review and interview, the facility staff failed to issue the Advanced Beneficiary Notice (ABN) to 1 (Resident 39) of 3 sampled residents which did not give the resident/resident representative the opportunity to appeal the facility's decision to discontinue Medicare A benefits. The facility had a census of 39. Findings are: A review of Resident 39's Notice of Medicare Non-coverage revealed that Resident 39's Medicare A services ended on 12/15/2021 and Resident 39 was notified on 12/15/2021. Interview on 06/06/22 at 01:24 PM with the Social Services Director confirmed that the ABN was not filled out within 48 hours prior to Medicare Services ending and that the facility had no policy for issuing the ABN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to submit a investigation of an injury of unknown source to the required state agency within 5 working days for 1 (Resident 36) of 7 investigations reviewed. The facility staff identified a census of 38. Findings are: Record review of Resident 36's Comprehensive Care Plan (CCP) printed on 6-01-2022 revealed Resident 36 was admitted to the facility on [DATE]. Record review of Resident 36's Progress Note dated 9-24-2021 revealed Resident 36 was evaluated as having a quarter of an inch slit with a fifty cent piece bruise to the right scapula. According to Resident 36's progress note dated 9-24-2021 it was unknown how the injury occurred. On 6-07-2022 at 10:40 AM an interview was conducted with the Regional Director of Operations (RDO). During the interview the RDO confirmed a investigation into Residents 36's injury of unknown source to the right Scapula had not been submitted to the required state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observation, interview, and record review, the facility failed to obtain an oxygen order for Resident 23. This affected 1 of 3 sampled residents. Total census was 38. Findings are: Record review of the facility's Oxygen Concentrator (a machine used to separate the oxygen from other gases in the air and send the oxygen to a resident) Policy dated 10/2020 revealed that oxygen is administered under orders of the attending physician. An observation on 05/31/2022 at 09:28 AM of Resident 23 revealed the resident was wearing oxygen from an oxygen concentrator. An observation on 06/01/2022 at 09:41 AM revealed Resident 23 was on 2 liters per minute (L/M) of oxygen from an oxygen concentrator. Record review of the Minimum Data Set (MDS)(a comprehensive assessment of each resident's functional capabilities) dated 02/02/2022 revealed that Resident 23 was on oxygen prior to admission and while a resident at the facility. Record review of the MDS dated [DATE] revealed that Resident 23 was on oxygen while a resident at the facility. Record review of Resident 23's Clinical Physicians Orders dated 06/01/2022 did not reveal an order for Resident 23 to be on oxygen. Registered Nurse (RN)-H confirmed in an interview on 06/01/2022 at 01:52 PM that Resident 23 was on oxygen at 2 L/M of oxygen from an oxygen concentrator and there was not an order for oxygen from the attending physician in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to evaluate and obtain treatment for Depression (a mental health disorder the presents as persistent depressed mood or loss of interest in activities, causing significant impairment to daily life) for Resident 191. This affected 1 of 2 sampled residents. Total census was 38. Findings are: An observation on 05/31/2022 at 04:07 PM revealed that Resident 191 was upset and emotional. The resident cried 3 times during the observation and interview. In an interview on 05/31/2022 at 04:07 PM, Resident 191 confirmed the resident's spouse passed away recently. The resident wanted to go home, but stated not sure why, nobody was there anymore. Resident 191 stated Resident 191 wanted to go home to die but confirmed the resident would not harm self. Resident confirmed loss of appetite and no interest in activities. An observation on 06/01/2022 at 07:05 AM revealed Resident 191 was sleeping in the recliner. In an interview on 06/02/2022 at 07:08 AM Resident 191 confirmed the resident feels tired and had a bad night. Resident 191 confirmed none of the facility staff has been in to discuss the death of the spouse. An observation on 06/02/2022 at 03:47 PM revealed resident laying in the recliner in the room. An observation on 06/06/2022 at 08:21 AM revealed resident sleeping in recliner in the room. An interview on 06/06/2022 at 12:12 PM confirmed Resident 191 did not eat lunch. Resident stated may only eat a third of the meals. Record review of the hospital Discharge summary dated [DATE] revealed Resident 191 had documented Depression and Failure to Thrive (a downward spiral of poor nutrition, weight loss, inactivity, depression and functional ability). Record review of the facility's Medical Diagnosis dated 06/01/2022 revealed diagnoses of Depression and adult Failure to Thrive. Record review of Resident 191's Section D0200 of the Minimum Data Set (MDS)(a comprehensive assessment of each resident's functional capabilities) dated 05/20/2022 revealed the resident felt depressed, slept too much, had a poor appetite, felt bad about self, and had thoughts of being better off dead or hurting self in some way 12-14 days (nearly every day) Record review of Resident 191's Care Plan (a plan the provided direction on the type of care the resident may need) revealed the resident had a mood problem and the interventions were: administer medications as ordered and assist the resident to identify positive coping skills and reinforce these. Record review of Resident 191's Clinical Physicians Orders dated 06/01/2022 did not reveal an order for medications to treat Depression. Record review of the Social Services/Admissions Director Job Description signed 05/02/2022 revealed The Social Service Director would ensure that residents who display mental illness or psychosocial (involving mental, emotional, and social aspects) difficulties such as coping with grief and loss, will have access to appropriate treatment and resources. Record review of the Mental Health providers schedule for the facility did not reveal that Resident 191 was on the schedule to be seen. An interview with the Social Services Director (SS)-J on 06/02/2022 at 09:17 AM confirmed SS-J had worked with Resident 191 on cares but not for Resident 191's mental status. SS-J was unsure what medications Resident 191 was on, and the resident was not on the schedule to see the Mental Health provider. An interview with SS-J on 06/06/2022 at 12:12 PM confirmed the Social Services Director is responsible for working with residents that show signs and symptoms of Depression and Resident 191's condition should have been addressed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 medications administered revealed 4 errors resulting in an error rate of 16%. The errors effected 1 (Resident 10) of 3 residents sampled. The facility staff identified a census of 38, Findings are: Record review of Resident 10's Order Summary Report printed on 6-02-2022 revealed Resident 10's practitioner ordered medications that included the following: -Flonase (used for sinus type of issues) 1 spray each nostril. -Levo thyroxine (used for thyroid treatment) to be given 30 minutes before a meal. -Linzess ( medication used in the treatment for bowl issues) to be given 30 minutes before the first meal of the day. -Omeprazole ( medication to reduce stomach acid) to be given 60 minutes before a meal. Observation on 6-01-2022 at 9:25 AM revealed Licensed Practical Nurse (LPN) G prepared Resident 10's medication. LPN G took Resident 10's medications to the resident room. LPN G without cueing Resident 10, gave Resident 10 the flonase with Resident 10 completing 2 sprays to each nostril. LPN G handed Resident a medication cup containing the oral medication including the Levothyroxine, Linzess and Omeprazole medications. Resident 10 took the medications with water. On 6-01-2022 at 9:35 AM an interview was conducted with Resident 10. During the interview Resident 10 reported having breakfast prior to the medications being administered. On 6-01-2022 at 9:47 AM an interview was conducted with LPN G. During the interview LPN G confirmed medications were given after Resident 10 had eaten breakfast.

Licensure Reference Number 175 NAC 12-006.05(17) Based on observation, interview, and record review, the facility failed to address Resident Council grievances (complaint or protest) regarding housekeeping, maintenance, food, activities, and staff concerns. This had the potential to affect 32 residents on the 100 and 200 hallways. Total census was 38. Findings are: Observation on 06/01/2022 at 10:30 AM revealed the Resident Council (RC) attendance was Resident16, 8, 10, 9, and 39. Record review of the 01/25/2022 RC meeting minutes revealed the RC voiced the following concerns: o Greeting cards and stamps should be available for purchase at the business office. o The kitchen was still not reading menu tickets and the residents are getting items they are allergic to or do not want. o The laundry is not coming back fast enough. o Maintenance needed help around the building. o Nurses are short staffed. Record review of the 02/22/2022 RC meeting minutes revealed the RC voiced the following concerns: o No activities o A lot of staff changes, and the residents are not sure who is in charge. o The cook did not cook per the meal tickets and did not follow the meal tickets or recipes. o Laundry did not get clothes back and still no update on missing items. o Housekeeping needed to vacuum more. o Nursing needed more training, did not listen to concerns or complaints, took a long time for nursing to come to the residents, and nursing assistants rush and did not do things correctly. o Needed more help on the floor. Record review of the 03/22/2022 RC meeting minutes revealed the RC voiced the following concerns: o RC wanted better snacks and complained the snacks were being left at the nurse's station. o The residents would like to get to know the Social Services Director (SS) better. o Maintenance might benefit from an assistant. o The smoking residents were being allowed out at special times. Record review of the 04/26/2022 RC meeting minutes revealed the RC voiced the following concerns: o Complaint about an agency nursing assistant. o The staff may be overworked. o Somethings that were suggested to the kitchen were being dropped from the menu. o Laundry is overworked o Please finish the courtyard. Record review of the 05/24/2022 RC meeting minutes revealed the RC voiced the following concerns: o The residents wanted activities again. o Laundry not getting back in time. o Maintenance needed a helper. o Medicaid transportation did not show up. In an interview on 06/01/2022 at 10:30 AM with the RC, the group as a whole and specifically RC President (Resident 16) confirmed the facility would listen to the RC's issues and complaints, but the facility did not change anything or act on the RC's recommendations. In an interview on 06/01/2022 at 10:30 AM with the RC, Resident 39 confirmed the facility and Grievance Official (GO)(staff member assigned to review and act on resident's complaints) did not act on the RC's grievances and recommendations, and the RC did not get a response back as to why the issues did not get acted on. In an interview on 06/01/2022 at 10:30 AM with the RC, Resident 8 confirmed the RC does makes suggestions to change some of the facility's rules, but the facility did not act on the RC's suggestions. Record review of the Resident and Family Grievances Policy dated 04/19/2019 revealed the SS (Social Service) was designated as the GO. Grievances may be made during a verbal complaint during RC meetings. The GO would record the information about the grievance and take steps to resolve the grievance. The GO will issue a written decision to the resident or representative at the end of the investigation. Record review of the Resident Council Meetings Policy dated 04/2019 revealed the facility would act upon the concerns and recommendations of the RC, make attempts accommodate (fit in with wishes or needs) recommendations to the extent practicable and communicate the facility's decisions to the RC. In an interview with SS-J on 06/02/2022 at 08:57 AM, SS-J confirmed SS-J was unsure where the RC complaints go after the Activities Director received them. SS-J was unsure if the GO was supposed to be involved in the RC complaints and recommendations. SS-J was not sure of the grievance process for RC, and SS-J confirmed SS-J was not addressing the RC complaints or recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review; the facility failed to ensure the negative ventilation system was working and maintain residents room lighting, floors, walls, light fixtures, doors, outdoor fencing clean and in good repair. This had the potential to affect all 38 residents in the facility. Total census was 38. Findings are: A. An observation on 05/31/2022 on 09:42 AM of rooms 104, 106, 108, and the restroom that connects room [ROOM NUMBER] and 110 revealed all the overhead lights in the resident rooms and the restroom were not working. Resident 20 in room [ROOM NUMBER] had pulled the light partially off the wall and triggered the electrical circuit breaker (an electrical switch designed to protect an electrical circuit from damage caused by short circuit). The light switches in room [ROOM NUMBER] had tape over the switches. No bare wires were observed. No alternative light sources were observed in any of the rooms. Interview with Resident 38 on 05/31/2022 at 09:42 AM confirmed room [ROOM NUMBER] did not have lights in the room or in the restroom for 2 days. Resident 38 stated Maintenance and Housekeeping Director (MD)-D was supposed to fix the lights but had not been there yet to fix the light. Interview with Resident 39 on 05/31/2022 at 12:02 PM confirmed the light in the restroom between room [ROOM NUMBER] and 110 has not worked since 05/30/2022. Record review of Resident 20's progress note dated 05/30/2022 at 07:45 AM revealed the resident pulled the light on the wall and electrical sparks started coming from the light. Observation of rooms [ROOM NUMBERS] on 05/31/2022 at 12:40 PM revealed the room lights were working again. An interview on 06/08/22 at 07:54 AM with Resident 38 confirmed that when the power was out in the room on 05/30/2022 and 05/31/2022, the resident was not offered a lamp or other form of lighting. An interview on 06/08/22 at 08:00 AM with Registered Nurse (RN)-H confirmed lights were out so the staff helped the resident to restroom and no other lights were offered. An interview on 06/08/22 at 08:05 AM with Resident 39 in room [ROOM NUMBER] confirmed the power was out in the restroom, and the resident was not offered any other lighting options. In an interview on 06/08/22 at 08:32 AM the Regional Director confirmed the staff tested the breaker that was triggered, and the resident rooms did not have lighting when the breaker was off. In an interview with MD-D on 06/07/2022 at 09:00 AM, MD-D confirmed that the light in Resident 20's room was broke on Monday 5/30/22 and the residents did not have power until Tuesday 5/31/22. MD-D was notified but could not come in to fix it. B. An observation on 06/07/2022 at 09:00 AM with the MD-D revealed the following: The negative draw ventilation system throughout the facility was not working. The fence was coming down in Dementia Care Unit courtyard. The doors were scraped in rooms [ROOM NUMBER]. The tile floors in rooms 106, 107, 214, and 220 were stained and scuffed. The carpets were dirty in rooms [ROOM NUMBERS] and were stained and wore. The covers of 2 entrance lights by the front entrance had a coating of dead bugs in them. In an interview with MD-D on 06/07/2022 at 09:00 AM, MD-D did confirm the following items needed repaired: The negative draw ventilation system throughout the facility was not working. The fence was coming down in Dementia Care Unit courtyard. The doors were scraped in rooms [ROOM NUMBER]. The tile floors in rooms 106, 107, 214, and 220 were stained and scuffed. The carpets were dirty in rooms [ROOM NUMBERS] and were stained and wore. The covers of 2 entrance lights by the front entrance had a coating of dead bugs in them. An interview on 06/08/2022 at 08:12 AM with the Regional Director revealed the negative draw ventilation system for the building had a bad belt and had been repaired. In an interview on 06/07/22 at 03:01 PM MD-D confirmed there was not a preventative maintenance schedule for building repairs and there was not a budget for room repairs or maintenance. MD-D had to get quotes from companies and submit them to owners for approval of the repairs.

B. Record Revied of the undated Office of the Long-Term Care Ombudsman (an official appointed to investigate resident's complaints) Facility Initiated Transfer and Discharge Notice Checklist revealed that when a resident is temporarily transferred on an emergency basis to a hospital, that transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Copies of the notices for emergency transfers must also be sent to the Ombudsman, when practicable. Record review of Resident 20's Progress Notes dated 04/26/2022 at 08:08 AM revealed the resident was sent to the emergency room. Record review of Resident 20's Transfer Notification Form dated 04/26/2022 revealed the facility notified the resident's representative of the emergency room transfer via phone. Record review of an email from the Social Services Director (SS)-J to the Ombudsman dated 06/06/2022 at 03:21 PM revealed the Bed Hold Notice was emailed to the Ombudsman. In an interview on 06/06/2022 at 03:30 PM SS-J confirmed the Ombudsman notification was emailed 06/06/2022, and the transfer notification was not mailed to the resident representative until 06/06/2022. An interview with the Regional Director (RD)-A on 06/07/2022 confirmed the resident representative transfer notification had been done verbally and the Ombudsman notification was not sent until 06/06/2022. C. Interview with Resident 2 on 05/31/22 at 12:59 PM revealed they had been recently hospitalized . A review of Resident 2's progress notes revealed that Resident 2 was transferred to the hospital on 5/8/22. There was no documentation of a written notice of transfer being given to the resident or resident representative. Interview on 06/07/22 at 02:56 PM with the Regional Director of Operations confirmed that the facility did not give Resident 2 a written notice of transfer. LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on record review and interview; the facility staff failed to provide written notice of the reason for transfer and failed to notify the Ombudsman of the residents who discharged from the facility for 3 (Resident 2, 20 and 40) of 5 residents. The facility staff identified a census of 38. Findings are: A. Record review of Resident 40's medical record revealed Resident 40 had discharged to the hospital on 5-03-2022. Record review of a Bed Hold Notice dated 5-04-2022 revealed Resident 40's responsible party was given the notice for holding Resident 40's bed. Further review of the bed hold notice dated 5-4-2022 revealed it did not identify in writing why Resident 40 had transferred to the hospital. On 6-07-2022 at 10:43 AM an interview was conducted with the Regional Director of Operations (RDO). During the interview the RDO confirmed a written notice for the reason for transfer had not been provided to Resident 40's responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observations, record review and interview; the facility staff failed to evaluate and implement interventions to promote healing for skin breakdown for 1 (Resident 22) of 1 sample resident. The facility staff identified a census of 38. Findings are: Record review of Resident 22's Comprehensive Care Plan (CCP) printed on 6-01-2022 revealed Resident 22 was at risk for skin breakdown related to impaired mobility. The goal identified for Resident 22 was to have intact skin. Record review of Resident 22's Minimum Data Set (MDS: a federally mandated assessment tool used in care planning) dated 3-23-2022 revealed the facility staff assessed the following about the resident: -Brief interview of Mental status (BIMS) was 0. According to the MDS [NAME] a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance of 1 person for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -No skin breakdown was identified on the MDS dated [DATE]. Observation on 6-01-2022 at 1:50 PM of personal care revealed Nursing Assistant (NA) M completed Resident 22 cares. Observations during the personal care revealed Resident 22 had a nickel sized wound to the right knee. During the observation NA M reported the area to Resident 22's right knee has been there a few days. Record review of Resident 22's medical record that included practitioners orders, treatment records and progress notes revealed there was not an indication the wound to the right knee was evaluated and a treatment requested. Observation on 6-02-2022 at 10:20 AM with Licensed Practical Nurse (LPN) P of Resident 22's right knee was completed. During the observation LPN P reported not being aware of Resident 22's skin breakdown to the right knee and had not been notified. Record review of a Wound Evaluation sheet dated 6-02-2022 at 1:22 PM completed by Advanced Practice Registered Nurse (APRN) Q. According to the Wound Evaluation sheet dated 6-02-2022 of the right lateral knee, the wound was covered in 100 percent of Eschar ( according to Woundsource.com, Eschar is dead tissue) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. An observation on 06/01/2022 at 09:22 AM revealed Resident 20 was sitting alone in a wheelchair in the room with a plate of uncut pancakes soaked in syrup on the overbed table. Approximately 5% had been eaten. Nursing Assistant (NA)-R removed the breakfast tray from the room without offering a substitute. An observation on 06/02/2022 at 07:20 AM revealed Resident 20 was sitting at a table in the dining room (DR) with a plate that contained a whole omelet and whole slice of ham in front of the resident. There was a bowl of cereal, with milk on the cereal. The resident drank a cup of orange juice and ¾ of a cup of milk. The resident started to complain that the resident was cold and needed to use the restroom. The Human Resources Director (HR)-C took the resident from the DR. None of the food had been eaten. An observation on 06/02/2022 at 07:37 AM of the DR revealed Resident 20's meal was still on the table. An observation on 06/02/2022 at 08:01 AM revealed Resident 20 was in the resident's room without food, and observation of the DR revealed Resident 20's meal was still on the DR table. Dietary Manager (DM)-F scraped Resident 20's meal into the garbage. Record review on 06/02/2022 at 11:39 AM of Resident 20's 30-day Amount Eaten report dated 06/02/2022 revealed the column of 76% to 100% had been marked for 06/02/2022. In an interview with NA-S on 06/02/2022 at 12:04 PM, NA-S confirmed Resident 20 had not eaten in the room or was offered a substitute after returning from the DR. NA-S confirmed NA-S marked the column 75% to 100% amount eaten for breakfast on 06/02/2022 but did not know the resident had not eaten any food in the DR. Record review of the Weight Summary dated 06/02/2022 for Resident 20 revealed a weight of 222.0 pounds on 03/26/2022 and a weight of 202.0 pounds on 04/25/2022 for a weight loss of 20 pounds which is a 9.01% weight loss. No May 2022 weight was listed. Record review of Resident 20's Clinical Physician Orders dated 06/02/2022 revealed an order for Glucerna Shake 2 times per day started on 05/20/2022 and Regular Diet, Mechanical Soft Texture, finger foods. Record review of Resident 20's MDS (Minimum Data Set) dated 03/25/2022, Section K0510 revealed the resident was on a mechanically altered diet and no weight loss at that time. The MDS Section G0110 revealed for Eating that the resident is a limited assist by 1 person for support. Record review of Resident 20's Care Plan (a plan the provided direction on the type of care the resident may need) dated 05/18/22 revealed a focus area of: Nutrition, Potential for alteration due to mechanically altered diet texture. Interventions included: alternates for foods not well eaten, Diet of Mechanical soft finger foods, Glucerna shake 2 times per day. Monitor meal intakes and weights, notify physician of significant weight changes. The Care Plan also listed an intervention of supervision by 1 staff to eat. In an interview on 06/02/2022 at 08:03 AM, DM-F confirmed Resident 20 is on a special diet of finger foods, had not eaten much lately, and needed more assistance than the resident used to. In an interview with NA-S on 06/08/2022 at 08:47 AM, NA-S confirmed that Resident 20 will eat if NA-S assisted the resident, if the staff did not assist the resident, Resident 20 would just throw the food. NA-S did confirm the resident was on a regular diet with no restrictions. In an interview on 06/06/2022 at 04:16 PM, DM-F confirmed there was not a way to do mechanical soft finger food for Resident 20. The dining ticket system they use (DiningRD) has the resident listed as regular diet, finger foods. DM-F confirmed pancakes with syrup is not finger food, cereal with milk is not finger food, a slice of ham and an omelet can be finger food only if it was sliced into finger size pieces. DM-J confirmed Resident 20 should have been a 1 assist with dining instead of supervised because the resident did not eat unless the resident was assisted. E. A record review of Resident 2's orders dated 2/8/22, revealed an order for weekly weights to be done on Tuesday mornings. A review of Resident 2's weight record revealed: -5/12/2022 at 18:59; 402.5 Lbs -4/20/2022 at 15:27; 405.5 Lbs -4/9/2022 at 15:18; 403.0 Lbs -4/2/2022 at 07:57; 408.0 Lbs -3/26/2022 at 10:30; 416.0 Lbs -3/16/2022 at 14:50; 413.5 Lbs -3/2/2022 at 21:18; 412.0 Lbs -2/8/2022 at 20:24; 408.5 Lbs Interview on 06/07/22 at 03:30 PM with the Regional Director confirmed there was an order for weekly weights and it had not been getting done as ordered. LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observations, record review and interview; the facility staff failed to ensure water was within reach or available for 3 (Resident 22, 25 and 36) of 3 sampled residents, failed to implement assessed interventions to prevent further weight loss for 1 (Resident 20) and failed to obtain weekly weights for 1(Resident 2) of 5 sampled residents. The facility staff identified a census of 38. Findings are: A. Record review of Resident 22's Nutritional Assessment (NA) dated 3-14-2022 revealed Resident 22 admitted to the facility on [DATE]. Further review of Resident 22's NA revealed Resident 22's daily fluids needs was 1400 milliliters. Observation on 5-31-2022 at 10:15 AM revealed Resident 22 was in a wheelchair in (gender) room and did not have water within reach. Observation on 6-01-2022 at 9:16 AM revealed Resident 22 was up in a wheelchair in (gender) room with water out of reach for the resident. Observation on 6-02-2022 at 10:16 AM revealed Resident 22 was up in a wheelchair in (gender) room and did not have water within reach. On 6-02-2022 at 10:16 AM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview LPN B confirmed Resident 22 did not have water within reach. B. Record review of Resident 25's NA dated 10-18-2021 revealed Resident 25 admitted to the facility on [DATE]. Observation on 5-31-2022 at 10:21 AM revealed Resident 25 was seated in a wheelchair in Resident 25's room with water out of reach of the resident. Observation on 6-01-2022 at 9:15 AM revealed Resident 25 was seated in a wheelchair in Resident 25's room and the water was not in reach of Resident 25. On 6-01-2022 at 10:15 AM a interview was conducted with Licensed Practical Nurse (LPN) B. During the interview LPN B confirmed Resident 25 did not have water within reach and confirmed water should be within reach for Resident 25. C. Record review of Resident 36's NA dated 4-05-2022 revealed Resident 36 admitted to the facility on [DATE]. Observation on 5-31-2022 at 10:30 AM revealed water was not in reach for Resident 36. Observation on 6-02-2022 at 10:15 AM revealed a pitcher of water was behind Resident 36's back and not within reach of the resident. On 6-02-2022 at 10:15 AM an interview was conducted with LPN B. During the interview LPN B confirmed the pitcher of water was behind Resident 36's back and not within reach.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to implement non pharmacological interventions prior to the administration of antianxiety medications for Resident 242, failed to address the use of an antianxiety as needed medication in excess of 14 days per regulation for Resident 26 and failed to complete a sleep study for Resident 40. Findings are: A. Review of Resident 26's physician orders revealed an order for Lorazepam (a psychotropic medication) injection 2 milligrams per milliliters to be given every 4 hours as needed for 6 months, with a start date of 4/21/2021. Interview with the Director of Nurses on 06/08/22 at 01:04 PM revealed the PRN lorazepam was ordered for 6 months and should have only been ordered for 14 days. B. Record review of Resident 242's Medication Administration Record (MAR) for August 2021 revealed Resident 242's practitioner ordered medications that included Lorazepam ( an anti-anxiety medication) as needed every 8 hours. Further review of Resident 242's MAR for August 2021 revealed Resident 242 received the as needed Lorazapam 15 times in August 2021. Review of Resident 242's medical record that included MARS, Resident 242's progress notes and practitioners orders revealed there was not evidence the facility staff had attempted non pharmacological interventions prior to the Lorazapam as needed medication. On 6-08-2022 at 9:08 AM an interview was conducted with the facility Administrator. During the interview, the facility administer confirmed Resident 242 had received the as needed Lorazapam and did not have non pharmacological interventions implemented. C. Record review of Resident 40's Order Summary Report printed on 6-01-2022 revealed Resident 40's practitioner ordered medications that included Trazadone ( an anti-depressant medication and used to assist in sleeping) for insomnia. Record review of Resident 40's medical record revealed there was no any indications the facility staff had completed a sleep study prior to the use of the Trazadone medication. On 6-2-2022 at 11:30 AM a interview was conducted with Licensed Practical Nurse (LPN) B. During the interview LPN B confirmed a sleep study had not been completed for Resident 40.

Licensure Reference Number 175 NAC 12-006.11D Based on observation and interview, the facility staff failed to ensure that food was being served at temperatures to prevent foodborne illness. The facility had a census of 38. Findings are: Observation on 6/2/22 at 11:44 AM revealed a drink cart in the dining room with pitchers of drinks on ice. The lemonade was at 45 degrees and the milk at 45 degrees per the Dietary Manager (DM). Interview with the DM on 6/2/22 at 11:45 confirmed the drinks should have been at 41 degrees or below. Observation on 06/02/22 at 12:28 PM of a sample room tray brought to the administrators office for a sample tray for temperature testing with the DM. Temperature of food: -Broccoli 118* -Mashed potatoes 120* -Salisbury steak 112* Interview on 06/02/22 at 1:00 PM with DM revealed no facility policy on temperature regulation of room tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.03I5 Based on observation and interview, the facility failed to ensure each resident in a semiprivate (a room shared by 2 people) room had individualized closet space. This had the potential to affect 32 of 38 residents in the facility. Total census was 38. Findings are: An observation on 05/31/2022 at 10:14 AM of Resident 20's room revealed the room was set up as a semiprivate room, but only had 1 closet without shelves or dividers. An observation of 3 rooms that are shared by 2 residents, (room [ROOM NUMBER]. 105, and 108) on 06/07/2022 at 03:01 PM with the Maintenance and Housekeeping Director (MD)-D revealed there was only 1 closet in the rooms and that closet did not have shelves or dividers to give each resident their own private closet space. In an interview with MD-D on 06/07/2022 at 03:01 PM, MD-D confirmed all rooms in the facility are the same size and layout. MD-D confirmed all rooms in the facility only had 1 closet and did not have shelves or dividers. MD-D confirmed all rooms on the 100 and 200 hallways were semiprivate rooms. MD-D did confirm MD-D was not aware of the regulation for closet space.

C. Observation of Resident 13's room revealed; 3 rugs on the floor, sharp metal clamps on the end of the bed, a moving dolly in the closet, tools in a toolbox including screwdrivers and pliers. A television was lying on its side on the nightstand and the resident stated it needed an overhaul. A triangular shaped lightbulb was hanging by the cord in the bathroom. Interview with Resident 13 on 5/31/22 at 10:43 AM revealed Resident 13 likes to tinker. Interview with Resident 13 on 5/31/22 at 10:44 AM revealed Resident 13 has fallen down before. A review of Resident 13's careplan revealed Resident 13 is at risk for falls due to an unsteady gait. Interventions included to provide a clutter free environment. A record review of the undated In Room Falls Communication Form revealed the interventions should be: declutter room, remove mats and anything in pathways to prevent falls. Interview on 06/02/22 at 09:16 AM with Licensed Practical Nurse (LPN) L confirmed Resident 13's room is not clutter free. Rugs were on the floor, tool box was in the bathroom, tools were in the room and tv trays were in room and was full of items including lap top, dishes and tools. Interview on 06/08/22 at 01:29 PM with the Provisional Administrator revealed there is a Performance Improvement Plan (PIP) plan that started on 5/2/22 for falls and potential for falls but they had only focused on the residents who had recently fallen. They did not evaluate Resident 13's room. LICENSURE REFERENCE NUMBER 175 NAC 12-006.18Ea1 LICENSURE REFERENCE NUMBER 175 NAC 12-00618Ea2 Based on observations, record reviews and interview; the facility staff failed to ensure bathing water temperatures were maintained at a level to prevent the potential of scalding. This had the potential to affect all residents in the facility. The facility failed to ensure hand sink water temperatures were maintained to prevent the potential for scalding for 1 (Resident 36) of 16 residents on the initial pool and failed to ensure a clutter free environment to prevent falls for 1(Resident 13) of 2 sampled residents. Findings are: A. Record review of a Bathing Resident Policy and Procedure revised on 10/2020 revealed the following information: -It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. -The water temperature should be 98.6 degrees to 100 degrees. Record review of the facility Policy and Procedure for safe water temperatures dated 4/2019 revealed the following information: -It is the policy of this facility to maintain appropriate temperatures in resident care areas. -Thermometers will be available as needed by all staff. -Water temperatures will be set to a temperature of no more than 120 degrees or the state's allowable maximum water temperature. -Maintenance staff will check water heater temperatures controls and the temperature of water in all hot water circuits weekly and as needed. Record review of Nebraska Health and Human Services Regulations and Licensure found at 175 NAC 12-006.18E3a1 revealed water temperatures at resident bathing and therapy fixtures must not exceed 110 degrees and 175 NAC 12-006.18E3a2 revealed water at handwashing fixtures must not exceed 120 degrees. Observation on 5-31-2022 at 1:00 PM with the facility Maintenance/Housekeeping Director (MHD) revealed the MHD using a facility thermometer and the bathing water temperature in the main bathhouse was 118 degrees. On 5-31-2022 at 1:00 PM an interview was conducted with the MHD. During the interview the MHD reported not knowing what the maximum temperature for bathing was supposed to be. The MHD reported thinking 118 to 119 degrees would be safe for bathing. The MHD reported 2 bath houses had recently been repaired. On 5-31-2022 at 12:45 PM an interview was conducted with Nursing Assistant (NA) K who was working in the secured unit of the building. During the interview NA K reported the bath house in the secured unit was out of order and so all residents from the unit were taken to the main bath house for shower/baths. Record review of the facility Tap Water Temperature Checks revealed the following information: -3-07-2022 the water heater was set at 150 . -3-07-2022, bath house water temperature was 118 degrees. -3-14-2022, water heating setting was 140 degrees. -3-14-2022,bath house water temperature was 117.9 degrees and the secured unit bath house water temperatures was 118.3 degrees. -3-21-2022, water heating setting was 140 degrees. -3-21-2022,bath house water temperature in the secured unit was 119.1 degrees. -4-18-2022, bath house water temperature was 118.3 degrees. -5-02-2022, water heating setting was 140 degrees. -5-02-2022, bath house water temperature was 118. degrees -5-09-2022,bath house water temperature in the secured unit was 118.9 degrees. -5-16-2022, water heating setting was 145 degrees. -5-16-2022,bath house water temperature was 118.3 degrees. On 5-31-2022 at 1:12 PM a follow up interview was conducted with the facility MHD. During the review of the water temperatures in the main and secured unit bath houses were reviewed for 3-07-2022, 3-14-2022, 3-21-2022,4-18-2022, 5-02-2022, 5-09-2022 and 5-16-2022. The MHD confirmed the water for bathing residents was above 110 degrees and there was not an adjustment to lower the temperature of the bathing water. B. Observation on 5-31-2022 at 12:35 PM of Resident 36's handwashing sink water temperature revealed the facility MHD using a facility thermometer and MHD obtained a temperature at Resident 36's handwashing sink of 132 degrees. On 5-31-2022 at 12:35 PM an interview was conducted with the MHD. During the interview the MHD confirmed the water in Resident 36's hand sink was too hot. Record review of information at www.antiscald.com revealed the following information: -Exposure to hot water at 118.4 degrees for 15 minutes resulted in a 2nd degree burn and exposure to hot water for 20 minutes resulted in a 3rd degree burn. According to the Mayoclinic.org a 2nd-degree burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-degree burns can cause scarring and a 3rd degree burn reaches to the fat layer beneath the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, causing numbness.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record reviews and interview; the facility management failed to utilize its resources to attain or maintain the highest practicable physical, and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 38. Findings are: -F565. The facility failed to address resident council grievances, housekeeping, maintenance, food, activities and staff concerns. -F582. The facility staff failed to provide liability notice to 1 (Resident 39). -F584. The facility failed to maintain residents room lighting, floors, walls, light fixtures, doors, outdoor fencing in a clean manor and in good repair. -F609. The facility staff failed to submit an investigation to the required state agency within 5 working days of an investigation of an injury of unknown source for 1 (Resident 36). This is a repeated citation from the prior annual survey. -F623. The facility staff failed to give written notice of the reason for transfer and failed to notify the Ombudsman of the residents discharge from the facility. -F679. The facility staff failed to provide an individualized activity program for 3 residents. -F684. The facility staff failed to evaluate and request treatment for skin breakdown resulting in harm for Resident 22. Observation on 6-02-2022 at 10:20 AM with Licensed Practical Nurse (LPN) P of Resident 22's right knee was completed. During the observation LPN P reported not being aware of Resident 22's skin breakdown to the right knee and had not been notified. This is a repeated citation from the prior annual survey. -F686. The facility staff failed to implement intervention, evaluate the condition of a pressure ulcer and evaluate casual factors for the development of the pressure ulcer for resident 40 resulting in harm. On 6-06-2022 at 11:17 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 40's weekly skin assessments had not been completed and further confirmed an assessment when the left heel pressure ulcer with casual factors had not been completed and should have been. -F689. The facility staff failed to ensure bathing and hand sink water temperatures were maintained at a level to prevent the potential for scalding and failed to ensure a clutter free room. This had the potential to affect all residents in the facility placing the facility in a substandard level of care requiring an extended survey. This is a repeated citation from the prior annual survey. On 5-31-2022 an interview was conducted with the facility Maintenance/housekeeping Director (MHD). During the interview the MHD reported not being aware of the maximum temperature bathing and handwashing sinks could be. On 6-09-2022 at 8:15 AM an interview was conducted with Human Resources (HR) C. During the interview HR C reported there was not anyone to train the Maintenance Director. HR C confirmed there was not an orientation check list for the MHD file. On 6-09-22 at 8:40 AM an interview was conducted with the MHD. During the interview the MHD reported not understanding what the job description and what MHD was supposed to do. -F692. The facility staff failed to ensure water was available and within reach for Resident 22,25 and 36, failed to implement assessed interventions to prevent further weight loss for Resident 20 and failed to obtain weekly weights for Resident 2. -F695. The facility staff failed to obtain oxygen orders for 1(Resident 23). -F740. The facility staff failed to evaluate and obtain treatment for depression for 1 (Resident 191). -The facility staff failed to implement non-pharmacological interventions prior to the administration of an anti-anxiety medication for 2 (Resident 26 and 242), failed to address the use of an anti-anxiety as needed medication in excess of 14 days for 1 (Resident 2) and failed to complete a sleep study for 1 (Resident 40). -F759. The facility staff failed to ensure a medication error rate of less than 5%. The facility medication error rate was 16%. -F804. The facility staff failed to food was served at temperatures to prevent foodborne illness. -F880. The facility staff to ensure staff and visitors COVID-19 screening questions were evaluated prior to entrance into the facility and failed to ensure oxygen tubing was changed and stored to prevent the potential for contamination for 2 (Resident 2 and 39). This is a repeated citation from the prior annual survey. -F886. The facility failed to ensure non up to date facility staff and contracted staff were tested for COVID-19 according to the transmission rate. -F888. The facility staff failed to fully implement the facility COVID-19 contingency plan for staff with exemptions. -F917. The facility staff failed to ensure each resident in semi-private rooms had individualized closet space.

Licensure Reference Number 175 NAC 12-006.17A(2) Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to ensure staff and visitors' COVID-19 screening questions were completed and evaluated prior to entrance into the facility and failed to ensure oxygen tubing was changed and stored to prevent the potential for contamination for Resident 39 and 2. This had the potential to affect all residents in the facility. Total census was 38. Findings are: A. An interview with Social Services Director (SS)-J on 05/31/2022 at 08:40 AM confirmed staff and visitors that entered the facility were to just complete the Employee/Visitor COVID-19 Screening Sign-In sheets and leave the sheets on the left side of the book. SS-J said the staff will collect the sheets at the end of the day. An observation on 06/02/2022 at 01:00 PM revealed a Vendor was allowed entrance into the facility without an Employee/Visitor COVID-19 Screening Sign-In sheet being completed. Record review of the Employee/Visitor COVID-19 Screening Sign-In sheets with the Infection Preventionist (IP)-B and HR-C located on the left side of the book at the screening station revealed the Vendor had not completed an Employee/Visitor COVID-19 Screening Sign-In sheet. An interview with IP-B confirmed the Vendor had not completed an Employee/Visitor COVID-19 Screening Sign-In sheet. Record review of the Employee/Visitor COVID-19 Screening Sign-In sheets for the date of 06/07/2022 from 08:04 AM - 11:24 AM revealed 6 Employees or Visitors had completed an Employee/Visitor COVID-19 Screening Sign-In sheet, only 2 had been reviewed, and 1 unreviewed sheet revealed a visitor of Resident 13 did not complete the screening questions. An observation on 06/09/2022 at 08:44 AM revealed Vendor Delivery Person (VDP)-N and VDP-O walked down the 200 hallway from the kitchen/dining room area and exit the facility out the front entrance door. Record review of the Employee/Visitor COVID-19 Screening Sign-In sheets on 06/09/2022 from 06:54 AM - 08:44 AM revealed VDP-N and VDP-O and not completed an Employee/Visitor COVID-19 Screening Sign-In sheet. The Director of Nursing (DON) confirmed in an interview on 06/09/2022 at 08:46 AM that VDP-N and VDP-O should not have been in the building without having completed an Employee/Visitor COVID-19 Screening Sign-In sheet. The DON confirmed that an Employee/Visitor COVID-19 Screening Sign-In sheet for VDP-N and VDP-O had not been completed. Record review of the Coronavirus Surveillance (close observation for signs or symptoms of COVID-19) revealed the facility would conduct screening for visitors and staff for signs or symptoms of COVID-19. An interview with IP-B on 06/08/2022 at 09:27 AM confirmed that an Employee/Visitor COVID-19 Screening Sign-In sheet should have been completed and that form reviewed by the facility staff prior to any staff member or visitor being allowed entrance into the facility. B. Record review of the Coronavirus Testing Policy dated 03/2020 revealed the facility will maintain proper infection control and use recommended Personal Protective Equipment (PPE), which includes a N-95 respirator (a device designed to achieve a very close fit to the face and very efficient filtration of airborne particles), eye protection, gloves, and a gown. The facility will clean, disinfect, and maintain testing equipment. An observation on 06/07/2022 at 07:15 AM revealed the Infection Preventionist (IP)-B self-tested for COVID-19 and did not wear any PPE. IP-B placed the rapid test card on the Testing Log clipboard, and then moved it to on top of the testing instructions sheet and covered it with an unused face shield. IP-B did not sanitize the testing surfaces before or after the test and did not use a barrier between the testing surface and the COVID-19 testing card. In an interview with IP-B at 06/07/2022 at 07:34 AM, IP-B confirmed the staff was not required to use a barrier when testing and IP-B was supposed to have sanitized the testing surfaces before and after the test but did not do it. An observation on 06/09/2022 at 09:45 AM revealed the Director of Nursing (DON) COVID-19 tested Advanced Practice Registered Nurse (APRN)-Q. The DON only had a surgical mask and gloves on during the testing process. The DON did not sanitize the testing surfaces before and after, did not utilize a barrier, and placed the testing card directly on the table in the foyer by the testing sign in sheets. Interview with the DON on 06/09/2022 at 10:14 AM confirmed the DON did not sanitize the surfaces before and after the test or use a barrier, and the testing card was placed directly on the overbed table by the sign in sheets. C. Observation on 06/06/22 at 03:56 PM of Resident 39's oxygen tubing and nasal cannula revealed a date of 12/26/21 and the nasal cannula was lying on the floor. Interview with Resident 39 on 6/6/22 at 3:57 PM stated the oxygen is used at night. Review of the Oxygen Concentrator policy with review date of 10/20/20, stated in section 5, Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Interview on 06/07/22 at 08:27 AM with the Director of Nurses (DON) confirmed that the oxygen tubing should be changed weekly and Resident 39's was not. The DON also confirmed the cannula should not be laying on the ground. D. Observation on 06/01/22 at 11:15 AM of Resident 2 on oxygen at 2 liters per minute per nasal cannula with oxygen tubing dated 5/16. Nebulizer kit in room not dated and not in bag. Observation on 6/6/22 at 4:18 PM of Resident 2 in tv lounge area with oxygen on at 2 liters per minute per nasal cannula and tubing dated 5/16. Review of the Oxygen Concentrator policy with review date of 10/20/20, stated in section 5, Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Interview on 06/07/22 at 08:27 AM with the DON confirmed that the oxygen tubing should be changed weekly and this resident 2's was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 as evidenced by the following: -1). Failure to complete contact tracing and perform outbreak testing accordingly. -2). Failure to perform COVID-19 testing in accordance with manufacturer's directions. These failures had the potential to affect all residents residing in the facility. At the time of the survey, a total of 4 residents and 1 staff member had tested positive for COVID-19 since the start of the outbreak. The facility had a total census of 36 residents. The findings are: A. In an interview on 8/17/22 at 10:10 AM, the DON (Director of Nursing) reported the facility currently had 2 residents positive for COVID-19. Both lived in the secured unit and both tested positive on 8/12/22. The DON reported all residents (9) in the secured unit were tested on [DATE] and were only being tested again if they showed symptoms of COVID-19. In an interview on 8/17/22 at 10:13 AM, the Administrator reported the facility was not doing any outbreak testing. The Administrator reported the facility was testing their unvaccinated staff members two times a week and testing all other staff once a month. The Administrator reported PTA (Physical Therapy Assistant) L was in charge of infection control and oversaw COVID-19 testing. In an interview on 8/17/22 at 10:17 AM, PTA L reported the facility had two residents test positive for COVID-19 on 8/12/22 and one staff member test positive for COVID-19 on 8/9/22. B. A review of facility resident COVID-19 testing logs revealed the following: -7/31/22 - Resident 40 tested positive for COVID-19 and resided in the secured unit. -8/5/22 - Resident 26 tested positive for COVID-19 and resided in the secured unit. -8/12/22 - Residents 500 and 501 tested positive for COVID-19 - both resided in the secured unit. Further review of facility resident COVID-19 testing logs revealed all residents (9 residents) residing in the secured unit were tested on [DATE] and 8/12/22. No residents in the rest of the facility were tested during the time period of 7/31/22 -8/17/22. A review of facility staff COVID-19 testing logs revealed the following: -8/9/22 - Housekeeper (HK) B tested positive for COVID-19 A review of HK B's schedule revealed the following: -8/3/22 - worked in laundry -8/4/22 - worked in laundry -8/5/22 - sick -8/6/22 - worked on the floor and laundry In an interview on 8/18/22, RN A (Registered Nurse) reported the facility did not staff a nurse in the secured unit. RN A stated they had to go back to the secured unit to do any care that required a nurse, like treatments or insulin. In an interview on 8/18/22 at 9:02 AM, NA H (Nurse Aide) reported they worked in the secured unit frequently, but not always. NA H stated there was only one staff member scheduled in the unit each shift. NA H also stated there was only one bath aide scheduled for the building daily. NA H stated the bath aide either brought residents from the secured unit up to the front bathhouse or went back to the secured unit to do the bathing in the bathhouse there. NA H also reported the staff members outside of the secured unit were responsible for relieving the staff member working in the secured unit for breaks. An interview was conducted with the Administrator on 8/18/22 at 1:33 PM. During the interview, the Administrator reported the COVID outbreak was contained to the secured unit, so the facility did not do any testing outside of the secured unit. The Administrator confirmed the secured unit shared a nurse, bath aide, and housekeeping staff with the rest of the building. The Administrator also reported HK B started having symptoms of COVID-19 on 8/8/22 and tested positive on 8/9/22 after arriving to work. The Administrator stated HK B tested in the vestibule prior to their shift on 8/9/22 and did not ever enter the building. The Administrator confirmed the facility was in outbreak status as of 7/31/22. A review of the facility's Coronavirus Testing Policy, last revised 2/2022, revealed the following information: -Outbreak is a new COVID_29 infection in any healthcare personnel or any nursing-home onset COVID-19 infection in a resident. -Testing Summary -Testing Trigger: Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts. Staff: Test all staff, regardless of vaccination status, that had a higher risk exposure with a COVID-19 positive individual. Residents: Test all residents, regardless of vaccination status, that had close contact with a COVID-19 positive individual. -Testing Trigger: Newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts. Staff: Test all staff, regardless of vaccination status, facility-wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility). Residents: Test all residents, regardless of vaccination status, facility-wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility). -Testing of Staff and Residents in Response to an Outbreak -1). A new COVID-19 infection in any staff or any nursing home onset COVID-19 infection in a resident will trigger an outbreak investigation. -2). Upon identification of a single new case of COVID-19 infection in any staff or residents, testing will begin immediately. -3). Outbreak testing will be performed either through contact tracing or broad-based (e.g. facility-wide) testing (see above) -4). In a broad-based approach, perform testing for all residents and HCP (Health Care Personnel) on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after exposure, if known) and, if negative, again 5-7 days later. -5). If no additional cases are identified during the broad-based testing, room restriction and full PPE (Personal Protective Equipment) use by HCP caring for residents who are not up to date with all recommended COVID-19 vaccine doses can be discontinued after 14 days and no further testing is indicated. -6). If additional cases are identified, testing should continue on affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE used for care of residents who are not up to date with all recommended COVID-19 vaccine doses, until there are no new cases for 14 days. -a. If antigen testing is used, more frequent testing (every 3 days), should be considered. In an interview on 8/18/22 at 3:05 PM, the Administrator confirmed the facility did not complete any contact tracing for positive COVID-19 cases in the building. In an interview on 8/18/22 at 3:45 PM, the RDO confirmed HK B's symptoms of COVID-19 began on 8/8/22 and they last worked in the facility on 8/6/22. The RDO confirmed no contact tracing was completed for HK B's positive COVID-19 test. C. A review of an [NAME] BinaxNOW COVID-19 Antigen Card - Training Checklist, dated 9/2020 revealed the following information: -To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage, or the nostril that is most congested if drainage is not visible. Using gentle rotation, push the swab until resistance is met at the level of the turbinate (less than one inch into the nostril). Rotate the swab 5 times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril. -For Patient Testing: -2. Hold Extraction Reagent bottle vertically. Hovering ½ inch above the top hole, slowly add 6 drops to the top hole of the swab well. Do not touch the card with the dropper tip while dispensing. -3. Insert sample swab into bottom hole and firmly push upwards so that the swab tip is visible in the top hole. -4. Rotate (twirl) swab shaft 3 times clockwise (to the right). Do not remove swab. -5. Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. -6. Read result in the window 15 minutes after closing the card. It is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes. An observation on 8/17/22 at 12:12 PM revealed LPN M (Licensed Practical Nurse) performed COVID-19 antigen testing utilizing [NAME] BinaxNOW COVID-19 antigen cards on the 200 hallway. Observations on 8/17/22 from 12:23 PM - 12:45 PM revealed the DON (Director of Nursing), RN A (Registered Nurse), and the SSD (Social Services Director) performed COVID-19 antigen testing utilizing [NAME] BinaxNOW COVID-19 antigen cards in the facility's secured unit. An observation of on 8/17/22 at 12:27 PM revealed RN A (Registered Nurse) inserted a nasal swab into a BinaxNOW COVID-19 Antigen Card and turned swab back and forth 6 times. In an interview on 8/17/22 at 12:27 PM, RN A stated they rotated the swab 3-4 times in each side of the resident's nose. RN A reported they then use 6 drops of the reagent in the top hole of the BinaxNOW card prior to inserting the nasal swab. RN A confirmed they turned the swab back and forth in the hole of the BinaxNOW card 6 times. RN A made a motion with their hand of moving the swab to the right, then to the left 6 times total. RN A peeled the adhesive and closed the card. No collection time was written on the card. An observation on 8/17/22 at 12:33 revealed the SSD inserted a nasal swab collected by RN A into a BinaxNOW card and spun it clockwise 4 times. The SSD peeled the adhesive and closed the card. No collection time was written on the card. In an interview at this time, the SSD confirmed they rotated the nasal swab 4 times. An observation on 8/17/22 at 12:35 PM revealed the SSD stood at a bedside table in the hallway of the secured unit with 3 tests stacked on top of one another, separated by pieces of aluminum foil in between. There were no collection times written on any of the tests. In an interview at this time, the SSD confirmed they had not been writing collection times on the test. The SSD further confirmed they did not know when the 15 minutes was complete for the tests, since no collection time had been written on them. In an interview on 8/17/22 at 12:37 PM, the DON reported they rotated the swab 3-4 times in each side of the resident's nose to collect a sample for COVID-19 testing. The DON stated they then use 6 drops of the reagent in the top hole of the BinaxNOW card prior to inserting the nasal swab and then rotated the swab 1-2 times in the card after inserted. An observation on 8/17/22 at 12:41 PM revealed RN A collected a nasal swab from a resident in the secured unit. RN A rotated the swab 3 times in each side of the resident's nose. In an interview on 8/17/22 at 12:47 PM, LPN M reported they rotated the swab 3 times in each side of the nose to collect a sample for COVID-19 testing. LPN M stated they then use 6 drops of the reagent in the top hole of the BinaxNOW card prior to inserting the nasal swab and then rotated the swab 3 times in the card after inserted. In an interview on 8/17/22 at 2:00 PM, the DON confirmed the observed [NAME] BinaxNOW COVID-19 antigen testing was performed incorrectly. The DON confirmed the nasal swab should be rotated in both sides of the nose at least 5 times each and the swab should be rotated clockwise in the testing card 3 times. The DON further confirmed the COVID-19 antigen testing done at the facility that date could be inaccurate since the testing was not performed in accordance with manufacturer's directions.

Based on observations, interviews, and record review; the facility failed to fully implement the facility COVID-19 Contingency Plan for staff with exemptions. Less than 25% of staff were unvaccinated. Total census was 38. Findings are: Record review of the facility's Employee COVID-19 Vaccinations Policy with a Reviewed date of 05/2022 revealed the facility would require addition precautions to prevent the transmission and spread of COVID-19 for all staff that are not fully vaccinated against COVID-19. Those precautions would include the use of a N-95 or higher- level respirator (a device designed to achieve a very close fit to the face and very efficient filtration of airborne particles). An interview on 05/31/2022 with the Social Services Director (SS)-J confirmed the facility was not in an outbreak status and had not been since January 2022. Record review of the COVID-19 Staff Vaccination Status for Providers dated 01/2022 revealed that Licensed Practical Nurse (LPN)-L had not been vaccinated against COVID-19. An observation on 06/02/2022 at 07:43 AM revealed LPN-L was wearing a surgical mask and face shield as LPN-L administered medications to residents in the dining room. An observation on 06/08/2022 at 08:33 AM revealed LPN-L was wearing a surgical mask and face shield. LPN-L confirmed in an interview on 06/08/2022 at 08:33 AM that LPN-L was only wearing a surgical mask and did work on all units of the facility. The Infection Preventionist (IP)-B confirmed in an interview on 06/08/2022 at 10:22 AM that unvaccinated staff against COVID-19 were required to wear an N-95 mask and a face shield or safety glasses. IP-B confirmed LPN-L was not wearing an N-95 and should have been.