Licensure Reference Number 175 NAC 12-006.05(S) Based on observation, record review, and interview; the facility failed to ensure a privacy bag was utilized for a catheter bag to promote dignity for Resident 5. The sample size was 1 and the facility census was 45. Findings are: A record review of the facility policy Promoting/Maintaining Resident Dignity dated September 2024 revealed all staff members were involved in providing care to residents to promote and maintain resident dignity and respect resident rights, the resident's lifestyle and personal choices would be considered when providing care and services, and staff would maintain resident privacy. A record review of the facility policy Catheter Care dated September 2024 revealed privacy bags would be available, catheter drainage bags would be covered at all times while in use, and privacy bags would be changed out when soiled, with a catheter change, or as needed. A record review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used in Care Planning) dated 4/3/25 revealed the resident had serious mental illness, had an indwelling catheter, and had diagnoses of Neurogenic Bladder (a condition where a problem in the brain, spinal cord, or peripheral nerves disrupts the signals that control bladder function and can lead to difficulty emptying the bladder or holding urine), Renal Disease, Anxiety, Depression, and Schizophrenia. A record review of Resident 5's Care Plan last revised 4/29/25 revealed the resident had an indwelling catheter with a diagnosis of neuromuscular dysfunction of the bladder, staff were to keep the catheter bag and the tubing below the level of the bladder and away from the entrance room door. The following was observed regarding Resident 5: -On 4/30/25 at 9:40 AM the resident's catheter bag was hanging on the resident's walker. No privacy bag was utilized, and the catheter bag was visible from the hallway. -On 4/30/25 at 1:45 PM the resident was lying in bed with the catheter drainage bag hanging on the resident's walker, no privacy bag was used, and the drainage bag was visible from the hallway. -On 5/1/25 at 7:45 AM the resident was lying in bed with the catheter drainage bag hanging on the resident's walker, no privacy bag was used, and the drainage bag was visible from the hallway, -On 5/1/25 at 11:10 AM the resident was lying in bed with the catheter drainage bag hanging on the resident's walker, no privacy bag was used, and the drainage bag was visible from the hallway. -On 5/1/25 at 1:45 the resident was lying in bed with the catheter drainage bag hanging on the resident's walker, no privacy bag was used, and the drainage bag was visible from the hallway. -On 5/5/25 at 8:05 AM the resident was lying in bed with the catheter drainage bag hanging on the resident's walker, no privacy bag was used, and the drainage bag was visible from the hallway. -On 5/6/25 at 8:10 AM the resident was lying in bed with the catheter drainage bag hanging on the resident's walker, no privacy bag was used, and the drainage bag was visible from the hallway. Interview on 5/5/25 at 2:20 PM with the Director of Nursing confirmed Resident 5 did not have a privacy/dignity bag over their catheter bag. Further interview confirmed dignity bags were to be used for all residents with catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews, the facility failed to; notify Resident 23's practitioner of the unavailability of an anticoagulant medication and to notify Resident 33's practitioner of the resident's non-compliance with fluid restriction and edema wear and failure to administer the resident's steroid eye drops after a surgical procedure. The sample size was 2 and the facility census was 45. Findings are: A record review of the Unavailable Medications Policy dated September 2024 revealed the facility was to notify the physician of the inability to obtain medications when the facility was made aware the medications were not available. If a resident missed a scheduled dose of the medication, the staff were to follow the procedures for a medication error, including notifying the physician. A. A record review of Resident 23's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 3/12/25 revealed the resident was admitted [DATE] with diagnoses of cancer, atrial fibrillation, dementia, and malnutrition. The following was assessed for Resident 23: -cognition was severely impaired. -verbal behaviors directed at others and rejection of care. -required staff assistance with toileting, dressing, transfers, personal hygiene, and bed mobility. -received an anticoagulant (medication used to help prevent blood clots) daily. A record review of Resident 23's Medication Administration Record (MAR) dated 3/2025 revealed an order dated 3/6/25 for Xarelto (anticoagulant) 15 milligrams (mg) 1 tablet daily. Further review of the MAR revealed from 3/18/25 to 3/24/25 (7 days) the medication was not administered. During an interview on 5/6/25 at 9:29 AM the Director of Nursing (DON) confirmed Resident 23 did not receive the Xarelto 15 mg daily from 3/18/25 to 3/24/25. In addition, the DON confirmed that the resident's practitioner was never notified the resident's anticoagulant medication was not provided for 7 days. B. A record review of Resident 33's April 2025 MAR revealed a physician's order for: -1800 milliliter (ml) fluid restriction for 24 hours start date 6/27/24, -there was no fluid intake documented for 3 out of 90 shifts, and -the resident's intake exceeded 1800 ml 20 days out of 30. Interview on 5/5/25 at 10:55 AM with the DON confirmed that the resident was on an 1800 ml fluid restriction and staff were not notifying the physician if resident exceeded the 1800 ml intake. A record review of Resident 33's December 2024 MAR revealed the resident had an order for: -prednisoLONE Acetate eye drops (decrease inflammation) 1 drop to right eye four times a day for post cataract surgery for 1 month. The order had a start date of 12/10/24 at 5:00 PM and a discontinue date of 1/7/25 at 10:00 AM. A record review of Resident 33's MAR for December 2024 revealed that the resident did not receive the eye drops on 12/30/24 at 9:00 PM and missed 3 doses on 12/31/24. A record review of Resident 33's MAR for January 2025 revealed the resident received 6 of the 25 doses of the eye drops. Interview on 5/5/25 at 10:55 AM with the DON confirmed that the physician was not notified of eye drops not administered between 12/30/24 at 9 PM through 1/7/25. A record review of Resident 33's December 2024 MAR revealed the resident had an order for: -thigh high compression garments on during the day off at night with a start date 6/27/24. A record review of Resident 33's MAR for December 2024 and January 2025 revealed the resident did not have the compression garments from 12/21/24 to 1/26/25. A record review of Resident 33's nursing documentation from 12/21/24 to 1/26/25 revealed that the compression garments were not being put on because the facility was waiting for a larger size of compression garments. The physician was notified on 1/13/25 of resident's increased non-pitting edema to all extremities and neck, shortness of breath and not having the compression garments due to larger size being ordered. No follow up documentation was received from the physician. An interview on 5/5/25 at 10:55 AM confirmed that the resident should not have gone from 12/21/24 to 1/26/25 without some type of compression garment, the physician should have been notified before 1/13/25 and there was no follow up with the physician after 1/13/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview; the facility failed to ensure Gradual Dose Reduction (GDR, stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) had a documented clinical rationale as to why they were not attempted for Resident 5; and failed to ensure as needed antipsychotic medications (a type of psychoactive medication which alters chemicals in the bran to effect changes in behavior, mood, and emotion) were limited to 14 days for Resident 34. The sample size was 5 and the facility census was 45. Findings are: A record review of the facility policy Use of Psychotropic Drugs, last reviewed February 2020 revealed the following: -residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, -a psychotropic drug was any drug that affected brain activities associated with mental processes and behavior, -psychotropic drugs included but were not limited to antipsychotics, antidepressants, anti-anxiety and hypnotics, -the indications for use would be documented in the medical record, -residents who used psychotropic drugs would receive GDR's unless clinically contraindicated in effort to discontinue the medication, -as needed (PRN) orders for psychotropic drugs would be used only when the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record and for a limited duration of 14 days, -if the prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she would document their clinical rationale in the resident's medical record and indicate a duration, and -PRN orders for antipsychotic drugs were limited to 14 days and cannot be renewed unless the prescribing practitioner evaluated for appropriateness of that medication. A. A record review of Resident 5's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning) dated 4/3/25 revealed the resident had a serious mental illness; was cognitively intact; had diagnoses of anxiety, bipolar disorder, and schizophrenia; and received routine anti-psychotic, anti-anxiety, and anti-depressant medications. A record review of Resident 5's Care Plan last revised 4/29/25 revealed the resident received anti-psychotic, anti-depressant, and anti-anxiety medications for diagnoses of schizophrenia, bipolar disorder and anxiety disorder. A record review of Resident 5's Medication Administration Record (MAR) for April 2025 revealed the resident received the following anti-psychotic medications: -Haloperidol (an antipsychotic medication) 5 milligrams (mg) 25 out of 30 doses, -Quetiapine (an antipsychotic medication) 200mg 25 out of 30 doses, -Quetiapine 400mg 27 out of 30 doses, -Clonazepam (a benzodiazepine medication) 0.5mg 52 out of 60 doses, and -Lorazepam (an antianxiety medication) 0.5mg 52 out of 60 doses. Further review of the MAR revealed the missed doses were due to hospitalizations. A record review of the facility facsimile (fax) sent to the prescribing provider for Resident 5 signed 1/21/25 revealed the GDR's for Quetiapine and Haloperidol were marked as contraindicated. There was no documented clinical rationale as to why the dose reduction was not attempted. A record review of the facility fax sent to the prescribing provider signed 2/3/25 revealed the GDR's for Clonazepam and Ativan were marked as contraindicated. There was no documented clinical rationale as to why the dose reduction was not attempted. Interview on 5/6/25 at 8:45 AM with the Director of Nursing (DON) confirmed there was no documented clinical rationale for the contraindicated GDR's for Quetiapine, Haloperidol, Clonazepam, and Ativan. B. A record review of Resident 34's MDS dated [DATE] revealed the resident had non-traumatic-brain dysfunction, Alzheimer's disease, dementia, anxiety and depression; cognition is severely impaired; and received an antipsychotic medication. A record review of Resident 34's Care Plan last revised 4/7/25 revealed the resident received antipsychotic medications for anxiety and unspecified dementia. A record review of Resident 34's MAR for April 2025 revealed the resident received the following antipsychotic medication: ABH - (Ativan 1 mg, Benadryl 25mg, Haldol 1mg) every 4 hours as needed (PRN) for agitation and restlessness, apply 1 milliliter (ml) to wrist or back of neck with a start date of 12/27/24. A record review of Consultant Pharmacist's Medication Regimen Review (MRR, includes medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences) revealed the following: -MRR date: 2/10/25, Follow up and add stop date to MAR, ABH gel 1mg every 4 hours as needed, start date 12/27/24, a new order must be written every 14 days for PRN antipsychotic, -MRR date: 3/11/25, Follow up and add stop date to MAR, ABH gel 1mg every 4 hours as needed, start date 12/27/24, a new order must be written every 14 days for PRN antipsychotic, -MRR date 4/8/25, Follow up and add stop date to MAR, and ABH gel 1mg every 4 hours as needed, start date 12/27/24, a new order must be written every 14 days for PRN antipsychotic. A record review of Resident 34's MARs revealed the following: ABH - (Ativan 1 mg, Benadryl 25mg, Haldol 1mg) every 4 hours as needed (PRN) for agitation and restlessness apply 1 mg to wrist or back of neck with a start date of 12/27/24. -January 2025: Administered on the 2nd, 5th, 6th and 8th, -March 2025: Administered on the 4th, 8th and 28th, and -April 2025: Administered on the 3rd, 6th, 15th and 29th. Interview on 5/1/25 at 11:00 AM with the DON confirmed that the facility did not renew the order for the PRN antipsychotic medication ABH every 14 days as required and continued to administer the medication.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record reviews and interviews, the facility staff failed to obtain pressure ulcer treatment for 1 (Resident 196) of 1 sampled resident. The facility staff identified a census of 45. Findings are: A record review of the hospital Discharge Summary dated 3/20/25 revealed Resident 196 had been admitted to the hospital after being found in poor condition in the resident's home. The resident had not been eating, only primarily drinking. The resident had a large sacral pressure ulcer. The resident wanted to return home, but the resident realized the sore to the resident's sacrum was serious and could lead to long term problems. Required dressing change 1-2 times a day. A record review of a Nursing Progress Note for Resident 196 dated 3/20/25 at 1:19 PM revealed the resident was admitted from the hospital with diagnoses of chronic pain, adult failure to thrive, pressure ulcer to the sacral region, malnutrition, and alcohol use. A record review of an admission Skin Assessment for Resident 196 dated 3/20/25 at 1:12 PM revealed the resident had a stage II pressure ulcer (partial thickness skin loss that presents as an abrasion, blister, or shallow crater) which measured 3.5 centimeters (cm) by 2.8 cm with a depth of 1.5 cm. A record review of Resident 196's electronic medical record from 3/21/25 to 3/24/25 revealed no evidence a treatment had been ordered and/or completed on the resident's stage 2 pressure ulcer to the resident's coccyx. A record review of a Nursing Progress Note for Resident 196 dated 3/24/25 at 8:58 PM revealed the resident had notified the Social Service Director and Nursing that the resident was leaving. The resident indicated the wound to the resident's coccyx was not being treated and/or assessed and so the resident was leaving. The resident was educated about the risks of leaving the facility Against Medical Advice (AMA). The resident left the facility with a neighbor at 11:39 AM with the resident's belongings. Interview on 5/6/25 at 9:29 AM with the Director of Nursing (DON) confirmed the resident had been admitted from the hospital on 3/20/25 with a stage 2 pressure ulcer to the resident's coccyx. There were no admission orders related to the care and treatment of the wound and staff failed to contact the resident's physician regarding a treatment order. The resident had alerted the facility on 3/24/25 that the resident was going home as the resident had not received treatment to the pressure ulcer while admitted to the facility. In addition, the facility did not have a policy currently related to the care and management of pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review of the Unavailable Medications Policy dated September 2024 revealed the facility was to utilize uniform guidelines for unavailable medications. The following guidelines were identified; -the facility was to maintain a contract with a pharmacy provider to supply the facility with routine, as needed and emergency medications. -a supply of commonly used medications was to be maintained in-house for the timely initiation of medications. -staff were to take immediate action when it was known a medication was not available: 1) determine the reason for unavailability, length of time the medication was unavailable and what efforts had been attempted by the facility or the pharmacy provider to obtain the medication; 2) notify the physician of inability to obtain medication upon notification or awareness that medications were not available. Obtain alternate treatment order and/or specific orders for monitoring the resident while medication was on hold; and 3) if the facility allows, determine if the resident has a home supply and obtain an order to use the home medication supply. -if a resident missed a scheduled dose of the medication, the staff were to follow the procedures for a medication error, including notifying the physician/family, completion of a medication error report and monitoring the resident for adverse reactions to omission of the medication. A record review of Resident 23's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of cancer, atrial fibrillation, dementia, and malnutrition. The following was assessed for Resident 23: -cognition was severely impaired. -verbal behaviors directed at others and rejection of care. -required staff assistance with toileting, dressing, transfers, personal hygiene, and bed mobility. -received an anticoagulant (medication used to help prevent blood clots) daily. A record review of Resident 23's Medication Administration Record (MAR) dated 3/2025 revealed an order dated 3/6/25 for Xarelto (anticoagulant) 15 milligrams (mg) 1 tablet daily. Further review of the MAR revealed from 3/18/25 to 3/24/25 (7 days) the medication was not administered. A record review of Resident 23's Nursing Progress Notes revealed the following regarding administration of the Xarelto 15 mg daily: -3/18/25 at 9:40 AM the staff were unable to find the medication. -3/19/25 at 8:54 AM the staff were unable to find the medication. -3/21/25 at 10:27 AM the staff were unable to find the medication. -3/22/25 at 7:40 AM the staff were awaiting pharmacy. -3/23/25 at 7:52 AM staff were awaiting drug from the pharmacy. -3/24/25 at 10:31 AM staff were waiting for the pharmacy to deliver the medication. C. A record review of Resident 196's Face Sheet revealed the resident was admitted [DATE] with diagnoses of low back pain, diverticulosis, irritable bowel syndrome, adult failure to thrive, pressure ulcer to the sacral region and malnutrition. A record review of Resident 196's admission orders dated 3/20/25 revealed the following: -Potassium and Sodium Phosphate (electrolyte replacement) powder one packet daily. -Aspirin 81 mg twice a day. -Amlodipine (medication used to treat high blood pressure) 10 mg daily. A record review of Resident 196's MAR dated 3/2025 revealed the following: -from 3/21-3/24 the Amlodipine 10 mg daily was not available/administered. -from 3/21 to 3/23 the Potassium and Sodium Phosphate packets were not available/administered. -from 3/21 to 3/24 the Aspirin 81 mg was not available/administered. During an interview on 5/6/25 at 9:29 AM the DON confirmed the following regarding Residents 23 and 196: -Resident 23 did not receive the Xarelto 15 mg daily from 3/18/25 to 3/24/25. -Resident 196 did not receive Amlodipine 10 mg daily and Aspirin 81 mg twice a day from 3/21/25 to 3/24/25 and did not receive the Potassium and Phosphate packets daily from 3/21/25 to 3/23/25. -no evidence the facility had determined why the resident's medications were not available from the pharmacy. -no evidence of any actions taken to obtain alternate orders for the resident's missing medications. -no monitoring of the residents while these medications were on hold. Licensure Reference Number 175 NAC 12-006.09 Based on observations, record review, and interviews; the facility failed to ensure laboratory work was obtained in a timely manner for Resident 10; to monitor Resident 33's fluid restriction; to follow Resident 33's physician orders related to eye drops and the resident's edema wear; to assess Resident 40's wound; and to follow Residents 23 and 196's physician orders regarding medications. The sample size was 5 and the facility census was 45. Findings are: A. A record review of the facility policy Provision of Physician Ordered Services dated September 2024 revealed the following: -the facility would maintain a schedule of diagnostic tests (such as laboratory) in accordance with the physician's orders, -qualified nursing personnel would submit timely requests for physician ordered services to the appropriate entity, -qualified nursing personnel would receive and review the diagnostic test reports and communicate the result with the ordering practitioner within 24 hours of receipt, and -documentation of diagnostic tests, results, and date/time of physician notification would be maintained in the resident's medical record. A record review of Resident 10's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 4/24/25 revealed the resident had a serious mental illness, was cognitively intact, had moderate depression, exhibited verbal behaviors, was independent with activities of daily living, and diagnoses included anemia, schizophrenia, dementia, anxiety, and depression. A record review of Resident 10's Care Plan last revised 4/24/25 revealed the resident was independent with activities of daily living; had diagnoses of schizophrenia, anxiety, and depression; and staff were to obtain lab work per orders and notify the physician of the results. A record review of the facility form Order Summary dated 2/27/25 for Resident 10 revealed orders were received for blood tests: a Hemoglobin A1C (measures the average blood sugar level over a 3 month time period), Complete Blood Count (CBC- analyzes the size and quality of blood cells), Basic Metabolic Panel (BMP-measures fluid balance, electrolytes and kidney function), Thyroid-Stimulating Hormone (TSH-measures the thyroid hormone function), Lipid Panel (measures cholesterol in the blood), a Vitamin B12 level, and a urinalysis. A record review of Resident 10's lab results dated 3/5/25 revealed the urinalysis was obtained (9 days after it was ordered). A record review of Resident 10's lab results dated 3/18/25 revealed the blood work (Hemoglobin A1C, CBC, BMP, TSH, Lipid Panel, and Vitamin B12 were obtained (22 days after they were ordered). An iron panel was added onto the labs by the provider and the provider noted they would like to talk to the resident in the clinic about the blood test results with an appointment made for 3/25/25. A record review of Resident 10's Progress Notes an entry dated 3/25/25 revealed the resident returned from the appointment with new medication orders and needed an ifob stool sample (a type of stool test that checks for hidden or occult blood in the stool). A record review of the facility form Order Summary dated 4/15/25 for Resident 10 revealed an order was put in for the occult stool sample (21 days after the progress note entry). A record review of Resident 10's lab results dated 4/24/25 revealed the stool sample was collected (30 days after the progress note entry and 9 days after the order was put in). A record review of Resident 10's Progress Notes revealed no documentation that orders were received for lab work on 2/27/25, there were no entries that blood work was obtained on 3/18/25, there were no entries that blood work was refused, no documentation that the facility received the order for the stool test on 4/15/25 and no documentation that the facility obtained the stool sample on 4/24/25. Interview on 5/5/25 at 2:10 PM with the Director of Nursing (DON) confirmed staff should have documented in the resident's medical record any refusals to obtain the lab work, when the lab work was obtained, and when the results were received and sent to the provider. Further interview confirmed the labs were not obtained in a timely manner. D. A record review of the facility's Fluid Restriction Policy with a date of March 2025 revealed the following: -facility was to ensure that fluid restrictions will be followed in accordance with physician's orders, -the nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours between the nutrition and nursing department. The fluid intake will be recorded in the medication record, and -the resident had the right to refuse the fluid restriction, if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident's refusal. A record review of the facility's Skin Assessment Policy dated December 2024 revealed the following: -a full body, or head to toe, skin assessment would be conducted by a licensed or registered nurse weekly, -Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions, -Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title, b. Document observations, c. Document type of wound, and d. Describe wounds (measurements, color, type of of tissue in wound bed, drainage, odor, pain). A record review of Resident 33's April 25 MAR revealed a physician order for: -1800 milliliter (ml) fluid restriction for 24 hours start date 6/27/24, -no fluid intake documented 3 out of 90 shifts, and -the resident's intake exceeded 1800 ml 20 days out of 30. A record review of Resident 33's nurse documentation revealed that the physician had not been notified when the resident exceeded the 1800 ml per day and no documentation was found showing why the resident was on a fluid restriction. Interview on 5/5/25 at 10:55 AM with the DON confirmed that resident was on an 1800ml fluid restriction, staff were not monitoring the fluid intake amount and notifying the physician if resident exceeded the 1800 ml intake. DON unable to provide documentation that stated why the resident was on a fluid restriction. A record review of Resident 33's December 2024 MAR revealed the resident had an order for: -prednisoLONE Acetate eye drops (decrease inflammation) 1 drop to right eye four times a day for post cataract surgery for 1 month. The order had a start date of 12/10/24 at 5:00 PM and a discontinue date of 1/7/25 at 10:00 AM. A record review of Resident 33's MAR for December 2024 revealed that the resident did not receive the eye drops on 12/30/24 at 9:00 PM and missed 3 doses on 12/31/24. A record review of Resident 33's MAR for January 25 revealed the resident received 6 of the 25 doses of the eye drops. A record review of Resident 33's nurse documentation from 12/30/24 to 1/7/25 revealed the eye drop medication was waiting to be received from the pharmacy. No documentation was found to reveal that the pharmacy was notified of needing the medication or the physician being notified of the eye drops not being administered. Interview on 5/5/25 at 10:55 AM with the DON confirmed that the pharmacy was notified on 1/4/25 of needing the eye drops, eye drops were not received, and the pharmacy was not notified of the eye drops not being received. DON also confirmed that the physician was not notified of eye drops not administered from 12/30/24 at 9 PM to 1/7/25. A record review of Resident 33's December 2024 MAR revealed the resident had an order for: -Thigh high compression garments on during the day off at night with a start date 6/27/24. A record review of Resident 33's MAR for December 2024 and January 2025 revealed the resident did not have the compression garments from 12/21/24 to 1/26/25. A record review of Resident 33's nursing documentation from 12/21/24 to 1/26/25 revealed that the compression garments were not being put on because the facility was waiting for a larger size of compression garments. The physician was notified on 1/13/25 of the resident's increased non-pitting edema to all extremities and neck, shortness of breath and not having the compression garments due to larger size being ordered. No follow up documentation was received from the physician. An interview on 5/5/25 at 10:55 AM with the DON confirmed that Resident 33 should not have gone from 12/21/24 to 1/26/25 without some type of compression garment, the physician should have been notified before 1/13/25 and there was no follow up with the physician after 1/13/25. An interview on 5/5/25 at 2:30 PM with the Business Office Manager (BOM-M) confirmed that the compression garments were ordered on 12/19/24, and on 1/13/25 a larger size of compression stockings were ordered and received on 1/27/25. E. A record review of Resident 40's MDS dated [DATE] revealed that resident was admitted on [DATE] with: -diagnoses of non-traumatic brain dysfunction and dementia, -cognition was severely impaired, -dependent on staff for toileting hygiene, bathing, dressing, bed-mobility, transfers, -always incontinent of bowel and bladder, and -3 unstageable non-removable dressing: Known but not stageable due to non-removable dressing/device. a record review of Resident 40's care plan revealed that resident was admitted with an unstageable pressure injury to the left shoulder, left outer trochanter and left outer thigh. Left shoulder and left outer thigh were healed. Observation of cares on 5/1/25 at 10:50 AM revealed that Resident 40 had a wound dressing intact to left hip with a date of 5/1/25. Observation of Resident 40 on 5/5/25 at 10:30 AM revealed a wound dressing to left hip with a date of 5/5/25. Observation on 5/6/25 at 8:10 AM of skin treatment to Resident 40's left hip by the DON revealed that there was an open area to the left hip. A record review of Resident 40's nursing documentation revealed that no weekly documentation for left hip was being completed. Interview with the DON on 5/6/25 at 11:15 AM confirmed that the facility has not completed weekly documentation or measurements to monitor the wound on the left hip.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(I) Based on observations, record review and interviews; the facility failed to assure a safe environment as the staff failed to 1) utilize safe transfer techniques with use of the mechanical lift to prevent potential accidents for Resident 31; 2) revise current interventions or develop new interventions to prevent ongoing falls for Resident 5; and 3) implement assessed fall interventions for Residents 29, 34 and 40. The sample size was 8 and the facility census was 45. Findings are: A record review of the facility policy Safe Resident Handling/Transfers dated 7/24/23 revealed it was the policy of this facility to ensure the residents were handled and transferred safely to prevent or minimize risks of injury and provide and promote a safe, secure and comfortable experience for the residents while keeping the employee safe in accordance with current standards and guidelines. All residents required safe handling when transferred to prevent or minimize the risk of injury to themselves and the employee that assisted them. The Interdisciplinary Team or designee was to evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. Mechanical lifting equipment or other approved transfer aids were to be used based on the resident's needs to prevent manual lifting except in medical emergencies. Mechanical lifts included equipment such as full body lifts (mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance), sit-to-stand lifts (a mobile lift that allows patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) or ceiling track mounted lifts. The following procedure was to be followed: -2 staff members were to be utilized when transferring residents with a mechanical lift. -staff were to be educated on the use of safe handling/transfer practices to include use of the mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. -staff members were expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. -resident's lifting and handling was to be performed according to the resident's individual plan of care. -staff were to perform mechanical lift/transfers according to the manufacturer's instructions for use of the device. A record review of the facility'sFall Prevention Program Policy dated 9/2024 revealed each resident was to be assessed for fall risk and was to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive care plan. Fall interventions were to be monitored for effectiveness and the care plan was to be revised as needed. If any resident has a fall the facility will: -assess the resident. -complete a post-fall assessment. -complete an Incident Report. -notify the physician and the family. -review the resident's care plan and update as indicated. -document all assessments and actions. A. A record review of Resident 31's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 3/13/25 revealed the resident was admitted [DATE] with diagnoses of previous stroke, high blood pressure, hemiplegia (paralysis on 1 side of the body), seizure disorder, and depression. The following was assessed for Resident 31: -cognitively intact. -dependent on staff for assistance with toileting hygiene, showering/bathing, dressing, transfers, and bed mobility. -occasionally incontinent of urine. A record review of Resident 31's Care Plan dated 3/21/24 revealed the resident was at risk for falls related to left side hemiplegia, neuropathy, and convulsions. An intervention dated 4/3/24 was identified by the therapy department for two nursing staff to be used for all transfers for the resident utilizing the sit-to-stand mechanical lift. One staff member was to control the lift, and the other staff was to manage the resident's left hand/shoulder. The staff were to use both of their hands (one on the resident's left hand and one on the resident's arm) to ensure proper positioning and to prevent injury risk. During an interview on 4/30/25 at 10:13 AM, Resident 31 identified a history of a previous stroke with left side paralysis/contractures. The resident reported that when the resident was transferred with the mechanical lift, there were always supposed to be 2 staff to assist with the transfer. However, now the staff frequently only used 1 staff person to transfer the resident with the lift and this made the resident feel uncomfortable. During an observation on 5/1/25 at 11:01 AM, Resident 31 was transferred from the commode to the recliner with the mechanical lift. Nurse Aide (NA)-D used the controls to lift the resident from the commode to a standing position and NA-F stood directly behind the resident. The resident used the right hand to hang onto the lift handle, but the resident's left hand/arm hung at the resident's side. When the resident was transferred from the commode, staff failed to place the resident's left hand on the handle of the lift and to hold the left hand in place and to support the resident's left arm/shoulder. The resident was unable to maintain weight bearing status once stood and started to bend at the knees with the resident's left side hanging flaccid. NA-F performed hygiene cares for the resident and then staff quickly moved the resident over to the recliner and lowered the resident to the seat. During an interview on 5/1/25 at 11:45 AM, NA-E and NA-F confirmed 2 staff were not always available to assist Resident 31 with transfers in the mechanical lift. NA-E and NA-F verified education was provided by the therapist for 2 staff to be used for all transfers when using the lift for Resident 31. B. A record review of Resident 29's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of dementia, psychotic disturbance, Alzheimer's disease, history of traumatic brain injury, osteoarthritis, and anxiety. The following was assessed for Resident 29: -severe cognitive impairment. -dependent on staff for assist with eating/drinking, personal hygiene, toileting hygiene, showering/bathing, dressing, transfers, and bed mobility. -functional limitation of range of motion with impairment to both sides of both upper and lower extremities. A record review of Resident 29's Care Plan dated 2/4/25 revealed Resident 29 was at risk for falls related to poor balance and need to use the full mechanical lift for all transfers. The care plan indicated the resident had a fall on 2/7/25 with a new intervention for a mesh Stop Sign across the entrance door of the resident's room and had a fall out of bed on 4/2/25 at 4:15 AM with an intervention for a body pillow to be used to assist with positioning in the resident's bed. Observations of Resident 29 in the resident's room revealed the following: -On 4/20/25 at 10:00 AM the resident was in the wheelchair. The mesh Stop Sign was not across the door of the resident's room. -On 5/1/25 at 7:40 AM the resident was in the room in the wheelchair and the mesh Stop Sign was not across the door of the room. -On 5/1/25 at 10:35 AM and at 2:02 PM the resident was lying in the bed. The body pillow was in a chair next to the resident's bed and was not utilized as a fall intervention. In addition, the mesh Stop Sign had not been placed across the resident's room door. -On 5/5/25 from 8:02 AM to 9:30 AM the resident was lying in bed. The body pillow was in a chair next to the resident's bed and was not utilized in the bed. In addition, the mesh Stop Sign had not been placed across the resident's room door. -On 5/5/25 at 10:35 AM the resident was transferred from the wheelchair and into the resident's bed. The body pillow remained in the chair next to the resident's bed. -On 5/6/25 at 7:39 AM the resident was positioned in the bed. The body pillow had not been placed in the resident's bed and the mesh Stop Sign was not in place across the resident's room door. During an interview on 5/5/25 at 8:57 AM the Director of Nursing (DON) confirmed the following regarding Resident 29's falls: -On 2/7/25 at 3:10 AM, the resident was found lying on the floor next to the resident's bed. Due to the resident's contractures and total dependence on staff for mobility, the staff felt another resident, who had also been found in the room, had removed the resident from bed and laid the resident on the floor. A new intervention was put into place to place a mesh Stop Sign across the doorway of the resident's room to keep any wandering residents out of Resident 29's room. -On 4/2/25 at 4:00 PM the resident was found on the floor beside the resident's bed. A new intervention was put into place for a body pillow to be placed in the bed to assist the resident with positioning and prevent further falls from the bed. -Both interventions remained in place and should have been implemented throughout the survey. E. A record review of Resident 5's MDS dated [DATE] revealed the resident had a serious mental illness, was cognitively intact, was independent with activities of daily living, had an indwelling catheter, had diagnoses of renal disease, neurogenic bladder (a condition where a problem in the brain, spinal cord, or peripheral nerves disrupts the signals that control bladder function and can lead to difficulty emptying the bladder or holding urine), diabetes, anxiety, bipolar disorder, and schizophrenia, had 2 or more falls without injuries and 1 with a major injury, and had a feeding tube. A record review of Resident 5's Care Plan, last revised 4/29/25 revealed the resident was at risk for falls, required a standby assist with walker but often self-transferred and had the following fall interventions in place: -bed and chair alarms implemented 4/30/24, -encourage non-skid footwear implemented 4/30/24, -transfers and ambulates with a standby assist with walker implemented on 4/30/24, and -new gripper socks implemented 1/1/25. A record review of Resident 5's Fall Risk Evaluation dated 4/3/25 revealed the resident was a high risk for falls. A record review of the facility Incident Reports for Falls for Resident 5 revealed the following: -A fall on 2/23/25 at 4:00 PM where the resident was found on the floor in the resident room next to the bed with an intervention of bed and chair alarms applied, -A fall on 3/11/25 at 4:15 AM where the resident was found sitting on the floor at the end of the bed with no socks on with an intervention to be a standby assist with a walker for transfers and ambulation, and -A fall on 4/24/25 at 12:52 AM where the resident was found lying on their back beside the bed with an intervention to ensure gripper socks were worn. Interview with the DON on 5/6/25 at 8:45 AM confirmed the falls on 2/23/25, 3/11/25, and 4/24/25 did not have new interventions implemented to prevent further falls. C. A record review of Resident 34's MDS dated [DATE] revealed the resident had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, dementia, anxiety and depression. The following was assessed regarding the resident: -cognitive skills for decision making were severely impaired, -inattention and disorganized thinking fluctuate, -dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing and personal hygiene, transfers, bed mobility and wheelchair mobility, -always incontinent of bowel and bladder, -receiving hospice care, -had bed alarm daily and other alarm daily, and -functional limitation of range of motion with impairment to 1 lower extremity. A record review of Resident 34's care plan dated 9/22/23 revealed the resident was at risk for falls related to diagnosis of Alzheimer's disease, used the full mechanical lift for all transfers, and had a history of falls. The care plan indicated the resident had: -A tabs alarm initiated 10/22/24, -secure tabs alarm to the waistband of the pants initiated 11/11/24, -chair alarm initiated 11/21/24, and -do not leave the resident unattended alone in their room when they are in their wheelchair, and assist to the recliner or bed before leaving the room initiated 11/21/2024. On 5/5/25 at 11:00 AM, documentation for the fall from 12/18/24 was reviewed with the DON. Documentation revealed that the resident was sitting on the floor in front of their wheelchair on their bottom. The resident was trying to put a blanket on the bed and slid out. The resident had no alarms in place. Observations of Resident 34 in their room revealed the following: -on 4/30/25 at 10:00 AM Resident 34 was sitting in their room in wheelchair with their eyes closed, no staff were in the room. -On 5/1/25 at 2:25 PM Resident 34 was sitting in their room in wheelchair, eyes opened, reaching for items, sitting forward in the wheelchair. No staff were in the room. During an interview on 5/5/25 at 11:00 AM, DON confirmed the following: -Resident 34 did get left alone in their room in the wheelchair at times, -The resident did not have alarms in place as care planned when their fall occurred on 12/18/24. D. A record review of Resident 40's MDS dated [DATE] revealed the resident had diagnoses of non-traumatic brain dysfunction and dementia. The following was assessed regarding the resident: -cognitive skills for decision making were severely impaired, -had poor attention continuously and disorganized thinking fluctuate, -dependent on staff for oral hygiene, toileting hygiene, bathing, dressing and personal hygiene, transfers, bed mobility and wheelchair mobility, -always incontinent of bowel and bladder, and -had 1 fall with no injury. A record review of Resident 40's care plan dated 3/10/25 revealed the resident was at risk for falls related to diagnosis of dementia, need to use full mechanical lift for all transfers and was dependent on staff for mobility in wheelchair. The care plan indicated the resident had a fall on 3/6/25 with an intervention to lay down after meals. Observations of Resident 40 revealed the following: -On 4/30/25 at 9:45 AM the resident was sitting in the wheelchair in the lobby area watching TV. -On 4/30/25 at 11:00 AM the resident was sitting in the wheelchair in the lobby area watching TV, closed eyes off and on. -On 4/30/25 at 12:10 PM staff pushed the resident into the dining room for noon meal. -On 4/30/25 at 2:00 PM the resident was sitting in the wheelchair in the lobby area, eyes were closed. -On 5/1/25 at 10:20 AM the resident was sitting in wheelchair in the resident's room with eyes closed. -On 5/1/25 at 10:50 AM the resident had been laid down in bed. -On 5/1/25 at 1:45 PM the resident was sitting in wheelchair in the lobby area, eyes were open and the resident was rocking back and forth in wheelchair. -On 5/1/25 at 2:25 PM the resident was being laid down in bed. An interview with the DON on 5/6/25 at 11:15 AM confirmed that the resident was to be laid down after meals and the expectation was for this to be within 30 minutes of completing meal. DON confirmed that the resident did not always get laid down after meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12(A) Based on record reviews and interviews, the facility failed to address gradual dose reductions (GDR, stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) in a timely manner for Residents 31 and 14; and to document a clinical rationale as to why GDRs were not attempted for Residents 5, 14, and 31. The sample size was 5 and the facility census was 45. Findings are: A. A record review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used in Care Planning) dated 4/3/25 revealed the resident had a serious mental illness; was cognitively intact; had diagnoses of anxiety, bipolar disorder, and schizophrenia; and received routine anti-psychotic, anti-anxiety, and anti-depressant medications. A record review of Resident 5's Care Plan last revised 4/29/25 revealed the resident received anti-psychotic, anti-depressant, and anti-anxiety medications for diagnoses of schizophrenia, bipolar disorder, and anxiety disorder. A record review of Resident 5's Medication Administration Record (MAR) for April 2025 revealed the resident received Venlafaxine (anti-depressant medication) 125 milligrams (mg) 78 out of 90 doses. Further review of the MAR revealed the missed doses were due to hospitalizations. A record review of the facility facsimile (fax) sent to the prescribing provider signed 2/3/25 for Resident 5 revealed the GDR for Venlafaxine was marked as contraindicated. There was no documented clinical rationale as to why the dose reduction was not attempted. Interview on 5/6/25 at 8:45 AM with the Director of Nursing (DON) confirmed there was no documented clinical rationale for the contraindicated GDR for Venlafaxine. B. A record review of Resident 31's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of stroke, high blood pressure, seizure disorder and depression. The assessment indicated the resident was cognitively intact, reported feeling down, depressed, and hopeless at times and the resident received an antidepressant medication daily. A record review of a Note to the Attending Physician/Prescriber from the Consultant Pharmacist dated 9/9/24 for Resident 31 revealed a recommendation to review the resident's orders for Prozac (medication used to treat depression) 20 mg daily and Trazadone (medication used to treat insomnia/depression) 50 mg every evening for potential GDRs. The physician/prescriber returned the note on 9/23/24 and no GDR was identified. Further review revealed there was no evidence that a clinical rationale had ever been provided by the prescriber as to why the GDR was clinically contraindicated. A record review of the Consultant Pharmacists Monthly Medication Regimen (MMR, includes medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences) reviews for Resident 31 revealed the following recommendations: -12/10/24 at 1:25 PM: GDR of the Prozac and Trazadone. -1/14/25 at 2:19 PM: follow up for a GDR of the Prozac and Trazodone. A record review of the Consultant Pharmacists MMR dated 2/11/25 at 8:57 AM for Resident 31 revealed a follow up recommendation for a GDR for the resident's Prozac. A record review of Resident 31's physician orders revealed on 2/24/25 the resident's Trazadone was decreased from 50 mg to 25 mg daily. Further review of the resident's physician orders revealed no evidence the resident's Prozac was reviewed for a potential GDR. An interview with the DON on 5/6/25 at 9:40 AM confirmed the following related to Resident 31's psychotropic medications: -Current orders for Prozac 20 mg for depression and Trazadone 50 mg 1/2 tablet at bedtime for insomnia. -On 9/9/24 the Consultant Pharmacist made a recommendation for a GDR of the resident's Prozac and Trazadone. -On 9/23/24 the physician refused the GDR but there was no documented clinical rationale as to why the GDR was contraindicated. -On 12/10/24 the Consultant Pharmacist again recommended a GRD for the resident's Trazadone and Prozac. -On 1/14/25 the Consultant Pharmacist sent a follow up letter regarding a recommended GDR of the resident's antidepressant medications. -On 2/24/25 the resident's Trazadone was decreased from 50 mg to 25 mg daily for insomnia, but the resident's Prozac was not addressed. C. A record review of Resident 14's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of debility, heart failure, high blood pressure, previous stroke, depression, and anemia. The resident was cognitively intact and took an antianxiety and an antidepressant medication daily. A record review of the Consultant Pharmacists MMRs for Resident 14 revealed the following: -On 11/12/24 at 1:19 PM a letter was sent to the resident's physician with a recommendation for a GDR of the resident's Buspar (medication used to treat anxiety) and Remeron (medication used to treat depression). -On 12/10/24 at 1:44 PM a follow up letter was sent with a recommendation for a GDR of the Buspar and the Remeron. -On 1/14/25 at 5:31 PM a letter was sent again to the resident's prescriber about a GDR for the resident's Buspar and Remeron. A record review of a Note to the Attending Physician/Prescriber from the Consultant Pharmacist dated 1/14/25 for Resident 14 revealed a recommendation to review the resident's orders for Buspar 10 mg daily and Remeron 15 mg daily for potential GDRs. The physician/prescriber returned the note on 1/17/25 and no GDR was identified. Further review revealed there was no evidence that a clinical rationale had ever been provided by the prescriber as to why the GDR was clinically contraindicated. A record review of an MMR by the Consultant Pharmacist on 4/8/25 at 1:08 PM for Resident 14 revealed a note had been sent to the physician regarding a potential GDR for the resident's Buspar and Remeron. During an interview on 5/6/25 at 9:40 AM, the DON confirmed the following related to Resident 14's psychotropic medications: -Current orders for Buspar 10 mg daily for mood, Remeron 15 mg at HS for insomnia and Prozac 20 mg daily for depression. -On 11/12/24 the Consultant Pharmacist made a recommendation for GDR of the resident's Buspar and Remeron. -On 12/10/24 a follow up letter was sent to the provider by the pharmacist regarding a GDR for the Buspar and Remeron. -On 1/14/25 another follow up letter was sent to the provider by the pharmacist regarding a GDR for Buspar and Remeron. -On 1/17/25 the physician addressed the Consultant Pharmacist recommendations, and no dose reduction was ordered. Further review revealed there was no clinical rationale as to why the GDRs were contraindicated. -On 4/8/25 another letter was sent to the physician from the Pharmacist regarding a potential GDR for the Buspar and Remeron. -On 4/10/25 no GDRs were ordered and there was no clinical rationale as to why the dose reductions were clinically contraindicated.

Licensure Reference Number 175 NAC 12-006.12(D)(vi) Based on observation, interview and record review, the facility failed to ensure insulin pens for 4 (Residents 5, 8, 10, and 14) of 6 sampled residents were dated when opened to ensure the insulin was not given beyond the recommended effective date. The facility census was 45. Findings are: A record review of the facility's undated Medication Storage policy revealed the facility policy ensured all medications housed on the premises were stored in the pharmacy and/or the medication rooms according to the manufactures recommendations, and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. A record review of the facility policy Storage of Medications Requiring Refrigeration Policy dated April 2025 revealed the following: -The facility assured proper and safe storage of medications to prevent potential alteration or medication by exposure to improper temperatures. -The facility provided safe and effective storage of all drugs consistent with state and federal requirements and within professional standards of practice. -Staff observed proper storage and labeling requirements for all medications during daily task performance and demonstrated safety regarding medication integrity. -The facility dated any multi-use vials when they were first accessed and discarded them within 28 days unless the manufacturers specified differently. During observation of the facility medication carts on 5/1/25 from 11:33 AM-11:57 AM multi-dose insulin pens for Residents 5, 8, 10, and 14 did not contain dates indicating when they had been first accessed or opened. A record review of the undated facility list of Insulin Dependent residents revealed the facility had 6 resident who received insulin injections. A. A record review of Resident 5's Care Plan revealed the resident had Diabetes Mellitus, had the potential for fluctuating blood sugar levels and received sliding scale insulin (insulin given based on blood glucose monitoring levels/results). A record review of Resident 5's Medication Administration Record (MAR) dated April 2025 revealed the resident had orders for Glargine insulin that was given twice daily, and Novolog insulin up to three times daily based on blood glucose levels. B. A record review of Resident 8's Care Plan dated 4/30/24 revealed the resident had Diabetes Mellitus with fluctuating blood sugars and received scheduled insulin. A record review of Resident 8's MAR dated April 2025 revealed the resident received Glargine insulin twice daily. C. A record review of Resident 10's Care Plan dated 12/11/24 revealed the resident had Diabetes Mellitus and the potential for fluctuating blood sugars. A record review of Resident 10's MAR dated April 2025 revealed the resident received Insulin Aspart up to 4 times a day based on blood glucose levels. D. A record review of Resident 14's Care Plan dated 2/4/25 revealed the resident had Diabetes Mellitus, potential fluctuating blood glucose levels, and received scheduled and sliding scale insulin. A record review of Resident 14's MAR dated April 2025 revealed the resident received Glargine insulin twice daily and Novolog Insulin up to 3 times daily. During an interview on 05/1/25 at 11:34 AM with Licensed Practical Nurse (LPN)-H confirmed that all insulin was to be dated when opened to prevent the insulin from being used past 28 days and confirmed that Residents 5, 8, 10, and 14's insulins had not been dated when opened. During an interview on 5/5/25 at 2:30 PM the Director of Nursing confirmed that all insulin was to be dated when opened and used within 28 days, or discarded, and not dating insulin could result in the insulin being used past the recommended days of use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. A record review of the facility policy Enhanced Barrier Precautions (EBP) dated September 2024 revealed the following: -an order would be obtained for enhanced barrier precautions wound be obtained for residents with wounds or an indwelling medical device (urinary catheters/feeding tubes) or if they had an infection or colonization with a Center's for Disease Control (CDC) targeted Multi-Drug-Resistant Organism (MDRO) when contact precautions did not otherwise apply, -gloves and gowns would be available near or outside the resident room, -Personal Protective Equipment (PPE) for EBP was only necessary when performing high-contact care activities, -PPE would be discarded prior to exit of the room, -high-contact resident care activities included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care, -MDRO's targeted by the CDC included Methicillin-Resistant-Staphylococcus Aureus (MRSA), and -EBP wound be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. A record review of Resident 18's MDS dated [DATE] revealed the resident was cognitively intact, required assistance with dressing and transfers, and had diagnoses of high blood pressure, a history of MDRO, and depression. A record review of Resident 18's Care Plan, last revised 4/15/25 revealed the resident required assistance with activities of daily living and was on EBP for having a history of MSRA. Observation on 5/1/25 at 7:45 AM there was a sign located on Resident 18's door to the room indicating that the resident required PPE while assisting the resident. During an observation on 5/6/25 at 9:15 AM, Medication Aide (MA)-L was pushing Resident 18 in the wheelchair to the resident's room. The PPE caddy was located on the back of the resident's door to the room, and there were trash cans to dispose of the PPE after removal and before exiting the resident room near the door. No hand hygiene was observed to be performed. MA-L applied a gait belt to the resident once in the resident room and the resident self-propelled the wheelchair into the bathroom. MA-L, while not wearing any PPE, assisted the resident to standing. The resident grabbed onto the grab bar and pivoted to be positioned over the toilet. MA-L applied gloves, but no gown, then pulled the resident's underwear and pants down. The resident sat on the toilet. The resident had a bowel movement and when the resident was finished, MA-L still wearing the same pair of gloves and no gown, provided perineal cares using pre-moistened wet wipes. While continuing to wear the same pair of soiled gloves with no gown, MA-L pulled the residents underwear and pants up. MA-L assisted the resident to transfer back to the wheelchair by holding onto the gait belt. MA-L continued to wear the soiled gloves and removed the resident's gait belt and put it into a bag on the back of the wheelchair. MA-L removed their gloves and did not perform hand hygiene and assisted the resident to back out of the bathroom. MA-L then assisted the resident out of the resident room towards the facility door. No hand hygiene was observed to be completed. Interview with MA-L on 5/6/25 at 9:20 AM confirmed PPE was not utilized during high-contact cares and that hand hygiene was not completed at appropriate intervals. F. A record review of Resident 5's MDS dated [DATE] revealed the resident had a serious mental illness, was cognitively intact, was independent with activities of daily living, had an indwelling catheter, had diagnoses of renal disease, neurogenic bladder (a condition where a problem in the brain, spinal cord, or peripheral nerves disrupts the signals that control bladder function and can lead to difficulty emptying the bladder or holding urine), diabetes, anxiety, bipolar disorder, and schizophrenia, had 2 or more falls without injuries and 1 with a major injury, and had a feeding tube. A record review of Resident 5's Care Plan, last revised 4/29/25 revealed the resident had an indwelling catheter, a feeding tube, required assistance with transfers and had EBP in place. Observation on 4/30/25 at 9:40 AM there was a sign located on Resident 18's door to the room indicating that the resident required PPE while assisting the resident. During an observation 5/1/25 at 11:10 AM Licensed Practical Nurse (LPN)-H had the resident's medications and water to flush the feeding tube in a basin that LPN-H had placed at the foot of Resident 5's bed on top of the bedspread. The Registered Nurse (RN)-C placed a handful of gloves onto the foot of the bed near the basin. LPN-H and RN-C, while not wearing any PPE, assisted to move Resident 18 up in bed. LPN-H while continuing to not wear any PPE or gloves, assisted the resident to pull the feeding tube out from underneath their clothing. LPN-H performed hand hygiene and applied a gown without tying the gown and applied gloves. LPN-H administered the resident's medications, feeding and water flushes without concerns. When completed, LPN-H removed their gloves and performed hand hygiene. While continuing to wear the gown, LPN-H grabbed the basin off the resident's bed and exited the room then went to the medication cart and put the basin on top of the medication cart without using a barrier. LPN-H while continuing to wear the gown, obtained medication cards from the medication cart and placed them back into the cart. LPN-H then walked back to the resident's room and removed the gown and placed it into the appropriate receptacle and performed hand hygiene. LPN-H then walked back to the medication cart, grabbed the basin without cleaning the medication cart and went into the medication room. Interview with LPN-H on 5/1/25 at 11:20 AM confirmed PPE was not doffed when exiting Resident 5's room and a barrier should have been placed before placing the basin on the medication cart. Observation on 5/5/25 at 2:10 PM MA-J entered Resident 5's room and applied gloves. MA-J obtained a graduate, an alcohol swab and 2 paper towels from the resident's bathroom. MA-J placed the paper towels down on the floor and placed the graduate on top. MA-J continuing to only wear gloves, emptied the resident's catheter bag into the graduate. MA-J clamped and then cleaned the spout of the drainage bag with alcohol. MA-J picked up the graduate and the barrier and went into the resident's bathroom. MA-J emptied the graduate into the toilet and rinsed the graduate with water before placing it on the back of the toilet. MA-J threw the paper towels away, removed their gloves and performed hand hygiene. An interview on 5/5/25 at 2:10 PM with MA-J revealed MA-J stating that PPE was not needed to drain the resident's catheter. Interview on 5/6/25 at 1:00 PM with the DON and the Administrator confirmed PPE should be worn with high-contact cares and hand hygiene should be completed after removing gloves and when exiting the resident room. Licensure Reference Number 175 NAC 12-006.18(B) Based on observations, interviews, and record reviews; the facility failed to prevent the potential for cross contamination related to 1) the completion of perineal hygiene for Resident 23; 2) the performance of hand hygiene and the changing of gloves during toileting/incontinence cares for Residents 23 and 18; 3) utilization of required Personal Protective Equipment (PPE, includes clothing, gloves, face shields, goggles, facemasks, respirators, and other equipment to protect front-line workers from injury, infection, or illness) during cares for Residents 5 and 18 who were on Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices)); and 4) cleaning/disinfecting the mechanical lift between resident uses for Resident 23, 34, 40 and 31. The total sample size was 19 and the facility census was 45. Findings are: A record review of the facility policy Perineal Care Policy updated September 2024 revealed it was the practice of this facility to provide perineal care to all incontinent residents during routine baths and as needed to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown. Perineal care referred to the care of external genitalia and the anal area. The following process was identified: -perform hand hygiene and put on gloves. -if the perineum was grossly soiled, turn the resident to the side, remove fecal material with toilet paper, and discard. -cleanse buttocks and anus, front to back, scrotum to anus, using a separate washcloth or wipe for each stroke. -thoroughly dry -reposition the resident to a supine position. Change gloves if soiled and continue perineal care. For males: -gently rinse penis, and with wet washcloth or wipe and apply perineal cleanser. -retract the foreskin if applicable, hold the shaft of the penis with one hand and with the other hand begin cleansing the tip of the penis at the urethral meatus using a circular motion and working outward. -replace foreskin if applicable and cleanse the shaft of the penis using downward strokes toward the scrotum. Use separate section of the washcloth or new disposable wipe with each stroke. Cleanse the scrotum using a clean portion of the washcloth, new washcloth, or new disposable wipe with each stroke. -remove gloves and discard then perform hand hygiene For females: -wet the washcloth or wipe and apply perineal cleanser. -separate the resident's labia with one hand, cleanse the perineum with the other hand by wiping from the front to the back. -clean the urethral meatus and vaginal orifice using a clean portion of the washcloth or a new disposable wipe with each stroke. -pat dry. Additional Considerations: the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning clean gloves and immediately after removing gloves. A record review of the facility policy Hand Hygiene dated May 2024 revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene was to be performed when indicated, using the proper technique consistent with accepted standards of practice: -when hands were visibly soiled. -between resident contacts. -after handling contaminated objects. -before applying and after removing PPE including gloves. -before and after handling medications. -before and after handling clean or soiled dressings, linens, etc. -before performing resident care procedures. -after handling items potentially contaminated with blood, body fluids, secretions, and excretions. -when during personal care, moving from a contaminated body site to a clean body site. A record review of the Cleaning and Disinfection of Resident-Care Equipment Policy dated 2/2024 revealed resident care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment can be a source of indirect transmission of pathogens. Reuseable resident care equipment was to be cleaned and disinfected in accordance with current infection control recommendations to break the chair of infection. The following procedure was identified: -each user was responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. -staff were to wear gloves when cleaning/disinfecting equipment. -use only EPA-registered disinfectant with kill claims for the common organisms found in the facility. If the equipment was exposed to residents on Transmission Based Precautions (TBP) staff were to verify the disinfectants were registered for use with the relevant organism. -verify the disinfectant was compatible with the equipment. -follow manufacturer's directions/recommendations for cleaning equipment. A. A record review of Resident 23's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 3/12/25 revealed the resident was admitted [DATE] with diagnoses of cancer, atrial fibrillation, dementia, and malnutrition. The following was assessed regarding Resident 23: -short and long-term memory loss with severely impaired decision-making skills. -required staff assistance with toileting hygiene, showering/bathing, dressing, personal hygiene, bed mobility and transfers. -frequently incontinent of bowel and bladder. During an observation of cares on 5/1/25 at 8:30 AM, Nurse Aide (NA)-D and NA-E entered Resident 23's room, who remained in bed. Without washing hands or performing hand hygiene, staff placed on clean gloves and gowns. The resident wore only a disposable urinary incontinence brief which was visibly soiled with urine. NA-D proceeded to remove the incontinence brief, and identified the resident was also incontinent of feces. NA-D used pre-moistened cleansing cloths to remove the feces from the resident's buttocks and removed soiled gloves but failed to perform hand hygiene before placing on clean gloves. NA-D placed a clean urinary incontinence brief on the resident without performing perineal cares to the resident's external genitalia despite the resident's urinary incontinence. The resident was then assisted to the side of the resident's bed and was transferred with the mechanical sit-to-stand lift (a mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) to the resident's wheelchair. Staff then propelled the mechanical lift out of the resident's room and positioned in the corridor. Staff failed to clean/disinfect the lift after use for Resident 23. During an interview on 5/1/25 at 9:30 AM, NA-E and NA-D confirmed the following: -hand hygiene should have been completed when entering the resident's room, before placing on clean gloves and when removing soiled gloves. -staff failed to provide complete perineal hygiene despite the resident's bowel and bladder incontinence. -staff failed to clean the mechanical lift after the resident was transferred out of bed and it should have been cleaned/disinfected before the staff placed in the corridor for use with another resident. B. A record review of Resident 31's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of previous stroke, high blood pressure, hemiplegia (paralysis on 1 side of the body), seizure disorder, and depression. The following was assessed for Resident 31: -cognitively intact. -depending on staff for assist with toileting hygiene, showering/bathing, dressing, transfers, and bed mobility. -occasionally incontinent of urine. During an observation on 5/1/25 at 11:01 AM, Resident 31 was transferred from a bedside commode to a wheelchair by NA-F and NA-D with use of the mechanical sit-to-stand lift. The staff then positioned the lift in the corridor outside of the resident's room. Staff failed to cleanse/disinfect the lift before exiting the resident's room. During an interview on 5/1/25 at 10:45 AM, NA-D and NA-F confirmed they did not clean/sanitize the sit-to-stand mechanical lift after use for Resident 31 and before use for subsequent residents. In addition, staff confirmed the lift should have been cleaned/disinfected between resident uses. C. A record review of Resident 34's MDS dated [DATE] revealed the resident had diagnoses of Alzheimer's disease, dementia, anxiety and depression. The following was assessed for Resident 34: -cognition was severely impaired. -depending on staff for assistance with transfers and bed mobility. During an observation on 5/1/25 at 10:10 AM, Resident 34 was transferred from a wheelchair to the bed by NA-F and NA-G with the use of the mechanical full body lift. NA-G removed the mechanical lift from the room and positioned the lift in the hall outside of Resident 34's room. Staff failed to cleanse/disinfect the mechanical lift before exiting the room. During an interview on 5/1/25 at 11:30 AM, NA-G confirmed that the mechanical lift did not get cleansed/disinfected after use for Resident 34 and before use on subsequent residents. NA-G confirmed that the mechanical lift should have been cleansed/disinfected before exiting the room. D. A record review of Resident 40's MDS dated [DATE] revealed the resident had a diagnosis of dementia. The following was assessed for Resident 40: -cognition was severely impaired. -dependent on staff for assistance with bed mobility and transfers. During an observation on 5/1/25 at 10:50 AM, Resident 40 was transferred from a wheelchair to the bed by NA-F and NA-G with the use of the mechanical full body lift. NA-F removed the mechanical lift from the room and positioned the lift in an empty room outside of Resident 40's room. Staff failed to cleanse/disinfect the mechanical lift before exiting the room. During an interview on 5/1/25 at 11:45 AM, NA-F confirmed that the mechanical lift did not get cleansed/disinfected after use for Resident 40 and before use on subsequent residents. NA-F confirmed that the mechanical lift should have been cleansed/disinfected before exiting the room.

Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement an Antibiotic Stewardship (coordinated plan aimed at optimizing antibiotic use to prevent resistance, unnecessary exposure, and adverse outcomes) Plan to identify if the facility use of antibiotic was within the criteria defined to prevent the overuse or unnecessary use, of antibiotics and/or to prevent potential adverse outcomes. This had the potential to affect all residents residing within the facility. The facility census was 45. Findings are: A record review of the facility Antibiotic Prescribing Practices dated 10/2019 revealed that antibiotic use protocols, including prescribing practices, were implemented as part of the facilities Antibiotic Stewardship Program for the purpose of optimizing treatment of infections and reducing adverse effects associated with antibiotic use. A record review of the facility Antibiotic Stewardship Policy dated 3/2023 revealed the facility implemented an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The program's purpose was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. The facility Infection Preventionist led the Antibiotic Stewardship Program with administrative support, coordinated antibiotic stewardship activities, maintained documentation and served as a staff resource. The program utilized protocols and a system to monitor antibiotic use, including completing infection screening evaluations, laboratory testing in accordance with standard of practice, and monitoring antibiotic use including data collection forms, process, and outcome measures. A record review of the facility's Infection Surveillance dated May 2024 through May 2025 revealed no culture (identifying present bacteria for analysis) results, no pathogen (an organism causing disease) data, and no review to determine if antibiotic use/prescribing criteria had been met. During an interview on 5/1/25 at 2:43 PM the Infection Preventionist (IP) confirmed the facility had not identified, tracked, or trended the organisms identified through laboratory testing to determine if antibiotic use was appropriate or meeting the identified treatment criteria for antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 35 or the resident's representative the required bed hold notification when the resident was transferred to the hospital. The sample size was 1 and the facility census was 34. Findings are: Review of the undated facility policy Bed Hold Notice Upon Transfer revealed the facility would provide the resident and/or resident representative written notice at the time of transfer for hospitalization or therapeutic leave, which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. In the event of an emergency transfer, written notice will be provided within 24 hours. Review of Resident 35's Hospital Transfer Form revealed the resident was transferred to the hospital on 1/29/24 at 4:00 PM after the resident had a fall. Further review revealed no documented evidence the resident or the resident's representative had been notified in writing of the facility's bed hold policy and information addressing the return of the resident. An interview with the Director of Nurses (DON) on 4/18/24 at 12:30 PM confirmed residents and/or resident representatives should be provided with a written bed-hold notification at the time a resident is hospitalized . In addition, the DON confirmed Resident 35 was hospitalized on [DATE] and there is no documented evidence the resident/representative was provided written notification regarding the bed-hold policy and information that addressed the resident's return.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Review of Resident 24's MDS dated [DATE] revealed the following: -an admit date of 3/28/23, -level 1 PASARR, -diagnoses of anxiety disorder, depression, bipolar disorder, psychotic disorder and Alzheimer's disease, -received an antipsychotic and antidepressant medications. Review of Resident 24's MAR for April 2024 revealed the resident received antipsychotic medication 17 out of 17 days for bipolar disorder. Further review of the MAR revealed the resident was taking Quetiapine 25mg daily for bipolar disorder with a start date of 3/15/23 and Quetiapine 50mg twice per day for bipolar disorder with a start date of 3/14/23. Review of Resident 24's Care Plan last revised 3/8/34 revealed the resident had a PASRR Level 1 and used psychotropic medications, was at risk for behavior and mood problems related to Alzheimer's Disease, Bipolar Disorder, Delusional Disorder, Anxiety Disorder and Depressive Disorder. Staff were to monitor for target behaviors of self-isolation, withdrawn, agitation, aggression associated with dementia and anxiety. Further review revealed no documentation that a new screen had been completed with the new diagnosis of bipolar disorder. Review of the facility facsimile (fax) form dated 3/13/23 revealed the physician wrote a diagnosis of bipolar disorder for use of the quetiapine. Review of Resident 24's PASRR screen dated 3/24/22 revealed the resident had no signs or suspicion of a serious mental illness. Interview on 4/17/24 at 1:15 PM with RN-O confirmed the resident had a bipolar disorder diagnosis. Further interview at 2:40 PM confirmed there was no documentation that a new PASRR had been completed with the new diagnosis of bipolar disorder and a new PASRR should have been completed with the new diagnosis. Licensure Reference Number 175 NAC 12-006.09B Based on interview and record review, the facility failed to ensure a PASARR [Preadmission Screening and Resident Review - used to determine individuals with a mental disorder, intellectual disability, or a related condition receives care and services in a setting appropriate to their needs] had been completed after 2 residents (Residents 22 and 24) were diagnosed with a serious mental disorder and received antipsychotic medications (used to treat psychiatric conditions) while residing in the facility. The sample size was 2 and the facility census was 34. Findings are: A. Review of the undated facility policy Resident Assessment-Coordination with PASARR Program revealed the following: -The facility coordinated assessments with the PASARR program to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in a setting appropriate for their needs. -The Social Services Director (SSD) would be responsible for keeping track of each resident's PASARR. -Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be referred promptly to the state mental health or intellectual disability authority for review. Examples include: 1) a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder and 2) a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. B. Review of Resident 22's medical record revealed the following: -Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used to develop a resident's plan of care) dated 1/25/24, Section N indicated the resident received an antipsychotic medication and Section I indicated the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). -Diagnosis Report with a print date of 4/17/24 indicated the resident's PTSD diagnosis occurred during the residents stay at the facility and was dated 3/14/23. -Medication Administration Record (MAR) dated 4/1/24 to 4/30/24 indicated the resident had been taking an antipsychotic medication (Seroquel 25 milligrams [mg] 1/2 tablet daily for PTSD) since 2/13/24. -There was no evidence a new PASARR was completed after the PTSD diagnosis was identified on 3/14/23 and the resident had received an antipsychotic medication while residing at the facility. During an interview on 4/17/24 at 10:25 AM the SSD confirmed Resident 22 did not have a new PASARR completed after the resident was diagnosed with PTSD and had been taking an antipsychotic medication. An interview with Registered Nurse (RN)-O on 4/17/24 at 1:15 PM confirmed residents identified with a new mental illness diagnosis, significant change in behaviors and/or started on antipsychotic medication should have a new PASARR completed promptly. In addition, RN-O confirmed Resident 22 had been diagnosed with PTSD on 3/14/23, had been taking an antipsychotic medication and a new PASARR should have been completed at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.06B Based on record review and interviews; the facility failed to maintain a system to identify repeat resident grievances, and to ensure sustainable resolutions of resident concerns. The sample size was 7 and the facility census was 34. Findings are: Review of the facility's undated Grievance Policy revealed the following: -It was the facilities policy that each resident had the right to voice grievances without discrimination or fear of reprisal. -The facility ensured prompt resolution to all grievances and kept the resident and/or resident representatives informed throughout the investigation and resolution process. -The facility grievance process included a designated person to receive and track grievances through their conclusion, lead necessary investigations, maintain confidentiality, communicate with residents throughout the process, and coordinate with other State and Federal Agencies as required. -The objective of the grievance policy was to ensure the facility made prompt efforts to resolve resident grievances, and the facility reviewed the facility Grievance Policy with the Resident Council annually or as needed. -All grievances identified during Resident Council meetings were immediately submitted to the grievance official for investigation and resolution. -The facility strived for prompt resolutions for all grievances and completed written responses to the resident/s or resident representative/s which included the date of the grievance, a summary, steps of the investigation, findings, and dated resolutions, outcomes, and actions. Review of the Resident Council Meeting Minutes from 3/2/23 through 4/5/24 revealed the following concerns: -3/2/23 -cold food especially at breakfast, not answering call lights in a timely manner, not getting [NAME] and ice every day, television channels not working properly, and 6 residents reported missing laundry/clothing. -4/6/23 -cold food especially for breakfast, meat being tough and hard to eat, not answering call lights in a timely manner, not getting fresh water and ice daily, and snacks not being offered daily. In addition, there was no evidence old business was discussed, or included what the facility did to resolve the resident's concerns from the previous month. -5/4/23 -pasta not being fully cooked, meat being tough and hard to eat, not answering call lights in a timely manner, getting ice but not fresh water daily. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -6/9/23 -not answering call lights in a timely manner, getting ice but no fresh water, and missing clothing/personal items. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -7/7/23 -residents needed help filling out menus, one hallway not receiving fresh ice water, and missing laundry. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -8/4/23 -residents needed help filling out menus, not answering call lights in a timely manner, and loud environment during mealtime. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -9/1/23 -call lights were not answered in a timely fashion and not left within reach of residents, staff being loud at the nurses' station, ordered treatments not being completed, and medications not re-ordered in a timely manner. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -10/12/23 -snack cart not always coming around on time, overcooked meat and undercooked pasta, call lights not being answered in a timely manner, treatment not being completed as orders, medications not getting reordered such as bedside items, residents not being notified of medication changes, and clothing but put away in the wrong closets. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -11/3/23 -options available on the snack cart, call lights being answered in a timely manner, convenience of medication administration times, and timely reordering of medications. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -12/1/23 -snack cart options, call lights being answered in a timely manner, variety of available activities, and missing laundry/clothing items. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -1/18/24 -snack cart options and availability times, overcooked and hard to eat food, linen availability, call lights being answered in a timely manner, ice availability in resident room, not respecting resident choice to not eat in the dining room, adequacy of staff, and beds not getting made in the mornings. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -2/2/24 -snack cart not available until after residents were in bed, linen availability, and staff's attitude towards resident's needs. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -3/1/24 -cold, undercooked and or overcooked food, snack cart not offered until 10:00 PM or later, not getting ice, staff had not provided assistance to walk residents to meals, availability of linens, and availability of activities. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. -4/5/24 -available options on the snack carts, and occasional missing laundry. In addition, there was no evidence old business was discussed or included what the facility did to resolve the resident's concerns from the previous month. Review of the facility Grievance log dated June 2023 through April 2024 revealed the facility received 16 grievances involving call light response times and availability, 9 grievances involving food options and palatability, 7 grievances involving snack cart options and availability, 6 grievances involving treatment and medication concerns, 4 grievances involving missing laundry items, and 4 grievances involving the availability of fresh water/ice. There was no evidence the facility had implemented corrective actions or sustained resolutions to the grievances to prevent repeat concerns from occurring. On 4/17/24 at 10:15 AM Surveyor 42360 met with 7 Resident Council Residents Representatives (Resident's 4, 6, 22, 25, 27, 31, and 33). The primary concern was timely resolution of resident grievances, or concerns occurring during the Resident Council meetings. The concerns revolved around resolution of missing laundry, palatability of food including tough meat, food temperatures, and snack choices. The group was also concerned about timely response to call lights. The members were aware of the grievance process. During the meeting all residents in attendance agreed the facility had not come up with solutions to grievances or got back to them to see if they were in agreement with the facility plan or resolution. During an interview on 4/17/24 at 12:45 PM the facility Administrator confirmed the facility had not implemented a grievance process that had consistently identified repeat grievances, or implemented a sustainable process to ensure repeat grievances were consistently resolved. In addition, the facility had no evidence the facility presented sustainable resolutions to the Resident Council to ensure the resolutions were acceptable to those involved in the grievance process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12B2 Based on observation, interview and record review, the facility failed to ensure 8 residents (Residents 12, 138, 139, 140, 141, 142, 143 and 144) medications had a record of accounting to prevent loss or theft of medications while awaiting disposition. The sample size was 8 and the facility census was 34. Findings are: Review of the undated facility policy Destruction of unused medications revealed the following: -All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. -A Non-Controlled Medication Destruction Record must be maintained for all non-controlled drugs destroyed and such record must be verified by the consultant pharmacist. -Information included on the record consisted of; name and address of facility, date medication destroyed, prescription number, name, strength and quantity of the medication being destroyed, and signature of persons witnessing the destruction. An observation of the medication storage room on [DATE] at 10:55 AM revealed a locked cabinet inside labeled destroyed medications with a large quantity of medications stored inside. There was no evidence of record keeping/accounting for each medication awaiting destruction. An interview with the Director of Nurses (DON) on [DATE] at 11:00 AM confirmed there was no evidence of documentation related to medications awaiting destruction for the following residents and medications: -Resident 12 [Bisacodyl (laxative) 10 suppositories]. -Resident 138 [Insulin Aspart 4 pens and Insulin Lantus 3 pens]. -Resident 139 [Milk of Magnesia 355 doses]. -Resident 140 [Aloe Vesta 1 bottle]. -Resident 141 [Maalox 1 bottle, Antacid-antigas 1 bottle, [NAME]-Na (used to treat low sodium levels) 8 packets, Lasix (used to remove excess fluid) 30 tablets, Melatonin 30 tablets, Tylenol 30 tablets, antacid 56 tablets, anti-gas 28 tablets]. -Resident 142 [Tylenol 6 tablets]. -Resident 143 [ Aspercreme 4 ounces, zinc oxide cream 16 ounces, tylenol suppositories 12, Baza (antifungal) cream ½ bottle, Biofreeze gel ½ bottle, biofreeze gel 1 bottle, Desitin cream 4 ounces, Vaseline jelly 1.75 ounces, triamcinolone cream (anti-itch) 8 ounces, Nystatin (fungal) cream 1 and ¼ bottle, Betamethasone cream (anti-itch/swelling) 1 bottle, Nystatin powder .15 grams, Insulin Aspart 1 pen, Gabapentin (treats seizures) 58 tablets, Omeprazole (treats acid production in stomach) 20 tablets]. -Resident 144 [Bisacodyl 3 suppositories, Biofreeze gel ½ bottle, Nystatin 1 bottle, Tylenol 7 tablets]. In addition, the DON confirmed the residents' medications were at risk of potential loss or theft without the required documentation and should have included the residents' name, date, medication name, dosage, and quantity of each medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure food service equipment was cleaned and maintained, outdated food was not available for consumption, and staff safe handling of ready to eat food was in place to prevent the potential spread of food borne illness. The sample size was 28 and the facility census was 34. Findings are: Review of the facility policy Dietary Employee Personal Hygiene dated 2019 revealed the following: -the facility utilized guidelines for employees to prevent contamination of food by employees, including monitoring of employee health for communicable diseases, ensuring clean clothing, and ensuring hand/fingernails hygiene. -hand hygiene included handwashing prior to work, always after using the restroom, eating, drinking, or smoking, after sneezing/coughing, and before putting on and after removing gloves, and -employees were never to use bare hand contact with any foods, ready to eat or otherwise. Review of the facility policy Dietary Sanitation with a revision date of 5/2021 revealed the following. -the food service area would be maintained in a clean and sanitary manner. -all kitchen, kitchen areas and dining areas would be kept clean, -all equipment, food contact surfaces and utensils were washed to remove soil using manual or mechanical means necessary, -specific equipment that required cleaning by an outside vender such as the exhaust hoods would be cleaned semi-annually or sooner as determined by the facility, -the Food Services Manager was responsible for scheduling staff for regular cleaning of the kitchen and dining areas to maintain cleanliness throughout the kitchen. During an observation of dining on 4/15/24 at 8:40 AM Nurse Aide-F delivered a tray to a resident, offered to butter the toast, then picked up the toast with bare hands and buttered it, then returned it to the resident's plate, then picked a slice of bacon from the resident's plate and handed it to the resident. During the initial kitchen tour on 4/15/24 at 8:54 AM a large container of egg salad dated 4/9/24 was noted in the facility walk in refrigerator. During an interview on 4/15/24 at 8:55 AM Dietary Aide-Q confirmed leftovers were supposed to be disposed of after 3 days. During a follow-up sanitation tour of the facility on 4/16/24 at 12:15 PM with the Corporate Certified Dietary Manager (CDM) the following concerns were identified. -the facility stove/oven had a buildup of grease and grime on the outer edges of the anterior lateral oven sides, -a sticker on the fire suppression system indicated an inspection and cleaning was due in [DATE], but was not dated as completed, -piping to the overhead fire suppression system located above the stove was coated with grease and debris, and -the facility had no evidence of a cleaning schedule for facility equipment including the facility oven/stove. During an interview on 4/16/23 at 12:20 PM Cook-P confirmed having no cleaning schedules available, and just kept things clean when the staff had a chance or time to do so. During an interview on 4/16/24 at 12:30 PM the facility Corporate CDM confirmed the following: -Staff were not to handle food ready for consumption with their bare hands. -The left-over egg salad from 4/9/24 should have not been available for consumption in the facility refrigerator. -The facility stove had a buildup of grease and grime on the outer edges of the anterior lateral oven sides that should have been cleaned. -The piping to the overhead fire suppression was coated with grease and debris and had not been cleaned. -The facility fire suppression system was due to be serviced in February 2024 and this had not been done. -The facility had no evidence of cleaning lists for food service equipment.

Licensure Reference Number 175 NAC 12-006.17 Based on record review and interview; the facility failed to develop/implement a water management program which identified a risk assessment and control measures/testing protocols to address potential hazards. This had the potential to affect all facility residents. The facility census was 34. Findings are: Review of the facility policy Water Management Program dated 9/2022 revealed the Water Management Plan referred to the documents that contained all the information pertaining to the development and implementation of the facility's water management activities for reducing the risk of Legionella (bacterium which causes Legionnaires disease, a serious type of pneumonia. The bacteria can be found in human-made building water systems such as sink, shower heads, decorative fountains, hot tubs, or large complex plumbing systems). The policy indicated the facility was to develop a risk assessment to identify where Legionella and/or other opportunistic pathogens could grow and spread in the facility's water system. In addition, the facility was to develop/implement control measures and testing protocols to address potential hazards. Review of the facility's water management program revealed no evidence of documentation the facility had 1) developed a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems and 2) implemented control measures and testing protocols to address potential hazards. During an interview on 4/18/24 at 11:15 AM the administrator confirmed no risk assessment had been completed to identify and prevent the potential development of Legionella related to the water management plan and there was no evidence control measures and testing protocols were implemented to address potential hazards.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report a fall with injury as a potential allegation of abuse/neglect to the State Agency for 1 (Resident 1) of 6 sampled residents. The facility census was 42. Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation dated 9/2022 revealed the following related to reporting/responding to abuse: -report all alleged allegations of abuse to the Administrator, the State Agency, Adult Protective Services (APS) and to all other required agencies within the specified timeframe's (immediately, but not later than 2 hours after the allegation was made if serious bodily injury occurs and not later than 24 hours if the cause of the allegation does not result in bodily injury). -the Administrator will follow up with government agencies during business hours to confirm the initial report was received and to report the results of the investigation when final within 5 working days of the incident. B. Review of an Incident Report dated 1/29/24 at 12:39 PM revealed Resident 1 had a fall out of their wheelchair in the resident's room. The resident had a large skin tear to the left leg and a large gash to the left side of the resident's forehead. The resident was transferred to the emergency room (ER) for evaluation. Review of a Discharge Summary form dated 2/1/24 from the hospital revealed the resident had fallen and had suffered a laceration to the left side of the resident's forehead which had required sutures. In addition, the resident had a Urinary Tract Infection (UTI) which was to be treated with an Intravenous (IV) antibiotic and was admitted to the hospital with left sided weakness and a facial droop. The family had decided to transition the resident to hospice care and the resident was to be discharged to another Nursing home on hospice care. Review of the facility's reports of alleged and/or suspected abuse from 1/1/24 through 2/20/24 revealed no documentation a report had been filed for the allegation of potential abuse/neglect related to Resident 1's fall with injury. During an interview on 2/20/24 at 12:40 PM, the RN Consultant confirmed the following regarding Resident 1: -sent to the ER for an evaluation after the resident's fall on 1/29/24. The resident had struck their head with the fall and had a laceration to the forehead. -was admitted to the hospital and was treated for a UTI and stroke symptoms. -when discharged from the hospital, the resident was admitted to a different Nursing Home. -staff were unaware the resident had received sutures in the ER after the resident's fall. -the facility did not report the resident's fall with injury to the State Agency as a potential abuse/neglect allegation.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify resident's responsible parties about falls for 2 (Resident's 1 and 3) of 3 sampled residents. The facility census was 48. Findings are: A. Review of the facility policy Change in Condition Notification with a revised date of 12/31/23 revealed the purpose of the policy was to monitor residents for changes in their condition, respond appropriately to those changes and to notify the physician and responsible party/family member of changes. B. Review of Resident 1's undated care plan revealed the following: -the resident was at risk for falls related to poor balance, required a wheelchair for ambulation, and had a history of falls prior to admission; -severe cognitive impairment; and -required extensive assistance with transfers, toileting, personal hygiene and mobility. Review of Resident 1's Nursing Progress Note dated 11/29/23 at 09:09 AM revealed the resident had a fall and was found on the floor on hands and knees. The resident was unable to state what occurred and was assessed for injury and vital signs were obtained. There was no evidence the resident's responsible party was notified of the fall. An interview with the administrator on 1/24/24 at 3:15 PM confirmed the resident's responsible party should have been notified of the fall on 11/29/23 and there was no evidence in the resident's medical record the responsible party had been notified. C. Review of Resident 3's undated care plan revealed the following: -the resident was at risk for falls related to poor balance, foot pain, antidepressant medication and poor awareness of safety; -moderate cognitive impairment; and -required extensive assistance with activities of daily living. Review of Resident 3's Nursing Progress Note dated 11/16/23 at 07:17 AM revealed the resident had a fall 'trying to get to the bathroom' and was found on [gender] knees in the room in front of the wheelchair. The resident was assessed and vital signs were obtained. There was no evidence the resident's responsible party was notified of the fall. An interview with the administrator on 1/24/24 at 3:25 PM confirmed the resident's responsible party should have been notified of the fall on 11/16/23 and there was no evidence in the resident's medical the responsible party was notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, record review, and interview; the facility failed to provide assistance related to toileting care for Resident 3 and dining assistance to prevent weight loss for Resident 15. The sample size was 24 and the facility census was 40. Findings are: A. Review of Resident 3's Care Plan with a revision date of 10/26/22 revealed the resident required extensive assistance for mobility, hygiene, bathing, and toileting. Review of Resident 3's Minimum Data Set (MDS- federally required comprehensive assessment used to develop the resident care plan) dated 12/29/22 revealed the following; -the resident received extensive assistance with bed mobility, transfers, dressing, bathing, and toileting, -was frequently incontinent of bowel and bladder, and -had severe cognitive impairment. Observations of Resident 3 on 3/7/23 revealed the following; -at 8:08 AM the resident was in the facility hallway, the resident was self-mobile in a wheelchair out to the dining room for breakfast. -at 9:22 AM the resident was self-mobile in a wheelchair in central hallway of facility. -at 11:23 AM the resident continued to slowly self-propel in the wheelchair, snacking on a unit dose snack on the resident's lap, and remained in central hallway of facility. -at 12:08 PM the resident was sitting in the dining room at the table for lunch. -at 1:45 PM during an observation of care provision the resident was assisted in the bathing room by hospice Nurse Aide (NA)-P. Facility NA-K entered to assist, and the resident was transferred via a stand-up mechanical lift from the wheelchair to the toilet. The resident's wheelchair pad, cushion, pants, and incontinence brief were soaked with urine, and a strong urine odor was noted. The resident was encouraged and allowed time to void. No voiding occurred. The resident was then transferred from the toilet to a bathing chair and into the bathtub. All the while, continuous urine leakage from the bladder occurred. During an interview on 3/7/23 at 1:50 PM Medication Aide (MA)- K confirmed the resident was soaked in urine when toileted at 1:45 PM, was nearly always incontinent, and had not been toileted or changed since approximately 8:00 AM that morning. During an interview on 3/7/23 at 2:10 PM NA-P confirmed when the NA arrived weekly to bathe Resident 3, at least 50 percent of the time the resident was urine soaked. Observations of Resident 3 on 3/8/23 revealed the following; -at 7:42 AM the resident was sitting in a wheelchair outside of the resident's room and was sipping on water from a Styrofoam cup. -at 8:07 AM the resident was sitting in the dining room waiting for breakfast. -at 8:34 AM the resident was in the dining room eating breakfast. - at 10:24 AM the resident was sitting in a wheelchair in the facility central hallway and had a packet of nuts on the resident's lap. -at 11:02 AM the resident continued to sit in a wheelchair in the central hall and visited with hospice nurse. -at 12:03 PM the resident was in the dining room and snacked on crackers and a red juice with cake present in front of the resident. -at 12:43 PM the resident remained in the dining room seated in a wheelchair. Registered Nurse (RN)-H provided cueing and encouragement for the resident to eat. During an interview on 3/8/23 at 12:04 PM NA-Q confirmed Resident 3 should be toileted every 2-3 hours; additional interview confirmed the resident had wandered in the center hall all morning, had not returned to the room since breakfast, and had not been toileted since prior to breakfast. During an interview on 3/8/23 at 2:08 PM the Director of Nursing (DON) confirmed Resident 3 should be toileted at least every 3 hours, and not being toileted between the breakfast and noon meal was not acceptable, and did not meet the resident's needs. B. Review of Resident 15's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of cancer, stroke, Alzheimer's dementia, anxiety and depression. The following was assessed regarding the resident: -cognition was moderately impaired; -mood interview was conducted, and the resident identified feeling tired, having little energy with little interest or pleasure in doing things and poor appetite; -required extensive staff assistance with eating and drinking; and -weight of 95 pounds. Review of the resident's Care Plan dated 2/3/21 revealed the resident had a self-care performance deficit related to Alzheimer's dementia and poor vision. The resident required extensive assistance with all cares including eating/drinking. Staff were to explain location of food and drinks when meals were served and were to place food items in individual bowls to assist the resident with handling food. Observation of Resident 15 on 3/6/23 revealed the following: -10:21 AM the resident was seated in a wheelchair in the resident's room. A bedside table was positioned next to the resident and the table had a container of Ensure Clear. The supplement was labeled with the resident's name, the date and a time of 10:00 AM. The lid had been removed from the supplement, but none of the supplement had been consumed; -12:32 PM to 1:05 PM the resident was in a wheelchair and was positioned at an assisted table in the dining room. The resident made no attempt to eat and/or drink any of the food served for the meal. There was no nursing staff at the table or in the dining room to provide the resident with assistance or cues to eat; and -1:52 PM the resident was in the resident's room with the bedside table and the nutritional supplement next to the resident. The lid remained off the supplement but none of the drink had been consumed. Observations of Resident 15 on 3/7/23 revealed the following: -10:12 AM the Ensure Clear which was labeled with the resident's name, the date of 3/6/23 and the time of 10:00 AM remained on the bedside table with no additional supplement from the previous day consumed; -12:34 PM the resident was assisted out to the dining room and was positioned at the assisted table; -12:36 PM the dietary staff served the resident the noon meal and cued the resident as to the placement of each item served. None of the food items had been placed into separate bowls to make it easier for the resident to handle food; and -12:39 PM to 1:05 PM no nursing staff was available in the dining room. The resident was not provided cues/supervision or assist with dietary intakes. The resident consumed only bites of the noon meal before staff assisted the resident back to the resident's room. During an interview with the Assistant Director of Nursing (ADON) on 3/8/23 at 9:04 AM, the ADON confirmed the following: -the resident required extensive to total assist with eating/drinking; -Charge Nurses were to administer the resident's Ensure Clear and were to stay with the resident and provide assist as needed with intake; and -nursing staff were to be available in the dining room at meals to provide the resident with assist and cueing as needed to ensure adequate food/fluid intakes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interviews; the facility failed to ensure assessments and ongoing monitoring were completed for Resident 21 related to dialysis (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) and to complete neurological assessments (assessment of motor and sensory skills, hearing, speech, vision, coordination and balance to determine a potential injury or change in status) after Resident 21 had a fall with head injury. The sample size was 4 and the facility census was 40. Findings are: A. Review of the facility policy Care of the Resident Receiving Dialysis Treatments with a reviewed dated of 11/21 revealed the purpose of the policy was to prevent complications such as fluid overload, infection or clotting of the access area or hemorrhage in the dialysis resident. The following procedures were identified regarding monitoring of the dialysis resident: -monitor feet and hands for edema; -monitor for elevated blood pressure, shortness of breath, or chest pains; -monitor for nausea and vomiting; -monitor for bleeding to access site, mouth, urine or feces; and -monitor for swelling, pain, redness or drainage to access site. B. Review of Resident 21's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 2/16/23 revealed the resident was admitted [DATE] with diagnoses of anemia, end stage renal disease, diabetes, Parkinson's disease and depression. The following was assessed regarding the resident: -cognitively intact; -required limited assistance/monitoring with bed mobility, transfers, dressing, toilet use and personal hygiene; -occasionally incontinent of urine; -impaired balance; -2 falls without injury and 1 fall with injury (except major) since previous assessment; and -received dialysis. Review of the resident's current Care Plan dated 8/4/22 revealed the resident was at risk for complications related to diabetes and end stage renal failure with need for dialysis 3 times a week. The resident was identified as having a port to the left subclavian (type of tube inserted into a large vein in the neck for dialysis access) area. The following interventions were identified: -observe for signs and symptoms of bleeding and low blood pressure; -observe for signs and symptoms of infection to dialysis access site; -monitor, document and report complications related to renal disease; fluid overload, itching, blood pressure changes, confusion, altered mental status, fatigue, nausea, vomiting or restless leg syndrome; -monitor, document and report complications related to dialysis; low blood pressure, chest pain, cough, cyanosis (bluish color to skin or mucous membrane due to lack of oxygen in the blood), bleeding, decreased cardiac output (weak and/or irregular pulse and edema to feet and hands) and infection; and -provide Dialysis Center with vital signs and notify of changes in condition via the Dialysis Communication Form. Further review of the resident's Care Plan revealed the resident was at risk for falls related to Parkinson's disease, poor balance and weakness after dialysis treatments on Monday, Wednesdays and Fridays. The following fall prevention interventions were identified: -assure bed is at the proper height for resident to safely sit on the edge; -encourage resident to call for help when feeling unsteady; -encourage use of urinal at night; -assure resident wears non-skid footwear; and -always assure walker within reach. Review of an Incident Report dated 7/25/22 at 10:00 AM revealed the facility had received a call at 9:11 AM from the van driver. Resident 21 was being transported to dialysis via the facility van, the driver had hit a bump and the resident's wheelchair went over backwards with the resident striking head on the lift gate. The Director of Nursing (DON) advised the van driver to continue to dialysis and the DON notified dialysis of the resident's fall. The DON met the resident at dialysis to assess the resident. The resident had a 1-centimeter (cm) skin tear to the left forefinger, a 2 cm abrasion to the scalp and a 2 cm hematoma to the right, lower, back of head. The report identified the resident's vital signs, and a neurological check were completed and within normal limits. Further review of the report revealed no evidence the DON documented the resident's vital signs or the neurological assessment. Review of a Dialysis Communication Record dated 7/25/22 revealed the staff were to complete and/or document a set of vital signs, a weight, the resident's fasting blood sugar, any medications administered, pain level, assessment of the dialysis access site, any change in the resident's condition, new physician orders or laboratory results since the previous treatment. In addition, the facility was to use the form to document the resident's vital signs, the resident's pain level, a description of the dialysis access site and any signs of bleeding or complications upon return from dialysis. Further review of the record dated 7/25/22 revealed there was no documentation regarding the resident's condition with return from dialysis and after the resident's fall with head injury. Review of the resident's medical record revealed no evidence the staff documented the time Resident 21 had returned from dialysis or that any assessments of the resident were completed at dialysis or with the resident's return to the facility despite the resident's fall with head injury. Review of a Nursing Progress Note dated 7/25/22 at 7:27 PM revealed the staff had called the resident's provider to obtain an order for Tylenol as the resident was complaining of a headache and a stiff neck. Staff identified the resident had a fall earlier in the day with a head injury and had an emesis after returning from dialysis. An order was received for the resident to be seen at the emergency room for an evaluation. Review of the resident's medical record revealed no documentation of when the resident returned from the Emergency Room, or any evidence further assessments were completed on the resident. Review of a Neurological Assessment form revealed vital signs and neurological checks were first documented on 7/26/22 at 10:40 AM (25 hours and 39 minutes after the resident's fall). Review of a facility investigation dated 7/27/22 related to the resident's fall in the van on 7/25/22 at 9:11 AM revealed the resident was diagnosed with a concussion when the resident was evaluated in the emergency room on 7/25/22. Review of Dialysis Communications Records from 2/1/23 to 3/3/23 revealed the staff failed to complete and to document the required assessments before dialysis on 2/1/23, 2/8/23, 2/10/23 and on 2/13/23 (4 out of 13 times the resident received dialysis). In addition, the facility failed to complete and to document the required assessments when the resident returned from dialysis on 2/1/23, 2/3/23, 2/6/23, 2/8/23, 2/10/23, 2/13/23, 2/17/23, 2/20/23, 2/22/23, 2/24/23, 2/27/23, 3/1/23 and on 3/3/23 (13 out of 13 times the resident received a dialysis treatment). There was no evidence a Dialysis Communication Record was completed with the resident's treatment on 2/15/23. During an interview with the Assistant Director of Nursing (ADON) on 3/8/23 at 1:05 PM the following was confirmed: -staff were to complete neurological assessments after any unwitnessed fall or for a witnessed fall in which the resident struck their head. Assessments should be completed at a minimum every 15 minutes times 4, every 30 minutes times 4, every hour times 4 and every shift for 72 hours. -Resident 21 had a fall and sustained a head injury on 7/25/22 at 9:11 AM. There was no evidence vital signs or neurological assessments were completed until 7/26/22 at 10:40 AM; and -the facility staff were to use the Dialysis Communication Record to document an assessment of the resident before dialysis, the forms were to be sent to dialysis to assure continuity of care and then facility staff were to complete a follow-up assessment when the resident returned to the facility.

Licensure Reference Number 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to develop fall interventions based on causal factors related to falls for Resident 20. The sample size was 4 and the facility census was 40. Findings are: A. Review of the facility policy Fall Prevention and Fall Leaf Program last revised 2/23 revealed the purpose of the program was to identify fall risks and implement interventions to prevent falls. For falls, a post fall evaluation would be reviewed at the next department clinical meeting for interdisciplinary review of the fall, interventions and determination of need for additional intervention(s) and/or revision of current intervention(s). B. Review of Resident 20's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/23/23 revealed diagnoses of high blood pressure, diabetes, cerebral vascular accident, dementia, and major depressive disorder. The MDS identified the following: -moderate cognitive impairment, -required extensive assistance with bed mobility, transfers, dressing, and toilet use, -incontinent of bowel and bladder, and -history of falling. Review of the Facility Report Incident dated 9/13/22 revealed the following: -the resident had a fall on 9/10/22, -causal factor identified by the facility was toileting needs, -intervention to prevent the accident from reoccurring was to have the residents room door open as the resident would allow and bed/chair alarms placed, and -urinalysis performed in the emergency room on 9/10/22 with negative result. Review of the residents Care Plan last revised 2/22/23 revealed the following: -the resident was at risk for falls, -a fall intervention for the door to be left open as the resident would allow implemented on 9/10/22, and -no documentation of interventions implemented to address toileting needs. Interview with the Assistant Director of Nursing Services on 3/8/23 at 2:40 PM confirmed no interventions were implemented to address the causal factor identified for the resident's fall on 9/10/22. Further interview on 3/9/23 at 10:55 AM confirmed the emergency room performed a urinalysis on 9/10/22 with a negative result but no interventions were implemented to address toileting needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.D8b Based on observation, record review, and interview; the facility failed to implement measures to prevent ongoing weight loss for Residents 15 and 32. The sample size was 2 and the facility census was 40. Findings are: A. Review of the facility policy Weight Monitoring dated 2/2023 revealed the following; -the facility would ensure that all resident's maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrated that this was not possible. -weights would be followed by the interdisciplinary team members, -the Registered Dietitian (RD) would be consulted to assist with interventions, the physician would be consulted to assist with interventions, and the -the interdisciplinary team would communicate care instructions to the staff, follow up with weight loss, and track until stable. B. Review of Resident 32's Minimum Data Set (MDS-a federally mandate comprehensive assessment used to develop the resident's plan of care) dated 1/5/23 revealed the following; -an admission date of 12/29/22, -a mood score of 07 out of 27 indicative of mild depression, -diagnoses of anemia, high blood pressure, hip and other fractures, constant pain, and falls prior to admission, and -a weight of 127 pounds. Review of Resident 32's Care Plan dated 1/2/23 revealed the following; -the resident was at risk for nutritional compromise, -the facility would notify the Dietary Manager (DM) and Physician of significant weight loss or gain, -the facility would notify the DM, RD, and Physician of a 3 pound or more weight loss/gain/discrepancy, -the facility would alert the RD, MD, and responsible party of any significant weight changes of 5 percent in 1 month, 7.5 percent in 3 months or 10 percent in 6 months. -staff would notify the Charge Nurse and the DM if the resident ate less than 50 percent of a meal, and -the facility would offer alternate menu choices, and assist the resident with menu choices as needed. Review of Resident 32's Physician Progress Notes dated 1/16/23 revealed the physician ordered a protein supplement of the resident's choice twice daily. Review of Resident 32's Significant Weight Change Notification dated 2/20/23 revealed no evidence the Physician received or responded to a notification of continued weight loss. Review of Resident 32's Nutritional Progress Notes revealed the following; -On 2/18/23 the resident's weight was 112 pounds and the resident had lost 12 pounds since 1/27/23. Fortified (added calories) food/drink at meals were initiated, staff visited with the resident regarding initiation of snacks/supplements, and family had brought in a supplement drink; however, the resident could not remember to drink the supplement. The facility would assist the resident to remember, and put the supplements on the snack cart between meals. The resident also commented that they would eat more meat, if it was cut up. The facility indicated they would continue to follow closely. -On 2/27/23 dietary staff were informed by the resident's family that the resident was not receiving the supplement, thus staff checked and supplements were present on the snack cart, and the resident had an unopened supplement in the resident room. The resident reported needing assistance opening the supplement. -On 3/2/23 dietary staff indicated the resident had lost 17 pounds since 1/27/23 and the resident continued to receive fortified food/drink at meals, and Boost Breeze supplement twice daily. Further review indicated the facility was requesting an order for the supplement. Further Review of the Resident 32's medical record revealed no evidence the resident's supplement was being provided/documented, and/or the amount of the supplement that was being consumed was documented. Review of Resident 32's Weight Record revealed the following; -on 1/1/23 the resident's weight was 127 pounds, -on 1/27/23 the resident's weight was 124 pounds, -on 2/3/23 the resident's weight was 113 pounds, -on 2/23/23 the resident's weight was 107 pounds, -on 3/1/23 the resident's weight was 102 pounds, and -on 3/8/23 the resident's weight was 100 pounds. Observations of Resident 32 revealed the following; -On 3/6/23 at 10:56 AM Resident has 3 dietary supplements sitting on the overbed table next to the bed in the resident room. The resident was lying in the bed. One supplement was opened, had only sips out of it, and the remaining 2 supplements remained unopened. -On 3/6/23 at 12:30 PM the resident was in the dining room eating independently. Food present included pizza, salad, and dessert; and at the end of the meal the resident had consumed less than 25 percent There were no observed offers from staff to assist, or no substitutes offered. No protein supplements were seen at the meal. -On 3/7/23 at 12:55 PM the resident was in the dining room and consumed 50 percent of sweet potatoes, took only a couple bites of fish and coleslaw, and sips of fluids (coffee, juice, and water). The resident was observed continuously from 12:35 PM until 12:55 PM and no cueing or encouragement was provided by staff, and no substitutes were offered. No supplement was seen at the meal. During an interview on 3/9/23 at 11:42 AM Registered Nurse (RN)-G confirmed the nurse was aware Resident 32 continued to lose weight, but was not accepting supplements. The facility had visited with the family about hospice care given the resident's advanced age (101) and weight loss. Additional interview confirmed the facility had not documented the resident's supplement intake or refusals. During an interview on 3/9/23 at 12:15 PM the Director of Nursing (DON) confirmed Resident 32 has lost 27 pounds since admission, and the facility has no documented evidence the recommended supplements were being given as ordered. C. Review of Resident 15's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of cancer, stroke, Alzheimer's dementia, anxiety and depression. The following was assessed regarding the resident: -cognition was moderately impaired; -mood interview was conducted, and the resident identified feeling tired, having little energy with little interest or pleasure in doing things and poor appetite; -required extensive staff assistance with eating and drinking; and -weight of 95 pounds. Review of the resident's Care Plan dated 2/3/21 revealed the resident had poor vision related to glaucoma and was at risk for altered nutrition related to Alzheimer's disease, breast cancer, anxiety, dementia and weakness. The following nutritional interventions were identified: -fortified foods/drinks at meals; -monitor intakes and document every meal; -staff to explain location of food and drinks at the beginning of each meal; and -use individual, disposable bowls to separate each food item at meals due to blindness and to assist with handling food. Review of the resident's Weights and Vitals Summary Sheet (document used to record the resident's weights) revealed the following: -10/14/22 weight was 101 pounds; and -11/10/22 weight was 95 pounds (down 6 pounds or a 6 percent loss in 1 month). Review of a Nutrition Progress Note dated 11/18/22 at 10:40 AM revealed a new order for Ensure Clear (nutritional supplement with added calories and protein) to be given once a day for weight loss. Review of the resident's Weights and Vitals Summary Sheet revealed the resident's weight on 12/9/22 was 92 pounds (down 3 pounds in 1 month). Review of a Nutrition Progress Note dated 12/21/22 at 11:41 AM revealed a recommendation by the RD to increase the resident's Ensure Clear supplement to 3 times a day. Review of a facsimile (fax) dated 12/23/22 at 4:11 PM from the resident's Physician revealed the staff had updated the Physician regarding the RD's recommendation to increase the resident's Ensure Clear. The physician advised the resident was on Hospice and the weight loss was not unexpected. The Physician further indicated if the resident wanted additional supplement that was fine. Review of the resident's Weights and Vitals Summary Sheet revealed the resident's weight on 2/9/23 was 95 pounds. Review of the resident's Medication Administration Record (MAR) for 3/2023 revealed the resident continued to receive the Ensure Clear daily at 10:00 AM. Observation of Resident 15 on 3/6/23 revealed the following: -10:21 AM the resident was seated in a wheelchair in the resident's room. A bedside table was positioned next to the resident and the table had a container of Ensure Clear. The supplement was labeled with the resident's name, the date and a time of 10:00 AM. The lid had been removed from the supplement, but none of the supplement had been consumed; -12:32 PM to 1:05 PM the resident was in a wheelchair and was positioned at an assisted table in the dining room. The resident made no attempt to eat and/or drink any of the food served for the meal. The resident's food items were not placed in individual bowls and there was no staff at the table or in the dining room to provide the resident with assistance or cues to eat; and -1:52 PM the resident was in the resident's room with the bedside table and the nutritional supplement next to the resident. The lid remained off the supplement but none of the drink had been consumed. Observations of Resident 15 on 3/7/23 revealed the following: -10:12 AM the Ensure Clear which was labeled with the resident's name, the date of 3/6/23 and the time of 10:00 AM remained on the bedside table with no additional supplement from the previous day consumed; -12:34 PM the resident was assisted out to the dining room and was positioned at the assisted table; -12:36 PM the dietary staff served the resident the noon meal and cued the resident as to the placement of each item served. None of the food items had been placed into separate bowls; and -12:39 PM to 1:05 PM no nursing staff was available in the dining room. The resident was not provided cues/supervision or assist with dietary intakes. The resident consumed only bites of the noon meal before staff assisted the resident back to the resident's room. During an interview with the Assistant Director of Nursing (ADON) on 3/8/23 at 9:04 AM, the ADON confirmed the following: -the resident remained on Hospice; -Charge Nurses were to administer the resident's Ensure Clear and were to stay with the resident and provide assist as needed with intake. Nurses were to then document the amount consumed on the resident's MAR; -the resident was asked about receiving additional supplement, but the resident had refused, however, staff failed to document refusal; -the resident required extensive to total assist with eating/drinking; and -nursing staff were to be available in the dining room at meals to provide the resident with assist and cueing as needed to ensure food/fluid intakes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Review of Resident 35's MAR for February 2023 revealed the resident received an order for lorazepam (a psychoactive medication that alters chemicals in the brain to effect changes in behavior, mood and emotions) 0.25 milligrams by mouth every 12 hours as needed for target behaviors: agitation and anxiety for a diagnosis of adjustment disorder with depressed mood. There was no documentation for the as needed lorazepam to be limited to 14 days. The medication was administered on 2/22, 2/24, and 2/25 which was 2-5 days past the limit of 14 days. Review of the MAR for March 2023 revealed the resident received the medication on 3/4 which was 12 days past the limit of 14 days. Review of the resident's Progress Notes revealed an entry dated 2/13/23 by the Pharmacist Consultant that a letter was sent to the physician to address the needed stop date of 14 days or extension of the order for as needed lorazepam. Review of the residents Care Plan last revised 2/27/23 revealed the following: -severe cognitive impairment, -the resident had a diagnosis of adjustment disorder with depressed mood, and -staff were to monitor for target behaviors for lorazepam like agitation and anxiety. Interview on 3/9/23 at 10:55 AM with the ADON confirmed that the lorazepam had no stop date and had been administered past the 14-day limit. LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility failed to follow up on the Consultant Pharmacist's recommendations related to gradual dose reductions (GDR) of Resident 10's psychotropic (any drug capable of affecting the mind, emotions, and behavior) medications and to ensure that PRN (as needed) orders for a psychotropic drug was limited to 14 days or have a duration documented by the physician for Resident 35. The facility census was 40 and the sample size was 6. Findings are: A. Review of the facility policy Use of Psychotropic Drugs dated 2/2020 revealed residents were not to be given psychotropic drugs unless the medication was necessary to treat a specific condition/diagnosis and was beneficial to the resident as demonstrated by monitoring and response to the medication. The policy revealed the following: -residents who use psychotropic medications shall receive GDR's, unless clinically contraindicated, to discontinue the drugs; -PRN orders for psychotropic medications shall be used only when the medication is necessary to treat a diagnosed, specific condition, and for a limited duration (14 days); -if the physician believes it is appropriate for the PRN medication to be extended beyond 14 days, the physician was to document rationale and indicate the duration for the PRN order; and -PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the physician evaluates the resident for the appropriateness of the medication. B. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment tool used for care planning) dated 1/12/23 revealed the resident was admitted [DATE] with diagnoses of non-traumatic brain dysfunction, diabetes, anxiety, manic depression, schizophrenia and diabetes. The assessment identified the following regarding Resident 10: -cognitively intact; -no depression indicators; and -no behaviors. Review of the resident's current Care Plan dated 5/20/21 revealed the resident preferred to remain in the resident's room as was sensitive to sounds, touch and sights. The resident had a history of trauma related to a physical assault and unwanted sexual experiences. Review of the resident's physician orders revealed the following medications were ordered on the following dates: -Clonazepam (medication used for control of seizures and for treatment of panic attacks) 0.25 milligrams (mg) daily for diagnosis of schizophrenia with a date of 1/21/22; -Haloperidol (medication used to treat nervous, emotional and mental conditions) 5 mg once a day for schizophrenia dated 1/21/22; -Seroquel (medication used to treat certain mental/mood disorders) 200 mg in the morning and 400 mg in the evening for diagnosis of schizophrenia and dated 1/21/22; -Lorazepam (medication used to treat anxiety) 0.5 mg twice a day for anxiety dated 1/21/22; and -Effexor (medication used to treat depression) 100 mg 3 times a day dated 1/21/22 for diagnosis of depression. Review of a Consultant Pharmacist's monthly Medication Regimen Review (MRR) dated 9/23/22 at 9:35 AM revealed a recommendation for a GDR of the following medications: -Clonazepam 0.25 mg in the evening; -Lorazepam 0.5 mg twice a day; -Effexor 100 mg 3 times a day; -Haloperidol 5 mg daily; and -Seroquel 200 mg daily and 400 mg in the evening. Review of the Consultant Pharmacist's monthly MRR dated 10/18/22 at 1:18 PM revealed the pharmacist was to send a follow-up letter to the physician regarding GDR recommendations from 9/23/22. Review of the Consultant Pharmacist's monthly MRR dated 11/15/22 at 9:33 AM revealed the pharmacist was to send a follow-up letter to the physician regarding all the GDR recommendations from 9/23/22. Review of the Consultant Pharmacist' MRR dated 12/15/22 at 2:09 PM revealed the pharmacist was to send a letter to the physician regarding previous recommendation for GDR of the resident's Haloperidol, Seroquel, Effexor, Clonazepam and Ativan which had still not been addressed by the physician. Review of the Consultant Pharmacists MRR dated 1/12/23 at 12:04 PM revealed a follow up letter was to be sent to the physician regarding GDR for use of the resident's Seroquel, Haloperidol, Effexor, Clonazepam and Ativan. Review of the Consultant Pharmacists MRR dated 2/13/23 at 9:33 AM revealed the pharmacist was to send a follow up letter to the physician regarding the GDR the pharmacist had first recommended on 9/23/22 and had continued to recommend monthly. Review of the resident's medical record from 9/23/22 through 3/8/23 revealed no evidence the resident's physician had addressed any of the GDR's recommended by the Consultant Pharmacist regarding the resident's medications. Review of the resident's Medication Administration Record (MAR) dated 3/2023 revealed the resident continued to receive the following medications: -Clonazepam 0.25 mg daily; -Haloperidol 5 mg once a day; -Seroquel 200 mg in the morning and 400 mg in the evening; -Lorazepam 0.5 mg twice a day; and -Effexor 100 mg 3 times a day. Interview with the Assistant Director of Nursing (ADON) on 3/8/23 at 3:23 PM confirmed Resident 10's physician had failed to address any of the pharmacist's recommendations regarding GDR of the resident's medications.

LICENSURE REFERENCE NUMBER 174 NAC 12-006.11D Based on observation and interview: the facility failed to ensure food temperatures were maintained to prevent the potential for food borne illness and ensure the palatability of the food for Resident 21. The total sample size was 24 and the census was 40. Observations on 3/6/23 of room tray distribution for Resident 21's noon meal revealed the following: -the resident's noon meal was delivered to the resident's room at 12:12 PM, Resident 21 remained outside of the facility at dialysis; -12:30 PM (18 minutes after the resident's meal had been delivered to the resident's room) the resident returned from dialysis; -12:33 PM the resident removed the thermal cover from the meal tray and tasted the food. The resident indicated the food was warm but was not hot. Resident 21 reported staff frequently delivered the noon meal to the resident's room when the resident was still at dialysis. Observations on 3/8/23 revealed the following: -8:34 AM the resident left the facility to receive dialysis treatment; -12:13 PM the resident remained at dialysis. The resident's noon meal tray was delivered to the resident's room and was left on a bedside table; -12:47 PM (34 minutes later) the resident returned from dialysis and self-propelled wheelchair to the resident's room; and -12:48 PM the Dietary Manager (DM) removed the thermal covering from the resident's room tray and obtained the following food temperatures; green beans were 106 degrees Fahrenheit (F), potatoes were 110 degrees (F) and chicken breast with gravy was 109 degrees (F). During an interview on 3/8/23 at 1:00 PM, the DM confirmed Resident 21's room tray should not have been delivered to the resident's room until the resident had returned from dialysis. In addition, the DM verified the green beans should have been served at a temperature between 140 degrees and 150 degrees (F), the potatoes should have been served at a temperature of 140 degrees to 155 degrees (F) and the chicken should have been served at a temperature between 145 degrees to 155 degrees (F).

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on interview and record review; the facility failed to protect the residents from potential abuse as the facility failed to assure abuse training was completed for 3 out of 5 newly hired employees. The total sample size was 24 and the facility census was 40. Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation dated 9/2022 revealed it was the policy of the facility to protect the health, welfare and rights of each resident. The policy further indicated all new employees were to be educated on abuse, neglect, exploitation and misappropriation of resident property during their initial orientation. Training topics were to include: -prohibiting and preventing all forms of abuse; -identifying what constitutes abuse; -recognizing signs of abuse, including injuries of unknown origin; -the reporting process for abuse; and -understanding behavioral symptoms of residents that may increase the risk of abuse and neglect. B. Review of Dietary Aide (DA)-C's employee file revealed the staff was hired on 2/27/23. Further review of the file revealed the DA-C had not completed the required, initial training related to abuse, neglect, exploitation and misappropriation. C. Review of DA-D's employee file revealed a date of hire of 2/27/23. Further review of the employee file revealed DA-D had failed to complete the required, initial training related to abuse, neglect, exploitation and misappropriation. D. Review of Maintenance Worker (MW)-E's employee file revealed the employee was hired on 3/1/23. MW-E had completed orientation however, MW-E had failed to complete the mandatory abuse, neglect, exploitation and misappropriation training. E. Interview with the Administrator on 3/8/23 at 2:39 PM confirmed DA-C, DA-E and MW-E were all new hires who had completed their initial orientation and had been placed on the schedule and had been working in the facility. The Administrator further confirmed the staff should have completed the mandatory abuse training prior to being scheduled and working around and/or with the residents.