**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on interview and record review, the facility staff failed to report an allegation of verbal abuse within the required timeframes for 2 (Resident 8 & 59) of 2 sampled residents. The facility staff identified a census of 143.The findings are:Record review of a facility policy entitled Abuse Reporting dated revised 8/8/2024 revealed: -3. All personnel, residents, family members, visitors, etc., are encouraged to report incident of resident abuse or suspected incidents of abuse. Such report may be made without fear of retaliation from the facility or its staff. -4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator/Director of Nursing/Social Services director. -5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator/Director of Nursing/Social Services director. The following information should be reported: -a. The name(s) of the resident(s) to which the abuse or suspected abuse occurred; -b. The date and time that the incident occurred; -c. Where the incident took place; -d. The name(s) of the person(s) allegedly committing the incident, if known; -e. The name(s) of any witnesses to the incident. -f. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); -g. A written statement of the above information; and -h. Any other information that may be requested by management. 6. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment of offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. It may also result in facility disciplinary action or termination. -7. Staff members and persons affiliated with this facility shall not knowingly: -b. Fail to report an incident of mistreatment or other offense. -8. The Administrator and the Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home and informed of such incident. -9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. -14. In accordance with the Elder Justice Act, the facility administrator or his/her designee will notify immediately, but not later than two hours after the allegation is made if the events that cause the allegation involved result in serious bodily injury or not later than 24 hour if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the following persons or agencies of such incident as applicable: -a. The State licensing/certification agency responsible for surveying/licensing the facility; -b. The local/State Ombudsman; -c. The resident's representative; -d. Adult Protective Services; -e. Law enforcement officials; -f. The resident's Attending Physician; and -g. The facility Medical Director.Record review of Resident 8's quarterly 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 5/20/2025 identified the facility admitted the resident on 2/14/2025. Further review of the MDS identified Resident 8 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident was cognitively intact. The MDS identified Resident 8 had diagnoses which included dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]), anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), depression, bipolar disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone), and psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions).Record review of Resident 59's admission MDS dated [DATE] identified the facility admitted the resident on 6/2/2025. Further review of the MDS revealed Resident 59 had a BIMS score of 14 and the resident had delusions (misconceptions, or beliefs that are firmly held, contrary to reality) during the review period. The MDS identified Resident 59 had diagnoses which included dementia, anxiety disorder, and depression.Record review of Resident 59's Progress Notes dated 7/4/2025 showed a note written by Licensed Practical Nurse (LPN)-C that Resident 59 was requesting to move into a different room because Resident 8 had called Resident 59 derogatory names several times. Resident 59 also reported to facility staff that Resident 8's television was too loud.Record review of Resident Abuse Investigation Report Form (investigation) dated 7/11/2025 revealed on 7/4/2025, Resident 59 requested to be moved to a different room due to Resident 8 calling (gender) derogatory names several times. Resident 59 told staff that the roommate would not work and that Resident 8's television was too loud. Resident 59 called a family member to advise them of what the roommate had said.Further review of the investigation revealed on 7/7/2025 at approximately 12:00 PM, Resident 59's Nurse Practitioner (NP) notified Social Worker (SW)-B of Resident 59's concerns with the television. SW-B began an investigation and identified the progress note dated 7/4/2025 and written by LPN-C in Resident 59's medical record. At approximately 3:30 PM on 7/7/2025 the facility moved Resident 59 to a different room.An interview on 8/28/2025 3:23 PM with the Administrator (ADM) confirmed the verbal incident between Resident 8 and Resident 59 occurred on 7/4/2025. The ADM further confirmed that the allegation of verbal abuse was not reported within 24 hours and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff 1) failed to utilize hand-washing and gloving techniques to prevent potential food contamination during food preparation and meal service and 2) store foods in a manner to prevent potential food borne illness. This practice had the potential to affect all residents in the facility who ate meals from the kitchen. The facility also failed to monitor refrigerator temperatures daily on resident personal refrigerators. This had the potential to affect all residents that used the unit refrigerator on [NAME] and [NAME] Units. The facility census was 143.Findings are: A. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-301.14 Food employees shall wash hands and exposed portions of their arms immediately before engaging in food preparation:-after touching bare human body parts other than clean hands and clean, exposed portions of arms,-after handling soiled equipment or utensils,-during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when tasks are changed,-after handling soiled equipment; and-before donning gloves to work with food. -3-304.15 (A) Single use gloves should be used for only one task and should be discarded when soiled or when interruptions occur in the operation -3-305.11(A) Food shall be protected from contamination by storing the food where it is not exposed to splash, dust, or other contamination. Review of the facility policy Handwashing Guidelines for Dietary Employees implemented 8/16/24 revealed the following:-Handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees should clean their hands in a handwashing sink.-Dietary employees should clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and:-Every time an employee enters the kitchen at the beginning of the shift, after returning from break and after using the toilet,-After hands have touched anything unsanitary (garbage, soiled utensils or equipment and dirty dishes).-After hands have touched bare human body parts other than clean hands (such as face, nose and hair) and -Before donning gloves for working with food. Review of the facility policy Food Safety Requirements with an implemented date of 3/25/25 revealed the following:-It was the policy of the facility that foods would be stored, prepared, distributed and served in accordance with professional standards for food service safety.-Food safety practices should be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the residents. B. Observation on 8/28/25 at 10:50 AM to 11:25 AM revealed the following:- Prep Cook, (PC-D) without washing hands donned clean gloves, cut cucumbers into slices and placed them in a large bowl, removed the gloves, opened the refrigerator door and placed the bowl with cucumbers in the refrigerator. No handwashing was identified after removing the gloves.- PC-D then took 5 packages of Hawaiian King buns, donned gloves, removed the buns from the packages, separated the buns and put them in a large white colored rectangle shaped container.- PC-D removed the gloves, picked up the empty bun packages, lifted the lid to the garbage can and threw the bun containers away in the garbage. No handwashing was identified before donning or after removing gloves. -PC-D then opened the refrigerator, brought out a container of sliced cheese and a package of bread. Donned clean gloves, opened the cheese container and package of bread, spread butter on 1 side of 2 pieces of bread, placed a piece of cheese on 1 slice of bread, placed another slice of bread on top of cheese, put the sandwich in a sandwich bag and then put the cheese sandwich in the refrigerator next to the serving line. Gloves were removed, the cheese container was put back into the refrigerator and then closed the package of bread. No hand washing was identified before donning or after removing gloves.- At 11:29 AM Dietary Aide, (DA-E) without washing hands donned clean gloves picked up a plate, used tongs and placed brisket on the plate, picked up another set of tongs and placed a bun on the plate, picked up other tongs and put a baked potato on the plate, plate was put on the serving tray. -DA-E picked up a plate, opened the door to the heating unit and picked up a container of hamburgers, picked up a hamburger bun with the gloved hand, put it on the plate, used tongs to pick up the hamburger and put it on the hamburger bun, used tongs to pick up baked potato and placed the plate on the serving tray with out completing hand hygiene. -DA-E then opened the heating unit door and returned the container of hamburgers to the shelf. -At 12:08 PM DA-E touched a pair of glasses that they were wearing and rubbed the right side of their face. -At 12:38 PM DA-E picked up 2 plates, opened the door on the heating unit, took out the container of hot dogs and container of hamburgers, with the gloved hand picked up a hot dog bun and placed on 1 plate and 2 hamburger buns placed on a plate. DA-E used tongs to pick up a hot dog and placed them on the hot dog bun, then used tongs to pick up 2 hamburgers that were put on the hamburger buns. DA-E then opened the refrigerator next to the serving line and with gloved hand picked up 2 pieces of cheese and put them on the hamburgers. DA-E used tongs to put baked potato on 2 plates then placed the plates on the serving tray. The same pair of gloves was used through the meal service; no changing of gloves or handwashing was identified. C. On 8/28/25 at 11:00 AM an observation in the food prep area revealed the following; - There was a food rack that had 2 layers of bowls of watermelon that were not covered with a protective covering. The watermelon was for the noon meal on 8/28/25. Directly on the right side of the rack were 3 trash cans that PC-D had thrown garbage into while the watermelon was next to the trash cans. On the left side of the rack was soiled breakfast plates, cups and silverware that were being separated, and food and liquids were being dumped into a bucket next to the watermelon. -At 11:05 AM PC-D took the garbage bags out of the garbage cans that were by the uncovered watermelon.An interview with the Director of Dietary Services on 8/28/25 at 11:43 AM confirmed that dietary staff were to wash hands in between glove changes. An interview with the Registered Dietician on 8/28/25at 1:00 PM confirmed that:- Dietary staff were to wash their hands when entering the kitchen at the beginning of the shift, when coming back from break or using the bathroom, before donning clean gloves and after soiled gloves are removed. - Food was to be covered when waiting to be served and not kept next to hazardous material. - A clean pair of gloves would be worn whenever touching ready to eat food if gloved hands touched another surface.D. Review of the Log Fridge temperature sheet dated July 2025 at the [NAME] Unit revealed that no temperatures were completed on the following dates:-The morning temperatures were not logged on July 12th, 13th, 17th, 18th, 20th, 21st, 26th, 27th, 30th and 31st.-The evening temperatures were not logged on July 1st, 9th and 23rd. Review of the Log Fridge temperature sheet dated August 2025 at the [NAME] Unit revealed that no temperatures were completed on the following dates:-The morning temperatures were not logged on August 3rd, 4th, 5th, 6th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 26th, 27th, 28th, 29th, 30th and 31st.-The evening temperatures were not logged on August 2nd, 4th, 10th, 12th, 13th, 15th and 20th. Review of Log Fridge temperature sheet dated August 2025 at the [NAME] Unit revealed that no temperatures were completed on the following dates:-The morning temperatures were not logged on August 6th, 17th, 21st, 22nd, 25th, 26th and 27th.-The evening temperatures were not logged on August 3rd, 4th, 5th, 6th, 10th, 15th, 20th, 23rd and 29th. An interview on 9/2/25 at 10:30 AM with the Director of Nursing confirmed that temperatures are to be checked daily on the resident personal refrigerators on the separate units. Record review of the facility policy Resident Personal Refrigerators with a revised date of 6/14/24 revealed the following:-Each refrigerator must be equipped with a reliable thermometer, and it will be located so that the temperature can be easily read.-Refrigerators would be maintained at a temperature range between 34 to 40 degrees Fahrenheit or less.-The temperatures of all lounge refrigerators will be monitored and recorded daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04 (F)(i)(5) Based on record review and interview, the facility staff failed to notify the physician of a missed dialysis appointment for 1 of 1 residents (Resident 54). The facility identified a census of 150. Findings are: Record review of Resident 54's Census Sheet revealed an admission date of 3/12/2019 to the facility and had the diagnoses of Renal Dialysis Record review of Resident 54's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 5/8/2024 revealed Resident 54 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) with a score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. Resident 54 required set up/clean up assist with eating, substantial/maximum assist with bed mobility and toileting, and was dependent for transfers and had the diagnosis of renal insufficiency, renal failure, End Stage Renal Disease (ESRD). Record review of Resident 54's Care Plan revealed a Focus dated 6/11/2021 Resident 54 needs dialysis and on Hemodialysis as evidenced by End Stage renal failure. Record review of Resident 54's Progress Notes dated 7/8/2024 revealed Resident 54 did not get Hemodialysis and that staff would reschedule the treatment. On 7/08/2024 at 9:05 AM an interview was conducted with Resident 54. During the interview Resident 54 reported their appointment had been cancel due to canceled as the dialysis center did not have enough staff and was rescheduled. A interview on 7/10/2024 at 2:12 PM was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 54 had missed a dialysis appointment and that Resident 54 practitioner had not been notified and should have been. Record review of the policy Change of Condition dated 4/2023: -Policy Statement -It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative according to their authority and reported to the attending physician or delegate (hereafter designated as the physicians). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by staff. -Objective of the notification of change policy The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intent of the policy is to provide appropriate and timely information about changes relevant to a resident's condition or change in room or roommate to the parties who will make decisions about care, treatment, and preferences to address the changes. -Purpose The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident right to make choices about treatment and care preferences. -Procedure: 1. The nurse will immediately notify the resident, resident's physician, and the resident representative for the following: a. An accident involving the resident, which results in injury and has the potential for requiring physician intervention, b. A significant change in the resident physical, mental, or psychosocial status is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complications. c. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment. d. A decision to transfer or discharge the resident from the facility. 2. The nurse will notify the resident, resident physician, and the resident representative of non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. 3. Document the notification and record any new orders in the resident medical record. 4. Educate the resident and/or representative about the proposed plan to treat, manage, or monitor the resident change in condition. 5. Educated the resident and/or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of the treatment or alternative that they prefer. Communicate the resident's preference to the provider if it differs from the provider's proposed plan. 6. Update the resident's care plan, transcribe, and implement the provider's orders. 7. Communicate the changes to the staff on the oncoming shift.

Licensure Reference Number 175 NAC 12.006.02(H) Based on record review and interview, the facility failed to complete a thorough written investigation and report an allegation of staff to resident abuse within the required timeframe to the Department of Health and Human Services [DHHS] for 1 (Residents 143) of 3 facility self-report investigations reviewed. The facility census was 150. Findings are: Record review of 2 facility policies entitled Abuse Investigations and Abuse Reporting dated August 2006 revealed the following information: Abuse Investigations: 1. When the incident or suspected incident of resident abuse, neglect, or injury of unknown source is reported, the administrator will appoint a staff member to investigate the incident. 2. The person conducting the investigation will, as a minimum: a. An interview with the person reporting the incident. b. Interviews with any witnesses to the incident. c. An interview with the resident. d. An interview with the attending physician when deemed appropriate and a review of the residents' medical record. e. Am interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident. f. Interviews with the residents roommate, family members, visitors g. Interviews with other residents to which the accused employee provides care or services. h. A review of all circumstances surrounding the incident. 12. The results of the investigation will be kept with the abuse file in the SS [social services] office and remain confidential. 13. A copy of the completed Resident abuse investigation report form will be provided to the administrator within 5 working days of the reported incident. 14. Upon completion of the investigation or sooner if necessary, the abuse investigation committee will convene to review all necessary information concerning all allegations of abuse. 16. The results of all investigations and report shall be faxed or emailed to the State survey and certification agency (Nebraska DHHS) within 5 days of the notification of the allegations. Abuse reporting: # 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to the facility management regardless of the time lapse since the incident occurred. # 14. In accordance with the Elder Justice Act, the facility administrator or designee will immediately notify, but not later than 2 hours after the allegation is made if the events that caused the allegation involved result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, the following persons or agencies of such incident as applicable: a. The state licensing / certification agency responsible for surveying the facility. b. The state / local Ombudsman c. The resident's representative d. Adult Protective Services e. Law Enforcement f. The residents attending physician g. The facility Medical Director #16: The Administrator / designee will provide the Department of Health and Human Services - Health Facility Investigations a written report of the findings of the investigation within 5 business days of the occurrence of the incident. Record review of Resident 143's significant change Minimum Data Set (MDS, a clinical assessment of the resident used to develop a comprehensive plan of care) dated 6/11/24 revealed an admission date of 9/5/23 with diagnoses that included adult failure to thrive, Diabetes Mellitus, Alzheimer's disease and Parkinson's. The MDS identified that Resident 143 had a BIMS (Brief interview Mental Status, a brief screener that aids in detecting cognitive impairment) score of 10 (indicated moderate cognitive impairment), lower extremity impairment with walker and wheelchair use, substantial to maximum assist with lower body dressing, putting on/taking off footwear and sitting to lying on the bed. Record review of an Adult Protective Services [APS] report dated 1/12/24 revealed that facility staff had called in an allegation of staff to resident abuse against Resident 143 on 1/12/24 at 4:20 PM. The APS report revealed that the facility reporter stated that Resident 143 had reported to staff a week ago that a male caregiver had gotten upset and slammed [gender] feet on the bed. The event was reported to have happened on 1/5/24. Interview on 07/08/24 at 09:50 AM with Resident 143 revealed that Resident 143 had no memory of any negative instances that involved staff. Resident 143 was unable to remember any incident in which staff had slammed [gender] legs onto the bed. Record review of all facility reportable incidents since January 1st 2024 revealed that no incidents that involved Resident 143 had been reported to APS or DHHS. Record review of Resident 143's Electronic Medical Record Progress Notes since January 1st 2024 revealed no written record of any incidents with staff or reports to the facility Social Worker [SW] of alleged abuse. Interview on 07/08/24 at 02:21 PM with the facility Administrator confirmed that no written investigation had been completed or a 5-day report sent into DHHS within 5 working days. Interview on 07/10/24 at 10:43 AM with SW A confirmed that Resident 143 had been interviewed by SW A on 1/12/24 about the allegation and APS was called to report the allegation of staff to resident abuse. SW A confirmed that a written investigation had not been completed and an investigation report had not been sent into DHHS within 5 working days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number NAC 12-006.09 (B) Based on record review and interview, the facility failed to accurately identify Special Treatments in Section O-Special Treatments, Procedures, and Programs on the Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) for 2 (Residents 54 and 122) of 30 reviewed. The facility staff identified a census of 150. Findings are: A. Record review of Resident 54 Census Sheet revealed an admission date of 3/12/2019 to the facility with the diagnoses of Dependence on Renal Dialysis. Record review of Resident 54's MDS dated [DATE] revealed the Resident 54 had renal insufficiency, renal failure, End Stage Renal Disease (ESRD) marked on the MDS. Section O, Question J 1 Dialysis revealed the MDS was not coded for Dialysis treatment. A interview on 07/10/24 at 2:38 PM was conducted with the MDS Coordinator. During the interview the MDS Coordinator confirmed the MDS dated [DATE] should have had Section O-Question J 1 marked for Dialysis While a Resident and was not. B. Record review of Resident 122's Census Sheet revealed a readmission date of 3/5/2024 to the facility. The Census Sheet also revealed that on 4/15/24 Resident 122 started on Hospice Services. Record review of Resident 122's Order Summary revealed an order for Hospice dated 4/15/2024. Record review of Resident 122's MDS dated [DATE] revealed Under Section O-Special Treatments, Procedures, and Programs question K 1 Hospice Care was not marked. A interview on 07/10/24 at 2:38 PM, with MDS Coordinator confirmed the MDS dated [DATE] should have had Section O-Question K 1 marked for Hospice While a Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a new PASRR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) referral had been completed after a diagnosis of a mental disorder was identified for 1 (Resident 57) out of 3 reviewed for PASRR screens. The facility census was 150. Findings are: Record review of a facility policy entitled Admissions and PASRR update policy dated 5/25/23 revealed the following information: 4. PASRR process: - a. Screening: The discharging hospital or nursing home staff or designated PASRR coordinator shall conduct an initial screening of all individuals seeking admission to determine if there is a reasonable suspicion of serious mental illness, intellectual or developmental disabilities, or both. Screening may involve a review of medical records, assessments, and interviews with the individual or their authorized representative. Re-screens or status updates of residents may be necessary due to changes in condition, new diagnoses, or other situational circumstances that warrant re-evaluation by the screening agency. Record Review of Resident 57's PASRR Level 1 screen with a determination date of 4/18/17 revealed the following information: The level 1 screen conducted for this individual determined that there was no evidence to suggest the presence or known conditions of mental illness, intellectual disability, or a condition related to intellectual disability, As such, no further level 1 screening is required unless the individual is later suspected or found to have a mental illness or intellectual disability condition. Record review of Resident 57's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/4/24 revealed that Resident 57 was admitted on [DATE]. Section A1500 for PASRR revealed that Resident 57 was not considered by the State level PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS identified that Resident 57 had a BIMS (Brief interview for mental status, a screener to determine level of cognitive impairment] score of 3 which indicated severe cognitive impairment. The MDS identified diagnoses that included non-Alzheimer's dementia, traumatic brain injury, anxiety, depression, Post Traumatic Stress Disorder, and major depressive disorder. Record review of Resident 57's Diagnoses List revealed that Resident 57 received the following new psychiatric diagnoses on the following dates: - 9/28/20: adjustment disorder with depressed mood - 8/4/21: generalized anxiety disorder - 10/1/22: vascular dementia, moderate, with other behavioral disturbance - 11/4/22: Post Traumatic Stress Disorder - 1/13/23: major depressive disorder Record review of Resident 57's Electronic Medical Record revealed that a referral for a new PASRR had not been completed since 4/18/17. Interview on 07/10/24 at 05:52 AM with the facility Administrator confirmed that Resident 57 had received several new psychiatric diagnoses since admission on [DATE] and that a referral for a new PASRR screening had not been made to determine whether further evaluation through a level 2 screen was required. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately complete a Level I PASARR screen (PASARR, a federally mandated screening process to ensure Nursing Home residents will mental illness and/or developmental disabilities receive the care and services they need in the most appropriate setting) for 1 (Resident 23) of 2 sampled residents. The facility census was 150. Findings are: Record Review of PASARR screen dated 05/04/2018 revealed Resident 23 was assessed as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). Record Review of Facility's Diagnosis Report for Resident 23 revealed the following admission diagnoses which would have triggered a Level II screen: -Vascular Dementia, mild, with mood disturbance -Moderate intellectual disabilities -Major Depressive Disorder, recurrent, moderate -Generalized Anxiety Disorder -Unspecified Psychosis not due to a substance or known physiological condition Record Review of Resident's 23 medical record revealed no other completed PASARR screens since 05/04/2018. Record review of Medication Administration Record for 07/01/2024 thru 07/31/2024 revealed the following medical conditions: -Mild Cognitive Impairment of uncertain or unknown etiology, Moderate Intellectual Disability, Unspecified Psychosis not due to a substance or known physiological condition, Major Depressive Disorder-recurrent and moderate, Generalized Anxiety Disorder, Vascular Dementia- mild with mood disturbance. Interview on 07/10/24 at 8:17 AM with Administrator confirmed the PASARR completed on 05/04/18 for Resident 23 was not accurate and if the initial PASARR was completed correctly that a Level II PASARR would have triggered for further review. The facility's Admissions and PASRR update Policy with Dated Implemented: 03/05/2022 and Date Reviewed/Revised: 05/25/2023 revealed Policy statement: This policy outlines the Pre-admission Screening and Resident Review (PASRR) process for determining the appropriateness of admission to a nursing home. The PASRR process is designed to identify individuals with a serious mental illness ([NAME]), intellectual or developmental disabilities (IDD) or both, and ensure they received the necessary specialized services and appropriate placement in accordance with federal regulations and state guidelines.

Licensure Reference Number 175 NAC 12.006.09(H)(i)(3) Based on observation, interview, and record review the facility failed to provide position changes and incontinence care for 1 (Resident 33) of 4 residents. The facility census was 150. Findings are: Record Review of Resident 33's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-27-2024 revealed Resident 33 had the diagnosis of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Lewy body Dementia (a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood.), Schizophrenia (Schizophrenia is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and Depression. The MDS also indicated Resident 33 was not able complete a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment), was incontinent of bowel and bladder and was dependent on facility staff for eating, oral hygiene, bathing, dressing, toileting, bed mobility and transfers. Record Review of Resident 33's Care Plan (CP) printed on 07-09-2024 revealed facility staff were to assist Resident 33 with position changes and skin care every 2 hours and to check incontinence brief every 3 hours. A continuous observation on 07-10-2024 from 8:15 AM to 12:15 PM of Resident 33 revealed no provision of assistance with position changes or incontinence care. An observation on 07-10-2024 at 2:30 PM of Nurse Aid (NA) D and NA E assisting Resident 33 into bed and providing incontinent care revealed Resident 33's incontinent brief was wet. An interview on 07-10-2024 at 2:38 PM with NA D and E confirmed that Resident 33 was not repositioned or provided with incontinence care from 8:15 AM until 2:30 PM. An interview conducted on 07-10-2024 at 2:45 PM with Licensed Practical Nurse (LPN) D confirmed Resident 33's normal routine is to be checked for incontinence between breakfast and lunch and was to be transferred to bed after lunch and checked for incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** the facility failed to implement assessed interventions for accidents with injury for resident 105 and 63. B. Record Review of Resident 63's MDS dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. The MDS revealed Resident 63 had diagnosis of Parkinson's Disease, Lewy Body Dementia, Stroke, anxiety, and depression. The MDS also indicated Resident 63 required partial assistance from staff for bed mobility, personal and oral hygiene, and upper body dressing and required maximal assistance with toilet hygiene, showering, lower body dressing and transfers. Record Review of Resident 63's care plan dated 06-02-2023 revealed Resident 63 was at high risk for falls with a fall assessment score of 9 and the interventions the facility had put into place were: -03-01-2024 FALL: per resident report she was reaching for an item and slid out of the wheelchair. A piece of Dycem (a non-slip material that keeps objects from sliding) will be applied to the chair to prevent reoccurrence. -03-05-2024 FALL: Blue tape applied to the wall to indicate appropriate bed height and non-skid strips applied to the floor for increase grip. -06-06-2024 FALL: [NAME] will be assisted with morning cares and assisted to the main lounge by 630 am to prevent future occurrences. -03-15-2023 FALL: will offer toileting at 6:30 AM -06-14-2023 FALL: will place a sign on her wall for visual cues to remind her to use the call light for assistance A continuous observation on 07-11-2024 from 6:15 AM to 7:40 AM revealed Resident 63 was not assisted by staff until 7:20 AM when Nurse Aid (NA) L entered the room and assisted Resident 63 to the bathroom. This observation also revealed the absence of Dycem in the wheelchair, the absence of blue tape on the wall to indicate the appropriate bed height, and the absence of signage to remind resident to call for help. NA L took Resident 63 to the main lounge at 7:40 AM. During the continuous observation on 07-11-2024 from 6:15 AM to 7:40 AM, an interview was conducted with NA L which revealed NA L did not know to check for Dycem in Resident 63's wheelchair, and confirmed the absence of Dycem in the wheelchair, blue tape on the wall, and signage in the room to remind Resident 63 to use the call light. Record review of the facility Fall Policy and Procedure dated 01-29-2021 revealed under Evaluation Procedure: -A fall risk assessment will be done within the first 14 days of admission, readmission, annually and with a significant change to identify potential risk factors and fall history. -The completed fall risk assessment will be presented to the interdisciplinary care plan team to evaluate the information and to place the resident in low, moderate, or high-risk categories. -Once a resident has been identified as High Risk, the interdisciplinary care plan team will implement the 'Falling Star' program with increased interventions and an escalating plan of care and treatment that is designed to reduce risk of injury from any potential falls. -the Clinical Manager or designee and the interdisciplinary team will include fall risk in the care plan and include all interventions being used. An interview conducted with Licensed Practical Nurse (LPN) G, Clinical Manager on 07-11-2024 at 8:40 AM confirmed Resident 63 was not assisted and out of room in main lobby area by 6:30 AM, the Dycem was not in place in wheelchair, the blue tape was not on the wall near the bed, and signage was not posted to use call light. Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observations, record review and interviews, the facility failed to implement assessed interventions to prevent skin injuries for Resident 105 and falls for Resident 63. A total of 4 residents were reviewed for accident prevention. The facility census was 150. Findings are: A. Record review of Resident 105's annual Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used for care planning) dated 4/7/24 identified an admission date of 7/7/24. The MDS Identified that Resident 105 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 5 which indicated severe cognitive impairment. The MDS identified that Resident 105 exhibited inattention and disorganized thinking, physical and verbal behavioral symptoms, and rejection of care 1-3 days per week, required wheelchair use for ambulation, required substantial to maximum assistance with transfers from the bed to the wheelchair and had no alterations in skin condition. Diagnoses included depression, vascular dementia, and age-related osteoporosis. Record review of Resident 105's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 4/24/24 identified the following concerns for Resident 105: Problem: Potential for alteration in skin integrity related to frequent reopening of an area to the left shin, potential for shear and friction occurring during bed mobility and transfers, her skin is thin and fragile, history of skin tears, she is on Xarelto [a blood thinner medication that increases risk of bruising] which has to potential for bruising and bruises easily. Braden assessment [a skin risk assessment to determine level of risk for skin concerns] score of 17. [This was an indication of high risk for skin concerns.] Interventions included: - Rooke [a soft protective boot that surrounds the leg and foot to protect the skin] boot to LLE while up and with transfers. Record review of a facility investigation that involved Resident 105 dated 2/8/24 revealed that on 2/3/24 Resident 105 received an injury / skin tear to the lateral left side of the leg while being transferred from the wheelchair to the bed. The resident was immediately assessed, the wound cleaned, and the resident was sent to the hospital for further treatment. The resident returned to the facility with staples to the lateral left leg. The facility investigation revealed that Resident 105 had a similar incident in August 2022 with the leg area being at risk and split and reopened at that time with sutures required. The facility investigation revealed that Resident 105's family were aware of the risk to the left leg and that it had been an ongoing issue since 2020 when the resident had a hematoma [Bruise] that wouldn't resolve. The family stated that was why the area was discolored and had opened many times in the past. The facility identified interventions after the incident 2/3/24 as follows: - Due to the fragility of [Resident 105's] skin on the left leg, a [NAME] boot will be placed and [Resident 105] will be given a new wheelchair. [Resident 105] will also be assessed by therapy to see if [gender] can propel herself in a wheelchair. - Order was received for therapy for wheelchair mobility. Record review of Resident 105's Physician Orders revealed the following dated orders: 2/5/24: Rooke Boot to left lower extremity [LLE] while up and with transfers. 2/7/24: OT [Occupational Therapy] to evaluate for wheelchair. Interview on 07/10/24 at 11:50 AM with Social Worker [SW] J revealed that an order was received for a referral for therapy for the wheelchair but that this order was never communicated to OT and never got done. Observations of Resident 105 on the following dates and times revealed the following; - 07/08/24 12:52 AM: Resident seated in a wheelchair in the main dining room, no Rooke boot present on the left leg. - 07/8/24 1:00 PM: Rooke boot laying on the floor in Resident 105's room at the foot of the bed. - 07/09/24 11:45 AM; Resident not in room. Rooke boot laying on the floor. - 07/09/24 11:55 AM: Resident in lobby area in wheelchair. No Rooke boot in place on the left leg. - 07/9/24 2:00 PM: seated in wheelchair in the therapy gym participating in an activity. No [NAME] boot on left leg. - 07/9/24 2:06 PM: Rooke boot on the floor in room - 07/10/24 8:06 AM: Resident seated in the dining room waiting for breakfast. No Rooke boot on the left leg. - 07/10/24 10:13 AM: Resident seated in activity area by nurses' station. No Rooke boot in place on left leg. - 07/10/24 10:20 AM: Rooke boot on the floor in room. - 07/10/24 12:00 PM: Observation with the facility Administrator: Observed Resident 105 not in room. Observed Rooke boot laying on the floor at the foot of the bed in the same position as all previous observations. Interview on 07/10/24 at 12:05 PM with the facility Administrator confirmed that the Rooke boot was laying on the floor at the foot of the bed and should be on Resident 105 when up and also for transfers to protect the left leg. Observation on 07/11/24 between 7:10 AM and 7:25 AM with Restorative Aide [RA] H and NA I revealed an observation of transfer from the bed to the wheelchair for Resident 105. The resident was seated on the edge of the bed with a walker in front of the resident. A Rooke boot was present on the left leg. NA I removed the Rooke boot and placed a shoe on the resident. RA H placed a gait belt on the resident, positioned the walker and assisted the resident to stand and pivot transfer to the wheelchair. NA I then placed the Rooke boot back onto the residents left leg. Interview on 07/11/24 at 07:26 AM with RA H confirmed that the Rooke boot was taken off during the transfer because the staff felt there was a potential for the resident to slip if the boot was in place during the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.14 Based on observation, record review and interview, the facility failed to ensure 1 (Resident 55) of 1 sampled residents received follow up dental services. The facility census was 150. Findings are: An interview with Resident 55 was conducted on 07/08/2024 at 9:54 AM. During the interview, Resident 55 reported that they had no teeth, was seen and fitted for dentures in April (2024) and that they were still waiting for their dentures. A record review on 07/09/2024 of a Doctor Referral Form for Resident 55, dated 05/20/2024 revealed Resident 55 was seen by the dentist with the following notation tried in teeth in wax. Patient approved. Next Visit-Deliver Dentures. A review of Resident 55's medical record revealed there was not any evidence that the facility had any contact with the dentist from 05/21/2024 through 07/08/2024. An interview with facility's Social Worker (SW) on 07/09/2024 at 2:22 PM confirmed that the facility was unaware that Resident 55 hadn't received their dentures and that after calling the dentist, the dentures for Resident 55 would be delivered to the facility on [DATE]. Record review of facility policy labeled Dentures Policy and Procedure dated 2005 Med-Pass, Inc (Revised April 2007) revealed the following: Preface: This facility promotes and supports a resident centered approach to care. The purpose of this policy is to ensure that the facility has integrated a system for proper resident assessment and care with dentures and assisting the resident in obtaining necessary repair or replacement of damaged or lost dentures timely to meet the quality of care of the resident. In addition, the facility with outline the process and circumstances for responsibility for financial replacement of dentures. Policy: It is the policy of the facility to provide ongoing assessment an care of the resident with dentures. In the event that the resident's dentures are damaged or lost, the facility will refer the resident for dental services timely, within 3 days for an appointment, The resident will not be charges for the repair or replacement of dentures in the event that the loss or damage of dentures was incurred by facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 178 NAC 1-005.06(D) Based on observation, record review and interview, the facility staff failed to perform hand hygiene and gloving to prevent cross contamination in 2 residents (Resident 122 and Resident 33) of a sample size of 30. The facility identified a census of 150. Findings are: A. Record review of Resident 122's Census Sheet revealed the resident was readmitted to the facility on [DATE]. Record review of Resident 122's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 4/21/2024 revealed a Brief Interview of Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) with a score of 6. A score of 6 indicated the resident was severely cognitively impaired. Resident required substantial/maximal assist with eating and was dependent for toileting, bed mobility, and transfers. Record review of Resident 122's Care plan revealed an intervention dated 3/5/2024 for catheter cares every shift. Care plan entry dated 5/3/2024 revealed a focus of Enhanced Barrier Precautions for Foley Catheter Care. Interventions for Enhanced Barrier Precautions included: -Green star on the wall front of the door near the room to alert staff of enhanced barrier precautions. -Ensure all staff members are proficient in hand hygiene practices, including handwashing with soap and water or using alcohol-based hand sanitizers. -Regularly assess the catheter site for signs of infection, such as redness, swelling, or discharge. -Encourage the resident to maintain good perineal hygiene. Provide assistance with hygiene as needed. -Ensure the resident bedding and clothing are kept clean and changed regularly to minimize the risk of contamination. -Use barrier precautions, such as disposable gowns when providing cares. -Monitor the resident's fluid intake and output to ensure adequate hydration and urinary drainage. -Communicate any changes in the resident condition or catheter-related issues to the healthcare team promptly. Observation on 7/10/24 at 7:34 AM with the facility Director of Nursing (DON) of Nursing Assistant (NA)-M preparing to complete catheter care on Resident 122. NA-M completed hand hygiene with hand sanitizer then gowned and gloved. NA-M removed a positioning pillows from around the resident unhooked the tabs on the brief and pushed the dirty brief between Resident 122's legs NA-M wiped the catheter tubing from the penis away from the resident twice, using a clean peri-wipe each time. NA-M removed gloves and completed hand hygiene with hand sanitizer. The DON left the room to get the charge nurse,Licensed Practical Nurse (LPN)-N. LPN-N completed hand hygiene with hand sanitizer and then applied a gown and gloves and assisted NA-M with Resident 122's personal care. NA-M and LPN-N assisted the resident to roll to right side and LPN-N began doing peri-care at the anal area revealing each wipe LPN-N made removed bowel movement. After Resident 122's anal area was clean, LPN-N went to the hand sanitizer dispenser, put hand sanitizer on (gender) gloves, rubbed gloved hands together and then went to the bed to finish with Resident 122's cares. LPN-N with the same soiled gloves assisted NA-M with placed a clean brief on Resident 122 and touched Resident 122's blanket. Interview on 7/10/24 at 8:10 AM, LPN-N confirmed (gender) put hand sanitizer over (gender) gloved hands, rubbed hands together and continued to assist with peri-care and touched linen on the bed for Resident 122. Record review of Infection Control Guidelines for All Nursing Procedures revealed the purpose was to provide guidelines for general infection control while caring for residents. Preparation: 1. Prior to having direct-care responsibilities for resident, staff must have appropriate in-service training on general infection and exposure control issues, including: a. The facility protocols for isolation (standard and transmission-based precautions; b. The location of all personal protective gear; c. The location of medical waste disposal containers; d. The facility exposure control plan; and e. The facility protocol for occupational exposures to bloodborne pathogens. 2. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing infections in residents, including: a. Types of Healthcare-Associated Infections b. Methods of preventing their spread; c. How to recognize and report signs and symptoms of infection; and d. Prevention of the transmission of multi-drug resistant organisms. General Guidelines 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 2. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. 3. Employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents. b. When hands are visibly dirty or soiled with blood or other body fluids; c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions; f. Before eating and after using a restroom; and g. When there is likely exposure to spores such as C. Difficile or Bacillus anthracis). 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; c. Before performing any non-surgical invasive procedures; d. Before preparing or handling medications; e. Before handling clean or soiled dressing, gauze pads, etcetera. f. Before moving from a contaminated body site to a clean body site during resident care; g. After contact with a resident's intact skin h. After handling used dressings, contaminated equipment, etcetera; i. After contact with objects (for example medical equipment) in the immediate vicinity of the resident; and j. After removing gloves. 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. 6. In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted. B. Record Review of Resident 33's MDS dated [DATE] revealed Resident 33 had the diagnosis of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Lewy body Dementia (a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood.), Schizophrenia (Schizophrenia is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and Depression. The MDS also indicated Resident 33 was not able complete a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) was incontinent of bowel and bladder and was dependent on facility staff for eating, oral hygiene, bathing, dressing, toileting, bed mobility and transfers. An observation on 07-10-2024 at 8:15 AM of Nurse Aid (NA) E providing care to Resident 33 revealed NA E placed 3 washcloths in the bottom of the sink and turned the water on. After the washcloths were wet, NA E rung each one out and set them on the counter next to the sink., NA E brought the washcloths to the bedside and placed them in a clear plastic bag that was lying open on Resident 33's bed. NA E used the washcloths to provide perineal care (means washing the genitals and anal area) and to wash Resident 33's face. Record review of the facility policy Urinary Incontinence-Peri Care revealed a policy statement: It is the policy at Maple Crest to cleanse the perineal and rectal area of residents to prevent skin rash, skin breakdown, infection and odors. Under the Section Option 1: equipment needed gloves, wash basin, trash bag, soap and water, washcloth and towels, barrier ointment as designated. An observation on 07-10-2024 at 2:30 PM of NA E providing care for Resident 33 revealed NA E placed washcloths in the sink and ran water on them. After wringing out the washcloths, NA E placed the washcloths in a clear plastic bag on the bed. The washcloths were then used to perform perineal care for Resident 33. An interview on 07-10-2024 with NA E at 2:38 PM confirmed the washcloths were placed in the bottom of the sink, and the bottom of the sink could be contaminated. An interview with Licensed Practical Nurse (LPN) D on 07-10-2024 at 2:45 AM confirmed that by placing washcloths in the bottom of the sink could cause cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC12-006.12E1 Based on observation, interviews, and record review, the facility failed to secure one medication for 1 (Resident 55) of 4 sampled residents and failed to secure a medication cart on the first floor. The facility identified a total of 102 residents resided on the first floor and identified 8 residents who were self-mobile and had poor safety awareness. The facility census was 150. Findings are: A. Record review of clinical census in resident's electronic medical record revealed Resident 55 admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Congestive Heart Failure (a serious condition when the heart doesn't pump blood as well as it should), Chronic Kidney Disease (means a gradual loss of kidney function over time), Morbid (severe) Obesity due to excess calories (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher), Diabetes Mellitus with Diabetic Neuropathy (is nerve damage that can occur in people with diabetes), Altered Mental Status (is a symptom when there is a change in mental function that stems from an illness, disorder or injury affecting the brain), Schizoaffective Disorder (a serious mental illness that affects how a person thinks, feels and behaves), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) , and Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A record review of the MDS (Minimum Data Set (MDS is a federally mandated standardize tool used to assess a resident's capabilities and to help determine a resident's care) dated March 12, 2024 for Resident 55 revealed a BIMS (Brief Interview for Mental Status is a screening tool used to identify the cognitive condition of a resident) score of 12, which indicates moderate cognitive impairment. An observation on 07/09/2024 at 11:16 AM revealed a white bottle sitting in the windowsill in Resident 55's room next to a nebulizer mask and tubing. The white bottle had a visibly worn prescription label of Miconazole 2% powder with Resident 55's name on it. One half of the container is empty and Date on the label is illegible. A record review on 07/09/2024 of Physician Orders for Resident 55 revealed no order for Miconazole Powder. An interview with the Director of Nursing (DON) on 07/09/2024 at 11:30 AM when shown the Miconazole Powder in the windowsill in Resident 55's room, confirmed that medications should not be kept unsecured in resident rooms. DON then removed the Miconazole Powder from Resident 55's room. B. An observation of medication storage and medication carts with DON on 07/11/2024 between 7:00 AM and 7:20 AM revealed one medication cart, identified by staff as [NAME] East Treatment Cart, located in [NAME] Hallway near room [ROOM NUMBER] was unlocked. An interview with DON confirmed that all Medication and Treatment Carts should be locked when unattended. DON then locked the [NAME] East Treatment Cart. A record review of facility's Medication Storage policy dated 08/15/2023 revealed the Standard was: The facility must secure all medications in a locked storage area under proper temperature controls, and to limit access to authorized personnel consistent with state or federal requirement and professional standards of practice. #4 b revealed Medication Carts are locked when not in use or when unattended by authorized nursing personnel.

Licensure Reference Number 175 NAC 12-006.09B Based on observations, record review, and interviews, the facility failed to maintain the nutritive value of pureed food. This had the potential to affect 18 residents. The facility identified a census of 150. Findings are: Observation on 7/9/24 at 9:10 AM revealed [NAME] B scooped with a slotted spoon an indeterminate amount of cooked green beans into the blender. [NAME] B measured 2 teaspoons of salt and put it in the blender with the green bean. [NAME] B added 2 scoops of liquid butter to the blender and added boiling water of indeterminate amount. After this mixture was blended, [NAME] B added 4 ounces of thickener. Observation on 7/9/24 at 9:30 AM [NAME] B placed an indeterminate amount of cooked ground beef into the blender. [NAME] B added 2 scoops of country gravy and 2 cups of boiling water into the blender. After this mixture was blended, [NAME] B added 4 ounces of thickener. A interview was conducted on 7/10/24 at 8:40 AM with [NAME] B. During the interview [NAME] B reported having already pureed the meat for lunch. [NAME] B stated (gender) mixed 3 cooked turkey breasts with gravy (indeterminate amount) and 2 cups of boiling water. Observation of [NAME] C on 7/11/24 at 6:36 AM revealed [NAME] C added 10 cooked cheese omelets, 3 cups of boiling water, and 5 scoops of thickener and blended the mixture. [NAME] C then added an additional 2 scoops of thickener to the blended food. A interview on 07/11/24 at 7:19 AM, the Dietician confirmed the use boiling water in preparation of the pureed foods would not be appropriate. After tasting the pureed eggs prepared this AM the dietician stated the taste was not good. The Dietician confirmed 18 residents receive a pureed diet. Record review of recipe (undated) for pureed green and wax beans, turkey breast, and egg cheese omelets revealed the following: Green and Wax Beans The International Dysphagia Diet Standardization Initiative (IDDSI) is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures. IDDSI Level 4: Pureed: measure desired number of servings into a food processor. Blend until smooth. Use the fork Drip Test or the Spoon Tilt Test to confirm texture is within IDDSI Level 4 specifications. Note: For any of the above modified texture diets: Add small amounts of gravy, sauce, vegetable juice, cooking water, fruit juice, milk, or half and half to meet desired consistency. Drain and discard any excess liquid that has separated from the solid food pieces. Add commercial thickener if product needs thickening. Based on type and amount of liquid/ thickener added in texture modification process, nutrition information may vary. Turkey Roast (3 Breast) IDDSI Level 4: Pureed: measure desired number of servings into a food processor. Blend until smooth. Use the fork Drip Test or the Spoon Tilt Test to confirm texture is within IDDSI Level 4 specifications. Note: For any of the above modified texture diets: Add small amounts of gravy, sauce, vegetable juice, cooking water, fruit juice, milk, or half and half to meet desired consistency. Drain and discard any excess liquid that has separated from the solid food pieces. Add commercial thickener if product needs thickening. Based on type and amount of liquid/ thickener added in texture modification process, nutrition information may vary. Egg Cheese Omelet IDDSI Level 4: Pureed: measure desired number of servings into a food processor. Blend until smooth. Use the fork Drip Test or the Spoon Tilt Test to confirm texture is within IDDSI Level 4 specifications. Note: For any of the above modified texture diets: Add small amounts of gravy, sauce, vegetable juice, cooking water, fruit juice, milk, or half and half to meet desired consistency. Drain and discard any excess liquid that has separated from the solid food pieces. Add commercial thickener if product needs thickening. Based on type and amount of liquid/ thickener added in texture modification process, nutrition information may vary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.07(C) Based on record review and interview; the facility staff failed to identify and offer the Pneumococcal immunization to 4 (Resident 122, 138, 130, and 80) of 5 sampled residents. The facility staff identified a census of 150. Findings are: A. Record review of Facility Policy dated 8/2016 Pneumococcal Vaccine: Policy Statement: All residents will be offered Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessment of Pneumococcal vaccination status will be conducted within 5 days of the resident admission if not conducted prior to admission. 3. Before receiving a Pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the Pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. 4. Pneumococcal vaccines will be administered to the resident (unless medically contraindicated, already given, or refused) per our facility's physician-approved Pneumococcal vaccination protocol. 5. Resident/representatives have the right to refuse the vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of Pneumococcal vaccination. 6. For resident who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 7. Administration of the Pneumococcal vaccines or revaccination's will be made accordance with current Centers for Disease Control Prevention recommendations at the time of the vaccination. B. Record review of Centers for Disease Control Prevention current Pneumococcal vaccination recommendations are as follows for adults 65 years or older: Routine vaccination Administer Pneumococcal vaccine 15 (PCV15) or Pneumococcal Vaccine 20 (PCV20) for all adults 65 years or older. -Who have never received any Pneumococcal conjugate vaccine. -Whose previous vaccination history is unknown. Pneumococcal Vaccine 15 (PCV15): Additional vaccination needed. If Pneumococcal Vaccine 15 (PCV15) is used, administer a dose of Pneumococcal Polysaccharide 23 (PPSV23) one year later, if needed. PCV20: Additional vaccination not recommended. If PCV20 is used, a dose of PPSV23 isn't indicated. Recommendation for shared clinical decision-making: Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 if they have received both -PCV13 (but not PCV15 or PCV20) at any age and -PPSV23 at or after the age of [AGE] years old C. Record review of Resident 122 Diagnosis Sheet revealed Resident 122 was [AGE] years of age. Resident 122's diagnosis include: encounter for palliative care, congestive heart failure, hypertension, aortic valve stenosis, vascular dementia, and history of myocardial infarction (heart attack). Record review of Resident 122's immunization report dated 7/8/24 revealed there was no evidence the facility staff had identified and offered the Pneumococcal immunization to the resident. D. Record review of Resident 138 Diagnosis sheet revealed the resident was [AGE] years old. Resident 138's diagnosis include: chronic respiratory failure, adult failure to thrive, severe protein and calorie malnutrition, and Type II diabetes. Record review of Resident 138's immunization report dated 7/8/24 revealed there was no evidence the facility staff had identified and offered the Pneumococcal immunization to the resident. E. Record review of Resident 80 Diagnosis sheet revealed the resident was [AGE] years old. Resident 80's diagnosis include: cerebral infarction (stroke), vascular dementia, hypertension, type II diabetes, heart disease, and hypertension. Record review of Resident 80's immunization report dated 7/8/24 revealed there was no evidence the facility staff had identified and offered the Pneumococcal immunization to the resident. F. Record review of Resident 130 Diagnosis sheet revealed the resident was [AGE] years old. Resident 130's diagnosis include: Parkinson's disease, respiratory failure, neurocognitive disorder with Lewy body, dementia, severe protein-calorie malnutrition, hypothyroidism, osteoporosis, and anemia. Record review of Resident 130's immunization report dated 7/8/24 revealed there was no evidence the facility staff had identified and offered any additional Pneumococcal immunization to the resident. Resident 130 had received a PPSV23 on 12/3/2021. G. Interview on 7/11/24 at 2:15 PM, the Assistant Director of Nursing/Infection Preventionist Nurse confirmed there was no evidence the facility had offered or identified the need for the Pneumococcal vaccine for Resident 122, 138, and 80 and no additional Pneumococcal vaccine had been offered to Resident 130.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to report and thoroughly investigate an allegation of verbal abuse and submitted the investigation to the require state agency within 5 working days for 1(Resident 68) 1 residents. The facility staff identified a census of 147. Findings are: A. Record review of the facility Abuse Reporting policy dated 8-2006 revealed the following information: -Policy Statement: -It is the responsibility of our employees, facility consultants, attending Physican's, family members, visitors, etc, to promptly report any incident or suspect incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management, which will then be immediately reported to the appropriate state agencies and other entities or individuals. -Policy Interpretation and Implementation: -2c. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or their families, or saying things to frighten residents. -8. The Administrator and the Director of Nursing must be immediately notified of the suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and the Director of Nursing must be called at home and informed of such incident. -14. In accordance with the Elder Justice Act, the facility administrator or his/her designee will notify immediately , but no later then two hours after the allegation is made if the event that cased the allegation involved in serious bodily injury and does not involve abuse, the following persons or agency that included Adult Protective Services, Law Enforcement and the State Licensing Agency. -16. The results of all investigations and reports shall be faxed or emailed to the state survey and certification agency within 5 working days of notification of the allegation. B. Record review of the facility Abuse Investigation policy dated 8-2006 revealed the following information: -Policy Statement: -All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated. -Policy Interpretation and Implementation: -2. The individual conducting the investigation will at a minimum: -a. An interview with the person(s) reporting the incident. -b. Interview with any witnesses to the incident. -e. Interview with staff members (on all shift) having contact with the resident during the period of the alleged incident. -g. Interviews with other residents to which the accused employee provides care and services. B. Record review of a Resident Or Family Concern/Grievance Report Form (ROFCGRF) revealed on 7-03-2023 Resident 68's Guardian reported Resident 68 had pain and the exerciser worker didn't believe Resident 68 and reportedly said Resident 68 was lazy. Review of the resident medical record that included Resident 68's Progress Notes, Practitioners orders and incident reports revealed there was not a through investigation of the allegation of Resident 68 being called lazy and no indication an investigation was submitted to the required state agency within 5 working days. Interview on 7-13-2023 at 10:15 AM the Social Services (SS) L revealed they were notified via email on 7-03-2023 in the evening. SSL reported seeing the email on 7-05-2023 and did follow up with Resident 68. SS L confirmed calling a resident lazy could be demeaning and could be verbal abuse. SS L confirmed a complete investigation had not been completed and the report submitted the state within 5 working days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09D2c Licensure Reference Number 175 NAC 12.006.09D Based on observation, interview, and record review, the facility failed to ensure a Prevalon Boot (a heel protector designed with an open, floated-heel design) was applied while at rest to prevent the potential for skin breakdown for 1 (Resident 406) of 2 sampled residents and the facility failed to monitor bowel movements and implement a bowel management program to prevent the potential for bowel complications for 1 (Resident 148) of 1 sampled resident reviewed for bowel management. The total facility census was 146. Findings are: A. A record review of the undated Maple Crest Skin Care (General) Policy revealed preventative skin care would be used whenever possible for residents at risk for skin breakdown. A record review of Resident 406's Clinical Census dated 07/11/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 406's Medical Diagnoses dated 07/11/2023 revealed the resident had the following diagnoses: Encounter for Orthopedic Aftercare Following Surgical Amputation (care following surgical removal of body limb), Acquired Absence of Left Leg Below Knee (left lower leg removal), Infection of Amputation Stump, Left Lower Extremity (infection of the site of the surgical limb removal), Type 2 Diabetes Mellites (DMII)(uncontrolled blood sugars), and Peripheral Vascular Disease (PVD)(poor blood circulation in the limbs of the body), Methicillin Resistant Staphylococcus Aureus (MRSA)(infection resistant to antibiotics). A record review of Resident 406's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/16/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 15, The resident was a 2 person physical assist with Bed mobility and dressing. The MDS dated [DATE] revealed the resident did have a pressure reducing device for the chair and bed but did not reveal the resident had a splint or brace. A record review of Resident 406's Care Plan dated 06/22/2023 revealed the resident had a Focus area of alteration in skin integrity related to cognitive impairment, shear and friction (rubbing together), and diagnoses of DMII, Chronic Venous Insufficiency (poor blood circulation), and PVD. The Care Plan revealed an intervention of Prevalon Boots while in bed to the right foot. An observation on 07/10/2023 at 11:51 AM revealed Residents 406 was laying in bed and Resident 406's Prevalon Boot was laying on the floor at the end of the bed and did not have a Prevalon boot on the right foot. There was a sign located on the wall above Resident 406's bed that said the resident should have a Prevalon Boot on the right foot when resting. An observation on 07/11/2023 at 9:19 AM revealed Resident 406 was laying in bed and did not have a Prevalon Boot on the right foot. The resident's Prevalon boot was in the same spot on the floor at the end of the bed as the 07/10/2023 at 11:51 AM observation. An observation on 07/11/2023 at 3:26 PM revealed Resident 406 did not have a Prevalon Boot on the right foot while resting in the wheelchair with legs elevated. The Prevalon boot was located in the same place as the 07/10/2023 at 11:51 AM observation. The resident's right foot was placed directly on the wheelchair footrest. There was a sign located on the wall above the bed that said the resident should have a Prevalon Boot on the right foot when resting. In an interview on 07/11/2023 at 3:26 PM, Resident 406 confirmed [gender] did not have a Prevalon Boot on the right foot and has never refused to allow the staff to put the Prevalon Boot on. Resident 406 confirmed there was a sign on the wall to wear the Prevalon Boot. In an interview on 07/12/2023 at 7:59 AM, Nursing Assistant (NA)-H confirmed NA-H has never seen Resident 406 with a Prevalon Boot on and had not chose to refuse the Prevalon Boot. A record review of Resident 406's Clinical Physician Orders dated 07/11/2023 revealed Resident 406 had a physician's order to have a Prevalon Boot on the right foot when at rest and check the right foot daily every shift. In an interview on 07/12/2023 at 6:25 AM, with Registered Nurse (RN)-G revealed that [gender] observed the resident, and the resident did not have a Prevalon Boot on the right foot and should have had one on. B. Record review of an undated facility policy entitled: Bowel Monitoring Program revealed the following policy and procedures: - Purpose: To ensure that implementation of appropriate procedures to monitor and ensure assessments are being done and that Laxatives are given when needed. - Policy statement: The purpose of this policy is helping residents who have a diagnoses of constipation. Residents who have a diagnoses of constipation will have a care plan that is reflective of the potential problem for constipation and the interventions to be used, which reflect an individualized bowel regimen for that resident. - Responsibility: The nursing staff is responsible for monitoring the elimination patterns of all residents and to prudently administer laxatives or enemas prophylactically or as ordered by the physician. - Procedure: The consistency of the residents bowel movement shall be noted daily and documented on the daily BM in PCC and any signs of constipation or lack of bowel movement shall be reported to the charge nurse. Should regular bowel elimination be interrupted for a period of 72 consecutive hours, the following protocol may be implemented: - The overnight charge nurse will run a BM report so the oncoming nurse can initiate the BM protocol for those who have not had a BM over the past 72 hours. - The day charge nurse will then review the report and give the list to the med aide on the appropriate laxative to give. The charge nurse will also do an abdominal assessment which is to include palpitation of the abdomen and listening to bowel sounds for hypo / hyper activity then document the results. - The evening charge nurse will receive an end of shift report for the resident the resident that the BM protocol was initiated on, so the charge nurse can follow up laxatives if the resident has not had results from the laxative given on the previous shift, the charge nurse is to do another abdominal assessment and do a rectal examination and document the results. - The overnight charge nurse will assess if there continues to not be any elimination then the charge nurse needs to follow -up with administering PRN medication. - If there continues to be no results from the interventions made over the last 72 hours the day charge nurse will need to contact the physician and report: - lack of results from laxative intervention - Current assessment which needs to include: vital signs, bowel sounds, palpation of abdomen, last documented stools, amount and consistency, rectal exam results, any changes in resident intake, any changes in resident mental status. Record review of Resident 148's History and Physical dated 5/4/23 revealed that Resident 148 had been admitted to the Acute Care hospital on 5/4/23 with a fracture of the right ankle. While in the hospital between 5/4/23 and 5/7/23, the resident did not have any belly pain, constipation or diarrhea. The abdominal exam showed no distension, no masses and no tenderness to deep palpation. Record review of Resident 148's Minimum Data Set (MDS -a comprehensive assessment used to develop a resident's care plan) dated 5/17/23 revealed that Resident 148 was admitted to the facility from an acute care hospital on 5/7/23. The MDS identified that Resident 148 had a Brief Inventory of Mental Status (BIMS) score of 12 which indicated that the resident had moderate cognitive impairment. The MDS identified that Resident 148 required extensive assistance with transfers and toileting, was always continent of bowel, had no bowel toileting program in place and had no constipation issues. Record review of Resident 148's admission Diagnoses List dated 5/17/23 revealed diagnoses that included a fracture of the right lower leg, blindness of the left eye and constipation. Record review of Resident 148's Comprehensive Care Plan (CCP, an interdisciplinary process that identifies a residents potential needs, risks and interventions ) dated 5/19/23 identified that Resident 148 had the potential for constipation due to limited mobility, side effects from medications, and did have orders for a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements as needed. The goal for the CCP was that Resident 148 Resident would continue to be free of signs and symptoms of constipation as evidenced by bowel movement at least every other day through next review. The intervention listed in the CCP was to toilet the resident as needed for the bowels. Record review of Resident 148's Physician orders dated 5/11/2023 revealed the following orders: - May follow Bowel Management (BM) Protocol: If no BM after day 1: Prune Juice. If no BM after Day 2: Milk of Magnesia (MOM, a medication used to treat constipation) 30 cc (cubic centimeters and are equivalent to millimeters) as needed: Indication: Constipation. If no BM after Day 3, Dulcolax ( a laxative that stimulates bowel movement) suppository one rectally as needed. Indication: Constipation. If no BM after Dulcolax Suppository, please Give Fleet Enema (a liquid medication used to help have a bowel movement) and notify MD for further instructions. - Bisacodyl ( a stimulant laxative that increases the fluids and salts in the intestines and treats occasional constipation) 10 milligram (mg) suppository, insert 1 suppository as needed daily for constipation. (Related Diagnoses: Constipation. - Peg (Polyethylene Glycol) 3350 powder (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements) mix 17 grams in liquid and drink PO (orally) every 12 hours as needed for constipation. Record review of Resident 148's bowel records dated June and July 2023 revealed no documentation of any BM's between 6/15/23 and 7/4/23, a total of 18 days with no documentation of any bowel movements. The bowel records showed that Resident 148 had a small BM on 7/4/23 and a medium / large BM on 7/6/23. Record review of Resident 148's Medication Administration Record (MAR) for June and July 2023 revealed that Resident 148 had no Bisacodyl suppositories given in June or July 2023 and received 1 dose of Peg (Polyethylene Glycol) 3350 powder on 6/24/23 and 7/5/23. Resident 148 did not have orders for MOM during the stay at the facility. Record review of Resident 148's Progress Notes revealed the following: - 7/4/2023 10:13 PM Skilled Evaluation Gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4. Denies indigestion, nausea, vomiting, diarrhea or constipation. - 7/5/2023 1:34 PM Resident complained of stomach pain and nausea. painful urination and urgency. Resident stated, I don't feel well, I feel sick to my stomach. Stomach was auscultated (hypo active sounds in 1st and 4th quadrants) and palpated (pain upon palpation on 1st and 2nd quadrants). Last BM was 07/0/2023 [there was no documentation of this BM]. Resident reports hard stools and difficult pooping the last couple of days. This nurse administered MOM to help with constipation. This nurse called provider and received orders to administer Lactulose and Zofran for nausea. Family and administration has been notified. Care plan on going. - 7/5/2023 6:54 PM Resident refused shower tonight, stated she is not feeling well, daughter and granddaughter present for refusal. - 7/6/2023 5:12 PM Resident c/o [complains] of abdominal pain in the morning, provider was notified with UA/C/S [urinary analysis culture and sensitivity] result. Provider in this pm (afternoon) to see, noted lower and pain, order received to send resident to ER [Emergency Room] for CT scan, resident left unit at about 16:45 to [name] hospital ER as per family choice. - 7/6/2023 20:55 Resident admitted to [name] hospital with Small Bowel Obstruction. Record review of an Emergency Department Report from the Hospital dated 7/6/23 for resident 148 revealed the following: - admitted to the ED (Emergency Department) 7/6/23 at 4:56 PM, admit reason: Abdominal pain, Bowel Obstruction, Cholecystitis (inflammation of the gall bladder). - Discharge from the ED diagnoses: 1. Small Bowel Obstruction, 2. Cholecystitus, 3. Pericardial Effusion (accumulation of fluid in the pericardial cavity). - admitted to the hospital as inpatient. - CT [Computerized Tomography Scan, a medical imaging technique used to obtain detailed internal images of the body) of Abdomen completed with contrast. - Medications current include: Bisacodyl 10 mg rectal suppository daily as needed for constipation., Polyethylene glycol ( PEG oral powder) every 12 hours as needed for constipation. - History of present illness: Patient was sent from [gender] care facility for evaluation of abdominal pain and distension. Resident started getting some lower abdominal pain and discomfort a few days ago. They diagnosed [gender] with a UTI (Urinary Tract Infection) and was started on an antibiotic a couple days ago. Denies fever, actual vomiting, had not had a bowel movement so [gender] received 3 doses of Lactulose (a non absorbable sugar used to treat constipation) and has had 2 large bowel movements and an explosion of stool. [gender] did not feel any different after having had a bowel movement. [gender] had a partial Colectomy ( partial removal of the bowel)) a few years ago. - Assessment : Gastrointestinal: Mild distension with some right lower abdominal / pelvic area tenderness to palpitation without guarding or rebound. Good bowel sounds. - CT scan shows High grade Bowel Obstruction, Cholycistitus, Pleural Effusion. - Discussed plan with family, plan admit to hospital, consult with general surgery, IV (intravenous)Zosyn (antibiotic medication) ordered. Interview on 07/13/23 at 9:08 AM with the Assistant Director of Nursing confirmed that there was no documentation of BM's for resident 148 between 6/15/23 and 7/4/23 and confirmed that the facility staff did not follow the bowel protocol as specified in the physician orders. Interview with the Administrator (ADM) on 7/12/23 at 11:57 AM confirmed that the bowel management program for Resident 148 had not been followed as ordered by the physician and bowel policies had not been followed. The ADM confirmed that no bowel movements had been documented between 6/15/23 and 7/4/23 and medications for bowel management had not been given according to the bowel management protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09D7a Based on observation, interview, and record review, the facility failed to ensure that resident's footrests were applied to resident wheelchairs to prevent potential accidents while being transported (pushed or pulled) for 3 (Residents 24, 7 and 85) of 3 sampled residents. The total facility census was 146. Findings are: A record review of the Assistive Devices and Equipment Policy dated July 2017 revealed that equipment that assist with resident mobility, safety, and independence included wheelchairs. Staff can assist residents if wheelchair pedals are not present only if resident can independently lift their legs and maintain positions, if they cannot then foot pedals need to be added to the resident's wheelchair before transfer process occurs. To decrease the risk of avoidable accidents associated with a wheelchair, the facility would assess the resident for lower extremity (legs and feet) strength, range of motion, balance, and cognitive (thinking, reasoning, or remembering) abilities when determining the appropriateness for the resident's condition. A. A record review of Resident 24's Clinical Census dated 07/13/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 24's Medical Diagnosis dated 07/13/2023 revealed the resident had a primary diagnosis of Chronic (long term) Kidney Disease and had other diagnoses of Dementia (loss of intellectual functioning), Delusional disorder (unshakeable belief in something that is untrue), Paranoid Personality Disorder (exaggerated distrust and suspicion of others), Muscle Weakness, Need for Assistance with Personal Care, Difficulty in Walking, and others. A record review of Resident 24's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/15/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 15, The resident was a 1 person physical assist with locomotion on and off the unit. The MDS dated [DATE] revealed the resident used a wheelchair and needed partial/moderate assistance (helper lifts or holds limbs and provides less than half the effort) to wheel 50 feet with 2 turns and wheel 150 feet. An observation on 07/10/2023 at 11:41 AM revealed Unit Manager (UM)-B pushed Resident 24 in a wheelchair down the East hallway to the elevator. The observation revealed Resident 24's feet hit the floor and got tangled beneath the resident. The resident grimaced (a facial expression expressing disgust, pain, or disappointment) and quickly lifted her feet. In an interview on 07/11/2023 at 10:20 AM, Resident 24 confirmed that UM-B pushed the resident down the hall on 07/10/2023 and the resident's feet hit the floor and got tangled. In an interview on 07/12/2023 at 07:12 AM, Nursing Assistant (NA)-E confirmed that if a resident could self-propel (move without assistance) in a wheelchair, the staff did not have to use footrests on the wheelchair. In an interview on 07/12/2023 at 11:02 AM, UM-B confirmed that if a resident could self-propel in a wheelchair, the staff did not have to use wheelchair footrests to transport residents in the facility. In an interview on 07/13/2023 at 02:22 PM, Physical Therapist (PT)-J confirmed Occupational Therapy (OT)/Physical Therapy (PT) did assess Resident 24 for the safe ability to self-propel a wheelchair, OT/PT did not assess the resident for lower extremity strength, range of motion, balance, and cognitive abilities. In an interview with the Administrator on 07/13/2023, the Administrator confirmed the only assessment completed on the residents for the appropriateness of wheelchair safety was the OT/PT evaluation. B. A record review of Resident 7's Clinical Census dated 07/11/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 7's Medical Diagnosis dated 07/11/2023 revealed the resident was admitted to the facility for Palliative Care (care for a resident with a serious illness that focused on relief of symptoms and stress of the disease. Other diagnoses for Resident 7 included Arthritis (swelling of the joints), weakness, Cervical Spine Fracture (fracture of the neck area of the spine), Chronic Obstructive Pulmonary Disease (long term lung disease), Shortness of Breath, and others. A record review of Resident 7's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/19/2023 revealed the resident's Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) had not been completed due to the resident was rarely/never understood, The resident was a 1 person physical assist with locomotion on and off the unit. The MDS dated [DATE] revealed the resident used a wheelchair and needed substantial/moderate assistance (helper lifts or holds limbs and provides more than half the effort) to wheel 50 feet with 2 turns and wheel 150 feet. A record review of Resident 7's Restorative Nursing Screener dated 04/03/2023 revealed Resident 7 was assessed as Dependent - A helper completed the activities for the resident for Indoor Ambulation and assessed as Dependent - A helper completed the activities for the resident for Functional Cognition (how a resident utilizes and integrates the thinking and processing skills to accomplish things). An observation on 07/11/2023 at 07:12 AM revealed Nursing Assistant (NA)-E transported (pushed) Resident 7 in a wheelchair down the entire [NAME] hallway to the elevator with Resident 7's heels dragging on the floor. An observation on 07/12/2023 at 07:12 AM revealed NA-E assisted Resident 7 to walk down the North hallway from the resident's room to [NAME] hallway. Resident 7 told NA-E he was too exhausted to go any further when the resident reached the [NAME] hallway. NA-E assisted the resident into the wheelchair and transported Resident 7 down the [NAME] hallway to the elevator and the resident's feet were observed to hit the floor on multiple occasions. In an interview on 07/12/2023 at 07:12 AM, NA-E confirmed that if a resident could self-propel (move without assistance) in a wheelchair, the staff did not have to use footrests on the wheelchair. In an interview on 07/12/2023 at 11:02 AM, UM-B confirmed that if a resident could self-propel in a wheelchair, the staff did not have to use wheelchair footrests to transport residents in the facility. In an interview on 07/13/2023 at 02:22 PM, Physical Therapist (PT)-J confirmed Occupational Therapy (OT)/Physical Therapy (PT) did assess Resident 24 for the safe ability to self-propel a wheelchair, OT/PT did not assess the resident for lower extremity strength, range of motion, balance, and cognitive abilities. In an interview with the Administrator on 07/13/2023, the Administrator confirmed the only assessment completed on the residents for the appropriateness of wheelchair safety was the OT/PT evaluation. C. A record review of Resident 85's Clinical Census dated 07/11/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 85's Medical Diagnosis dated 07/11/2023 revealed the resident was admitted to the facility for Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease (uncontrolled blood sugars that resulted in long term kidney damage). Other diagnoses for Resident85 included Osteoarthritis (degeneration of the joint and underlying bone), Arthritis (swelling of the joints), Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), among others A record review of Resident 85's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/09/2023 revealed the resident's Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) had not been completed due to the resident was rarely/never understood, The resident was a 1 person physical assist with locomotion on and off the unit. The MDS dated [DATE] revealed the resident used a wheelchair but, did not reveal ability to wheel 50 feet with 2 turns and wheel 150 feet. A record review of Resident 85's Restorative Nursing Screener dated 06/06/2023 revealed Resident 85 was assessed as not applicable for Indoor Ambulation and assessed as not applicable for Functional Cognition (how a resident utilizes and integrates the thinking and processing skills to accomplish things). An observation on 07/11/2023 at 07:08 AM revealed Unit Manager (UM)-B transported (pushed) Resident 85 in a wheelchair from the resident's room to the elevator. The resident's feet were dragging on the floor. An observation on 07/11/2023 at 10:12 AM revealed UM-B pulled Resident 7 in the wheelchair from the unit dining room across the hall to in front of the nurse's station without footrests on the wheelchair. Resident 85 was wearing rubber Crocs style footwear and the resident's shoes were dragging on the floor. An observation on 07/12/2023 at 08:03 AM revealed Nursing Assistant (NA)-E transported Resident 85 down the East hallway without footrests on the wheelchair. Resident 85's feet were hitting the floor, so NA-E told the resident to keep the resident's feet up. An observation on 07/12/2023 at 11:45 AM revealed NA-F transported Resident 85 from the elevator across the Main dining room to the resident's table without the footrests on the wheelchair. In an interview on 07/12/2023 at 07:12 AM, NA-E confirmed that if a resident could self-propel (move without assistance) in a wheelchair, the staff did not have to use footrests on the wheelchair. In an interview on 07/12/2023 at 11:02 AM, UM-B confirmed that if a resident could self-propel in a wheelchair, the staff did not have to use wheelchair footrests to transport residents in the facility. In an interview on 07/13/2023 at 02:22 PM, Physical Therapist (PT)-J confirmed Occupational Therapy (OT)/Physical Therapy (PT) did assess Resident 24 for the safe ability to self-propel a wheelchair, OT/PT did not assess the resident for lower extremity strength, range of motion, balance, and cognitive abilities. In an interview with the Administrator on 07/13/2023, the Administrator confirmed the only assessment completed on the residents for the appropriateness of wheelchair safety was the OT/PT evaluation.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on observation, record review and interview; the facility staff failed to follow up on dental care for 1 (Resident 112) of 1 sampled resident. The facility staff identified a census of 147. Findings are: Record review of Resident 112's Progress Note dated 12-07-2022 revealed Nurse Practitioner (NP) M notified Social Services (SS) M Resident 112 needed to see a dentist. Review of Resident 112's medical record that included PN's, practitioner orders, referral section and assessment sections of the medical record revealed no indication follow up with a dentist had been completed. Observation on 7-10-2023 at 8:23 AM revealed Resident 112 was seated in a wheelchair in Resident 112's room. Further observation revealed Resident 112 had broken and blackish looking teeth. On 7-10-2023 at 8:23 AM during the observation, Resident 112 reported needing and wanted to see a dentist. Resident 112 reported not being aware if staff were attempting to assist in Resident 112 being able to see a dentist. On 7-11-2023 at 11:25 AM an interview was conducted with the SS O. During the interview SS O confirmed Resident 112 needed to see a dentist. SS O confirmed no follow up had been completed and the facility did not have a process in place to keep tract of who needed dental service and follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.17B Based on observation, interview, and record review, the facility failed to ensure 2 (Residents 406 and 123) of 3 sampled resident's nebulizer (a machine used to deliver liquid medicine to the lungs) administration set (neb kit) and 1 (Resident 35) of 1 sampled resident's Continuous Positive Airway Pressure (CPAP)(a machine used to deliver pressure to the resident's airway to keep it open) mask was cleaned and stored in a manner to prevent potential cross contamination. The total facility census was 146. Findings are: A. A record review of the Medication Administration - Nebulizer Policy dated 05/13/2020 revealed after the treatment was complete the staff should have disassembled and cleaned the neb kit in warm soapy water after each treatment and stored the neb kit in a clean plastic bag. A record review of Resident 406's Clinical Census dated 07/11/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 406's Medical Diagnoses dated 07/11/2023 revealed the resident had a diagnoses of Acute Upper Respiratory Infection (current upper airway infection) and Acute and Chronic Respiratory Failure with Hypoxia (current and long-term breathing problem with a low oxygen level). A record review of Resident 406's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/16/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 15, The resident was a 2 person physical assist with bed mobility and the resident did not ambulate in the room. A record review of Resident 406's Clinical Physician Orders dated 07/11/2023 revealed a physician's order for Ipratropium-Albuterol (a liquid respiratory medication consisting of 2 drugs) inhale 1 vial per nebulizer 4 times per day as needed. An observation on 07/10/2023 at 9:57 AM revealed Resident 406's nebulizer kit was laying on the bedside table uncovered with a small amount of liquid in it and an oily film on the mask. An observation on 07/11/2023 at 9:19 AM revealed the Resident 406's nebulizer kit was laying uncovered on the bedside table with a residual amount of liquid in it and an oily film on the mask. An observation on 07/11/2023 at 10:28 AM revealed Licensed Practical Nurse (LPN)-P was doing wound care and knocked the nebulizer kit on the floor with a cup of water. LPN-P picked up the neb kit and placed it back on the bedside table without cleaning the nebulizer kit. An observation on 07/12/2023 at 6:25 AM revealed Resident 406's nebulizer kit was laying on the bedside table uncovered in the same place as the 07/11/2023 at 9:19 AM observation. In an interview on 07/12/2023 at 2:50 PM, Registered Nurse (RN)-G confirmed RN-G observed that Resident 406's nebulizer kit was laying on the bedside table with a residual amount of medication in it and an oily film on the mask. RN-G confirmed the nebulizer kit had not been clean or placed in a plastic bag and should have been. B. A record review of Resident 123's Clinical Census dated 07/13/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 123's Medical Diagnoses dated 07/13/2023 revealed Resident 123's had diagnoses of: Respiratory Syncytial Virus (a virus that causes an infection of the respiratory tract) and Shortness of Breath. A record review of Resident 123's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/06/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13. The MDS revealed Resident 123 was a 2 person physical assist with bed mobility and did not ambulate in the room. A record review of Resident 123's Clinical Physician Orders dated 07/13/2023 revealed a physician's order for Albuterol (a liquid respiratory medication) 1 vial per nebulizer 3 times per day and every 4 hours as needed. An observation on 07/10/2023 at 2:23 PM revealed Resident 123's nebulizer kit was lying on the bedside table uncovered with a small residual (small) amount of liquid in it and an oily film that coated the mask. An observation on 07/11/2023 at 7:04 AM revealed Resident 123's nebulizer kit was lying on the bedside table uncovered with a small residual amount of liquid in it and an oily film that coated the mask. An observation on 07/11/2023 at 2:58 PM revealed Resident 123's nebulizer kit was lying on the bedside table uncovered with a small residual amount of liquid in it and an oily film that coated the mask. An observation on 07/12/2023 at 6:19 AM revealed Resident 123's nebulizer kit was lying on the bedside table uncovered with a small residual amount of liuquid in it and an oily film that coated the mask. In an interview on 07/13/2023 at 7:54 AM, Medication Aide (MA)-I confirmed that MA-I observed the nebulizer kit and confirmed the neb kit had not been cleaned since the last nebulizer treatment and should have been. MA-I confirmed the nebulizer kit was not in a plastic bag and should have been. C. A record review of the facility's Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BiPAP)/Trilogy Cleaning Policy dated October 2010 revealed the staff was to clean the resident's mask daily with soapy water, rinse, and air dry. A record review of Resident 35's Clinical Census dated 07/13/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 35's Medical Diagnosis dated 07/13/2023 revealed the resident had a diagnoses of Obstructive Sleep Apnea (OSA)(a condition where the upper airway restricts during sleep), and Chronic Obstructive Pulmonary Disease (COPD)(a long term lung disease). A record review of Resident 35's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/27/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13. The MDS revealed Resident 35 was a 1 person physical assist with bed mobility and the resident did not ambulate in the room. The MDS revealed Resident 35 utilized a CPAP machine. A record review of Resident 35's Clinical Physician Orders dated 07/13/2023 revealed an order for Daily CPAP cares - clean mask cushion/pillow with warm soapy water, rinse and air dry. An observation on 07/10/2023 at 11:04 AM revealed Resident 35's CPAP mask was laying on the floor. An observation on 07/11/2023 at 9:38 AM revealed Resident 35's CPAP mask was laying on the resident's pillow with an oily film on it. An observation with Registered Nurse (RN)-G on 07/12/2023 at 3:46 PM revealed Resident 35's CPAP mask was laying on the resident's bed with an oily film on it. In an interview on 07/12/2023 at 3:46 PM, RN-G confirmed Resident 35's CPAP mask had not been cleaned and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.17D Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17E Based on observation, interview, and record review, the facility failed to ensure staff completed handwashing in a manner to prevent cross contamination (transfer of bacteria from one surface to another), ensure expired items were removed from the facility's stock, ensure the floors in the walk-in refrigerator and walk-in freezer were clean, and ensure kitchen equipment was clean and in good working order. This had the potential to affect 144 residents that consumed (ate) food from the kitchen. The total facility census was 146. Findings are: A. A record review of the undated Maple Crest Hand Washing Policy revealed the staff should have washed their hands to prevent the spread of infection and disease by washing hands thoroughly with soap for 20 seconds. An observation on 07/12/2023 at 9:02 AM revealed the facility's [NAME] (CO)-C completed the process of pureeing (the process of blending food to a pudding-like consistency to make the food easier to swallow) the Prince [NAME] Vegetable Blend when CO-C removed gloves and washed the blender. CO-C then washed his hands with soap and water for 8 seconds before applying new gloves. CO-C pureed the Maple Glazed Ham, removed gloves, washed the blender, sanitized (cleaned with chemicals) the food prep surfaces, and then washed hands for 5 seconds with soap and water before applying new gloves. CO-C completed the process of blending the Mechanical Soft (blended to a soft consistency) Maple Glazed Ham, removed gloves, cleaned the blender, then washed hands with soap and water for 7 seconds before applying new gloves. An observation on 07/12/2023 at 11:08 AM revealed Dietary Aide (DA)-D served food with gloved hands off the steam table, changed pan of Maple Glazed Ham, and removed gloves. DA-D then washed hands with soap and water for 6 seconds before applying new gloves and returning to the steam table. In an interview on 07/13/2023 at 08:32 AM, the Dietary Manager (DM)-A confirmed CO-C and DA-D should have washed hands for greater than 20 seconds with soap and water. B. An observation on 07/10/2023 at 6:45 AM of the dry storage room across from the walk-in freezer revealed the following: • Open bottle of [NAME] Red Hot Sweet Chili Sauce dated 02/21 and Best Use by Date was Dec. 30, 2022 • 9 bottles of [NAME] Mango Sauce had an expiration date of 11/19/2021 • 11 bottles of [NAME] Caramel Sauce had an expiration date of 11/19/2021 • 13 bottles of [NAME] Caramel Sauce had an expiration date of 2/4/2023 • 10 bottles of [NAME] Caramel Sauce had an expiration date of 04/29/2023 • Open Bag of Coconut Flake was dated 11/20 and had an expiration date of 06/07/2023 • Open Box of Raisins was dated 05/22 but Best Use By date was 04/13/2023 • Zip Lock bag of 9 packets of Cheese Sauce dated 03/31/2023 had an Expiration date of 02/01/2023 An observation of the walk-in freezer on 07/10/2023 at 6:45 AM revealed: • An open and undated bag of Beef Topping Crumble • An open and undated bag of fish filet patties • An open and undated bag of onion rings • An open and undated bag of French fries • An open and undated Mirepoix Blend An observation of the walk-in freezer on 07/12/2023 at 09:40 AM revealed: • An open and undated bag of Beef Topping Crumble • An open and undated bag of onion rings • An open and undated bag of French fries • An open and undated Mirepoix Blend In an interview on 07/10/2023 at 07:18 AM, the Dietary Manager (DM)-A confirmed the items in the dry storage listed above were expired and should have been removed, and confirmed the items listed above in the walk-in freezer were opened and undated and should have been removed from the stock. C. A record review of the undated Sanitation of Food Service Department Policy revealed kitchen floors would be kept clean and sanitary. Kitchen floors would be swept and cleaned after each meal. An observation on 07/10/2023 at 6:45 AM revealed the floors in the dry storage room by the outside had a gray, sticky substance throughout the room, the floors in front of the walk-in refrigerator and walk-in freezer had a gray substance on the brown tile and were slick, the walk-in refrigerator's floors had scattered food and box particles throughout with a standing fluid pooled in the back corner to the right, and walk-in-freezer's floors had scattered food and box particles throughout with a gray coating on the brown tiles. In an interview on 07/10/2023 at 7:18 AM, the Dietary Manager (DM)-A confirmed the floors in the dry storage, in front of the walk-ins, and in the walk-in refrigerator and freezer were not clean and should not have been. An observation on 07/12/2023 at 9:46 AM with DM-A revealed the walk-in refrigerator's floors had scattered food and box particles throughout with a standing fluid pooled in the back corner to the right and walk-in-freezer's floors had scattered food and box particles throughout with a gray coating on the brown tiles. In an interview on 07/12/2023 at 9:46 AM, the Dietary Manager (DM)-A confirmed the floors in the walk-in refrigerator and freezer were dirty and should not have been. D. An observation on 07/13/2023 at 7:15 AM of the Level 1, South hall dining room freezer revealed a thick sticky substance on it in multiple areas. The refrigerator revealed 2 open and undated Pudding Snack Packs, a strawberry/banana yogurt with an expiration dated of 06/2023, a container of Mild Cheddar Cheese Dip that was opened and undated, and a container of Chick-Fil-A sauce that was expired, and some staff personal items in it. An observation on 07/13/2023 at 7:30 AM of the Level 1, North hall dining room freezer revealed the freezer had a sticky, orange substance on the bottom in multiple locations. The refrigerator contained a large plastic container with a green lid that contained an orange/brown substance that was not labeled or dated. In an interview on 07/13/2023 at 8:32 AM, the Dietary Manager (DM)-A confirmed the Level 1, South hall dining room freezer had staff personal items in it, the bottom has a thick sticky substance on it. The DM-A revealed the freezer should have been clean and only resident items stored in it. DM-A confirmed the Level 1, South hall dining room refrigerator had expired items in it, and all items should have been closed, labeled, and dated and were not. DM-A confirmed the Level 1, North hall dining room freezer had a sticky orange substance on it and should not have, and all items should have been labeled and dated. E. An observation on 07/13/2023 at 7:15 AM of the Level 1, South hall dining room revealed the refrigerator and ice machine had a gray fuzzy coating located on the tops of both units. The ice machine's vent on the left side was loose and was only held by 1 of 4 screws. An observation on 07/13/2023 at 7:30 AM of the Level 1, North hall dining room freezer revealed the refrigerator and ice machine had a gray fuzzy coating located on the tops of both units. The ice machine's vent on both sides were only held by 2 of 4 screws. The top self of the refrigerator was defective on the left front side. In an interview on 07/13/2023 at 8:32 AM, the Dietary Manager (DM)-A confirmed the Level 1, South hall dining room refrigerator and ice maker tops were dirty, and the ice machines vent was loose and was only held by 1 screw. DM-A confirmed the Level 1, North hall dining room refrigerator and ice maker tops were dirty, and the ice machines vents were only held by 2 of 4 screws.

Based on record review and interview, the facility failed to ensure a new PASRR (Pre-admission Screening and Resident Review) review had been completed after a diagnoses of mental illness was identified for 2(Resident 21 and 142 ) of 3 reviewed for PASRR. The facility census was 144. Findings are: A. Record review of Resident 21's PASSAR dated 5-22-2019 revealed there was not an indication Resident 21 had a serious mental illness. Record review of Resident 21's Order Summary Sheet printed on 4-14-2022 revealed Resident 21 had orders for Quetiapine ( an antipsychotic medication) for the diagnoses of Delusional Disorder. On 4-18-2022 at 11:05 AM an interview was conducted with the facility Assistant Director of Nursing (ADON). During the interview the ADON reported a new PASSAR had not been requested for Resident 21. B. Record review of Resident 142's PASSAR dated 10-16-2017 revealed Resident 142 did not have any serious mental illness. Record review of Resident 142's Order Summary Sheet printed on 4-14-2022 revealed Resident 142 had ordered for a antidepressant medication related to the diagnoses of Major depression and Invega (a antipsychotic medication) for the diagnoses of Delusional Disorder. On 4-18-2022 at 11:05 AM an interview was conducted with the facility Assistant Director of Nursing (ADON). During the interview the ADON reported a new PASSAR had not been requested for Resident 142.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observation and interview, the facility staff failed to ensure that all residents residing on the secured unit were treated in a manner that maintained their dignity during meal service. The facility staff identified a census of 144. The finding are: An observation of dining on 4/12/22 at 09:05 on the secured unit revealed all residents' breakfast plates were sitting in front of them on a meal tray and all meal trays had a plastic knife, fork and spoon. Observation on 4/12/22 at 12:00PM of lunch in the secured unit dining room revealed NA C (Nurse Aide) removing trays from the meal cart to another cart and removed the plastic glasses from the trays and replaced them with styrofoam cups. On 4/12/22 at 12:03 PM observation of staff passing meals trays to the residents on the secured unit revealed that plastic silverware was on the meal trays. On 4/13/22 at 11:41 AM NA C was observed removing trays from a meal cart to another cart and removing plastic glasses from the trays and replacing them with styrofoam cups. On 4/13/22 at 12:08 observation of the staff passing lunch trays in the dining room on the secured unit revealed each resident using plastic black silverware. Interview conducted on 4/13/22 at 9:00 AM with LPN B (Licensed Practical Nurse), LPN E and NA C regarding the reason for plastic silverware being used for residents on the secured unit. Interview revealed that the staff had no idea why the residents get plastic silverware. The staff reported that the plastic silverware could be a safety issue for some of the residents. The interview confirmed the use of plastic silverware is not written anywhere as a safety issue and the residents should be using real silverware. Further interview revealed the reason for the styrofoam cups is that some residents that eat in their room prefer the styrofoam cups. Staff confimed the use of styrofoam cups should not be used for all residents.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations and interview: the facility kitchen staff failed to ensure the cleanliness of counter tops, sides of grill, stove, fryer and microwave were maintained in a clean manor. The had the potential to effect all residents who eat from the kitchen. The facility staff identified a census of 144. Findings are: Observation on 4-14-2022 from 9:15 AM to 9:50 AM of the facility kitchen revealed the following issues: -Main cooking stove with multiple food drips down the sides of the stove. -The grill and Grill stand had blackish, greasy build up down the sides and top edges. The grill stand shelf had greasy equipment piled on the shelf. - The fryer had grease running down the sides with multiple dried on foods stains. The top of the fryer edges had a thick layer of greasy food particle build up. -The preparation counter shelf's had greasy, dusty looking build up along the railing portion of the counter shelf. -The microwave had dried on food spills on the outsides that ran down the sides of the microwave. - The counter next to the stove had binders and papers stacked and unorganized. On 4-14-2022 at 12:42 PM review of the identified area was completed with the Dietary Manager (DM). During the review the DM confirmed the items needed to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an Infection Preventionist was on staff. This had the potential to effect all residents in the facility. The facility had a census of 146 residents. Findings are: Record review of the Facility assessment dated [DATE] revealed staffing will include an Infection Preventionist part time. An interview with the Facility Administrator on 4/14/22 at 11:45AM revealed there is no infection Preventionist on staff at this time.