Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on observation, interview and record review the facility failed to ensure wound treatment orders were provided according to the practitioner's orders for 1 (Resident 331) of 4 residents sampled. The facility census was 82. The findings are: Record review of Resident 331's care plan revealed the following about the resident: -had wounds to the right lower leg -required 1-2 staff members for transfers -had a diagnosis of heart disease and seizures Record review of Resident 331's orders revealed an order for betadine (an antiseptic that is used in a medical setting to help promote healing of skin wounds) paint the second digit of the left foot and the bottom of the right foot daily. An observation of wound care on 02-04-2025 at 10:22 AM with Registered Nurse (RN) C revealed the RN painted the left foot second toe with betadine and did not paint the area to the bottom of the right foot. An interview conducted with RN C on 02-05-2025 at 2:05 PM revealed the area to the bottom of the right foot should have been painted with betadine along with the left foot second toe. An interview conducted with the Wound Nurse (WN) D on 02-06-2025 at 9:35 AM confirmed the order was to apply betadine to the left foot second toe and to the area on the bottom of the right foot. Record review of the facility policy Wound Treatment Management dated 01/2023 revealed a policy statement to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observation, interview and record review the facility failed to implement interventions to prevent falls for 1 (Resident 54) of 4 residents sampled. The facility census was 82. The findings are: Record review of Resident 54's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required extensive assistance with toileting and showering -required moderate assistance with dressing, transfers, and bed mobility Record review of Resident 54's Comprehensive Care Plan revealed Resident 54 was at risk for falls and the interventions dated 01-06-2025 to prevent falls for Resident 54 was Dycem (a non-slip product that grips on both sides to prevent sliding) to the wheelchair seat. An observation on 02-05-2025 at 7:36 AM revealed no Dycem in Resident 54's wheelchair. An observation on 02-05-2025 at 9:30 AM revealed no Dycem in Resident 54's wheelchair. An interview with Nursing Assistant (NA) I on 02-05-2025 at 9:40 AM revealed fall interventions for Resident 54 were for gripper socks, non-skid strips next to the bed and to wear shoes when transferring. NA I reported Resident 54 doesn't need anything applied to the wheelchair because Resident 54 does well in the wheelchair. An observation on 02-06-2025 at 12:22 PM of Resident 54's wheelchair with the Director of Nursing (DON) revealed no Dycem on the seat of the wheelchair. An interview conducted with the DON immediately following the observation confirming the intervention of Dycem in the wheelchair was not implemented according to the care plan. Record review of the facility policy Fall Prevention revealed the following: -Policy statement: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -provide additional interventions as directed by the resident's assessment including but not limited to assistive devices, increased frequency of rounds, low bed, alternative call system access and therapy referrals. -each resident's risk factors and environmental hazards will be evaluated when developing the comprehensive plan of care. Interventions will be monitored for effectiveness, and the plan of care will be revised as needed.

Licensure Reference Number 175 NAC 12-006.09(J) Based on record review and interview the facility failed to provide nutritional supplements for 1 (Resident 54) of 2 residents sampled. The facility census was 82. The findings are: Record review of Resident 54's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required extensive assistance with toileting and showering -required moderate assistance with dressing, transfers, and bed mobility. Record review of Resident 54's physician orders dated 2-05-2025 revealed an order for Med Pass 2.0 give 4 ounces 4 times a day for weight loss. Record review of Resident 54's progress notes revealed Resident 54 did not receive med pass 2.0 on 02-05-2025 at 8:00 PM due to the supplement was unavailable. An interview conducted with the Certified Dietary Manager (CDM) on 02-06-2025 at 9:15 AM revealed the facility had Med Pass 2.0 on hand. An observation conducted on 02-06-2025 at 9:20 AM revealed a carton of Med Pass 2.0 in the refrigerator at the nurse's station for Resident 54. An interview with Registered Nurse (RN) H on 02-06-2025 at 12 PM with the Director of Nursing (DON) present revealed Resident 54 did not receive Med Pass 2.0 at 10:00 AM today because RN H did not know what it was. An interview conducted with DON on 02-06-2025 at 9:43 AM confirmed the progress note from 02-05-2025 at 8:00 PM indicated that Med Pass 2.0 was not given because it was unavailable. A follow up interview conducted on 02-06-2025 at 12:30 PM with the DON confirmed the nutritional supplement was not administered as ordered. Record review of the facility policy Weight Monitoring dated 01/2025 revealed the following: -Policy statement- based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -the facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes developing and consistently implementing pertinent nutritional approaches.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of 5% or less as evidenced by 2 errors out of 28 opportunities for error resulting in a medication error rate of 7.14%. This affected 1 (Resident 328) of 3 residents sampled. The facility census was 82. The Findings are: An observation on 02-05-2025 at 9:50 AM of Medication Aid (MA) J administering medications for Resident 328 revealed MA J administered the following: -levothyroxine 75 micrograms (mcg) administered 1 tablet -Tylenol 500 milligrams (mg) tablet administered 2 tablets -lansoprazole 3mg per 1 milliliter (ml) administered 10 ml. An interview was conducted with MA J during the observation on 02-05-2025 at 9:50 AM revealed Resident 328 had already ate breakfast. Record Review of Resident 328's physician orders dated 1-25-2025 revealed the following: -levothyroxine 75 micrograms (mcg) tablet give 1 tablet on an empty stomach. Give 30 minutes prior to the meal. -Tylenol 500 milligrams (mg) tablets give 2 tablets three times a day. -lansoprazole 3mg per 1 milliliter (ml) give 10 ml by mouth with breakfast. An interview with MA J on 02-06-2025 at 6:48 AM confirmed levothyroxine should have bee given 30 minutes prior to breakfast and lansoprazole should have been given with breakfast. Record review of the facility policy Medication Administration dated 01-2025 revealed the following: -Policy statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. - compare medication with the medication administration record to verify the resident's name, medication name, form, dose, route, and time. -administer medication as ordered in accordance with manufacturer's specifications.

Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review and interview; the facility failed to follow Enhanced Barrier Precautions (EBP, use of gown and gloves during high-contact resident care activities) and failed to ensure supplies for wound care were not in contact with soiled items for 1 (Resident 49) of 5 sampled residents. The facility identified a census of 82. Findings are: A review of the facility policy entitled Enhanced Barrier Precautions dated 12/2023 revealed the following: -Policy Explanation and Compliance Guidelines: 1c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices. Record review of Resident 49's Quarterly Minimum Data Set (Minimum Data Set - a comprehensive standardized assessment of resident's functional capabilities and health needs) dated 11/01/24 revealed the resident had unclear speech and was rarely/never understood and rarely/never understands. The BIMS (Brief Interview for Mental Status, an assessment to aide in identifying cognitive impairment) assessment was not completed due to the resident was rarely/never understood. The staff assessment indicated the resident had a short-term and long-term memory problem and had no memory recall. The resident was identified as dependent on staff for all cares except the resident required substantial/maximum assistance with transfers. The MDS identified that Resident 49 had an open lesion (e.g. cancer lesion), had a pressure reducing device for the bed and chair, and application of non-surgical dressings other than to feet. A record review of Resident 49's Physician Orders revealed the following orders: - 1/18/2025 Clean left shoulder open area with soap and water, pat dry, and apply border gauze daily. Observation on 02/04/25 at 11:09 AM revealed that EBP signage was located on the door of Resident 49s room and that a gown and glove use were required during high-contact cares. The resident's name label on the outside of the door was marked with an orange EBP label which indicated Resident 49 was on EBP. Observation on 02/04/25 at 11:10 AM revealed Registered Nurse (RN) A knocked on the door, entered the room with no gown in place, and placed a stack of wash cloths on top of the covers at the foot of the bed with no barrier beneath. RN A explained to the resident that they were going to perform a wound treatment. RN A washed hands for 24 seconds, donned gloves and prepared a pink basin of soapy water. RN A placed the basin directly on the floor near the head of the bed with no barrier between the basin and the floor. RN A proceeded to perform wound care to the left shoulder. RN A doffed gloves, performed hand hygiene for 19 seconds, donned new gloves and applied a pre-dated and initialed dressing. RN A doffed gloves and performed hand hygiene for 22 seconds. Throughout the observation of wound care, RN A did not have a gown on as required by EBP. Interview on 02/04/25 at 11:30 AM with RN A confirmed that treatment supplies, including the basin of water and the washcloths were placed on soiled surfaces with no barrier beneath them. RN A confirmed that the basin of water should not have been placed directly on the floor and washcloths should not have been placed directly on the bed linens. RN A confirmed that no gown was donned prior to performing wound care treatment for Resident 49. Interview on 02/04/25 at 12:00 PM with Director of Nursing (DON) confirmed wound supplies should be placed on an overbed table with a barrier or place a barrier on the floor if supplies needed to be placed there. The DON confirmed that there should be a barrier for wound treatment supplies if placed directly on the bed. The DON confirmed that Resident 49 was on EBP and that a gown should have been worn during the wound treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. An observation on 02/16/2025 at 1:09PM with the Maintenance Director (MD) during a facility tour revealed the following: -room [ROOM NUMBER] had a hole in the wall at the floorboard level of the bathroom. -room [ROOM NUMBER] the base of the toiled was stained, there was a hole at the base of the bathroom door, the caulking around the bathroom sink was visibly cracked and there was a strong urine odor. -room [ROOM NUMBER] had unpainted repairs to the wall around the window. -room [ROOM NUMBER] had a stained toilet base with a strong urine odor, scratches to the wall behind the bed nearest the door and the caulking around the heating unit was cracked. -room [ROOM NUMBER] was missing a light cover over bed nearest the window, the base of the toilet was stained, and 2 lights were out in the bathroom. -In the memory care unit, the wallpaper border above the rooms NW4, NW7, NW8 and NW9 was torn and missing in places. -The utility sink in the memory care unit had a sharp uneven hole to the right rear of the sink unit and the back board of the sink was cracked and separating from the counter. -The handrail to the exterior steps beside the south entrance was rusted and not secured to the right side of the bottom step. An interview with the Maintenance Director at 1:09 PM confirmed the above issues and further confirmed there were no active work orders for any of the issues mentioned. Licensure Reference Number 175 NAC 12-006.19 Based on observation, and interview the facility failed to ensure that a doorbell was functional at the north entrance of the facility, this had the potential to affect 32 residents identified as independent with mobility from a facility census of 82. The facility failed to ensure wallpaper,walls, light covers,and fixtures were maintained in clean condition and good repair, in 9 (302, 303, 306, 405, 408, NW4, NW7, NW8, and NW9) of 43 occupied resident rooms. The facility failed to maintain a utility sink in good repair in the memory care unit. This had the potential to affect 15 of 16 residents that reside on the unit. The facility to ensure an exterior stair hand railing was secured to the bottom step at the entrance to the south side of the facility. This had the potential to affect 12 residents identified as self-mobile without assistive devices. The facility census was 82. The findings are: A. An interview conducted with Social Service Director (SSD) on 02-05-2025 at 11:52 AM revealed that residents that are outside can enter the south entrance to the facility by the push button automatic door and the main entrance and the service entrance both have doorbells for the residents to ring if they need help back in the facility. An observation conducted on 02-05-2025 at 1:06 PM of the front door revealed when the doorbell was pushed that no one answered the door. The temperature outside was 26 degrees Fahrenheit. An interview conducted on 02-05-2025 at 1:12 PM with the Receptionist (Rec) E confirmed that the doorbell at the main entrance did not sound when pushed. An interview conducted with the Administrator in Training (AIT) on 02-05-2025 at 1:23 PM confirmed the doorbell chime was not plugged in at the main entrance as it should have been, therefore the doorbell did not sound.

Licensure Reference Number NAC 175 12-006.11(E) Nebraska Food Code 2017 4-202.16 Based on observation, interview, and record review; the facility failed to maintain the reach in refrigerator and a utility cart in a sanitary manner and failed to ensure food containers were not placed directly on the floor in the facility kitchen. This had the potential to affect 81 of 82 residents that ate food from the facility kitchen. The facility failed to ensure food items were sealed and dated on the memory care unit which had the potential to affect 16 of 16 residents that reside on the memory care unit. The facility identified a census of 82. Findings are: Observation on 02/03/25 at 7:45 AM revealed a reach-in refrigerator with white and red liquid splashes on the walls and a black utility cart with breadcrumbs and food debris on the second and third shelves. Observation on 02/04/25 at 9:10 AM revealed [NAME] B was preparing the lunch meal. [NAME] B retrieved a large container of sugar from the shelf and placed the container directly on the floor with no barrier beneath. [NAME] B measured the required amount, placed the lid on the container and returned the container to the shelf. [NAME] B retrieved a large container of flour and placed the container directly on the floor with no barrier beneath. [NAME] B measured the required amount, placed the lid on the container and returned the container to the shelf. Observation on 02/04/25 at 9:33 AM with the Certified Dietary Manager (CDM) revealed two open, unsealed bags of cereal in the Memory Care Unit. Interview on 02/04/25 at 9:33 AM with the CDM confirmed the bags of cereal should be sealed in a container and dated. Interview on 02/04/25 at 09:37 AM with the CDM confirmed the presence of breadcrumbs and food debris on the shelves of the utility cart and the liquid splashes inside the refrigerator. The CDM revealed that there was a cleaning schedule for the kitchen, but it had not been filled out. The CDM confirmed that the utility cart should be cleaned daily, and the refrigerator should be cleaned of any spills at the time of occurrence. Interview on 02/05/25 at 12:01 PM with the CDM revealed that 81 of 82 residents receive food prepared by the facility and 16 of 16 residents receive food in the Memory Care Unit. A review of the facility policy entitled Sanitation Inspection dated 01/2025 revealed the following: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner: a. Daily: food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. A record review of Nebraska Food Code dated 2017 revealed the following: 4-202.16 Nonfood-Contact Surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure a Level II PASRR screen was completed after Resident's 17 and 47 were diagnosed with a serious mental illness while residing in the facility. This affected 2 (Resident 17 and 47) of 5 sampled residents. The facility identified a census of 72. Findings are. A. Record review of Resident 17's PASRR (Pre-admission Screening and Resident Review) dated 5/23/2013 reveals no mental illness was listed as the current diagnosis for this resident. The current diagnosis for Resident 17 was Mood Disorder, Anxiety Disorder, Major Depressive disorder, Pseudobulbar Affect, Psychosis not due to a substance or know physiological condition, Dementia with behavioral disturbances, Psychotic disturbance, and Mood disturbance. The SSD (Social Services Director) was interviewed on 1/18/24 at 1:30 PM. The SSD confirmed Resident 17 had a negative PASSR on 5/23/2013. The SSD confirmed Resident 17 currently does have new mental health diagnosis that would require a referral for a PASSR level II and this had not been done. B. Record review of Resident 47's PASRR dated 11/19/2021 revealed There are no signs of a serious mental illness, intellectual disability, or a related found during the level 1 screen. Resident 47 currently had the diagnoses of Dementia with behavioral disturbances, Anxiety disorder, Delusional disorders and adjustment disorder with Anxiety. The SSD was interviewed on 1/22/24 at 10:30 AM . The SSD Confirmed Resident 47 had a PASSR completed on 11/19/21. The SSD confirmed Resident 47 should have had a referral for a PASSR level II, since resident has had new mental health diagnosis listed. The SSD further confirmed a referral had not been completed for Resident 47. C. Review of the facility's policy Titled Resident assessment-Coordination with PASARR (program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs) dated 10/2022 reveals All applicants to this facility will be screened for a serious mental disorder or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. The facility policy also indicates that any resident who exhibits a newly evident or possible serious MD (Mental disability), ID (Intellectual disability), or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that 1 resident (Resident 63) had a guardian/conservator as recommended by physician. The facility reported a census of 72. Findings are: According to Resident 63 electric record Resident 63 was admitted to the facility on [DATE]. According to Resident 63's electronic record, Resident 63 had the following diagnosis - history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). A record review of Resident's 63's electronic health record revealed a Letter of Capacity written by the resident's physician and dated March 30, 2023. The letter stated the resident has severe traumatic brain injury following a motor vehicle accident. Due to the permanent brain damage, the residents' condition will never improve. The physician also stated their professional opinion was that the resident lacks the capacity to make financial or medical decisions and a guardian/conservator would be appropriate at this time. A record review of Resident 63's Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents) dated 11/20/23 and signed by the MDS Coordinator revealed Resident 63 had a Brief Interview for Mental Status (BIMS - an assessment used to monitor cognition) of 7. A BIMS of 7 indicated the resident is severely cognitively impaired. An interview on 1/22/2024 at 12:58 PM with the facility Social Services Director (SSD) confirmed Resident 63's father was reported by the discharging hospital to have made decisions related to the Residents care. The SSD confirmed there was no signed documentation stating the residents' father was the residents Power of Attorney (POA). The SSD stated they were frequently unable to reach the residents' father by phone. The SSD confirmed they did not know about the physicians' Letter of Incapacity. The SSD was unable to produce any documentation supporting their attempts to find the resident a guardian. The SSD confirmed Resident 63 did not have a guardian or conservator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NAC 175 12-006.18 Based on observation and interview the facility failed to ensure bathroom baseboards were secure in rooms [ROOM NUMBER] and failed to ensure a safe and secure sink in bathroom shared by room [ROOM NUMBER] and 308. This affected 10 of 18 sampled residents (Residents 69, 6, 9, 17, 59, 7, 22, 1, 31, and 49). The facility census was 72. The findings are: An observation with the Nursing Home Administrator (NHA) during a tour of the facility environment on 01-22-2024 from 12:00 PM to 12:30 PM revealed the following: -rooms [ROOM NUMBERS]'s sink had a visible crack in the seal between the sink and the wall and when NHA put weight on the sink it moved. -The bathrooms in rooms [ROOM NUMBER] had base boards that were not secure to the wall. An interview on 01-22-2024 at 12:30 PM with the NHA confirmed that the baseboards were loose in the bathrooms of rooms [ROOM NUMBER] and the sink in rooms [ROOM NUMBERS]'s shared bathroom was loose.

NAC 175 12.006.11D Based on observation, interview and record review the facility failed to prepare food that was palatable and served at a temperature to prevent the potential for food borne illness. This had the ability to affect 71 of 72 residents that reside who ate food from the kitchen. The facility census was 72. The findings are: Record Review of Prestige Healthcare Management Food Preparation Guidelines dated 01/2024 revealed the following: -Policy- it is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. -Policy Explanation and Compliance Guidelines: The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. -Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes but is not limited to preparing foods as directed. -Foods and drinks shall be palatable, attractive and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include serving hot foods/drinks hot and cold food/drinks cold. Record Review of Prestige Healthcare Management's policy Record of Food Temperatures dated 01/2024 revealed that hot foods should be held at a temperature of 135 degrees Fahrenheit (F) or greater. Record Review of the Dining RD recipe for Chicken [NAME] dated 2023 revealed that the recipe called for boneless, skinless chicken breast from frozen. Season and bake the chicken until it reaches 165 degrees F, then dice or cut into strips. An observation on 01/18/2024 at 10:00 AM of [NAME] A preparing chicken Alfredo. [NAME] A went to the walk in and obtained precooked chicken breast pieces. Using gloved hands and a large spoon, [NAME] A spread the precooked chicken onto 4 sheet pans and placed in the oven at 325 degrees F. An observation on 01/18/2024 at 10:40 AM of [NAME] A removing chicken from the oven. [NAME] A obtained the temperature of the chicken revealing it had reached 165 degrees F. The chicken was then mixed in with the [NAME] sauce. On 1/18/2024 at 1:00 PM and evaluation of a sample meal tray with [NAME] A and the Dietary Manager (DM) using the facility thermometer revealed the [NAME] Beans were 127.4 degrees and the chicken in the chicken [NAME] was had to chew. An interview with [NAME] A on 01/18/2024 at 1:10 PM revealed that the beans should have been warmer and the chicken was tough. An interview with CDM on 01/18/2024 at 1:10 PM revealed that the beans should have been 135 degrees F or higher.

Licensure Reference Number 175 NAC 12-006.16C Based on observation, interview, and record review the facility failed to ensure the residents medical records were safe from unauthorized use. This had the ability to affect all residents in the facility. The facility reports a census of 72. Findings are: An interview on 1/17/24 at 6:30 AM with Medication Aide (MA-B) revealed MA-B used their personal laptop to connect to the facility system and administer medications. MA-B reported the facility laptop does not hold a charge and needed to be continuously plugged to function. MA-B stated they deleted the facility program with residents' information before they left every day. MA -B reported no one observed them deleting the patient history from the personal lap top. MA-B confirmed MA-B could access the information of all the facility residents on their personal device. MA-B confirmed that they knew they should not use a personal electronic device to access the residents' information. An interview on 1/17/2024 at 3:44 PM with the Director of Nursing (DON) revealed that they were unaware that anyone was using their own laptop in the facility to administer medications. When the DON was asked what they would do if they saw someone using their own laptop, the DON stated they would educate them and tell them to use the facility laptop. When asked the DON stated they could not ensure resident information was deleted from a personal laptop prior to someone leaving the building. The DON confirmed they could not guarantee resident information had not been copied to the staff members personal laptop. An interview on 1/18/2024 at 8:30 AM with the Nursing Home Administrator (NHA) The NHA Administrator stated that protection of medical records had been covered in the facility's general orientation for all employees. The NHA stated that it should not have happened. A follow up interview with the NHA on 1/19/2024 at 9:00 AM confirmed that a staff member would have access to any residents' records from their personal device while signed on to the facility system in the building. The NHA confirmed that the facility could not guarantee the security of the residents' records if the staff were using their personal electronic equipment to perform medication administration.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to notify the resident representative of a change in condition for one resident (Resident 24). The facility census was 88. Findings are: A. Record review of the facility policy, Compliance with Reporting Allegations of Abuse/ Neglect/Exploitation revised 10/2022 revealed the following procedure for notification of a Resident Representative under title Procedure for Response and reporting Allegations of Abuse/ Neglect/ Exploitation, The Nurse Will: Notify the attending physician, resident's family/legal representative, Medical Director. An observation on 1/17/23 at 10:59 AM revealed Resident 24's right ear was purple from the middle of the ear to the top of the ear. The right ear was purple on the inside as well as the outer upper ear lobe. Record review of physician orders revealed that an order was obtained 1/16/23 at 7:45 PM from Primary Care Physician Ice Q hour (Q means every) PRN (means as needed) x 24 hours to right ear. On 1/17/23 at 12:42 PM an interview with the Resident Representative (RR) revealed that the RR was visiting Resident 24, when notification was made concerning the bruise on the right ear, and that the facility staff was unsure what the bruise was from. On 1/23/23 at 1:56 PM interview with the DON (Director of nursing) confirmed that an investigation had not been completed on Resident 24's right ear bruising. On 1/23/23 at 3:05 PM an interview with the Administrator (ADM)confirmed that the ADM was aware of the resident's bruised ear. The ADM stated, Yes an investigation should have been completed and called in. B. Record review of Resident 24's progress notes revealed that on 12/3/22, the nurse discovered an open area to the left heel. The nurse documented that notification was made to the Primary Care Physician. No documentation was received that notification was completed to the resident's representative. Record review of Prestige Weekly Wound Assessment, section 3.) Current Wound Status/Additional comments revealed a comment section with documentation that states. Discussed heel wound with Power of Attorney (POA) on 1/16/23 while in the facility. Interview on 1/17/23 at 12:42 PM with RR confirmed, the RR was not notified of the Left heel pressure ulcer until visiting the resident on 1/16/23. The RR questioned staff on the placement of the boot and was told that resident 24 had developed a Left heel pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.2(8) Based on observation, interview and record review, the facility failed to investigate and report potential neglect as evidenced by not reporting a significant injury for Resident 62; failed to investigate send an investigative report to the State Agency for a resident to resident altercation for Resident 56; and failed to investigate an injury of unknown origin for Resident 24. The facility census was 88. Findings are A. Record review of Facility Policy and Procedures entitled Compliance with reporting allegations of abuse/ neglect/exploitation dated revised October 2022 revealed the following information: - It is the policy of this facility to report all allegations of abuse / neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframe's. - Definitions included: - Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and , if verified, could be non compliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Investigation: The facility will investigate all allegations and types of incidents in accordance with facility procedures for reporting / response. - Reporting / Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to other agencies as required and take all necessary corrective actions depending on the results of the investigation. - Procedures for reporting allegations of abuse / neglect/ exploitation: When suspicion of abuse / neglect or reports of abuse / neglect occur, the Licensed nurse will: c. Notify the Administrator or designee. 2. The Administrator will: a. Notify the appropriate agencies immediately as soon as possible, but no later then 24 hours after discovery of the incident. In the case of serious bodily injury, no later then 2 hours after discovery or forming the suspicion. d. Follow up with the appropriate agencies during business hours to ensure the report was received. f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation and indicate any corrective actions taken, if the allegation was verified. Record review of Resident 24's diagnoses revealed the following: Alzheimer's Disease with late onset, Muscle Weakness, Difficulty in walking, other lack of coordination, unspecified abnormalities of gait and mobility. Record review of Resident 24's Minimum Date Set (MDS, a federally mandated assessment tool used for care planning)dated 1/3/2023 revealed that the facility staff assessed the following: Section M included pressure ulcer for Resident 24. Section G of the MDS assessed functional status and Resident 24 was total dependance with bed mobility, transfers, and repositioning. Record review of Resident 24's BIMS (Brief Interview of Mental status, a tool used to assess a resident's cognitive ability)revealed a score of zero and zero indicates Severe cognitive impairment. On 1/17/23 at 10:30 AM Resident 24 was in room, sitting in wheel chair. Deep blue discoloration noted on right ear. Bruise covered top half of right ear with slight swelling. Record review of New skin and wound identification and progresss record revealed Resident 24 had a new bruise identified on the right ear on 1/16/2023. Record review of physician orders for Resident 24 on 1/16/23 revealed an order was received for ice to the right ear every hour as needed for 24 hours. Record review of Resident 24's careplan dated 1/17/23 revealed no mention of the right ear bruise. An observation on 1/23/23 at 7:40 AM of Resident 24 being transferred with a mechanical lift, by Nurse Aide B and Nurse Aide C revealed the left side of the lift bumped the resident's head 10 times. An interview with Nurse Aide B on 1/23/23 at 2:14 PM confirmed Resident 24's transfer is difficult due to contractures and the lift rubs on the resident's head frequently. On 1/23/23 at 1:56 PM interview with the DON (Director of nursing) confirmed that the DON was unaware of the bruise to the right ear and that the Infection Preventionist (IP) tracks all the skins. The DON further confirmed that an investigation had not been completed on Resident 24's right ear bruising. Record review of the facility incident report log that was obtained from the DON revealed Resident 24's right ear bruise was not on the incident report log. An interview on 1/23/23 at 2:00 PM with the DON confirmed the right ear bruise was not on the incident report log and was not in Resident 24's assessments or in the risk management documentation in the computer. Further interview with the DON confirmed that the DON was aware of the bruise from the telehealth documentation to physician. An interview at 2:05 PM with the Infection prevention nurse (IP) revealed that the IP nurse only follow ups on skin concerns related to pressure ulcers and not bruises. On 1/23/23 at 3:05 PM an interview with the Administrator (ADM) confirmed that the ADM was aware of Resident 24's ear condition. The ADM stated, Yes an investigation should have been completed and called in. B. Observation on 01/17/23 at 08:30 AM revealed that Resident 62 resided on the secured unit of the facility due to dementia. Record review of Resident 62's most recent Quarterly MDS dated [DATE] revealed an admission date of 2/22/21. Diagnoses included Dementia with Behavioral Disturbances, Anxiety Disorder, Major Depressive Disorder severe with Psych symptoms, Delusional Disorder [a mental disorder in which a person can't tell real from imagined] and Psychotic disorder [a mental disorder characterized by a disconnection with reality]. The resident had a Brief mental Illness [BIMS] score of 00 which indicated severe cognitive impairment and required supervision with walking in and out of room. Record review of a facility Incident Report for Resident 62 dated 12/3/22 revealed that Resident 62 was found on the floor in the residents room after a fall had occurred. Resident 62 was seated on the floor and had blood on [gender] face from a laceration on the left eyebrow. The resident was unable to give a description of what had occurred. Resident 62 was assessed and was sent to the hospital due to a laceration to the eyebrow. The resident exhibited a pain level of 3 as exhibited by occasional moans, tensed distressed pacing, and was reassured by voice and touch. The resident exhibited wandering behavior prior to the fall with injury. Record review of Progress Notes revealed the following documentation related to the fall with injury: 12/3/2022 12:15 Nursing Note Text: Staff called this nurse and stated Resident is sitting on the floor and hit her head because her forehead is bleeding Upon entering room resident noted sitting on floor with gash to left eyebrow. Resident was moving around trying to get up and stand up. ROM is same as baseline. Pink area noted to left hip. No s/s of pain. Attempted to cleanse area with saline and apply steri strips. Notified Dr. received orders to send to ED [emergency department]. Call placed to residents husband and has been updated of transport. [Husband] would like a bed hold if gender is admitted to the hospital. 12/3/2022 16:25 Nursing Note Text: Resident returned from hospital via stretcher with medical transporting. Resident has a large hematoma to left eyebrow where laceration was sealed with dermabond [a liquid skin adhesive]. Record review of Weekly Skin Review dated 12/3/22 revealed a new open area. Documentation included: Resident fell today. Obtained laceration to left eyebrow 2.0 inches by 1.0 inches prior to sealing with dermabond, has redness to left hip that is fading. Old scabbed area to Left upper shoulder 1.3 centimeters by 1.0 centimeters. Record review of the facility Reportable Incidents for December 2022 revealed that the fall with significant injury for Resident 62 was not investigated as a significant injury and no report was made to the required state agencies. Interview on 01/23/23 at 11:11 AM with the facility Administrator [ADM] confirmed that it should have been investigated and reported as a significant injury. The ADM confirmed there was no facility investigation into Resident 62's significant injury other then the facility Incident Report and that the injury was not called in to the required state agencies. C. Record review of a note written on facility letter head dated 8/10/22 revealed documentation of a resident to resident physical altercation between Resident 62 and Resident 56. The note read: On August 10 2022, right after lunch, Resident 62 exited [gender] room and went up to Resident 56 who was at a table having a Hospice visit with a nurse and Resident 62's hand made contact with the right side of Resident 56's cheek. Hospice nurse witnessed the event. No injuries or redness present on Resident 62 and Resident 56 redirected successfully. This nurse placed call to Resident 56's Power of Attorney who stated they had already been notified by the Hospice nurse about the situation. Resident 56 reassessed later in the shift and remains without injury / redness. Administrator made aware of the situation. The note was signed by the Registered Nurse on duty. Record review of an intake sent into Adult Protective Services [APS] revealed a resident to resident incident which involved Resident 56 had occurred and was reported to APS on 8/11/22. Record review of all facility Reportable Incidents for August 2022 revealed that no facility investigation had been completed regarding the incident of resident to resident abuse between Resident 62 and Resident 56. Interview on 01/23/23 at 11:11 AM with the facility Administrator [ADM] confirmed there was no investigation into the incident between Resident 62 and Resident 56 . The ADM confirmed that a facility investigative report into the incident was not sent into the required state agencies within 5 working days as required.

Licensure reference: 175 NAC 12-006.09D1b Based on observation, interview, and record review, the facility failed to assistance at meals to 2 residents [Resident 10 and 33] of 2 sampled for eating assistance and failed to . The facility had a total census of 88 residents. Findings are: A. A review of Resident 10's quarterly MDS [Minimum Data Set, a comprehensive assessment used for care planning] dated 12/24/22 revealed Resident 10 required limited assist of 1 for eating. A review of Resident 10's care plan revealed focus area of activity of daily living self-care performance deficit. Intervention revised on 9/14/22 revealed Resident 10 is to be assisted with every meal. Observation on 1/17/22 between 12:29 PM to 12:57 PM revealed Resident 10 seated in the dining room with a plate in front of Resident 10. At 12:52 PM Resident 10 was observed to have eaten none of the food on the plate and the silverware was wrapped in the napkin. At 12:57 PM, Nurse Aide A unwrapped Resident 10's silverware, assisted Resident 10 with clothing protector and encouraged Resident 10 to eat. Resident 10 was observed to eat bites of main entrée and dessert. Observations on 1/23/23 between 12:54 PM to 1:39 PM revealed Resident 10 in the dining with their lunch plate. Resident 10 was assisted with set up and putting on clothing protector at 12:54 PM. No other assistance or cueing was provided. Resident 10 ate bites of roast beef. Resident 10 was assisted out of the dining room at 1:39 PM by Nurse Aide N. In an interview on 1/24/23 between 7:24AM to 7:41 AM, the Director of Nursing confirmed Resident 10 needs cueing and sometimes physical assist with eating. B. A review of Resident 33's 10/5/22 quarterly MDS [Minimum Data Set, a comprehensive assessment used for care planning] revealed Resident 33 required supervision of 1 for eating. A review of Resident 33's care plan revealed a focus area regarding Resident 33 requiring assistance with activities of daily living. Intervention dated 2/23/21 revealed Resident 33 required set up and limited assist as needed. Observations on 1/17/22 between 12:15PM to 12:50 PM revealed Resident 33 seated in the dining room with a lunch meal in front of Resident 33. Resident 33 sat at the dining room table with a lunch plate until 12:50 PM when Nurse Aide L came to assist Resident 33 and asked that Resident 33's meal be reheated. Observations on 1/23/23 at 8:42 AM to 9:21AM revealed Resident 33 at the table in the dining room with a breakfast meal. At 8:42 AM, Dietary Aide M assisted Resident 33 with eating a banana. Resident 33 was observed to hold a glass and attempt to drink from a straw when the straw fell out of the glass. Resident was assisted out of the dining room at 9:21 AM after eating part of a pancake. Observations on 1/23/23 between 12:48 PM to 1:21 PM revealed Resident 33 seated in the dining room and served a lunch plate at 12:48 PM. Between 1 PM to 1:28 PM Resident 33 was observed to eat bread from the lunch meal. No assistance was observed being provided between 1PM to1:28 PM. At 1:28 PM, Nurse Aide N asked Resident 33 if Resident 33 was done with their meal and wanted to lay down. Nurse Aide N then began feeding Resident 33. Resident 33 ate 25% of the meal before being assisted out of the dining room. A review of weights in the electronic medical record for Resident 33 revealed a weight of 186.2 lbs. on 12/26/22 and a weight of 176.7 lbs. on 1/24/23 which reflects a loss of 5.1%. In an interview on 1/24/23 at 7:24 AM with the Director of Nursing revealed Resident 33's need for assistance varies between cueing and extensive assistance. In an interview on 1/24/23 at 1:30 PM, the Consultant Registered Dietitian confirmed Resident 33 required assistance with eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Observation on 01/17/2023 at 10:45 AM revealed Resident 78 lying in bed. No TV on or music playing. Observation on 01/23/2023 at 02:30 PM revealed Resident 78 lying in bed. No TV on or music playing. Observation on 01/24/2023 at 11:30 AM revealed Resident 78 lying in bed. No TV on or music playing. Record review of Resident 78's Medical record revealed an admission date of 12/22/2023 with diagnosis of history of traumatic brain injury. Record Review of the Recreation Services assessment dated [DATE] revealed Resident 78's short-term and long-term memory is fair and decision making ability is fair. The assessment further revealed leisure preferences of trivia and discussions, program preferences of 1:1, with family/friends and in-room. Record review of the Interview for Daily and Activity Preferences for Resident 78 dated 12/29/2022 revealed the following: How important is it to listen to music you like? Coded as very important. How important is it to keep up with the news? Coded as somewhat important. How important is it to you to do things with groups of people? Coded as somewhat important. How important is it to you to do your favorite activities? Coded as very important. Review of the activity tasks in the electronic medical record for January 2023 revealed 1:1 program documented as TV on January 1, socialization on January 5, socialization on January 12, socialization on January 17, and socialization on January 18. There was no documentation of listening to music, keeping up with the news or trivia. Review of the Comprehensive Care Plan dated 12/22/22 revealed no individualized focus for activities. Review of the medical record for Resident 78 revealed no activity progress notes. An interview with the Director Of Nursing on 01/24/23 at 10:40 AM revealed the Activity Director should have developed an individualized activity program for Resident 78 from the assessment for activity preferences and should be providing activities. Licensure Reference Number 175 NAC 12-006.09D5a Based on observations, record review and interview, the facility failed to provide individualized activities for 3 ( Resident 56, 61 and 78) of 3 residents reviewed. The facility census was 88. Findings are: A. Record review of Resident 56's annual MDS [MDS, a comprehensive assessment used to develop a resident care plan] dated 6/24/22 revealed an admission date of 4/7/21, a Brief Interview for Mental Status [BIMS] score of 00 which indicated severe cognitive impairment, required extensive assist with Activities of Daily Living [ADL's] and locomotion on unit and total assist from staff with locomotion off the unit. Section F, the staff assessment of daily activities preferences, identified that Resident 56 enjoyed listening to music, doing things with groups of people, participating in favorite activities, spending time outdoors. Record review of Physician orders dated 9/20/21 revealed an order to admit to Prestige Care and Rehabilitation secured dementia unit. Record review of Resident 56's Recreation Services Assessment completed 6/28/22 identified that Resident 56's vision was good with glasses, hearing was intact, had clear speech, had wheelchair use, had activity adaptation of talking books and enjoyed being read to with 1:1 assistance. Leisure preferences include: read daily chronicle part of groups, social club, watching crafts, hand fidgets, soft music, watching bingo cards and tablet time, nature music and meditation, hand massage and relaxation programs, social parties and visiting with family. Record review of Resident 56's Comprehensive Care Plan dated 11/28/22 revealed the following information: · Provide emotional support through 1:1 visit by social service, activities staff as often as necessary · The resident is dependent on staff and activities for meeting emotional, intellectual, physical, and social needs r/t Disease process dementia · [ Resident name] will attend/participate in activities of choice 3-5 times weekly through 2/21/23 · All staff to converse with resident while providing care. · [Resident name] likes enjoys listening to soft relaxing music and sitting in her recliner watching tv shows, likes hand fidgets and dolls, enjoys watching most activities and being at the dinning room table. [Gender] enjoys visits and going with her family on outings. · Engage [resident name] in simple, structured activities that avoid overly demanding tasks · Provide a program of activities that accommodates Linda's abilities · Reminisce with [Resident name] using photos of family and friends. · Please continue to encourage [Resident name] socialization and activities if she is able and please listen and discuss any concerns. Interview on 01/17/23 at 11:25 AM with Resident 56's family revealed that the family visits several times per week and has not observed any activities being done in the secured care unit. Observations of Resident 56 revealed the following: - 01/17/23 8:45 AM resident seated in the recliner and sleeping in a room on the secured unit of the facility. The TV was off. - 01/17/23 9:00 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/17/23 9:15 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/17/23 9:30 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/17/23 10:25 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/17/23 1:10 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/17/23 2:15 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/17/23 3:18 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 07:30 AM Up and dressed and in wheelchair in dining area area of unit, eyes closed and had a puzzle game in front of the resident on the table. - 01/23/23 9:20 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/23/23 9: 50 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/23/23 10:00 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/23/23 10:25 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/23/23 1:10 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 2:15 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 3:10 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 03:40 PM seated in recliner in room, TV is on. staff are doing nail care for 2 residents in the dining area. Interview with Medication Aide [MA] E at 7:32 AM on 1/23/22 revealed that direct care staff do activities on the unit when they have time. Resident 56 doesn't really participate much but does like to have nails done. Interview with the facility Activity Director on 01/23/23 at 08:39 AM revealed the activities in the unit are provided by the direct care staff working in the unit. They have materials that they can do things with the residents. The higher functioning can come out and join the group activities outside of the unit. Documentation of activity participation is in the Electronic Medical Record [EMR] under the task area for POC response. The Activity Director confirmed that the activity staff for the facility do not do any activities on the secured unit. Interview on 01/23/23 at 9:55 AM with MA E revealed that direct care staff in the unit do not document activity participation in the EMR. The direct care staff tell the Activity Director what activities were done and the Activity Director documents in the EMR. Interview on 01/23/23 at 10:00 AM with Nursing Assistant [NA] D revealed that it is difficult to provide activities in the unit with this many residents in the unit. NA D stated that they spend all their time toileting, providing meals and assist, giving baths and watching residents that are a fall risk and who wander. NA D stated it is hard to get everything done and try to provide activities also. There are always just 2 staff scheduled in the unit on the day and evening shift and 1 on the night shift. Observation on 1/23/23 of the secured care unit in the facility revealed a total of 16 residents resided in the unit. Record review of Resident 56's Activity Participation Records [APR] revealed the following: - Record review of the past 30 days of 1:1 activity participation revealed no data found. - Record review of the past 30 days of group events revealed no data found - Record review of the past 30 days of sensory programs revealed no data found - Record review of the past 30 days of self directed activity revealed no data found Record review of Resident 56's Activity Progress Notes revealed no progress notes related to activities. B. Observation on 1/17/23 at 8:30 AM revealed that Resident 61 resided on the secured unit of the facility. Record review of Resident 61's significant change MDS dated [DATE] revealed an admission date of 12/21/21, a BIMS score of 2 which indicated severe cognitive impairment and required extensive assist with Activities of Daily Living [ ADL's] and locomotion on unit. Section B identifies clear vision and hearing, clear speech and usually understood and understands. Section E activity preferences included: very important to do favorite activities and go outside for fresh air when weather is good and somewhat important to do activities in groups. Diagnoses included: Dementia with Behavioral Disturbance, Anxiety and Delusional Disorder [a type of mental illness that causes people to be unable to distinguish reality from unreality]. Record review of Resident 61's Activity Assessment completed on 6/29/22: identified the following information for Resident 61: - Intact vision, hearing, speech, speaks Spanish only, interests in trivia, discussion, reading, social clubs, crafts, TV, trips out of facility bingo and cards, walking, religious activities and praying, music and hand massages. Prefers small groups or 1:1, in and out of room and outings. Record review of Resident 61's Comprehensive Care Plan dated 12/15/22 revealed the following information: · The resident is dependent on staff for emotional, intellectual, physical, and social stimulation r/t Cognitive deficits · The resident will attend/participate in activities of choice 2-3 times weekly by next review date 12/9/22 · Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as Spanish translation cards, the number for a translator 1-800-225- 5254, Compatible with individual needs and abilities; and Age appropriate. · [Resident name] speaks Spanish . Per daughter gender enjoys exercising, hand massages, nails painted, watching tv (Hispanic channels), coloring, painting, looking at pictures in magazines and books · Engage the resident in simple, structured activities that avoid overly demanding tasks. Observations of Resident 61 revealed the following: - 01/17/23 08:17 AM resting in bed in room, light off, no tv in room, no radio in room. No activities going on in the unit. - 01/17/23 08:45 AM NA D got resident up from bed and toileted her, then brought her into the dining area and provided breakfast. Ate independently. After breakfast, resident sat in the dining area with a baby doll until about 10:00 AM, then back to the residents room with staff. No activity going on in the unit. - 01/17/23 10:21 AM resident in bed sleeping, light off in room, No activity going on in the unit. - 01/17/23 11:40 AM MA E went into the residents room to toilet Resident 61 and get resident up for lunch. NA E brought resident to the lunch table and gave the resident a baby doll to play with. Resident sat and stared at it on the table. No other activities going on in the unit. - 01/17/23 12:15 PM resident ate lunch independently with cueing from staff. - 01/17/22 1:10 PM resident sat at table in dining area with baby, no activity going on in the unit, no staff interaction with the resident. - 01/17/23 2:10 PM resident in bed in room sleeping, no activity in unit, light off. - 01/17/23 3:20 PM resident remains in bed asleep. light off, no activity in the unit. - 01/23/23 07:32 AM resident in bathroom room with NA D. No activities going on in the unit - 01/23/23 08:45 AM Resident 61 ate breakfast in the dining area of the unit. Music was on in the dining area, no activities going on in the unit - 01/23/23 09:10 AM Resident 61 sat in the dining room, fiddling with a napkin. The Radio and TV were both on in the unit but no interaction from staff, no activities going on in the unit - 01/23/23 9:50 AM Sleeping in bed, no activities going on in the unit - 01/23/23 10:00 AM resident in bed sleeping, no activities going on in the unit. - 01/23/23 10:25 AM resident in bed sleeping, no activities going on in the unit. - 01/23/23 1:10 PM resident in bed sleeping, no activities going on in the unit. - 01/23/23 2:15 PM resident in bed sleeping, no activities going on in the unit. - 01/23/23 3:10 PM resident in bed sleeping, no activities going on in the unit. Record review of Resident 61's Activity Participation Records revealed the following: - Record review of the past 30 days of 1:1 activity participation revealed no data found. - Record review of the past 30 days of group events revealed no data found. - Record review of the past 30 days of sensory programs revealed no data found. - Record review of the past 30 days of self directed activity revealed no data found. Record review of Resident 61's facility Activity Progress Notes revealed no progress notes related to activities. Interview with MA E at 7:32 AM on 1/23/22 revealed that direct care staff do try to activities on the unit when they have time but it is difficult with all the tasks they have to ensure get done. Interview with the facility Activity Director on 01/23/23 at 08:39 AM revealed the activities in the unit are provided by the direct care staff back there. They have materials that they can do things with the residents. The higher functioning can come out and join the group activities outside of the unit. Documentation of activity participation is in the electronic medical record under the task area for POC response. The Activity Director confirmed that the activity staff for the facility do not do any activities on the secured unit. Interview on 01/23/23 at 09:35 AM with MA E confirmed that activities are done by the staff in the unit and no activity staff come back to provide any activities in the unit. Stated that NA D speaks Spanish and does converse with Resident 61 whenever NA D is working Interview on 01/23/23 at 9:55 AM with MA E revealed that direct care staff in the unit do not document activity participation in the electronic medical record. The direct care staff tell the activity director what activities were done and the Activity Director documents in the Electronic Medical Record. Interview on 01/23/23 at 10:00 AM with Nursing Assistant [NA] D revealed that it is difficult to provide activities in the unit with this many residents in the unit. NA D stated that they spend all their time toileting, providing meals and assist, giving baths and watching residents that are a fall risk and who wander. NA D stated it is hard to get everything done and try to provide activities also. There are always just 2 staff scheduled in the unit on the day and evening shift. Observation on 1/23/23 10:05 AM of the secured care unit in the facility revealed a total of 16 residents resided in the unit. Interview on 01/24/23 at 12:08 PM with the facility Administrator [ADM] confirmed that the facility staff was unable to find documentation of any activity participation for Resident 61. The ADM confirmed that direct care staff provide all activities in the secured unit and agreed that it would be difficult for 2 staff to provide activities and provide care to meet the residents needs with the census of 16 that resided in the secured unit.

B. On 01/17/23 at 01:20 PM observation of Resident 22 revealed a wanderguard to the right wrist and another wanderguard attached to Resident 22's wheelchair. Record review of the Comprehensive Care Plan for Resident 22 dated 12/08/2022 revealed a focus of At risk for elopement with opportunity. An intervention of apply wanderguard to right wrist and check for proper function at all times. Review of Resident 22's progress notes, Medication Administration Record for January 2023 and Treatment Administration Record for January 2023 revealed no documentation of checking the wanderguard for proper function. On 01/24/23 at 07:37 AM an interview with LPN-Q (Licensed Practical Nurse) revealed the nurses check the wanderguards and they document it in the computer daily. LPN-Q was unable to show documentation in the computer that the wanderguard is checked everyday. On 01/24/23 at 10:40 AM an observation and interview with the Administrator revealed the wanderguard that was attached to the wheelchair was checked by the Administrator and did not work and the expiration date on the wanderguard was 02/26/22. The wanderguard on the wrist of Resident 22 had an expiration date of 11/23/22. On 01/24/23 at 10:40 AM an interview with the DON (director of Nursing) confirmed there was no documentation in the medical record the wanderguard for Resident 22 had been checked daily. DON further confirmed the nursing staff are to check the wanderguards daily to ensure proper functioning. Licensure reference: 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to ensure Wanderguard bracelets [a bracelet that triggers alarms and can lock monitored doors to prevent residents from leaving unattended] were functional for 2 residents [Resident 10 and 22] of 2 sampled residents at risk for elopement. The facility had a total census of 88 residents. Findings are: A. A review of Resident 10's care plan revealed a focus area dated 6/27/22 regarding Resident 10 being at risk for elopement. Interventions for Resident 10 included ensure that Wanderguard bracelet is in placed and check for its functioning. A review of Resident 10 Medication and Treatment Administration Record for 1/2023 did not reveal any orders for Wanderguard bracelet or for checking Wanderguard bracelet for function. Observations on 1/23/23 at 10:45 AM revealed a Wanderguard bracelet attached to Resident 33's wheelchair. Licensed Practical Nurse O checked the Wanderguard bracelet and determined that it was not functional. In an interview on 1/23/23 at 10:45 AM, Licensed Practical Nurse O confirmed that there was no order for the Wanderguard bracelet and no orders for the bracelet to be checked for function. In an interview on 1/24/23 between7:24 AM to 7:41 AM, the Director of Nursing confirmed Wanderguard bracelets need to be checked for function daily and changed every 90 days.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(2) Based on observation, record review and interview; the facility failed to have a resident centered toileting program for Resident 57 and failed to provide pericare in a manner to prevent potential infections for Resident 24. The facility staff identified a census of 88. The findings are: A. Record review of Resident 57's comprehensive care plan dated 09/08/2020 revealed Resident 57 requires extensive assistance with toileting X 1 staff and Resident 57 is frequently incontinent of bladder and is continent of bowel. Review of the Quarterly/Comprehensive Bundle dated 12/12/2022 revealed Resident 57 is always continent of bladder and bowel. Review of Resident 57's Quarterly Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/18/22 revealed yes to a toileting program, and frequently incontinent of urine and bowel. According to the Resident Assessment Instrument (RAI) Manual simply tracking continence status using a bladder record or voiding diary should not be considered a trial of an individualized, resident-centered toileting program. Review of Resident 57's Medical Record revealed no evidence of a trial of an individualized, resident-centered toileting program. Review of Resident 57's Comprehensive Care Plan revealed no focus of an individualized resident centered toileting program. On 01/24/23 at 08:35 AM an interview with the MDS nurse confirmed there was no individualized toileting program for Resident 57. MDS nurse identified the intervention of toilet q 2-3 hours and PRN as the toileting program and agreed it was an intervention not a toileting program. Interview with the DON (Director Of Nursing) on 01/24/23 at 10:40 AM confirmed that Resident 57's comprehensive care plan did not address a individualized toileting program. The DON further confirmed that toilet q 2-3 hours and PRN is an intervention and not an individualized toileting program. B. Record review of the facility's Perineal Care Policy revised 10/2022 #9 under Policy Explanation and Compliance Guidelines: states If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. A. Cleanse buttocks and anus, front to back; vagina to anus in females using a separate washcloth or wipes. B. thoroughly dry. On 1/23/23 at 7:40 AM observation of Nurse Aide C providing perineal care to Resident 24 revealed Nurse Aide C wiping the resident's perineal area numerous times with 3 wadded up wipes that were were soiled with fecal matter. No additional wipes were utilized. The nurse aide removed the soiled gloves without the benefit of hand hygiene and then applied a clean pair of gloves. Interview with the Director of Nursing (DON) on 1/23/23 at 3:20 PM confirmed that Nurse Aide C did not follow the policy for proper perineal care to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6(7) Based on observation, record review and interview; the facility staff failed to change the Oxygen tubing weekly for Resident 12 and failed to change the nebulizer mask and tubing for Resident 57. The facility staff identified a census of 88. The findings are: A. On 01/17/23 at 10:09 AM an interview with Resident 12 revealed (gender) is on continuous oxygen. Resident 12 stated that (gender) does not think the oxygen tubing is changed as often as it should be. Observation on 01/17/23 at 10:15 AM revealed no date on the Oxygen tubing connected to Resident 12's oxygen concentrator and no date was on the tubing connected to the oxygen tank on the wheelchair. Review of the Comprehensive Care Plan dated 06/29/2021 revealed a focus of Resident 12 has Emphysema (a disorder affecting the tiny air sacs of the lungs) and Chronic Obstructive Pulmonary Disease (a condition constricting the airways and causing difficulty in breathing). Interventions include Oxygen at 2L Liters) per Nasal Cannula continuously. Review of the facility policy and procedure dated 4/2012 and revised 12/2022 revealed oxygen tubing and mask/cannula should be changed weekly and as needed if it becomes soiled or contaminated. Review of Resident 12's MAR/TAR (Medication Administration Record/Treatment Administration Record) revealed no indication of Oxygen tubing being changed. Interview with the DON (Director of Nursing) on 01/24/23 at 10:40 AM confirmed there is no documentation that staff have changed the oxygen tubing. B. Observation on 01/17/23 at 10:22 AM revealed Resident 57 had a nebulizer (a device that turns liquid medication into a misk which is inhaled into the lungs) mask laying on the bedside table uncovered. There was no date on the mask or tubing. On 01/17/23 at 11:04 AM observation revealed the nebulizer mask laying uncovered on the bedside table. On 1/23/23 at 08:33 AM observation revealed the nebulizer mask remained on the bedside table not covered. Review of physician orders for Resident 57 dated 11/30/22 revealed the following ALBUTEROL NEB (nebulizer) 0.083% INHALE ONE VIAL PER NEBULIZER EVERY 4 HOURS AS NEEDED (PRN) FOR WHEEZING Review of the MAR for December 2022 revealed PRN Albuterol was given on [DATE], [DATE] X 2, [DATE], [DATE] and [DATE]. Review of the January 2023 MAR/TAR revealed no documentation of PRN Albuterol treatment being administered. There is no indication in the medical record that the nebulizer mask was changed. Review of the nebulizer therapy policy and procedure dated 4/2019 and revised 12/2022 revealed after medication therapy is complete, turn the machine off and disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. Change nebulizer tubing every seventy two hours or per facility policy. Interview with the Director Of Nursing on 01/24/23 at 10:20 AM confirmed there was no documentation of the nebulizer mask and tubing being changed.

Licensure reference: 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to ensure pureed diets were prepared in a manner to maintain nutritional value of meal for 3 [Residents 24, 63, and 73] of 3 residents who received pureed diets. The facility has a total census of 88 residents. Findings are: A. Observations on 1/23/23 between 12 PM-12:27 PM revealed Dietary Aide U placing 3 servings of ground beef pot roast into robo coupe and adding a cup of gravy to mixture. Dietary Aide U then added an unmeasured amount of water from a pot on the stove that had been used to cook noodles. Dietary Aide U prepared beef base and added an unmeasured amount to the robo coupe. The pureed roast beef was than divided between 3 plates for residents receiving pureed food. B. Observations on 1/23/23 between 12 PM-12:27 PM revealed pureed cabbage/carrots were made with an unmeasured amount of beef base and divided between 3 plates for residents receiving pureed food. C. In an interview on 1/23/23 between 12 PM-12:27 PM, Dietary Aide U reported being unaware any recipes for pureed food. D. In an interview on 1/24/23 between 10:59 AM-12 PM, Dietary Director T T confirmed the facility has recipes for preparation of pureed food, liquids should be measure and the facility has veg soup base available for preparation of pureed foods. E. A review of undated recipe for pureed beef pot roast recipe for 3 servings revealed 9 ounces of pot roast is to be pureed with 3 ounces of brown gravy. The recipe stated if product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. F. A review of undated recipe for pureed cabbage with carrots for 3 servings revealed 1.5 cups of cabbage with carrots is to be pureed with 4 tablespoons and 2 teaspoons of margarine. The recipe stated if product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. G. On 1/24/23 at 1:30 PM, the Consultant Registered Dietitian provided a list that identified Residents 24, 63, and 73 had orders for pureed diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006-18 Based on observation and interview, the facility failed to ensure the bathroom floors were not worn and stained, ensure fall strips on the floors were secured to the fllor and not coming loose, ensure no holes or scrapes were in the walls and ensure furniture was not worn and dirty. This affected Rooms 503, 505, 509 and Rooms 2, 3, 4, and 9 in the Secured Unit. The facility staff identifed a census of 88. The findings are: On 01/24/23 from 09:30-09:50 AM an Environmental Tour was conducted with the Maintenance Director and the Administrator which revealed the following concerns: -room [ROOM NUMBER]: the bathroom floor worn/stained. -room [ROOM NUMBER]: the bathroom floor worn/stained. -room [ROOM NUMBER]: the floor is stained. -room [ROOM NUMBER]: the fall strips on the floor in front of the toilet were coming off the floor. -room [ROOM NUMBER]: the caulk was cracked around the toilet and there was a hole in the wall under teh toilet paper holder. -room [ROOM NUMBER]: there was scrapes on the wall by the trash can and the fall strips on the floor by the bed were coming loose and worn. -room [ROOM NUMBER]: there were scrapes on the wall by the trash barrel on the side of the headboard. -Furniture (chairs) in day room are worn and dirty. Interview on 01/24/23 at 09:50 AM with the Maintenance Director and the Administrator confirmed the observations and the Mainenance Director and Administrator agreed these items needed to be fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. On 01/23/23 at 02:38 AM Observation at the nurses station between the 400, 500, and 300 hall of the call light board ( a device to identify rooms that are requesting assistance) revealed a loud beeping sound coming from the call light board. The call light board was lit up with room [ROOM NUMBER] - 32 minutes and 506 - 25 minutes. LPN-Q (Licensed Practical Nurse), NA-N (Nurse Aide), and NA-X were sitting at the nurses station and did not respond to the call lights. RN-Y (Registered Nurse) confirmed the call lights were sounding at the nurses station, the staff should have looked at the call light board and answered the lights and that no call light should be going off for 25-32 minutes. Licensure Reference Number 175 NAC 12-006.04C Based on observation, record review and interview; the facility failed to provide staffing for the provision of individualized activities for Resident 56 and 61, assistance with eating for Resident 10 and 33, and to answer call lights in a timely manner in room [ROOM NUMBER] and 508). The facility census was 88. Findings are: A. Record review of the Facility Assessment updated 8/22 identified that the average daily census for the facility was between 70 and 75. The average for the secured unit of the facility was 16-18 residents, 52-57 residents on the skilled nursing facility main floor and 6-9 short term residents on the 100 hall. The facility assessment identified that 22 residents required assist of 1 - 2 staff with eating and 3 were totally dependent on staff to provide assist with eating. The Facility Assessment revealed a facility staffing plan which identified the following: Under the Certified Nurse Aide [CNA] section there is a range of numbers of CNAs required on each shift to meet the residents needs. The minimum staff is the least amount of CNA's required on each shift to meet the resident needs. The maximum number can be changed based on our resident population. The direct care staff numbers were identified as follows for the Alzheimer's Care Units: - Day shift: 6 AM - 2 PM 3-4 CNA's - Evening shift: ( 2 PM - 10 PM 2 - 4 CNA's - Night shift: ( 10 PM - 6 AM ) 2-3 CNA's The direct care staff numbers were identified as follows for the other areas of the facility: - Day Shift: 5-6 CNA's including bath aide - Evening shift: 4-5 CNA's - Night Shift: 2-3 CNA's Record review of the Direct Care staff Assignment sheets for the past 30 days on the Secured care Unit revealed the following number of staff that worked in the secured unit: - One Medication Aide and one Nurse aide on day shift. - One Medication Aide and one Nurse Aide on the evening shift. - One Nurse Aide on the night shift. Observation on 1/17/23 at 8:30 AM revealed 2 staff Medication Aide [MA] E and Nursing Assistant [NA] D worked on the secured unit of the facility. The secured unit had a total of 16 residents that resided on the unit. B. Record review of Resident 56's annual MDS [MDS, a comprehensive assessment used to develop a resident care plan] dated 6/24/22 revealed an admission date of 4/7/21, a Brief Interview for Mental Status [BIMS] score of 00 which indicated severe cognitive impairment, required extensive assist with Activities of Daily Living [ADL's] and locomotion on unit and total assist from staff with locomotion off the unit. Section F, the staff assessment of daily activities preferences, identified that Resident 56 enjoyed listening to music, doing things with groups of people, participating in favorite activities, spending time outdoors. Record review of Physician orders dated 9/20/21 revealed an order to admit to Prestige Care and Rehabilitation secured dementia unit. Record review of Resident 56's Recreation Services Assessment completed 6/28/22 identified that Resident 56's vision was good with glasses, hearing was intact, had clear speech, had wheelchair use, had activity adaptation of talking books and enjoyed being read to with 1:1 assistance. Leisure preferences include: read daily chronicle part of groups, social club, watching crafts, hand fidgets, soft music, watching bingo cards and tablet time, nature music and meditation, hand massage and relaxation programs, social parties and visiting with family. Record review of Resident 56's Comprehensive Care Plan dated 11/28/22 revealed the following information: · Provide emotional support through 1:1 visit by social service, activities staff as often as necessary · The resident is dependent on staff and activities for meeting emotional, intellectual, physical, and social needs r/t Disease process dementia · [ Resident name] will attend/participate in activities of choice 3-5 times weekly through 2/21/23 · All staff to converse with resident while providing care. · [Resident name] likes enjoys listening to soft relaxing music and sitting in her recliner watching tv shows, likes hand fidgets and dolls, enjoys watching most activities and being at the dinning room table. [Gender] enjoys visits and going with her family on outings. · Engage [resident name] in simple, structured activities that avoid overly demanding tasks · Provide a program of activities that accommodates Linda's abilities · Reminisce with [Resident name] using photos of family and friends. · Please continue to encourage [Resident name] socialization and activities if she is able and please listen and discuss any concerns. Interview on 01/17/23 at 11:25 AM with Resident 56's family revealed that the family visits several times per week and has not observed any activities being done in the secured care unit. Observations of Resident 56 revealed the following: - 01/17/23 8:45 AM resident seated in the recliner and sleeping in a room on the secured unit of the facility. The TV was off. - 01/17/23 9:00 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/17/23 9:15 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/17/23 9:30 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/17/23 10:25 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/17/23 1:10 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/17/23 2:15 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/17/23 3:18 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 07:30 AM Up and dressed and in wheelchair in dining area area of unit, eyes closed and had a puzzle game in front of the resident on the table. - 01/23/23 9:20 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/23/23 9: 50 AM resident seated in recliner sleeping no TV on in room, no activities going on in the unit. - 01/23/23 10:00 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/23/23 10:25 AM resident seated in recliner sleeping no TV on in room,no activities going on in the unit. - 01/23/23 1:10 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 2:15 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 3:10 PM seated in recliner in room no TV on in room, no activities going on in the unit. - 01/23/23 03:40 PM seated in recliner in room, TV is on. staff are doing nail care for 2 residents in the dining area. Interview with Medication Aide [MA] E at 7:32 AM on 1/23/22 revealed that direct care staff do activities on the unit when they have time. Resident 56 doesn't really participate much but does like to have nails done. Record review of Resident 56's Activity Participation Records [APR] revealed the following: - Record review of the past 30 days of 1:1 activity participation revealed no data found. - Record review of the past 30 days of group events revealed no data found - Record review of the past 30 days of sensory programs revealed no data found - Record review of the past 30 days of self directed activity revealed no data found Record review of Resident 56's Activity Progress Notes revealed no progress notes related to activities. E. Observation 1/17/23 at 8:30 AM revealed that Resident 61 resided on the secured unit of the facility. Record review of Resident 61's significant change MDS dated [DATE] revealed an admission date of 12/21/21, a BIMS score of 2 which indicated severe cognitive impairment and required extensive assist with Activities of Daily Living [ ADL's] and locomotion on unit. Section B identifies clear vision and hearing, clear speech and usually understood and understands. Section E activity preferences included: very important to do favorite activities and go outside for fresh air when weather is good and somewhat important to do activities in groups. Diagnoses included: Dementia with Behavioral Disturbance, Anxiety and Delusional Disorder [a type of mental illness that causes people to be unable to distinguish reality from unreality]. Record review of Resident 61's Activity Assessment completed on 6/29/22: identified the following information for Resident 61: - Intact vision, hearing, speech, speaks Spanish only, interests in trivia, discussion, reading, social clubs, crafts, TV, trips out of facility bingo and cards, walking, religious activities and praying, music and hand massages. Prefers small groups or 1:1, in and out of room and outings. Record review of Resident 61's Comprehensive Care Plan dated 12/15/22 revealed the following information: · The resident is dependent on staff for emotional, intellectual, physical, and social stimulation r/t Cognitive deficits · The resident will attend/participate in activities of choice 2-3 times weekly by next review date 12/9/22 · Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as Spanish translation cards, the number for a translator 1-800-225- 5254, Compatible with individual needs and abilities; and Age appropriate. · [Resident name] speaks Spanish . Per daughter gender enjoys exercising, hand massages, nails painted, watching tv (Hispanic channels), coloring, painting, looking at pictures in magazines and books · Engage the resident in simple, structured activities that avoid overly demanding tasks. Observations of Resident 61 revealed the following: - 01/17/23 08:17 AM resting in bed in room, light off, no tv in room, no radio in room. No activities going on in the unit. - 01/17/23 08:45 AM NA D got resident up from bed and toileted her, then brought her into the dining area and provided breakfast. Ate independently. After breakfast, resident sat in the dining area with a baby doll until about 10:00 AM, then back to the residents room with staff. No activity going on in the unit. - 01/17/23 10:21 AM resident in bed sleeping, light off in room, No activity going on in the unit. - 01/17/23 11:40 AM MA E went into the residents room to toilet Resident 61 and get resident up for lunch. NA E brought resident to the lunch table and gave the resident a baby doll to play with. Resident sat and stared at it on the table. No other activities going on in the unit. - 01/17/23 12:15 PM resident ate lunch independently with cueing from staff. - 01/17/22 1:10 PM resident sat at table in dining area with baby, no activity going on in the unit, no staff interaction with the resident. - 01/17/23 2:10 PM resident in bed in room sleeping, no activity in unit, light off. - 01/17/23 3:20 PM resident remains in bed asleep. light off, no activity in the unit. - 01/23/23 07:32 AM resident in bathroom room with NA D. No activities going on in the unit - 01/23/23 08:45 AM Resident 61 ate breakfast in the dining area of the unit. Music was on in the dining area, no activities going on in the unit - 01/23/23 09:10 AM Resident 61 sat in the dining room, fiddling with a napkin. The Radio and TV were both on in the unit but no interaction from staff, no activities going on in the unit - 01/23/23 9:50 AM Sleeping in bed, no activities going on in the unit - 01/23/23 10:00 AM resident in bed sleeping, no activities going on in the unit. - 01/23/23 10:25 AM resident in bed sleeping, no activities going on in the unit. - 01/23/23 1:10 PM resident in bed sleeping, no activities going on in the unit. - 01/23/23 2:15 PM resident in bed sleeping, no activities going on in the unit. - 01/23/23 3:10 PM resident in bed sleeping, no activities going on in the unit. Record review of Resident 61's Activity Participation Records revealed the following: - Record review of the past 30 days of 1:1 activity participation revealed no data found. - Record review of the past 30 days of group events revealed no data found. - Record review of the past 30 days of sensory programs revealed no data found. - Record review of the past 30 days of self directed activity revealed no data found. Record review of Resident 61's facility Activity Progress Notes revealed no progress notes related to activities. Interview with MA E at 7:32 AM on 1/23/22 revealed that direct care staff do try to activities on the unit when they have time but it is difficult with all the tasks they have to ensure get done. Interview with the facility Activity Director on 01/23/23 at 08:39 AM revealed the activities in the unit are provided by the direct care staff back there. They have materials that they can do things with the residents. The higher functioning can come out and join the group activities outside of the unit. Documentation of activity participation is in the electronic medical record under the task area for POC response. The Activity Director confirmed that the activity staff for the facility do not do any activities on the secured unit. Interview on 01/23/23 at 09:35 AM with MA E confirmed that activities are done by the staff in the unit and no activity staff come back to provide any activities in the unit. Stated that NA D speaks Spanish and does converse with Resident 61 whenever NA D is working Interview on 01/23/23 at 9:55 AM with MA E revealed that direct care staff in the unit do not document activity participation in the electronic medical record. The direct care staff tell the activity director what activities were done and the Activity Director documents in the Electronic Medical Record. Interview on 01/23/23 at 10:00 AM with Nursing Assistant [NA] D revealed that it is difficult to provide activities in the unit with this many residents in the unit. NA D stated that they spend all their time toileting, providing meals and assist, giving baths and watching residents that are a fall risk and who wander. NA D stated it is hard to get everything done and try to provide activities also. NA D stated there are always 2 staff scheduled in the unit on the day and evening shift. Observation on 1/23/23 10:05 AM of the secured care unit in the facility revealed a total of 16 residents resided in the unit. Interview on 01/24/23 at 12:08 PM with the facility Administrator [ADM] confirmed that the facility staff was unable to find documentation of any activity participation for Resident 61. The Adm confirmed that direct care staff provide all activities in the secured unit and agreed that it would be difficult for 2 staff to provide activities and to provide ADL care to meet the residents needs with the census of 16 that resided in the secured unit. The ADM agreed that there should be one more staff scheduled in the unit. F. A review of Resident 10's quarterly MDS [Minimum Data Set, a comprehensive assessment used for care planning] dated 12/24/22 revealed Resident 10 required limited assist of 1 for eating. A review of Resident 10's care plan revealed focus area of activity of daily living self-care performance deficit. Intervention revised on 9/14/22 revealed Resident 10 is to be assisted with every meal. Observation on 1/17/22 between 12:29-12:57 PM revealed Resident 10 seated in dining room with plate in front of Resident 10. At 12:52 PM Resident 10 was observed to have eaten none of the food on the plate and silverware was wrapped in napkin. At 12:57 PM, Nurse Aide A unwrapped Resident 10's silverware, assisted Resident 10 with clothing protector and encouraged Resident 10 to eat. Resident 10 was observed to eat bites of main entrée and dessert. Observations on 1/23/23 between 12:54 PM-1:39 PM revealed Resident 10 in the dining with lunch plate. Resident 10 was assisted with set up and putting on clothing protector at 12:54 PM. No other assistance or cueing was provided. Resident 10 ate bites of roast beef. Resident 10 was assisted out of the dining room at 1:39 PM by Nurse Aide N. In an interview on 1/24/23 between 7:24-7:41 AM, the Director of Nursing confirmed Resident 10 needs cueing and sometimes physical assist with eating. G. A review of Resident 33's 10/5/22 quarterly MDS [Minimum Data Set, a comprehensive assessment used for care planning] revealed Resident 33 required supervision of 1 for eating. A review of Resident 33's care plan revealed a focus area regarding Resident 33 requiring assistance with activities of daily living. Intervention dated 2/23/21 revealed Resident 33 required set up and limited assist as needed. Observations on 1/17/22 between 12:15-12:50 PM revealed Resident 33 seating in dining room with lunch meal in front of Resident 33. Resident 33 sat at dining room table with lunch plate until 12:50 PM when Nurse Aide L came to assist Resident 33 and asked that Resident 33's meal be reheated. Observations on 1/23/23 at 8:42-9:21AM revealed Resident 33 at table in dining room with breakfast meal. At 8:42 AM, Dietary Aide M assisted Resident 33 with eating a banana. Resident 33 was observed to hold glass and attempt to drink from straw when straw fell out of the glass. Resident was assisted out of dining room at 9:21 AM after eating part of a pancake. Observations on 1/23/23 between 12:48-1:21 PM revealed Resident 33 seated at dining room and served lunch plate at 12:48 PM. Between 1 PM-1:28 PM Resident 33 was observed to eat bread from lunch meal. No assist was observed being provided between 1-1:28 PM. At 1:28 PM, Nurse Aide N asked Resident 33 if Resident 33 was done with meal and wanted to lay down. Nurse Aide N then began feeding Resident 33. Resident 33 ate 25% of meal before being assisted out of dining room. A review of weights in electronic medical record for Resident 33 revealed a weight of 186.2 lbs. on 12/26/22 and a weight of 176.7 lbs. on 1/24/23 which reflects a loss of 5.1%. In an interview on 1/24/23 between 7:24-7:41 AM, the Director of Nursing reported Resident 33's need for assistance varies between cueing and extensive assistance. In an interview on 1/24/23 at 1:30 PM, the Consultant Registered Dietitian confirmed Resident 33 required assistance with eating. H. In an interview on 1/24/23 between 7:24-7:41 AM, the Director of Nursing reported 1/2 of the nurse aides on duty are to be in the dining room during meals to assist residents with eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview; the facility failed to ensure the ventilation system was working in room [ROOM NUMBER], 302, 306. 409, 412, 503 504, 505, 509 and 510. The facility staff identified a census of 88. The findings are: On 01/24/23 an environmental tour was conducted from 09:30-09:50 AM with the Maintenance Director and the Administrator which revealed the ventilation system was not operational in the following rooms: 301, 302, 306, 409, 412, 503, 504, 505, 509, and 510. An interview with the Maintenance Director and Administrator on 01/24/23 at 09:50 AM confirmed the ventilation system was not functioning in these rooms. The Maintenance Director confirmed that the ventilation system had not been checked.

Licensure reference: 175 NAC 12-006.04D2 Based on interview and record review, the facility failed to ensure the Dietary Director met qualifications. This has the potential to affect all 88 residents of the facility. Findings are: A review of the facility staffing list revealed Dietary Manager T was Director of the Dietary Department. In an interview on 1/24/23 between 10:59 AM to 12 PM, Dietary Manager T confirmed Dietary Manager T was in the process of completing the dietary manager program. In an interview on 1/24/23 between 10:59 AM to 12 PM, the Consultant Registered Dietitian reported consulting at the facility once per week for 8 hours.

Licensure reference: 175 NAC 12-006.04D Based on observation, interview, and record review, the facility failed to ensure staffing to provide meals in that met the facility's outlined meal times. This had potential to affect all 88 residents of the facility. Findings are: A. A review of the listed meal times revealed the following schedule: -Breakfast 8 AM, Memory support 8:10 AM, Room trays 9:10 AM -Lunch 12 PM, Memory support 12:10 PM, room trays 1:10 PM -Dinner 6 PM, Memory support 6:10 PM, Room trays 7:10 PM B. Observations of breakfast meal on 1/23/23 revealed all residents in the main dining room were served at 8:41 AM. First cart of room trays left the dining room at 9:03 AM and the second cart of trays left the dining room at 9:19 AM. The last breakfast tray was pulled from the cart and served to a resident at 9:46 AM. C. Observation on 1/23/23 at 11:25 AM revealed [NAME] V checked the temperature of the sweet potatoes and pizza casserole. The sweet potato temperature was 130.4 F and the pizza casserole temperature was 87 F. Both items were returned to the oven for further cooking. D. Observations on 1/23/23 revealed preparation of pureed food was started at 12 PM by Dietary Aide U. E. Observations of lunch meal on 1/23/23 revealed lunch service in the main dining room started after 12:27 PM. The last resident was served in the dining room at 1:20 PM. The second cart of room trays left the dining room at 1:51 PM and the last tray was pulled and served to a resident at 2:09 PM. F. Observations of the kitchen on 1/17/23 between 8:35-8:56 AM revealed the following: -ceiling vent by the door to the hallway soiled with a build-up of dust -floor in dry storage area soiled with dust and food spills -ceiling light near door to hallway with brownish-red discoloration -dried food spills in microwave G. Observations on 1/23/23 at 7:30 AM revealed dried meat juice in the bottom of the reach-in refrigerator. H. In an interview on 1/24/23 between 10:59 AM-12 PM, Dietary Director T reported residents are to have a 1 hour window of time to come to the dining room then room trays are to be started. Dietary Director confirmed that cleaning schedule was not being followed as due to staffing issues. Dietary Director T hiring staff as facility census has increased.

Licensure reference: 175 NAC 12-006.11E Based on observations, interviews, and record review, the facility failed to ensure food was prepared, served and stored in a manner to prevent potential cross contamination as evidenced by failure: -to store foods to prevent potential contamination -to ensure handwashing and glove changes to prevent cross contamination -to ensure equipment maintained in a clean manner and good repair -to store food off the floor -to ensure food was covered during service -to ensure pureed food maintained at temperature to prevent potential food bore illness on the steam table -to ensure unit refrigerators are clean, monitored for temperature and designated for resident food -to ensure storage room floor, ceiling vent and light fixture were maintained in a clean manner This has the potential to affect 87 residents who eat meals prepared at the facility. The facility has a total census of 88. Findings are: A. Observations of the kitchen on 1/17/23 between 8:35-8:56 AM revealed the following: -ceiling vent by the door to the hallway soiled with a build-up of dust -rust in bottom of center cabinet -guard off bottom of stove -floor in dry storage area soled with dust and food spills -ceiling light near door to hallway with brownish-red discoloration -dried food spills in microwave Observations on 1/23/23 at 7:30 AM revealed dried meat juice in the bottom of the reach-in refrigerator. In an interview during a tour of the kitchen on 1/23/23 between 10:59 AM-12 PM, Dietary Director T confirmed the kitchen and storage areas were in need of cleaning, the guard would not stay on the stove, the rusted cabinets needed to be replaced, ceiling vent and light were soiled, and the bottom of the reach-in refrigerator needed cleaning. The Dietary Director T reported that cleaning schedule was being followed as due to staffing issues. 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: -nonfood-contact surfaces shall be kept free on an accumulation of dust, dirt, food residue, and other debris -physical facilities shall be kept clean and in good repair B. Observations of the kitchen on 1/17/23 between 8:35-8:56 AM revealed the following: -uncovered mixer bowl in walk in refrigerator with batter in it -open container of relish in walk in refrigerator -pork roast thawing on shelf above a pitcher of tea in reach in refrigerator -23 boxes piled on top of each other with bottom box on the floor in dry storage area -a box of oranges and apples stacked with the bottom box on the floor in the kitchen Observations on 1/23/23 at 7:15 AM revealed beans soaking in an uncovered pot on the stove. Observations on 1/23/23 at 7:30 AM revealed glasses of orange juice covered with plastic wrap on a tray stored under raw meat including turkey products, cubed steaks, and raw hamburger in reach-in refrigerator. Dried meat juice observed in bottom of reach-in refrigerator. Observations on 1/23/23 at 9:26 AM revealed container holding ice on top of cart with meal trays in hallway. In an interview during a tour of the kitchen on 1/23/23 between 10:59 AM-12 PM, Dietary Director T confirmed boxes of food should not be stored on the floor, food should be covered, and beverages should not be stored under raw meat. A review of facility policy titled Food safety Requirements dated 5/2019 revealed the following: -Dry food storage-keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sexer/waste disposal pipes, and vents. - Refrigerated storage-food that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: . iii. Separating raw foods (e.g., beef, fish, lamb, pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices do not drip onto these foods; -Food and beverages shall be delivered to residents in a manner to prevent contamination. Strategies include, but are not limited to: a. Covering all foods with lids or plate covers. D. Observations on 1/23/23 between 11-11:25 AM revealed Dietary Aide M washing dishes and wiping hands on apron before starting to make juices. Further observations revealed Dietary Aide M continue to wash dirty dishes, wipe hand on a cloth towel and began to put away clean dishes. No hand washing was completed. Observations on 1/23/23 between 11:25 AM-11:52 AM revealed [NAME] V utilizes spray nozzle on dirty side of dishwasher to rinse robo coupe, touch trash can before returning to prep area to wrap remain beef roast. Observations on 1/23/23 between 12-12:27 PM revealed Dietary Aide U wearing gloves to prepare pureed roast beef, taking robo coupe equipment to dishwasher, spraying off equipment and placing in dishwasher. Dietary Aide U returned to pureeing cabbage/carrots with same gloves. Dietary Aide U wearing same gloves returned to rinse robo coupe equipment utilizing spray nozzle on dirty side of dishwasher. Then Dietary Aide U returned to prepare pureed sweet potatoes wearing same gloves. No glove changes or handwashing was completed during the observation. In an interview during a tour of the kitchen on 1/23/23 between 10:59 AM-12 PM, Dietary Director T confirmed handwashing should be completed when moving between stations, between dirty and clean dishes and when changing gloves. Review of facility policy titled Handwashing Guidelines for Dietary Employees dated 4/2019 revealed the following regarding frequency of handwashing: a. Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. b. after hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. c. after hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). d. After couging, sneezing, or blowing your nose, using tobacco, eating or drinking. e. After handling chemicals and before beginning to work with food. f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. g. When switching between working with raw food and working with ready to eat food. h. Before donning gloves for working with food. i. After caring for or handling service animals or aquatic animals. j. After engaging in any activity that may contaminate the hands. E. Observations on 1/23/23 between 12 PM-12:27 PM revealed Dietary Aide U preparing pureed for 3 residents receiving a pureed diet. Observations revealed pureed roast beef, carrots and cabbage, and sweet potatoes were pureed then place on plates for service to residents. Plates were observed to remain on counter area during preparation of all pureed foods then covered and placed on top of steam table. A temperature checks was completed on the last pureed plate on 1/23/23 at 1:16 PM. The temperature of the pureed roast beef was 102 F and the pureed sweet potato was 109 F. Interview with [NAME] V on 1/23/23 at 1:16 PM revealed the plate of pureed food would be microwave before service to the resident. In an interview during a tour of the kitchen on 1/23/23 between 10:59 AM-12 PM, Dietary Director T reported food should be kept and 165 F on the steam table and reported pureed food may need to be reheated before service. 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: -except during preparation, cooking, or cooling or when time is used as the public health control, foods shall be maintained at 135 F or above. -Observations on 1/24/23 at 10:02 AM revealed refrigerator in the back dining room with a mixture of staff and resident food including: -2 boxes of premier protein drinks -2 undated peach cups -3 bags of lettuce -1 bag shredded cheese -3 ensure plus with no names or dates -a pizza box. -containers with Chinese food Observations on 1/24/23 between 10:59 AM-12 PM revealed activities room refrigerator included food used for activities. The refrigerator was observed to have both resident and staff food and to have dried food spills in the bottom. In an interview on 1/24/23 between 10:59 AM-12 PM, Dietary Director T reported refrigerator in the back dining room was not to be used for resident food and is not monitored by the dietary staff. The Dietary Director T reported resident food would be stored in the activity room refrigerator. F. In an interview on 1/24/23 at 1:10 PM, the Administration reported all but one residents of the facility eat meals prepared in the facility kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17c, 12.006.18c, 12.006.17d Based on observation, record review and interview; the facility failed to monitor the community transmission rate for Covid 19 and follow facility policy for masking. This had the ability to affect all residents and the facility identified a census of 88. Findings are: A. An observation on 1/17/23 at 8:20 AM revealed a Visitor entry/Posted Signage posted at the facility entrance that said a Face mask covering required to enter the building. An observation on 1/17/23 at 8:20 am revealed Receptionist K without a face covering. An observaiton on 1/17/23 at 8:29 AM revealed the Administrator (ADM) enter the conference room without a face covering. An observation on 1/17/23 at 8:38 AM revealed Registered Nurse (RN) I at the nurses station without a face covering. An observation on 1/17/23 at 8:39 AM revealed a male therapist treating a resident without a face covering. An observation on 1/17/23 at 8:41 AM revealed the Infection Preventionist (IP) nurse with no face covering in the resident hallway. An onservation on 1/17/23 at 8:41 AM revealed RN I walking down the east hall without face covering. An observation on 1/17/23 at 8:42 AM revealed Transportation Staff J without a facemask in a resident area in the facility. An observation on 1/17/23 at 8:50 AM revealed Office staff (ADM, Director of Nursing (DON) and the Business Office Manager (BOM) putting equipment away and answering lights. ADM and BOM were not wearng a face mask. An observation on 1/17/23 at 8:50 AM revealed the therapy staff in therapy gym were not wearing face coverings and resident was present in the gym. B. Record review completed prior to survey of the Community Transmission rates through the Centers for Disease Control (CDC) for [NAME] county revealed the facility was in a county with a high transmission rate. Record review of the facility's Coronavirus Prevention and Response policy last revised 10/2022 revealed under 10.c: In counties where community transmission level is high, the facility should consider having HCP use PPE as follows: i. NIOSH-approved particulate respirators fwith N(% filters or higher used for: 1. All aerosol-generating procedures: 2. In other situations, where additional risk factors for transmission are present, such as the resident is unable to use source control and the are is poorly ventilated. 3. Residen care encounters or in specific units or areas of the facility at higher-risk for SARS-CoV-2 transmission. ii. Eye protection (i.e., goggles or a face shield that covers the front oand sides of the face) worn during all resident care encounter. An interview on 1/24/23 at 8:35 AM revealed the infection prevention nurse ( a nurse that tracks and monitors infections) (IP) states the facility pulled the community rate as of Thursday 1/19/23 and stated it was low. An interview on 1/24/23 at 1:30 PM with the IP nurse revealed that the IP nurse was monitoring community infection rate weekly and that the rate didn't show low. An observation on 1/24/23 at 1:30 PM of the IP nurse pulling the community transmission rate from the CDC website revealedthe community infection rates were being retrieved, not the community transmission level as required. An interview on 1/24/23 at 1:35 PM with the IP nurse confirmed that the facility community transmission level is high and that staff should be wearing masks per the facility policy. C. Observations of Infection Control Personal Protective Equipment use by facility staff revealed the following concerns: - Observation on 01/17/23 at 08:30 AM revealed a sign on the window to the business office just inside the door that read: Face masks are required to enter our building. - Observation on 01/17/23 at 08:40 AM revealed Dietary Aide F, Nursing Assistant [NA] G and [NAME] H in the dining area of the facility serving residents with no face masks in place. - Observation on 01/17/23 at 08:42 AM revealed the facility Administrator and the Business Office Manager in the hall near the business office with no face masks in place and several residents passed by within 6 feet of the staff. - Observation on 01/17/23 at 08:45 AM revealed Licensed Practical Nurse [LPN] I and [NAME] Transportation Personnel J in the hall by the central nurses station with no face masks in place and several residents seated nearby within 6 feet of the staff. - Observation on 01/17/23 at 08:48 AM revealed NA D and Medication Aide [MA] on the secured unit with no face masks in place. - Observation on 01/17/23 at 08:50 AM revealed the facility Receptionist K on the hall near the special care unit with no mask in place.