**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H) Based on record review, observation, and interview, the facility failed to identify and address potential adverse side effects of psychotropic (drug that affects brain activities associated with mental processes and behavior) medications for 1 (Resident 7) of 5 sampled residents. The facility identified a census of 60.Findings are: A record review of the facility's policy Psychotropic Drug Use with a last revised date of 4/21/2025 revealed the effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis upon physician evaluation routinely and as needed, during the pharmacist's monthly medication regimen review, during Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) quarterly, annually, and with any significant change, and in accordance with nursing assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. Additionally, the resident's response to the medication(s), including progress towards goals and the presence/absence of adverse side effects, shall be documented in the resident's medical record. A record review of the American Association of Psychiatric Pharmacists What You Need to Know About Tardive Dyskinesia (TD) dated November 2023, defined TD as a movement disorder that causes a range of repetitive movements in the face, neck, arms and legs that are beyond the person's control. Symptoms of TD can include difficulty swallowing, grimacing, jerking movements, lip smacking, eye blinking, eyebrow arching, and neck twisting. TD primarily occurs as an adverse side effect of medications such as antipsychotics, anti-nausea, and Parkinson's disease medications. Additional risk factors identified were being of an older age and having diabetes. The risk for TD can be managed by routine screenings at least every three months for these movements and early detection. A record review of Resident 7's Snapshot revealed Resident 7 was admitted to the facility on [DATE]. Resident 7 had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior) and Diabetes Mellitus (DM) Type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production.) A record review of Resident 7's medication list (as of 7/17/2025) revealed the following orders:- Buspirone (an anxiolytic - medication for anxiety) 5 milligrams (mg) with directions to take one tablet three times a day for Generalized Anxiety Disorder (GAD). This medication had a start date of 5/6/2025.- Olanzapine (an antipsychotic) 2.5 mg with directions to take once on Mondays and Thursdays for agitation. This medication had a start date of 12/26/2024. A record review of Resident 7's Care Plan revealed, as of 2/11/2025, Resident 7 was at risk for potential drug related complications associated with the use of psychotropic medications. A goal stating Resident 7 would be or remain free of related complications including hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL (Activities of Daily Living) decline, decline in appetite and abnormal involuntary movements through 09/07/25 had been developed. Interventions were as follows:1) Observe for and report to nurse any drug related signs or symptoms,2) Report to PCP any significant drug related signs or symptoms,3) Administer medications as ordered (see current orders),4) Monitor for side effects/effectiveness of medications such as decreased target symptoms, and5) Monitor for changes that may indicate the need for drug dose increase decrease or discontinuation A record review of Resident 7's Extended Care Pharmacist Monthly Medication Review dated 4/14/2025, revealed Resident 7 was noted to have a shuffling gait and facial grimacing. The note stated this may be associated with the reduction in their olanzapine dose from two 5 mg tablets every other day to two 5 mg tablets on Mondays and Thursdays on 12/25/2024. It was noted that olanzapine is associated with parkinsonism which is related to the dose. TD, which includes involuntary grimacing, is duration-related and can evolve into a full syndrome over days or weeks. The pharmacist recommended that even with the low dose [gender] may be experiencing extrapyramidal side effects of olanzapine and recommended the discontinuation. There was no response from the prescribing physician. A record review of Resident 7's Progress Notes from 5/9/2025-7/14/2025 revealed the following:- There was no evidence of body movements noted between 5/9/2025-6/11/2025.- On 6/12/2025, it was noted staff had reported Resident 7 having intermittent body twitches. Resident 7 was assessed by the nurse and was not having any twitches at the time of assessment. Staff were to continue to monitor for body twitches and update provider if indicated.- On 6/25/2025, it was noted staff reported Resident 7 having moments of twitching during the 6 AM - 2 PM shift. There was no evidence of further assessment.- There was no further evidence of documentation of Resident 7's body movements after 6/25/2025 or that Resident 7's mental health doctor was notified of the movements. A record review of Resident 7's Office Clinic Note from 6/17/2025 visit, revealed staff had reported to Resident 7's PCP of the jerking movements. PCP's note stated staff were monitoring this and will contact Resident 7's mental health provider to evaluate if medications are the cause. Further record review of Resident 7's electronic medical record revealed no evidence the facility had further assessed Resident 7's movements or notified their mental health doctor of the movements as of 7/16/2025. A record review of Resident 7's Abnormal Involuntary Movement Assessment (AIMS, a tool used to assess the presence and severity of involuntary movements in patients, particularly those taking antipsychotic medications, to screen for tardive dyskinesia. It helps monitor for and manage side effects of these medications) with a date of 3/27/2025 revealed a score of 0, which indicated no abnormal involuntary movements had been observed. A record review of Resident 7's AIMS assessment on 7/17/2025 at 4:00 AM revealed the following:- Minimal movement in the lips area.- Minimal movement in the jaw area.- Minimal movement in the lower extremities.- Moderate movement in the trunk, neck shoulder, and hips area.- Overall, severity of movements was rated as mild.- Minimal incapacity due to movement.- Mild improvement of movements during sleep.- The total score was 6. A record review of Resident 7's LTC Assmt Flowsheet Data from 5/30/2025-7/17/2025 under Psychotropic Medication Side Effects revealed the following:- 5/30-6/13: Documented as none apparent.- 6/14: Extrapyramidal symptoms - slight twitching movement often observed this evening in hands and arms.- 6/15-6/17: None apparent.- 6/18: Increase twitching movements.- 6/19-7/4: None apparent.- 7/5: Slept 6 hours.- 7/6-7/17: None apparent. An observation on 7/14/2025 at 11:47 AM revealed Resident 7 having frequent jerking movements in their trunk and legs. An observation on 7/14/2025 at 3:28 PM revealed Resident 7 having frequent jerking movements in their trunk area and facial grimacing. An observation on 7/15/2025 at 10:22 AM revealed Resident 7 having frequent jerking movements in their trunk and legs. An observation on 7/15/2025 at 3:50 PM revealed Resident 7 having frequent jerking movements in their trunk, legs, and facial grimacing. An observation on 7/16/2025 at 12:39 PM revealed Resident 7 having frequent jerking movements in their trunk and leg with facial grimacing while asleep. An observation on 7/16/2025 at 12:48 PM revealed Resident 7 continued to have frequent jerking movements in their trunk and leg with facial grimacing while asleep. An observation on 7/16/2025 at 1:10 PM revealed Resident 7 continued to have frequent jerking movements in their trunk and leg with facial grimacing while continuing to sleep. An interview on 7/16/2025 at 1:11 PM with Nurse Aide (NA) - A confirmed Resident 7 has these constant shaking movements that have worsened over the past few days.An interview on 7/17/2025 at 8:45 AM with the Social Services Director (SSD) revealed Resident 7 started having the jerking movements around May, which was the last time Resident 7 was seen by their mental health provider. An interview on 7/16/2025 at 3:30 PM with the Director of Nursing (DON) revealed the facility was currently in the process of implementing AIMS assessments being completed with every MDS and as needed but was unable to find an AIMS assessment since March 2025 or notification to Resident 7's mental health provider. A follow up interview on 7/17/2025 at 7:55 AM with the DON confirmed Resident 7 had not had an AIMS assessment completed since March 2025, but had staff conduct one that morning, confirming there were now symptoms present. Additionally, the DON was unable to find evidence of Resident 7's mental health provider being notified of the movements.

Licensure Reference Number 175 NAC 12-006.09(C)(ii) Based on record reviews and interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS, a federally mandated assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within 14 days of determining there had been a significant change (major decline in a resident's status that will usually not resolve) in the condition for 1 (Resident 7) of 1 sample resident. The facility identified a census of 60.Findings are: A record review of the facility's policy Resident Assessment last revised 6/17/2025, revealed the MDS Coordinator would be responsible for ensuring a comprehensive resident assessment was completed within 14 days of the facility determining there had been a significant change in the resident's status in accordance with the Resident Assessment Instruction (RAI) guidelines. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) with a last revised date of 10/2024, revealed a SCSA would be appropriate when a decline in two or more of the following areas are present:- Resident's decision-making ability has changed;- Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior);- Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment;- Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning;- Resident's incontinence pattern changes or there was placement of an indwelling catheter;- Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days);- Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status;- Resident begins to use a restraint of any type when it was not used before; and/or- Emergence of a condition/disease in which a resident is judged to be unstable. A record review of Resident 7's Encounter Psych Progress Note dated 5/28/2025 revealed the Social Services Director (SSD) reported Resident 7 had shown a notable decline in (gender) functional abilities. Resident 7 now required increased assistance with mobility, transfers, and movement while they previously had been independent. Resident 7 had also been displaying increased anxiety and fearfulness with an increase in behaviors, such as hitting staff. A record review of Resident 7's quarterly MDS with an Assessment Reference Date (ARD) of 4/7/2025 revealed the following:- Section D revealed a Patient Health Questionnaire (PHQ-2 to 9, A validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder) score of 0, which indicated no symptoms of depression.- Section E revealed no hallucinations or delusions, no physical behaviors, verbal/other behaviors 1-3 days, no rejection of care, or wandering.- Section E revealed Resident 7 had exhibited verbal/other behaviors 1-3 days and no behaviors of hallucination, delusions, physical behaviors, rejection of care, or wandering.- Section GG revealed Resident 7 was ambulatory 10-150 feet with supervision. A record review of Resident 7's annual MDS with an ARD of 6/13/2025 revealed the following:- Section D revealed a PHQ-9 score of 7, which indicated Resident 7 had symptoms of mild depression.- Section E revealed Resident 7's behavioral symptoms had worsened compared to the previous MDS.- Section GG revealed walking 10-150 feet had not attempted due to safety/ability concerns. An interview on 7/17/2025 at 8:45 AM with the SSD confirmed Resident 7 had a significant change in May 2025 as Resident 7 had gone from being ambulatory to wheelchair bound and having an increase in behaviors. An interview on 7/17/2025 at 9:48 AM with the Infection Preventionist (IP) revealed the IP and/or Director of Nursing (DON) are responsible for overseeing, certifying, and signing for the accuracy and completion of the MDS. The IP revealed the facility follows the RAI Manual to determine if a resident has had a significant change in their abilities. Additionally, the IP confirmed a SCSA was indicated but was not completed as indicated by the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(v)Based on record review, observation, and interview, the facility failed to provide care, treatment, and ensure services were obtained for a hand contracture (a condition where the fingers bend towards the palm and cannot be straightened due to tightened tissues in the hand) for 1 (Resident 40) of 2 sampled residents. The facility identified a census of 60. Findings are: A record review of [NAME] Healthcare's Contracture Management dated 11/1/2014, revealed limited mobility and the need for supportive therapies should be evaluated for on admission and at least quarterly. Treatment considerations were as follows:- Frequent, simple stretching, noting that even a few degrees of movement can help.- Consider positioning devices for long-term use such as splints. Positioning devices can ensure prolonged contracture management and limit further tone development.- Educate all staff and encourage to provide daily range of motion (ROM) stretching outside of therapy services. A record review of Resident 40's Problem List (as of 7/16/2025) revealed Resident 40 had a diagnosis of Severe Alzheimer's dementia with agitation. A record review of Resident 40's Progress Note dated 3/21/2025 revealed staff had reported Resident 40's 3rd and 4th fingers of their left hand were contracted and painful. Assessment revealed stiffness and pain in the hand. A message was sent to the resident's primary care physician (PCP) for a possible Occupation Therapy (OT) order. A washcloth was implemented to be used until the OT evaluation had been completed. A record review of Resident 40's Nurse Triage Notes dated 3/21/2025 revealed a message had been sent to the resident's PCP but the PCP's nurse had responded to send to the secondary physician due to the PCP being out of the office on Fridays. There was no evidence the secondary provider had been contacted or the primary provider had been followed up with. A record review of Resident 40's Care Plan with a last reviewed date of 6/5/2025 revealed no evidence of a focus area regarding the resident's hand contracture. A record review of Resident 40's Plan of Care Addendum Note dated 4/2/2025 noted Resident 40 had a contracture to their left hand and the facility had attempted to place a rolled washcloth in their hand, but the resident had refused due to the pain and would attempt to hit staff if attempted. There was no evidence of alternative interventions attempted. A record review of Resident 40's Plan of Care Addendum Note dated 6/3/2025 was a copy of the note from 4/2/2025 noting Resident 40 had a contracture to their left hand and the facility had attempted to place a rolled washcloth in their hand, but the resident had refused due to the pain and would attempt to hit staff if attempted. There was no evidence of alternative interventions attempted. A record review of Resident 40's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 3/31/2025 revealed 0 minutes of physical therapy (PT), OT, ROM exercises, or splint/bracing assistance had been completed in the past 7 days of the ARD. A record review of Resident 40's MDS with an ARD of 6/2/2025 revealed 0 minutes of PT, OT, ROM exercises, or splint/bracing assistance had been completed in the past 7 days of the ARD. A record review of Resident 40's chart revealed no evidence an OT evaluation had been completed. Additionally, there was no evidence of other interventions attempted to prevent worsening of the contracture or monitoring of the contracture for potential complications, such as skin breakdown.An observation on 7/16/2025 at 12:00 PM revealed Resident 40's left hand to be tightly closed.An interview on 7/16/2025 at 1:11 PM with Nurse Aide (NA) - A confirmed Resident 40's left hand was tightly closed and will no longer open. In the past, staff have tried to put a rolled-up washcloth in there, but the resident would get mad and take it out. NA-A was not aware of any other interventions having been attempted. An interview on 7/17/2025 at 7:55 AM with the Director of Nursing (DON) confirmed that although an OT referral had been requested in March 2025, the evaluation had never been completed. Additionally, the DON confirmed no further follow-up, or other interventions were attempted to prevent the worsening of the contracture or potential for complications. An interview on 7/17/2025 at 9:50 AM with the Quality Assurance Registered Nurse revealed the facility did not have a policy regarding contracture management or care.

Licensure Reference Number 175 NAC 12-006.09(H)(vi) and 175 NAC 12-006.14Based on record review, observation, and interview, the facility failed to provide assistance with eating and administration of medications that was consistent with the needs of an individual with a diagnosis of dementia for (a progressive disorder that primarily affects cognition, memory, and behaviors that includes agitation) 1 (Resident 40) of 4 sampled residents. The facility identified a census of 60.Findings are: A record review of the facility's undated policy, Dementia Care revealed the purpose of the policy was to provide appropriate treatment and services to those with dementia to meet their highest practicable well-being. This goal would be met by developing a care plan for the resident that was individualized to their symptoms and implementing interventions that were effective in enhancing the resident's well-being. A record review of Resident 40's Problem List (as of 7/16/2025) revealed Resident 40 had a diagnosis of severe Alzheimer's dementia with agitation. A record review of Resident 40's Care Plan with a last reviewed date of 6/5/2025 revealed the following:- A problem area for Dementia had been added revealing Resident 40 was having more difficulty being able to express their needs. An intervention of offer simple choices and honor preference and offer assistance/guidance as needed was added. - A problem area for Behavioral Symptoms had been added revealing Resident 40 would express their pain by exhibiting behaviors of raising their fist or yelling at staff. Interventions to assess for aggressive behavior, encourage appropriate behavior, redirect, and identify stressors and take steps to avoid had been added.- A problem area for Medication had been added revealing Resident 40 had a history of spitting out their medication. An intervention to gently encourage the resident to take their medication and monitor/report concerns had been added.- A problem area for Nutrition had been added revealing Resident 40 was at risk for malnutrition and an intervention for staff to help feed/encourage meals as the resident allows had been added. A continuous observation on 7/16/2025 from 12:10 PM through 1:15 PM revealed the following:- At 12:10 PM, staff had sat a plate of food in front of the resident. Resident 40 had their head down and appeared to be asleep. - From 12:10 PM to 12:21 PM, the resident continued to have their head down and appeared to be sleeping. No cueing or assistance was provided.- At 12:21 PM, Resident 40 began to holler out. Resident 40 had taken a sip of their fluids at this time, but no attempts to eat were made. Nurse Aide (NA) - B spoke to the resident seated across from Resident 40, but did not address, cue, or assist Resident 40. NA-B then sat down to assist another resident at a nearby table.- At 12:25 PM, Resident 40 had their head back down and appeared to be back asleep. - At 12:30 PM, NA-A had returned from delivering a meal tray and sat down at the same table as NA-B was assisting. - At 12:31 PM, NA-A stated to NA-B, I guess I should go help [Resident 40]. NA-A then pulled a chair next to Resident 40. NA-A then gently awoke, cued, and assisted Resident 40 with a bite of food. Resident 40 accepted bite without difficulty. - At 12:34 PM, Resident 40 had their head back down and appeared to be asleep. NA-A stated to NA-B, well [Resident 40] is falling asleep on me. NA-A then left Resident 40's table without any further cueing or attempts to assist the resident with their meal.- From 12:36 PM to 12:50 PM, Resident 40 had awoken and was taking sips of their juice, but no attempts were made to eat. No cueing or assistance with eating were provided.- At 12:50 PM, the Nursing Home Administrator (NHA) came over and started a conversation with the resident. Resident was alert and pleasantly conversating back with the NHA. No cueing or assistance was provided during the conversation.- From 12:51 PM to 1:00 PM, no cueing or assistance was provided to the resident for their meal. - At 1:00 PM, Medication Aide (MA) - C brought Resident 40's medications over to administer. Resident 40 refused, MA-C continued to attempt to administer the medication by placing the spoon of medications near the resident's mouth. Resident 40 raised their voice and yelled, get out of here at MA-C. MA-C continued to attempt to administer the medications by placing the spoon of medications near the resident's mouth. Resident 40 continued to refuse and escalate in agitation. - At 1:05 PM, Resident 40 yelled at MA-C threatening to kill them if they did not leave them alone. MA-C again attempted to speak to the resident but was cut off by Resident 40 yelling shut up and get out of here already. MA-C then walked away from the resident. - At 1:15 PM, Resident 40 was taken out of the dining room and assisted back to their room. Less than 10% of their food was observed as consumed. A record review of Resident 40's intake from the 7/16/2025, 1200 Lunch meal, revealed it had been documented Resident 40 refused and 0% of their meal was consumed. An interview on 7/16/2025 at 1:11 PM with NA-A confirmed Resident 40 required total assistance with all Activities of Daily Living (ADLs), including eating. An interview on 7/16/2025 at 1:20 PM with MA-C revealed if residents refuse medications, the MA would re-attempt later, then notify the nurse. An interview on 7/16/2025 at 3:30 PM with the Director of Nursing revealed Resident 40 does require total assistance with eating. The DON also confirmed their expectation would be for the MA to re-approach later if a resident was refusing and beginning to escalate at the first sign of escalation.

Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on record reviews, observations, and interviews; the facility failed to ensure staff followed proper glove use practices by changing gloves when contaminated or between tasks in accordance with facility policy and Center for Disease Control (CDC) guidelines during meal service to prevent the potential for cross-contamination. This had the potential to affect all 15 residents who reside within the Memory Care Unit (MCU). The facility identified a census of 60.Findings are: A review of the facility policy titled Hand Hygiene last revised 4/21/2025 revealed staff are required to perform hand hygiene after each resident contact, before and after glove use, and that glove use does not replace hand hygiene. A CDC guideline titled Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/2024 revealed gloves are to be changed between tasks and after contact with potentially contaminated surfaces or residents. A continuous observation on 7/16/2025 from 11:55 AM through 12:20 PM revealed the following:- Nurse Aide (NA) - A had donned gloves and began to pass out coffee mugs to each resident. After distributing mugs to all residents, NA-A had gone back to a resident and retrieved their cups. NA-A poured coffee and juice into this resident's cups with their gloved hands. NA-A then delivered their drinks back to their table, handling the drinking rims of both cups with their gloved hands. NA-A then grabbed another resident's cups from in front of the resident. NA-A dispensed juice into the resident's cup. Then pushed the lid with a drinking spout back onto the cup, touching the drink spout with their gloves, then delivered it back to the resident.- In continuing to dispense fluids to residents, NA-A had touched numerous surfaces with their contaminated gloves, including the juices, coffee handles, cupboard handles, then touched the rims of the residents' glasses to return them to the residents.- NA-A then obtained two cups from another resident, setting these down of the counter. NA-A then opened a cupboard door, closed the cupboard door, poured the resident's fluids, and then delivered the cups back to the resident, touching the rims of the cups, with their same gloved hands.- NA-A then was called over to a resident. The resident handed NA-A a towel that had been in contact with their body. NA-A sat the towel down on the kitchen counter and returned to preparing resident's fluid. NA-A touched the rims of two cups from another resident with their same gloved hands.- Once all residents had their fluids, NA-A then removed their gloves and completed hand hygiene. NA-A then donned a new pair of gloves and began delivering food trays to residents. NA-A was observed putting both of their gloved hands on their thighs, when speaking to a resident. Following, NA-A removed a food cover from a plate and had handled the plate with their thumb and first finger inside the inner rim of the plate with their gloved hands while delivering it to the resident.- NA-B was observed donning gloves. NA-B then began to pass meal trays to residents. NA-B removed the food covers with their gloved hands and then delivered to the residents. NA-B had used their gloved hand that had removed the food cover to handle the plate while delivering. Their hand had been positioned inside the inner rim of the plate and had touched the resident's food with their same gloved hand.- Medication Aide (MA) - C was observed donning gloves. MA-C then removed the plastic wrap that had been covering the tray of deserts with their gloved hands. MA-C then began to hand out the deserts to the residents. MA-C had touched the inside of the desert bowls with their thumb and first finger. MA-C delivered the deserts to five different residents and had touched the inside of each of the desert bowls with their same gloved hands. An interview on 7/16/2025 at 1:11 PM with NA-A confirmed their understanding that gloves are contaminated after contact with residents or surfaces and acknowledged gloves should have been changed during the observed tasks but had not been aware of the contamination in the moment. An interview on 7/16/2025 at 1:25 PM with the Infection Preventionist (IP) confirmed that contact with residents, surfaces and food coverings would contaminate gloves and confirmed gloves should be changed to prevent cross-contamination after contact.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interviews, and record review the facility failed to provide ongoing care and services to address 1 (Resident 42) of 1 sampled resident's lower extremity edema (swelling). The facility census was 43. Findings Are: A record review of Resident 42's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 3/4/2024 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated the resident had severe cognitive impairment. Section I revealed the resident had a diagnosis of non-Alzheimer's dementia, and Section K revealed the resident had not had any significant weight changes in the prior 6 months. An observation on 5/21/24 at 12:23 PM revealed Resident 42 sitting in a chair in the dining room with their lower legs visible. Resident 42 had edema to both of their lower legs and was wearing TED Hose (compression stockings) on both legs. The TED Hose on the resident's right leg was rolled down, causing a moderate indentation approximately 3 inches above their ankle, and there was edema above and below the indentation. An observation on 5/22/24 at 7:33 AM revealed Resident 42 sitting in a chair in the dining room with their right leg crossed over their left leg. Both of Resident 42's lower legs were edematous. An observation on 5/23/24 at 7:22 AM revealed Resident 42 standing outside their room in the hallway, wearing ted hose and tennis shoes,both of Resident 42's lower legs had edema. An interview on 5/23/24 at 8:05 AM with Medication Assistant (MA)-C confirmed Resident 42 was wearing TED hose as Resident 42 has swelling around their ankles. MA-C reported Resident 42 had started wearing the TED hose about a month prior. An interview on 5/23/24 at 8:10 AM with MA-D confirmed MA-D routinely assisted Resident 42 to get dressed in the mornings. MA-D reported Resident 42's lower legs were usually pretty swollen at that time. MA-D stated Resident 42's lower leg swelling was about the same as usual that morning. A record review of a document scanned into Resident 42's electronic health record (EHR) revealed the resident was seen by their physician on 4/16/24 and the physician documented an assessment of 2+ pitting edema (swelling caused by too much fluid trapped in the body's tissues) lower extremities bilateral. There was no documentation in the treatment or follow up sections that referenced the resident's edema or whether anything would be done to address it. A record review of Resident 42's progress note dated 4/16/24 at 1:00 PM revealed the resident had been seen by their provider that day and that the facility was going to try to place TED hose to both lower legs, putting them on in the morning and taking them off at night, if the resident tolerated them for their lower leg edema. A record review of Resident 42's progress note dated 4/19/24 at 3:20 PM revealed Resident 42 had a 6.5-pound weight gain in approximately one week, had increased edema to both lower legs and had begun wearing TED hose. The progress note also stated the resident's family and primary care provider were aware. A record review of Resident 42's weights recorded in the EHR revealed: -3/22/24: 115.8 pounds -4/23/24: 121.8 pounds -5/21/24: 124.8 pounds A record review of Resident 42's diagnosis list revealed the resident had no diagnoses related to edema. A record review of Resident 42's physician's orders revealed the resident was not taking any medications to treat their lower extremity edema. An interview on 5/22/24 at 1:47 PM with the Director of Nursing (DON) revealed the DON was not aware of Resident 42's ongoing lower leg edema. The DON also confirmed that there had been no additional assessments or treatments related to the resident's ongoing lower leg edema.

Based on interviews and record reviews, the facility failed to ensure residents were free from unnecessary antibiotic use for 2 (Resident 1 and 29) of 3 sampled residents. The facility census was 43. Findings are: A. A record review of Center for Disease Control's (CDC) document The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use revealed Surveys of antibiotic use have shown that (Urinary Tract Infection) UTI prophylaxis accounts for a significant proportion of antibiotic prescriptions. Very few studies support antibiotic use for UTI prophylaxis, especially in older adults, and many studies have shown this antibiotic exposure increases risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure and improve resident outcomes. A record review of a Resident Master Information indicated the facility admitted Resident 1 on 7/1/2019. A record review of Resident 1's quarterly Minimum Data Set (MDS), a standardized assessment tool that measures health status in nursing home residents, with an Assessment Reference Date of 4/15/2024 indicated Resident 1 had a Brief Interview for Mental Status of 3/15, which indicated Resident 1 had severe cognitive impairment. The MDS also indicated Resident 1 was being administered an antibiotic. A record review of Resident 1's Orders revealed Resident 1 had been taking Keflex (an antibiotic) for an indication of prophylaxis (prevention) for recurrent Urinary Tract Infections since 1/29/2024 with no stop date. A record review of a Drug Regimen Review with a date of 5/20/2024 revealed the Pharmacist had identified an irregularity of the antibiotic use and had recommended discontinuing the Keflex and switching to a conjugated estrogen. The physician had not responded as of 5/29/2024. An interview on 5/29/2024 with the Director of Nursing (DON) confirmed Resident 1 was on Keflex for prophylactic use for recurring Urinary Tract Infection. The DON also confirmed awareness of the CDC's recommendation against the use of prophylactic antibiotics for Urinary Tract Infections. B. A record review of Resident 29's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 4/8/2024 revealed in Section H that the resident was occasionally incontinent of bladder function. Section I revealed the resident had had a urinary tract infection (UTI) in the prior 30 days and that they had a history of UTIs. Section N revealed that the resident had been taking an antibiotic in the prior 7 days. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 milligrams (MG) capsule twice a day (BID) for a bladder infection from 10/30/2023 until 11/9/2023. A record review of Resident 29's medication orders revealed an order for Macrobid 100 MG capsule BID for cystitis from 11/22/2023 until 12/2/2023. A record review of Resident 29's medication orders revealed an order for Macrobid 100 MG capsule daily for prophylaxis and history of UTI from 12/3/2023 until 12/12/2023. A record review of Resident 29's medication orders revealed an order for Macrobid 100 MG capsule daily for prophylaxis and bladder infection from 12/14/2023 until 12/15/2023. A record review of Resident 29's medication orders revealed an order for Macrobid 100 MG capsule daily for prophylaxis and bladder infection from 12/16/2023 until 1/12/2024. A record review of Resident 29's medication orders revealed an order for Macrobid 100 MG capsule daily for bladder infection prophylaxis from 1/16/2024 until 5/22/2024. A record review of Resident 29's most recent urinalysis (a test that examines the visual, chemical, and microscopic aspects of urine), collected on 12/14/23 revealed the presence of bacteria was rare. The final result of the urine culture dated 12/16/23 revealed the growth of a bacteria, Proteus mirabilis. The culture also revealed the bacteria was resistant to Nitrofurantoin (another name for the antibiotic, Macrobid). A record review of Resident 29's Pharmacist Monthly Medication Review dated 12/1/23 revealed the pharmacist documented a medication irregularity of The duration of Resident 29's prophylactic Macrobid 100mg daily is currently on Resident 29's MAR for 10 days. Unsure if this is the duration you intended. Please note that prolonged use (>6 months) has been associated with diffuse interstitial pneumonitis and/or pulmonary fibrosis, chronic hepatitis, and the development of neuropathy. The pharmacist's recommendation was Please clarify the intended duration for Resident 29's prophylactic Macrobid 100mg daily. Resident 29's provider, MD-B, documented a response of Continue Macrobid prophylaxis for 30 days and then reassess on 12/13/23. An interview on 5/22/24 at 1:57 PM with the Director of Nursing (DON) confirmed that there had been no follow up regarding the provider's response documented on 12/13/23 to reassess Resident 29's Macrobid in 30 days. The DON also confirmed that Resident 29's urine culture from 12/16/23 showed the bacteria was resistant to nitrofurantoin (Macrobid) and that this was the medication the resident was taking for UTI prophylaxis.

Licensure Reference 175 NAC 12-006.10D Based on observations, interviews, and record reviews; the facility failed to administer medications at the right time for 2 (Resident 6 and 33) out of 9 sampled residents and ensure the medication error rate was less than 5%. There were 25 medication opportunities observed and there were 2 errors, this resulted in a medication errors rate of 8%. The facility census was 43. Findings are: A record review of the facility's Medication Administration policy with a last reviewed date of 2/15/2024 revealed to note directions in the comment section of the medication on the medication administration record during the first check. An observation on 5/23/2024 at 7:54 AM revealed Medication Aide (MA) - E had administered levothyroxine to Resident 33. Resident 33 had been in the dining room eating breakfast at the time of administration. A record review of Resident 33's levothyroxine order revealed administration instructions of administer at least 30 minutes before food. An observation on 5/23/2024 at 8:00 AM revealed MA-E had administered levothyroxine to Resident 6. Resident 6 had been in the dining room eating breakfast at the time of administration. A record review of Resident 6's levothyroxine order revealed administration instructions of administer at least 30 minutes before food. An interview on 5/23/2024 at 10:43 AM with MA-E confirmed MA-E did not give Resident 6's or Resident 33's levothyroxine per the administration instructions of at least 30 minutes prior to breakfast.

B. A record review of the facility's policy Care Plan with an approved date of 5/15/2024 revealed the comprehensive care plan will describe at a minimum any services that are to be furnished to attain or maintain the resident's high practical physical well-being. A record review of a Resident Master Information indicated the facility admitted Resident 30 on 2/12/2021. A record review of a quarterly Minimum Data Set (MDS), a standardized assessment tool that measures health status in nursing home residents, with an Assessment Reference Date of 5/6/2024 indicated Resident 30 had a Brief Interview for Mental Status score of 2/15, which indicated Resident 30 had severe cognitive impairment. The MDS also indicated Resident 30 used oxygen. A record review of Resident 30's Orders indicated Resident 30 had an order for continuous oxygen with the indication of hypoxemia (low oxygen levels.) A record review of Resident 30's Care Plan revealed no care focus area addressing Resident 30's oxygen use. An interview on 5/29/2024 at 11:00 AM with the Director of Nursing (DON) confirmed Resident 30's care plan did not include a focus area addressing Resident 30's oxygen use. The interview also revealed the DON would expect oxygen use to be included in the care plan. Licensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews and interviews the facility failed to develop and implement a comprehensive care plan for 2 (Residents 29, and 30) of 12 sampled residents. The facility census was 43. The Findings Are: A. A record review of facility policy Care Plan dated 5/15/24 revealed that the comprehensive care plan would describe the services that were being furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy also revealed the comprehensive care plan would describe care provided related to high-risk medications including, but not limited to psychotropics, anticoagulants, and antibiotics. The policy also revealed that care plans were to be updated with acute conditions or any unexplained change in the resident's condition (i.e., weight change, new diagnosis, change in pain), and with medication changes such as antibiotics, diuretics, and/or psychotropic or medications prescribed for sleep psychotropic benefit. A record review of Resident 29's diagnosis list revealed a diagnosis of History of recurrent UTI (urinary tract infection) was added to their list on 5/2/2023. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 MG capsule BID for a bladder infection from 10/30/2023 until 11/9/2023. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 MG capsule BID for cystitis from 11/22/2023 until 12/2/2023. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 MG capsule daily for prophylaxis and history of urinary tract infection (UTI) from 12/3/2023 until 12/12/2023. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 MG capsule daily for prophylaxis and bladder infection from 12/14/2023 until 12/15/2023. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 MG capsule daily for prophylaxis and bladder infection from 12/16/2023 until 1/12/2024. A record review of Resident 29's medication orders revealed an order for Macrobid (an antibiotic) 100 MG capsule daily for bladder infection prophylaxis from 1/16/2024 until 5/22/2024. A record review of Resident 29's care plan dated 5/3/23 and printed on 5/8/24 revealed no indication of the resident's history of urinary tract infections or of the resident's current prophylactic use of antibiotics related to their history of UTIs. An interview on 5/22/24 at 1:35 PM with the MDS Coordinator revealed the MDS Coordinator did not include prophylactic drugs on the residents' care plans because they were not being used to treat an acute condition. The MDS Coordinator stated this was the reason Resident 29's prophylactic antibiotic use was not included in their care plan.

Licensure Reference 12-006.11E Based on observations, interviews, and record review; the facility failed to a) ensure food products were disposed of prior to expiration dates, b) utilize handwashing as required to prevent potential food contamination during food preparation, and c) ensure food temperatures were maintained at least 135 degrees on the steam table as required during serving of meals. This had the potential to affect all residents who resided at the facility. The facility census was 43. Findings are: A. A record review of the facility policy General Requirements Food Supply with a last reviewed date of 2/6/2023 revealed food was to be stored in accordance with professional standards for food service safety. An initial observation 5/21/2024 at 8:55 AM of the kitchen's reach-in refrigerator revealed an opened container of Heavy Whipped Cream with an expiration date of 5/16/2024 and two opened containers of Hiland's Cottage Cheese with expiration dates of 5/19/2024. An interview on 5/21/2024 at 9:10 AM with the Certified Dietary Manager (CDM) confirmed the container of Heavy Whipped Cream and two containers of Hiland's Cottage Cheese were expired. The CDM disposed of the items following the interview. B. A record review of the facility policy Hand Washing Practices with a last reviewed date of 2/6/2023 revealed employees shall wash hands after touching personal body and after each task is completed for at least 20 seconds. An observation on 5/23/2024 at 9:03 AM revealed Cook-G had finished washing [gender] hands. Cook-G then patted Cook-G's hand on [gender] pants before obtaining a pan and cooking bag. Cook-G then used their bare hands to push the center of the liner bag down without the benefit of hand hygiene prior. An observation on 5/23/2024 at 9:20 AM revealed Cook-G completed hand hygiene with soap and water for 16 seconds. Cook-G then opened a bag of cheese, grazing the inside of the bag with their bare hand. An observation on 5/23/2024 at 9:28 AM revealed Cook-G had opened a small window of the refrigerator with their bare hand, then lined the pans with cooking liners without the benefit of hand hygiene prior. An observation on 5/23/2024 at 10:56 AM revealed Cook-G did not perform hand hygiene prior to beginning preparation of pureed foods that were to be consumed by residents at lunch that day. An interview on 5/23/2024 at 9:38 AM with Cook-G confirmed hand hygiene should be done in between each task and when hands have been contaminated after touching dirty objects, such as handles of refrigerators. C. A record review of the facility policy Food Temperature with a last reviewed date of 5/28/2024 revealed hot foods are held at or above 140 degrees Fahrenheit. If foods are less than that, they must be returned for heating or discarded depending on the timeframe. An observation on 5/23/2024 at 12:25 PM revealed the final meal temperatures on the steam table, obtained just after Cook-G had finished serving the residents, for the pureed meat was 122 degrees and ground cauliflower rice was 120 degrees. An interview on 5/23/2024 at 12:30 PM with Cook-G confirmed the meal temperatures for the ground cauliflower rice and pureed meat were below 135 degrees, which is the regulatory requirement, and should have been maintained at least 145 degrees.

B. A record review of the facility's policy Hand Hygiene with a last reviewed date of 4/18/2024 revealed hand hygiene with soap should be completed for at least 20 seconds. An observation on 5/23/2024 at 7:29 AM revealed Medication Aide (MA)-E had finished a medication pass for a resident. MA-E completed hand hygiene with soap and water for 15 seconds. An interview on 5/23/2024 at 8:14 AM with MA-E revealed MA-E was aware of the requirement to wash hands with soap and water for at least 20 seconds. An observation on 5/23/2024 at 8:38 AM revealed Licensed Practical Nurse (LPN)-F had finished a medication pass for a resident. LPN-F completed hand hygiene with soap and water for 11 seconds. An interview on 5/23/2024 at 8:39 AM with LPN-F revealed LPN-F was aware of the requirement to wash hands with soap and water for at least 20 seconds. C. An observation on 5/21/2024 at 12:10 PM revealed the Activities Director (AD) had been waiting to deliver a food plate and had touched [gender] hair. The AD did not complete hand hygiene prior to touching and delivering the plate of food to the resident. An interview on 5/21/2024 at 12:25 PM with the AD confirmed hand hygiene should be completed after touching any contaminated. A record review of facility policy Infection Prevention and Control - Long Term Care with a last reviewed date of 1/19/2024 revealed during the delivery of resident care services, avoid unnecessary touching of surfaces to prevent contamination of clean hands and transmission of pathogens from contaminated hands to surfaces. Licensure Reference Number 175 NAC 12-006.17D Based on observations, interviews, and record review the facility failed to implement hand hygiene as required while passing water pitchers to resident rooms, during medication administration, and during dining room services. This had the potential to affect all residents who resided within the facility. The facility census was 43. The Findings Are: A. An observation on 5/23/24 at 10:55 AM revealed Domestic Aide (DA)-H collecting old water pitchers and passing out new water pitchers to resident rooms. DA-H went into Resident 31's room and carried a water pitcher out of the room, sat it on the lower shelf of a rolling cart, and wrote down the total amount drank on a piece of paper. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 18's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H performed hand hygiene (HH) via Alcohol Based Hand Rub (ABHR). DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 19's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 33's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H performed HH via ABHR. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 36's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 30's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then performed HH via ABHR. DA-H then carried two new water pitchers that had been setting on the top shelf of the rolling cart into Resident 2 & 4's room, came back out of the room with two different water pitchers, sat the pitchers on the lower shelf of the rolling cart and wrote the total amounts drank on the paper. DA-H then started picking up a water pitcher from the top shelf of the cart, sat it back down, and performed HH via ABHR. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 23's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then rearranged 5 of the water pitchers sitting on the top shelf of the rolling cart while holding and referencing their sheet of paper and then put the paper back down. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 11's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 40's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then performed HH via ABHR and pushed the rolling cart to another hallway of resident rooms. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 12's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then carried two new water pitchers that had been setting on the top shelf of the rolling cart into Resident 1 & 13's room, came back out of the room with two different water pitchers, sat the pitchers on the lower shelf of the rolling cart and wrote the total amounts drank on the paper. DA-H performed HH via ABHR and then pushed the rolling cart farther up the hallway. DA-H then carried two new water pitchers that had been setting on the top shelf of the rolling cart into Resident 5 & 10's room, came back out of the room with two different water pitchers, sat the pitchers on the lower shelf of the rolling cart and wrote the total amounts drank on the paper. DA-H then carried two new water pitchers that had been setting on the top shelf of the rolling cart into Resident 15 & 22's room, came back out of the room with two different water pitchers, sat the pitchers on the lower shelf of the rolling cart and wrote the total amounts drank on the paper. DA-H performed HH via ABHR then pushed the cart further up the hallway again. DA-H then carried a new water pitcher that had been setting on the top shelf of the rolling cart into Resident 25's room, came back out of the room with a different water pitcher, sat the pitcher on the lower shelf of the rolling cart and wrote the total amount drank on the paper. DA-H then carried two new water pitchers that had been setting on the top shelf of the rolling cart into Resident 41 & 43's room, came back out of the room with two different water pitchers, sat the pitchers on the lower shelf of the rolling cart and wrote the total amounts drank on the paper. DA-H then performed HH via ABHR and then pushed the rolling cart to the kitchen. An interview on 5/23/24 at 11:15 AM with DA-H confirmed they did not routinely perform hand hygiene as required prior to taking clean water pitchers into each residents' room after being in other residents' rooms and handling soiled water pitchers belonging to the other residents. A record review of the facility policy Hand Hygiene dated 4/18/24 revealed that hand hygiene was to be completed after each resident contact and after handling contaminated objects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference number 175 NAC 12-006.09D Based on observation, interview, and record review, the facility failed to obtain a supporting diagnosis for the use of an antipsychotic medication (a medication utilized in the control of hallucinations, delusions, and disordered thinking) for one current sampled resident (Resident #33) out of 12 sampled Residents. The facility census was 44. Findings are: Record review of the Resident Master Information form for Resident #33 revealed the resident was admitted on [DATE]. A review of the Problem list for Resident #33 revealed the resident had no qualifying diagnosis or identified problem that is listed as an approved treatment for Abilify (an antipsychotic medication). The problem list for Resident #33 revealed the following diagnoses; diabetes; hypertension; hypothyroidism; diabetic peripheral neuropathy; hyperlipidemia; glaucoma; osteoarthritis; atherosclerosis of both carotid arteries; falls; blind R eye; lung nodule; edema of leg; vasomotor rhinitis; humeral head fracture, R closed initial encounter; humeral head fracture; tremors of nervous system; dementia without behavioral disturbance; anxiety; Parkinson's disease. Record review of the electronic medication administration record revealed Resident #33 was receiving Abilify for paranioa and mood. Record review of the Care Plan for Resident #33 revealed no approved diagnosis for the utilization of the antipsychotic medication (Abilify). Interview on 4/19/2023 with the Director of Nursing revealed there was no approved diagnosis related to the usage of the antipsycotic medication Abilify for Resident #33. Interview on 4/19/2023 with the facility Administrator revealed there was no approved diagnosis related to the usage of the antipsycotic medication Abilify for Resident #33.