Licensure reference number 175 NAC 12-006.09E(iii) Based on observation, record reviews and interviews, the facility failed to develop and implement a Comprehensive Care Plan (CCP, a written interdisciplinary comprehensive plan which detailed how to provide quality care for a resident) catheter for 1 (Resident 5) of 1 sampled resident. The facility census was 28. Findings are: Record review of Resident 5's admission record revealed admission was 8/27/24. Record review of Resident 5's diagnosis revealed Neuromuscular Dysfunction of Bladder, unspecified. Record review of Resident 5's Minimum Data Set (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) Section H, dated 9/3/24 revealed that Resident 5 did have a catheter. Record review of Physician's Orders for Resident 5 dated 08/27/2024 revealed: -Change dry dressing to Suprapubic Foley catheter insertion site daily and PRN. -Ensure catheter cares are completed during your shift. -Irrigate Suprapubic Catheter with 30ml of Normal Saline if clogged as needed. Record review of Physician's Orders for Resident 5 dated 09/01/2024 revealed: -Change Suprapubic Catheter - every month and PRN as needed based on clinical indications such as infection, obstruction, or when the closed system is compromised. Provide new drainage bag with new Foley catheter. Record review of Resident 5's Care Plan on 10/29/24 revealed that the Suprapubic catheter was not on the Care Plan. Interview with MDS coordinator on 10/30/24 at 9:28 AM revealed that the Resident 5's Suprapubic catheter should be on the care plan but wasn't. Record review of Care Plans Policy revised November 2023 revealed: Policy: It is the policy of this facility to develop a comprehensive, individualized plan of care for each resident. The care plan is developed by the interdisciplinary Care Plan Team and reviewed and revised as required. The Care Plan guides the care and treatment provided by all caregivers. 5. The care plan is individualized and addresses the resident's medical, nutritional, psychological, physical, functional, social, educational, and spiritual needs and the severity of the resident's condition, diagnosis, disease process, impairments, disability, medication, and treatments as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(h) Based on observation, record review, and interview, the facility failed to monitor resident behavioral symptoms to ensure the effectiveness or continued need for an antipsychotic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for 1 resident (Resident 1) out of 15 sampled residents and the facility failed to have a stop date on a PRN (as needed) antianxiety medication for 1 resident (Resident 11) out of 15 sampled residents. The facility census was 28. Findings are: A. A record review of the facility Policy entitled: Use of Psychotropic Drugs reviewed 2/20 included the following information: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines -Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. -Resident who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. A record review of Resident 1's admission Record with the printed dated of 10/29/24 revealed that Resident 1 was admitted to the facility on [DATE] with the diagnosis of: - Paranoid Schizophrenia (characterized especially by delusions of persecution, grandiosity, or jealousy and by hallucinations (such as hearing voices) chiefly of an auditory nature), anxiety disorder (a feeling of fear, dread, or uneasiness). - Major depressive disorder (serious mood disorder that can affect how people feel, think, and behave). - Insomnia (unable to fall asleep, stay asleep or get quality sleep). - Unspecified dementia, unspecified severity with other behavioral disturbance (drastic changes in behavior which may seem to occur out of nowhere). - Cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes). A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 8/26/24 revealed in section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 11 indicating Resident 1 has moderate cognitive impairment. A record review of Resident 1's Comprehensive Care Plan (CCP, a written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 10/12/24 revealed target behaviors of paranoia, delusional thinking, hallucinations, verbal and physical aggression, insomnia, self- isolation, anxiety, and finger-painting feces. A record review of the Physicians orders dated 4/21/24 for Resident 1 revealed the following medication orders: -Trazodone 75 milligram(MG) for insomnia (A drug used to treat depression. It may also be used to help relieve anxiety and insomnia (trouble sleeping) and to treat certain other disorders. -Clonazepam 0.5 mg give one table twice a day and 1 mg in the morning (It can treat seizures, panic disorder, and anxiety). -Seroquel 50 mg give one daily in the morning (treats several kinds of mental health conditions including schizophrenia and bipolar disorder). -Sertraline HCL 150 mg give one tab daily (used to manage and treat the major depressive disorder, obsessive-compulsive disorder, panic disorder). -Seroquel 200 mg give one tab at bedtime ( treats several kinds of mental health conditions including schizophrenia and bipolar disorder). -Invega Trinza Intramuscular 819mg/2.63ml every 90 days (used to treat certain mental/mood disorders). A record review of Resident 1's Electronic Medical Record (EMR) revealed no specific target behaviors were documented for the months of October, November and December of 2023. A record review of Resident 1's Gradual Dose Reduction (GDR) dated 1/30/24 revealed physician documentation that GDR was contraindicated due to behaviors noted in the care plan and charting. An interview on 10/29/24 at 2:30 PM with the MDS Coordinator confirmed that there had been no behaviors charted in the last 3 months of Oct. 23 Nov. 23 Dec. 23 for Resident 1 with the last GDR being done on 1/30/24 for the doctor to sign rational not to attempt a drug reduction. An interview on 10/29/24 at 3:00 PM with the Director of Nursing (DON) confirmed that there had been no behavior charting for Resident 1 and the physician should of been made aware. B. A record review of the facility Policy entitled: Use of Psychotropic Drugs reviewed 2/20 included the following information: -If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. -PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. A record review of Resident 11 admission Record with the printed date of 10/29/24 revealed that Resident 11 was admitted to the facility on [DATE] with the diagnoses of: -Unspecified dementia, unspecified severity, with other behavioral disturbance (drastic changes in behavior which may seem to occur out of nowhere). -Depressive disorder (a depressed mood or loss of pleasure or interest in activities). -Vascular dementia, unspecified severity with mood disturbance ( chronic condition that occurs when the brain's blood supply is interrupted, damaging brain tissue and causing a decline in thinking, memory, and behavior). -Anxiety disorder (a feeling of fear, dread, or uneasiness). A record review of Resident 11 Progress Notes dated 8/28/24 revealed a BIMS score of 12 indicating Resident 11 is moderate cognitive impairment. A record review of Resident 11 CCP dated 8/26/24 revealed focus, goals, and interventions for PRN depression medication. A record review of Resident 11 Physicians Orders revealed that Resident 11 had an order for Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth every 24 hours as needed (PRN) for irritability with no stop date on 10/29/24 An interview on 10/29/24 12:17 PM with the DON confirmed that the PRN Xanax should have a stop date.

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, record review, and interviews, the facility staff failed to perform hand hygiene (hand washing using soap and water or an alcohol based hand rub) for 15 seconds or more during the provision of wound care to prevent potential cross contamination for 1 (Resident 8) of 1 sampled resident and failed to place Resident 5's catheter bag to prevent potential cross contamination for 1of 1 sampled residents. The facility census was 28. A. Record review of Resident 8's admission record dated 10/29/24 revealed admission was 12/23/2018. Record review of Resident 8's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/15/24 revealed in Section C BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15. Record review of Resident 8 diagnosis revealed: Chronic Venous Hypertension (idiopathic, describes a disease of unknown cause) with ulcer (a condition that occurs when blood pressure in the leg veins doesn't decrease while walking causing ulcers to form) of right lower extremity, Non-pressure chronic ulcer of other part of right foot with unspecified severity, non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, and Type 2 Diabetes Mellitus (a chronic disease that occurs when the body is unable to control blood glucose levels) with diabetic chronic kidney disease (a long term condition that occurs when the kidneys are damaged and can't filter blood properly). Record review of Physicians Orders dated 09/10/24 for Resident 8 revealed: -Cleanse entire right leg with hibiclens in warm water and dry well. Soak wound bed of venous stasis ulcer to right anterior LE (lower extremity) with Vashe (a saline based wound cleanser) or 1/2 strength Dakin's (a bleach based wound cleanser) soaked gauze x 15 minutes prior to treatment application. Wipe wound bed well with moistened gauze to assist with removing biofilm (microorganisms) and debris (scattered pieces of waste or remains). Apply triad paste (a zinc-oxide based wound dressing paste) to peri-wound, Apply Hydrofera Blue dressing (an antibacterial foam dressing) to wound bed. Cover with an ABD (A highly absorbent pad used to treat wounds that drain heavily or are located in or on the abdomen) pad. Secure with gauze wrap and tape. Change 3 x weekly and PRN (as needed). Record review of Physician Orders dated 10/23/24 for Resident 8 revealed: -Cleanse right 2nd toe with hibiclense (an antiseptic skin cleanser that helps prevent skin infections) in warm water and dry well. Soak wound bed with Vashe or 1/2 Dakin's-soaked gauze x 15 minutes prior to treatment application. Wipe wound bed well with moistened gauze to assist with removing biofilm and debris, Apply triad paste to peri-wound, Apply Aquacel AG dressing to wound bed. Cover with gauze. Secure with gauze tape. Change 3x weekly and PRN (as needed) every day shift every Mon, Wed, Fri and as needed Interview with Registered Nurse (RN) on 10/30/24 at 9:57 AM revealed Resident 8 declines (refuses) some of the leg treatment frequently. RN said today resident is refusing to let the nurse do the soaking of the wound bed with Vashe for 15 minutes prior to treatment application or Triad paste to peri-wound of right 2nd toe and lower leg, and Resident 8's doctor is aware. Observation on 10/30/24 at 10:00 AM with RN for Resident 8 for wound care. RN donned (put on) gloves and cleansed the bedside table before placing supplies. RN doffed (removed) gloves and washed hands with soap and water for 12 seconds. RN donned (put on) a gown, mask, goggles and gloves. RN then removed the right 2nd toe dressing, doffed gloves, performed hand hygiene with hand sanitizer gel, then donned gloves. Resident refused to let the nurse do a Vashe or 1/2 Dakin's-soaked gauze x 15 minutes prior to treatment for leg or toe and refused triad paste. RN cleansed toe wound with hibiclens and normal saline to wound bed well to assist with removing biofilm and debris, rinsed with normal saline and dried. RN then cut a small piece of Aquacel AG dressing and applied to wound bed, covered with gauze, and secured with gauze tape. RN washed hands with soap and water for 9 seconds and donned gloves. RN removed the old dressing to right lower leg, doffed gloves, and performed hand hygiene with hand sanitizer gel, and donned gloves. RN cleansed the right leg wound and peri-wound with hibiclens in normal saline, wiped wound bed well with moistened gauze to assist with removing biofilm and debris, rinsed with normal saline and dried. RN performed hand hygiene, donned gloves, and applied Hydrofera Blue dressing to wound bed. RN covered with ABD pad and secured with gauze wrap and tape. RN dated the dressings. RN cleaned work area. RN removed gown, mask, goggles and gloves. RN then washed hands with soap and water for 9 seconds and took trash can liner out of room. Interview on 10/30/24 at 10:30 AM with RN confirmed that [gender] should have washed their hands at least 15-20 seconds. Interview on 10/30/24 at 11:20 AM with Director of Nursing (DON) confirmed that hand washing should be done for 20 seconds. Record review of Hand Hygiene Policy updated 2021 revealed: Policy: Hand hygiene - Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis. b. Apply enough soap to cover all hand surfaces. c. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use towel to turn off the faucet. B. Record review of Resident 5's admission record revealed Resident 5 admitted to the facilty 8/27/24 with a Suprapubic foley catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) because of a diagnosis of Neuromuscular Dysfunction of Bladder, unspecified (a condition that occurs when the nerves and muscles of the bladder don't communicate properly with the brain, resulting in bladder control issues). Observation on 10/28/24 at 10:50 AM revealed Resident 5's Suprapublic catheter bag was hooked onto the trash can by the bed and was resting on the floor without a protective bag covering it. Observation on 10/30/24 at 6:54 AM revealed Resident 5's Suprapubic catheter bag was hanging off the trash can with the catheter bag and was resting on the floor. Interview with DON on 10/30/24 at 6:58 AM confirmed the facility's expectation is not to have catheter bag on the floor.

Licensure reference number 175 NAC 12-006.04B2a Based on interviews and record reviews, the facility failed to ensure a nursing assistant/medication aide had 12 hours of ongoing inservice training for this past year. This had the potential to affect all 28 residents who reside within the facility. The facility census was 28. Finding are: Record review of listing of facility staff names and hire dates revealed Medication Aide (MA) was hired on 8/16/21. Record review of MA's Relias (a company/program that provides education and training) transcript dated 10/31/24 revealed 0 hours of training for the last 12 months. Interview with Director of Nursing on 10/31/24 at 12:00 PM confirmed that MA had no ongoing inservice training since 7/9/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09B1(2) Based on record review and interviews, the facility failed to complete a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities. The SCSA is required when there is a significant change in those capabilities) for Resident 25. This affected 1 of 13 residents reviewed for MDS completion. The facility census was 30. Findings are: A record review of Resident 25's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, diabetes, heart disease and repeated falls. A record review of the resident's Modification of admission MDS dated [DATE] revealed the resident required supervision with bed mobility, transfers, and eating. A review of the resident's Quarterly MDS dated [DATE] revealed the resident required extensive assistance with bed mobility and transfers and set-up assistance with eating. An interview on 9-13-2023 at 8:58 AM with the MDS nurse confirmed that the resident should have had a SCSA MDS done.

Licensure reference number 175 NAC 12-007.04D Based on observation, interview, and record review the facility failed to ensure the ventilation system was in working order in 6 resident bathrooms (rooms 4E, 9S, 8S, 4S, 6S, and 15S) out of 13 sampled resident rooms. The facility census was 30. Findings are: Observation on 9/14/23 between 12:20 PM and 12:40 PM with the Administrator (ADM) and Corporate Maintenance Consultant (CMC), revealed the bathroom vents in rooms 4E, 9S, 8S, 4S, 6S and 15S were not working. During an interview on 9/14/23 at 12:40 PM, the CMC confirmed the bathroom vents in rooms 4E, 9S, 8S, 4S, 6S and 15S were not working. The CMC further confirmed that there was no need to test the other vents as they were on the same ventilation unit and would also not be working. The CMC revealed there were no work orders for the ventiliation system and the CMC was unaware the vents were not working. During an interview on 9/14/23 at 12:40 PM the ADM revealed the vents had not been tested for approximately 2 weeks. During an interview on 9/14/23 at 12:40 PM the ADM revealed [gender] was unaware the ventilation system was not working. During an interview on 9/14/23 at 12:40 PM the Director of Operations (DoO) revealed [gender] was unaware that ventilation system was not working. During an interview on 9/14/23 at 1:20 PM the ADM revealed the facility did not have a policy on ventilation monitoring. Record review of Exhaust Fan Monthly Inspection Log revealed the last check of ventilation system was on 7/23/23. Places the ventilation was checked were offices, resident room (no room listed) utility room, kitchen, dining, and restrooms documented as cleaned.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report allegations of potential abuse and/or neglect to the State Agency, to complete an investigation and then submit the results of the investigation for 1 (Resident 30) of 2 sampled residents within the required time frames. The facility census was 30. Findings are: A. Review of the facility Abuse, Neglect, Misappropriation and Exploitation Policy a reviewed date of 10/2019 indicated the facility would: -report any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state regulations; -conduct an investigation of such allegations in accordance with state law; and -report all investigation findings to the State Agency in accordance with state regulations. B. Review of Resident 30's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/5/22 identified the resident was cognitively intact with diagnoses of fractures and multiple traumas, traumatic brain injury, anxiety, and depression. The assessment further indicated the resident required total staff assistance with transfers and toileting and extensive staff assistance with bed mobility and dressing. Review of a Nursing Progress Note dated 5/1/22 at 1:05 AM revealed the resident had indicated Nurse Aide (NA)-B was no longer allowed to come into the resident's room. The note further revealed will address with day shift. Review of a Nursing Progress Note dated 5/2/22 at 2:09 AM revealed a police officer arrived at the facility at 1:15 AM regarding a phone call received by the resident. Review of an Adult Protective Services (APS) Intake Worksheet dated 5/2/22 at 2:42 AM revealed the resident had called the police as staff had removed the resident's water and the resident's blankets from the room. Review of facility investigations from 4/1/21 through 7/18/22 revealed no investigation had been completed and then sent to the State Agency regarding the resident's concern on 5/1/22 at 1:05 AM regarding NA-B and on 5/2/22 at 1:15 AM regarding staff removing the resident's water and blankets from the resident's room. During an interview on 7/20/22 at 10:47 AM, the Administrator confirmed no report had been made regarding the resident's concerns about NA-B on 5/1/22 or regarding the resident's call to APS and the police on 5/2/22. In addition, no investigation was completed regarding potential abuse and the results of the investigation sent to the State Agency in accordance with regulations.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on record review and interview; the facility failed to follow up on the consultant Registered Pharmacist's recommendation regarding use of a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication for 1 (Resident 27) of 5 sampled residents. The facility census was 30. Findings are: Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/30/22 revealed diagnoses of stroke, diabetes, dementia, and depression. The MDS further indicated the resident displayed no adverse behaviors and was receiving psychotropic medication daily. Review of a Note to Attending Physician/Prescriber dated 11/30/2021 revealed a new order for Seroquel (psychotropic medication) 50 milligrams (mg) at bedtime for complaint of insomnia. Review of a Monthly Pharmacy Regimen Review (medication reviews completed by the consultant Registered Pharmacist) dated 1/27/22 revealed a recommendation for the facility to complete an AIMS (Abnormal Involuntary Movement Scale- assessments used to monitor for potential adverse side effects of a psychotropic medications) assessment related to use of the Seroquel. Review of a Monthly Pharmacy Regimen Review dated 2/28/22 revealed a second recommendation for the facility to complete an AIMS assessment for Resident 27. Review of a Monthly Pharmacy Regimen Review dated 3/31/22 revealed a third recommendation for the facility to complete an AIMS assessment for Resident 27. Review of an AIMS Evaluation dated 4/5/22 (4 months after the resident was started on the Seroquel) at 2:16 PM revealed the assessment was completed to determine potential neurological side effects related to use of Seroquel. Interview with the Director of Nurses (DON) on 7/19/22 at 2:52 PM confirmed the consultant Registered Pharmacist had identified a need to complete an AIMS assessment after the resident was started on the Seroquel 50 mg at bedtime. The DON indicated an AIMS assessment should have been completed when the medication was first initiated and then quarterly thereafter. The DON verified there was currently no system in place to assure consultant Registered Pharmacist recommendations were being followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review and interview; the facility failed to ensure equipment was operational and floors, ceilings, walls, doors, and ventilation covers were clean and in good repair. The facility census was 30. Findings are: A. Review of the facility Environmental Policy with a reviewed date of 6/22 revealed a safe, functional, sanitary, and comfortable environment was to be maintained for residents, staff, and the public. The facility was to maintain all essential mechanical, electrical and patient care equipment in safe operating condition. All facility personnel were responsible for reporting broken, defective or malfunctioning equipment or furnishings. B. Observations on 7/18/22 from 9:48 AM to 1:00 PM and on 7/21/22 from 8:45 AM to 10:00 AM with the Maintenance Manager revealed the following environmental concerns: East Corridor -the plastic door guard/veneer to the bottom half of the entrance door of room [ROOM NUMBER] was detached to the inner corner and presented a sharpened edge; -the wall beneath the window and near the baseboard of room [ROOM NUMBER] had a hole in the dry wall approximately 6 centimeters (cm) by 3 cm with the wall gouged next to the hole and a 12 cm by 3 cm hole in the drywall with gouges behind the headboard of the bed; -exterior of a ventilation cover in the ceiling of the corridor with a coating of dust/debris; -5 ceiling tiles in the corridor with brown discoloration; and -exit door to an outside courtyard at the end of the corridor with a broken Mag lock (lock that uses an electric current to produce the magnetic force. Due to the increased strength because of the current, the doors can withstand pressure, so they can't be forced open without use of the confirmed access method). South Corridor -wall next to the bed in room [ROOM NUMBER] with a heavy layer of spackle/plaster which had not been sanded and/or painted; -exterior of a ventilation cover in the ceiling of the corridor with a coating of dust/debris; and -floor to room [ROOM NUMBER] with food crumbs and a bedside table and flooring underneath of the table stained with paint which was no longer cleanable and had not been replaced. C. Review of Daily Maintenance Checklist (form used to document water temperature checks in resident's rooms, daily alarm checks of exit doors, call light checks and room temperature checks) from 6/1/22 through 7/20/22 revealed the Mag lock to the East Courtyard was non-functional. D. Interview on 7/21/22 with the Maintenance Supervisor from 8:45 AM to 10:00 AM confirmed the following: -the plastic door guard/veneer on the entrance door of room [ROOM NUMBER] East, the wall in room East 9 and the wall in room South 15 required repaired; -the ceiling tiles in the East corridor and the floor and bedside table in room South 18 needed to be replaced; and -the Mag lock to the East courtyard exit had been broken for at least the last 2 months. The parts to replace the lock had arrived about a week ago but the Maintenance Manager had not had the time to address the broken lock. E. Interview on 7/21/22 at 10:30 AM with Housekeeper (HK)-M verified the ventilation covers in the South and East corridors were covered with a coating of dust and the ventilation covers were not on the current cleaning schedules. In addition, the floor in room South 18 frequently had food debris as the resident ate in the room for all meals.

LICENSURE REFERENCE NUMBER 175 NAC 12-0006.12E8 Based on record review, observation and interview; the facility failed to assure medications awaiting destruction were accounted for to prevent misappropriation of medications for residents. This affected 17 residents. The sample size was 30. The facility census was 30. Findings are: Observation on 7/21/22 at 9:55 AM revealed a cupboard in the medication room housed several cards of medications that were awaiting destruction. The medication room was locked and only accessible with a key. Record review on 7/21/22 at 9:55 AM revealed no evidence of a log to account for the medications that were stored in the medication room awaiting destruction. Interview on 7/27/22 at 9:55 AM with Licensed Practical Nurse (LPN-E) revealed that the medications were tracked after the medications were destroyed but the facility did not track the medications that were stored in the cupboard prior to destruction. Interview on 7/21/22 at 10:10AM with the Director of Nursing (DON) confirmed that the facility did not keep a log of the medications that were stored awaiting destruction. The facility only recorded the medications that had been destroyed and that there was not a process in place to account for the medications that were stored in the cupboard until destruction.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, interview and record review; facility staff failed to ensure meals were palatable and maintained at the food temperatures to prevent foodborne illness. This had the potential to affect all residents. The facility census was 30. Findings are: Review of the undated facility policy on food safety measures revealed dietary staff must obtain and document the temperatures of all menu items before and after the meal service. Additionally, temperatures should never fall within the danger zone of 41-135 degrees Fahrenheit. Review of the facility's Meal Temperature Log between 7/10/22 and 7/16/22 revealed the following: -on 7/10/22, the breakfast meal had no documented temperatures at the end of the meal service for the eggs and meat; and -on 7/16/22, there was no evidence temperatures were documented for all menu items served before and after both the breakfast and lunch meals. On 7/20/22 from 11:20 AM to 12:10 PM, observations of the noon meal service revealed the following: - At 11:25 AM, Dietary [NAME] (DC)-S, removed 3 chicken fried steaks from the baking pan, placed them in the blender and ground them. DC-S then mixed the ground meat with gravy and placed the meat mixture into the steam table pan, but did not check the temperature of the ground meat before serving it to residents. - At 12:10 PM, DC-S had served up the last meal to residents from the steam table. Upon request, the meal temperature was checked by DC-S and the chicken fried steak was 110 degrees Fahrenheit (F) and the breaded chicken patty was 80 degrees F. DC-S indicated these food items would normally be maintained and served at a minimum temperature of 140 degrees F. During an interview with the Dietary Manager (DM) on 7/20/22 at 12:15 PM, the DM confirmed the food items should have been maintained in the steam table at temperatures above 135 degrees F throughout the meal service. The DM also confirmed there were missing entries on the meal temperature log and staff should have obtained and documented temperatures of all menu items before and after each meal.

Licensure Reference Number 175 NAC 12-006.04B2 Based on interview and record review; the facility failed to ensure that abuse training was completed for 20 of 34 employees who were employed at the time of training. The facility had a census of 30. The findings are: Review of the facility policy Abuse, Neglect, Misappropriation and Exploitation with a reviewed date of 10/2019 revealed all new employees were to be educated during their initial orientation. Annual education and training were to be provided to all existing employees. Review of the facility report titled Module Completions revealed a module titled Dementia Care; Preventing and Responding to Abuse was to have been completed by all staff by 8/31/21. Further review revealed of the 34 current staff, 12 staff had not started and/or completed the required training. Review of a facility report titled Module Completions revealed a module titled Understanding Abuse and Neglect was to have been completed by all staff by 3/31/22. Further review revealed of the 34 current staff, 9 staff had not started and/or completed the required training. During an interview on 7/21/22 at 9:29 AM, Nursing Assistant (NA)-C confirmed failure to complete the required training related to Abuse, Neglect, Misappropriation and Exploitation the previous year. Furthermore, NA-C had still not finished the mandatory training. Interview with the Administrator on 7/22/22 at 10:33 AM confirmed 20 of 34 employees had not completed the required training.