**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(4) Based on interview and record review, the facility failed to provide the bathing preferences for 3 (Residents 8, 12, and 78) of 7 sampled residents. The facility census was 85 at the time of survey. Findings are: A record review of the facility's Bathing Policy dated 5/2023 revealed residents will be provided bathing per request or as per facility schedule protocol and partial baths may be given between regular bathing schedules. A record review of the facility's Careplan Policy dated 7/2009 revealed the following: - Careplan will address problem, intervention, and goals. - Nursing Coordinator will be responsible for assuring this is initiated. - Ongoing changes to Careplans are made accordingly. A. A record review of Resident 8's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 7/9/2023, revealed an admission date to the facility of 8/16/2005 and 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 10, indicating low cognitive function. A record review of the task care within Resident 8's electronic medical record (EHR) for September and October 2023 revealed that Resident 8 received baths on 9/16/23, 9/30/23, 10/6/23, and 10/12/23. A record review of Resident 8's progress notes dated 9/1/23- 10/17/23 revealed no bathing refusals or documentation related to bathing. A record review of Resident 8's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) last review dated 9/3/23, revealed no resident preferences listed indicating when or how often the resident would like a bath. An interview on 10/16/23 at 1:22 PM with Licensed Practical Nurse (LPN) - A confirmed that Resident 8 did not have a bath for 14 days with no baths documented from 9/16/23 until 9/30/23. LPN - A further confirmed there was no documentation of bathing in the EHR and there would be no other place it would have been documented. An interview on 10/17/23 at 11:37 AM with LPN - A confirmed that Resident 8 did not have a Preference sheet filled out for bathing times and preferences on how often was not on the CCP and it should have been. No bathing audits or bathing schedules were provided. B. A record review of Resident 12's CCP, last reviewed dated 8/23/23 revealed an admission date of 7/28/22. A record review of Resident 12's MDS dated [DATE] revealed a BIMS score of 14 indicating high level of cognition. An interview with Resident 12 on 10/11/23 at 12:54 PM revealed that the resident wanted to receive 2 baths per week and that the resident had not been receiving 2 baths per week. Resident had told family members and was going to take it up with the staff. Resident 12 also confirmed that no baths were offered or refused from 10/1/23-10/10/23. A record review of the EHR for September and October 2023 revealed that Resident 12 received a bath on 9/8/23, 10/10/23 and 10/14/23. An interview on 10/17/23 at 10:12 AM with Registered Nurse (RN) - B revealed there was no documentation in the EHR of Resident 12 refusing baths, or any other baths documented for the months of September or October. RN - B further revealed that Resident 12's bath preference was not on the CCP and should have been. No bathing audits or bathing schedules were provided. C. A record review of Resident 78's MDS dated [DATE] revealed a BIMS score of 15 indicating resident is cognitively intact. A record review of Resident 78's CCP, date created 8/31/23 revealed an admission date to the facility of 8/31/23. An interview on 10/11/23 at 01:56 PM with Resident 78 revealed that they had not received 2 baths a week per their preference. A record review of Resident 78's EHR for baths for October 2023 revealed baths documented on 10/4/23 and 10/9/23. A record review of Resident 78's progress notes dated 10/1/23- 10/17/23 revealed no bathing refusals, no pericares, no bed baths offered, and no behaviors documented. An interview on 10/17/23 at 11:36 AM with LPN - A revealed there was no other documentation of bathing. No bathing audits or bathing schedules were provided. An interview on 10/17/23 at 11:37 PM with LPN - A revealed that Resident 78 did not have a Preference sheet filled out and bathing preferences were not on the CCP. An interview on 10/16/23 at 03:29 PM with the Director of Nursing (DON) confirmed there is no facility policy for the Preference Sheet to indicate residents bathing preferences but the resident preferences sheet should have been filled out for Residents 8, 12, and 78. An interview 10/17/23 12:50 PM with the DON confirmed that the facility staff should be following the facility's bathing policy for resident preferences and the CCP should have been updated and the resident preference sheet should have been scanned into the residents documents.

Based on interview and record review, the facility staff failed to provide documentation that a written notice of SNFABN (Skilled Nursing Facility Advance Beneficiary Notice-a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) and NOMNC (Notice of Medicare Non-Coverage-a notice issued to residents and/or their representative notifying them of when their Medicare coverage would end and how to file an appeal) was issued to 1 resident (Resident 31) of 3 sampled residents within the required time frame, denying the resident/resident representative the opportunity to appeal the facility's decision to discontinue Medicare A benefits. The facility census was 82. Findings are: A review of the form Beneficiary Notice-Residents discharged Within the Last Six Months completed by the facility revealed that Resident 31 was discharged from a Medicare covered Part A stay on 4/6/22 and remained in the facility. The facility initiated the discharge form Medicare Part A Services when benefit days had not been exhausted. A review of the form SNF (Skilled Nursing Facility) Beneficiary Protection notification Review completed by the facility revealed a last Covered Day for the resident of 4/5/22. A review of the NOMNC for Resident 31 revealed that the effective date that coverage for Medicare Part A Services would end was 4/4/22. This form was signed by the resident on 4/4/22. A review of the SNFABN for Resident 31 revealed that beginning on 4/5/22 the resident may be responsible for costs related to an Inpatient Skilled Nursing Facility Stay. This form was signed by the resident on 4/4/22. An interview conducted on 9/7/22 at 7:45 AM with the Business Office Director (BOD) G confirmed that the NOMNC and the SNFABN were both signed less than 2 days prior to the end of coverage.

Based on record review and interview, the facility failed to provide written notice of transfer to the hospital for Resident 17. This affected 1 of 1 residents sampled for hospitalization. The facility census was 82. Findings are: A review of Resident 17's Electronic Health Record (EHR) revealed that the resident had an emergency transfer to the hospital on 5/23/22. A Progress Note from 5/23/22 at 5:45 PM revealed that the resident's Power of Attorney was notified of transfer per phone. An interview conducted on 9/7/22 at 8:44 AM with the Director of Nursing (DON) confirmed that the facility was unable to provide documentation of a written notice of transfer being provided to the resident or resident representative. The DON further confirmed that one had not been done for that date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of the resident's functional abilities) regarding falls for 2 residents (57 and 75) out of 7 sampled for falls reflected the status of the resident at the time of the MDS assessment. The facility's census was 82. Findings are: A. A review of the facility's Monthly Fall Line Listing for July 2021 to August 2022 revealed that Resident 57 fell on 7/26/22 with a minor injury and fell on 7/27/22 with no injury. A review of Resident 57's 5-day MDS dated [DATE] revealed question J1900A was marked 2, indicating the resident had 2 falls without injury. J1900B was marked 0, indicating no falls with injury (except major). This category would include abrasions. J1900C was marked 0, indicating no falls with major injury. A review of Resident 57's admission MDS dated [DATE] revealed question J1900A was marked 1, indicating the resident had 1 fall without injury. J1900B was marked 0, indicating no falls with injury (except major). This category would include abrasions. J1900C was marked 0, indicating no falls with major injury. An interview conducted on 9/1/22 2:07 PM with the MDS nurse confirmed that on the 5-day MDS dated [DATE] 1 of the falls should have been coded as a fall with no injury, so J1900A should have been 1, and J1900B should have been 1. An interview conducted on 9/1/22 at 2:15 PM with the MDS nurse confirmed that the fall on the admission MDS dated [DATE] was coded twice on 2 different MDS. B. A review of the facility's Monthly Fall Line Listing for July 2021 to August 2022 revealed that Resident 75 had a fall with minor injury on 12/15/21. A review of the resident's Quarterly MDS dated [DATE] revealed question J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? was answered no, indicating the resident had not fallen since the previous MDS dated [DATE]. An interview conducted on 9/1/22 2:07 PM with the MDS nurse confirmed that the fall from 12/15/21 was not coded on the MDS.

Licensure Reference Number 175 NAC 12-006.09D5b Based on interviews and record reviews, the facility failed to provide a comprehensive assessment for 1 sampled resided (Resident 42) regarding current interests and activities. The facility identified a census of 82. Findings are: A record review of Resident 42's most recent activity quarterly progress note dated 12/28/2021 revealed Resident 42 watches television and reads. An interview on 09/06/22 at 09:45 AM with Activities Staff - E confirmed Resident 42 cannot see well enough to read or to watch television. A record review of Resident 42's annual Minimum Data Set (MDS: a comprehensive assessment of each resident's functional capabilities], dated 4/2/22 revealed the facility staff assessed the following about the resident: -Section F question F0500 was answered it is very important for Resident 42 to have books, newspapers and magazines to read. -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) was a score of 4. According to the MDS manual a score of 0-7 indicated a severe cognitive impairment. An interview with Med Aide - D on 9/7/22 at 08:44 AM confirmed that Resident 42 is not able to read. A record review of the facility Activity Policy dated 8/20 revealed in #1. Each resident's interest and needs will be assessed on a routine basis. An interview on 09/07/22 at 09:20 AM with Activity Director - F confirmed that there is no activity assessment done in the computer in the year of 2022 and also confirmed that the activity assessments were not done routinely and should have been for Resident 42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D5 Based on record reviews and interviews, the facility staff failed to identify, document and communicate specific targeted behaviors for 2 sampled residents (Residents 36 and 42). The facility identified with a census of 82. Findings are: A. A record review of the Behavior Policy dated 03/22 and titled Behavior Tracking and Documentation revealed nothing regarding identifying target behaviors. The policy read as follows related to behavior monitoring: 4. Mood and Behavior Tracking and Documentation a. Mood and behavior tracking will be completed by direct care staff to identify6 any mood and behavior patterns, interventions attempted, and the outcome of approaches. b. The interdisciplinary team will document behaviors and care plan approaches and interventions in the medical record. This documentation will be completed on admission and as needed. c. Mood and behavior tracking and documentation will be reviewed by the interdisciplinary behavior subcommittee as needed to determine trends and effectiveness of care plan interventions. B. A record review of Resident 36's current orders revealed orders for the following medications: - OLANZapine Tablet 2.5 MG (antipsychotic medication, a medication used to treat psychosis) -Citalopram Hydrobromide Tablet (antidepressant medication, a medication used to treat major depressive disorder, some anxiety disorders, some chronic pain conditions and or to help manage some addictions). A record review of Resident 36's Quarterly Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities) dated 8/15/22 revealed 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) which indicated a score of 3. According to the MDS manual a score of 0-7 indicated a severe cognitive impairment. The MDS also revealed Resident 36 taking antipsychotic and antidepressant medications for 7 days. A record review of Resident 36's comprehensive careplan Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed no target behaviors noted for antipsychotic or antidepressant medications. An interview on 09/06/22 at 02:25 PM with the Director of Nurses (DON) confirmed there are no target behaviors for psychotropic medications listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) or in the resident's comprehensive careplan. C. A record review of Resident 42's current orders revealed orders for the following medication: - RisperiDONE Tablet 0.5 MG (antipsychotic medication, a medication used to treat psychosis). A record review of Resident 42's MAR and TAR revealed no target behaviors listed. A record review of Resident 42's CCP revealed Psychotropic Medications used for Dementia with Behaviors, Delusions and Agitations. No target behaviors noted. A record review of Resident 42's MDS dated [DATE] revealed psychotropic medications were used 2 times. An interview on 09/06/22 at 02:25 PM with the Director of Nurses (DON) confirmed there are no target behaviors for psychotropic medications listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) or in the resident's comprehensive careplan.

LICENSURE REFERENCE NUMBER 12-006.09D LICENSURE REFERENCE NUMBER 12-006.12B(5) Based on record review and interview, the facility failed to ensure residents were free from unnecessary meds related to the use of pain medications given without pain ratings and non-pharmacological interventions for Resident 3. The sample size was 1. The facility census was 82. FINDINGS ARE: A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/19/22, section C, revealed Resident 3 had a 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) score of 7. A record review of the Active Orders Report ran on 9/1/22 revealed Resident 3 had the following pain medications ordered: -Acetaminophen (an over-the-counter medication used for mild to moderate pain or discomfort) Tablet Give 650 mg (milligrams) by mouth three times a day for pain. -Acetaminophen Tablet 500 MG Give 2 tablet by mouth every 6 hours as needed for pain Give 500mg 2 tabs = 1000mg. A record review of the Active Orders Report ran on 9/1/22 revealed a new order for routine Acetaminophen for pain had been initiated for Resident 3, the order reads as follows: -Acetaminophen Tablet 325 MG Give 650 mg by mouth three times a day for pain do not exceed 4Grams in 24 hours give 325mg tab X2 = 650mg. -Order Date 09/01/2022 0744 The record review of the Tylenol administration which began on 9/1/22 revealed no numerical pain rating or pain assessment with administration of pain medications documented on the September 2022 MAR for Resident 3. The record review of the Tylenol administration which began on 9/1/22 revealed no nonpharmacological interventions documented on the September 2022 MAR for Resident 3. A record review of the facility policy titled Pain Management with an original date of 01/02, effective dated 04/18 that reads as follows: -IV. 1) Use of a standard scale for assessing pain is essential. The Hearthstone's choice of pain intensity scale is 0-10 with: 0 equal to NO PAIN 5 equal to MODERATE PAIN 10 equal to Worst POSSIBLE PAIN -The tool is universally used and understood throughout the continuum of the care delivery system and is included in current pain evaluation. -2) The PAINAD Scale will be used for residents who are cognitively impaired. Total scores range from 0-10 (based on 0-2 for five times). The items scored are: Breathing, Negative Vocalization, Facial expression, Body Language and Console ability. Obtained scores are not to be used to infer absolute pain intensity. PAINAD scores are not necessarily equal to numerical pain scale scores. Scores are to be compared to the previous scores received, an increased score suggests an increase in pain, while a lower score suggests pain is decreased. Instructions: Observe the resident for 3-5 minutes during activity w/movement (such as bathing, turning, transferring). For each of the items included in the PAINAD, select the score (0,1,2) that reflects the current state of the person's behavior. Add the score for each item to achieve a total score. NOTE: Behavior observation scores should be considered in conjunction with knowledge of existing painful conditions and report from an individual knowledgeable of the person and their pain behaviors. Some residents may not demonstrate obvious pain behaviors or cues. VI. Communicate evaluation findings with the resident's physician for possible change in both pharmacological and non-pharmacological pain relief measures based on current clinically accepted guidelines. Nursing may implement the following as a nursing measure: massage, warm blankets, warm moist packs, warm blankets, and repositioning. VII. There is a wide range of pharmacological, physical, and behavior treatments related to the differing etiologies of pain, but analgesics should be held until the cause of pain is determined. Non-pharmacologic intervention should be initiated with or prior to analgesics depending on the severity of pain. A record review of the pain scale ratings listed under the Vitals tab for Resident 3 were not found to have three times daily pain rating but were documented as follows: 9/1/2022 08:01 1 PAINAD 8/31/2022 09:57 5 PAINAD 8/18/2022 17:10 0 Numerical 8/16/2022 21:36 0 PAINAD 8/16/2022 20:00 5 PAINAD 8/3/2022 04:56 0 PAINAD 8/2/2022 18:20 0 Numerical 8/2/2022 11:06 3 PAINAD 8/2/2022 03:10 0 PAINAD 8/1/2022 21:12 0 PAINAD An interview on 09/06/22 at 02:27 PM with the DON (Director of Nursing) revealed that the facility expectation for pain monitoring or assessment was reviewed quarterly and not completed more frequently at this time.

B. Observation on 8/31/22 at 12:36 PM of MA-D (Mediction aide) assisting 2 residents to eat in the 300 hall dining room revealed MA-D didn't perform hand hygiene in between assisting the 2 residents. A record review of Hand Hygiene Policy, approved by Infection Control Committee on 1/21 revealed under: l. Patient/Resident Care Personnel A. # 1. Alcohol based hand rub to be used: b. Before having contact with patients/residents. Interview on 09/01/22 at 01:15 PM with Dietary Manager confirmed that all staff should wash hands in between residents. Based on observation, record review and interview, the facility failed to A) prevent the potential spread of Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus)related to a staff member working a scheduled shift despite failing Covid-19 screening symptoms, and B) prevent the potential for cross contamination by not performing hand hygiene between assisting residents with their meals. This had the potential to affect 17 residents. The facility census was 82. FINDINGS ARE: A. A record review of the facility staff screening logs titled Hearthstone Staff Kiosk Log (06/30/2022-8/31/2022) revealed that on 07/19/2022 at 06:08 PM, NA-I (Nurse Aide) had a temperature listed of 100.4 degrees. A record review of the facility policy titled Coronavirus Surveillance and dated 3/2020 read as follows: C. Screening for visitors and staff; 1. Signs or symptoms of respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell). E. Staff who have a fever or signs and symptoms of a respiratory infection shall not report to work. An interview with the facility Director of Nursing (DON) on 08/31/22 at 03:27 PM revealed that the facility expectation of a fever was anything above 100.3 degrees. The interview with the DON on 08/31/22 at 03:27 PM, after review of the kiosk logs confirmed that on 07/19/2022 at 06:08 PM, NA-I should not have been allowed to work. When a copy of the timecard for NA-I was requested, the DON revealed that NA-I was no longer employed with the facility and that the name badge had been wiped clean and given to a new employee.