Every finding on record at Accura HealthCare of Hartington

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18Based on observation, record review and interview; the facility failed to ensure antibiotics ordered for 2 (Resident 9 and 14) of 12 sampled residents had an order for duration for use. The facility census was 34.Findings are:A.Review of the facility policy Antibiotic Stewardship updated 11/13/2024 revealed the following:-Accura HealthCare antibiotic stewardship program promoted the appropriate use of antibiotics and included a system of surveillance, monitoring and preventative measures to improve resident outcomes and reduce antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms. -If an antibiotic was ordered the Physician would identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. B.Review of Resident 9's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plan) dated 1/29/26 revealed the following: - Resident 9 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease Late Onset. Review of Resident 9's Treatment Administration Record (TAR) dated February 2026 identified the following order:-Mupirocin Ointment (an antibiotic) applied to both nares topically every 24 hours as needed for dry nose with a start date of 11/26/24. Further review revealed no ordered duration for use. An interview with the facilities Infection Preventionist Registered Nurse (IP-RN) on 2/23/26 at 10:05 AM confirmed that the order for Mupirocin External Ointment did not have a defined duration and the IP-RN had not monitored the use of the antibiotic. C.Review of Resident 14's MDS dated [DATE] revealed the following:-Ointment/medication was applied other than to feet. Review of Resident 14's Care Plan with a revision date of 1/20/26 revealed the resident had self-inflicted scratches to the left thigh and to provide wound care per treatment order. Review of Resident 14's Weekly Skin Check assessment dated [DATE] revealed resident had self-inflicted scratches to the front of the left thigh that measured 0.8 centimeters (cm) by 0.5 cm. Review of Resident 14's Medication Administration Record (MAR) dated February 2026 identified the following order:-Triple Antibiotic Ointment apply to the left knee, right and left thigh every day for self-inflicted scratches. D/C treatment when areas were healed. Start date was 8/21/25. Further review revealed no ordered duration for use. During an observation of the provision of care for Resident 14 on 2/19/26 at 11:00 AM revealed Resident 14 was sitting in the bathing room and had a whirlpool. Registered Nurse (RN-K) applied Triple Antibiotic Ointment to an open area on resident's left thigh. RN-K confirmed that the area does heal but then resident scratches at the area and the area reopens. An interview with the IP-RN on 2/23/26 at 10:05 AM confirmed that the Triple Antibiotic Order did not have a defined duration and the IP-RN had not monitored the use of the antibiotic.

Licensure Reference Number 175 NAC 12-006.09(H)(vi) Based on record review and interview; the facility failed to ensure that Resident 5 was free from use of unnecessary medications as a psychotropic medication (medication that affects the mind, emotions, and behavior) had been initiated without an indication for use. The sample size was 5 and the facility census was 32. Findings are: A. A record review of the facility policy Use of Psychotropic Drugs with a review date of 2/2020 revealed the following: -Residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the medical record, -the indication for initiating psychotropic medication's would be determined by the resident's actions and behaviors, -the indications for the use of psychotropic medications would be documented in the medical record, and -psychotropic medications would be initiated after admission after medical and physical causes had been identified and addressed. B. A record review of Nursing Progress Notes for Resident 5 revealed the following: -On 12/12/24 the resident was admitted from the assisted living facility and admitted with a psychotropic medication and an antidepressant. The resident's mood was pleasant, and no behaviors were witnessed. -On 12/14/24 at 11:52 PM nursing progress notes revealed that the resident's mood was pleasant with no behaviors. -On 12/18/24 a Social Services note revealed that the resident had confusion at times with a diagnosis of neurocognitive disorder with Lewy bodies (neurocognitive disorder that caused a gradual decline in mental abilities). -On 12/23/24 the psychotropic medication was discontinued. -From 12/24/24 to 1/7/25 nursing progress notes revealed that no behaviors had been documented. -On 1/7/25 a behavior meeting occurred with no change in medications. -From 1/7/25 to 1/27/25 nursing progress notes revealed that no behaviors had been documented. -On 1/27/25 the resident went to a neurology appointment with family and returned with an order for Seroquel (psychotropic medication) 12.5 milligrams (mg) at bedtime for 2 weeks then increase to 25mg at bedtime for diagnosis of Neurocognitive Disorder with Lewy Bodies. -On 1/31/25 at 10:20 AM nursing progress note revealed that staff had noted an increase in sleepiness in the morning, was difficult to awaken, and the neurologist had been notified. -On 1/31/25 at 1:19 PM nursing progress note revealed that the resident was showing more signs of confusion and wandering. A record review of Resident 5's Physician Visit/Communication Record dated 1/27/25 revealed Resident 5 went to a neurology appointment for a check-up. The Progress Notes section revealed Want to add Seroquel back. Start 12.5mg at bedtime x2 weeks, then increase to 25mg at bedtime. Do not remove unless directed by Neurology Clinic. This will be alongside to Celexa. The document did not include any evidence of an indication for the medication to be given to the resident. An interview on 1/29/25 at 9:45 AM with the Director of Nursing (DON) verified that the resident was admitted from an assisted living facility with a psychotropic medication, the resident did not have any documented behaviors and the psychotropic medication was stopped on 12/23/24. Further interview confirmed the psychotropic medication was restarted on 1/27/25 after a neurology appointment, the neurologist documented the medication could only be stopped by the neurology clinic and the resident was not exhibiting behaviors. The DON confirmed that the facility did not address stopping the psychotropic medication after 1/27/25 when the Resident 5 was not having behaviors or meeting the requirement for the medication prescribed.

Licensure Reference Number 175 NAC 12.006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure insulin pens were dated when opened for Residents 25 and 26. The sample size was 2 and the facility census was 32. Findings are: A record review of the undated facility policy Administering Medications revealed the following: -medications are administered in a safe and timely manner, and -when opening a multi-dose container, the date opened is recorded on the container. A. A record review of Resident 26's January 2025 medication administration record (MAR) revealed an order for Tresiba (a long-acting insulin) 6 units to be given 2 times daily. An observation on 1/30/25 at 7:30 AM with Registered Nurse (RN)-F revealed RN-F obtained Resident 26's Tresiba insulin pen out of the medication cart for administration. The Tresiba insulin pen had been opened and did not have an open date documented on it. B. A record review of Resident 25's January 2025 MAR revealed an order for Lantus (a long-acting insulin) 23 units to be given at bedtime. An observation of the medication cart on 1/30/25 at 7:35 AM revealed Resident 25's Lantus insulin pen had been opened and did not have an open date documented on it. An interview on 1/30/25 at 7:35 AM with RN-F confirmed that Resident 26's Tresiba pen and Resident 25's Lantus pen had been opened and had not been dated, but should have been. An interview on 1/30/25 at 10:30 AM with the Director of Nursing confirmed that the facility's expectation was for each resident's insulin pen to be dated when opened.

Licensure Reference Number: 175 NAC 12-006.04D2a Based on record review and interview; the facility failed to ensure the Dietary Manager (DM) had the credentialing to meet the requirements for the position. This had the potential to affect all residents who consumed food from the kitchen. The facility census was 33 with a total sample size of 15. Findings are: Review of the facility Job Description for the role of Dietary Service Manager revealed necessary qualifications included the completion of a Dietary Manager certification course. During an interview on 01/28/24 at 11:38 AM, the DM confirmed staff did not have the required training to meet the qualification for the DM position. The DM reported being enrolled in the DM course, however, has not completed the course.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff failed to: 1) utilize handwashing and gloving techniques to prevent potential food contamination during food service; and 2) clean and disinfect equipment between uses to assure food safety. These practices had the potential to affect all residents who consumed food from the kitchen. The facility census was 33 with a total sample size of 15. Findings are: A. Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-301.14 Food employees shall wash hands and exposed portions of their arms immediately before engaging in food preparation: -after handling soiled equipment; and -before donning gloves to work with food. -3-304.15 (A) Single use gloves shall be used for only one task and should be discarded when soiled or when interruptions occur in the operation. B. Review of the facility policy Dietary Employee Personal Hygiene (undated) revealed handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Gloves were to be worn and changed appropriately to reduce the spread of infection. C. Observations during the follow-up kitchen sanitation tour conducted on 1/28/24 from 11:10 AM to 12:35 PM revealed the following: -Dietary Cook (DC)-K used a digital thermometer probe to obtain food temperatures prior to the noon meal service. DC-K used the same thermometer to obtain the temperature of each of the following food items; baked beans, meatballs, fortified baked beans, puree baked beans, puree meatballs and mashed potatoes. DC-K failed to clean and/or sanitize the thermometer probe between uses; and -without washing hands, DC-K put on a pair of clean disposable gloves. DC-K used gloved hands and touched various kitchen surfaces including the resident's menu cards, dishes, serving utensils and opened a refrigerator. While continuing to wear the same pair of gloves, DC-K used gloved hands to open buns when preparing meatball sub sandwiches. This practice continued throughout the meal service. Interview with the Dietary Manager on 1/28/24 at 1:00 PM confirmed DC-K should have wash hands before donning clean gloves and a clean pair of gloves should be worn whenever touching ready to eat foods or a serving utensil should have been used. In addition, DC-K should have cleaned/sanitized the digital thermometer probe between each use.

Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure background checks through the State Nurse Aide (NA) registry were completed on 2 of 5 employees. The facility census was 33 with a total sample size of 15. Findings are: A. Review of the facility policy titled Abuse, Neglect, and Exploitation dated 9/22 revealed, the purpose of the policy was to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures to prohibit and prevent abuse, neglect, misappropriation of resident property and exploitation. The facility would screen employees for a history of abuse, neglect, or mistreating residents by attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. B. Review of 5 employee files on 1/29/24 revealed no evidence Hospitality Aide (HA)-H (hired 10/29/23) and Dietary Cook (DC)-I (hired 11/21/23) had background checks completed through the State Nurse Aide registry at the time they were hired. C. An interview with the Administrator on 1/29/24 at 1:22 PM, confirmed there was no evidence background checks through the State NA registry were completed for employees HA-H and DC-I at the time they were hired.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to identify, investigate and to report allegations of potential staff to resident neglect involving an elopement for Resident 10. The sample size was 15 and the facility census was 27. Findings are: A. Review of the facility's policy Elopement and Wandering Residents with a revised date of May 2020 revealed the following: -the facility would ensure residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents; -an elopement occurs when a resident leaves the premises or a safe area without authorization and supervision; -the facility is equipped with door locks/alarms to help avoid elopements; -alarms are not a replacement for supervision and staff should respond in a timely manner; and -when a resident elopes, a report to the state agency shall be completed. B. Review of the facility's policy Abuse, Neglect and Exploitation dated September 2022 revealed the following: -the facility would ensure residents are protected from abuse, neglect, exploitation and misappropriation of personal property by preventing, identifying, investigating, and protecting residents from physical and mental harm; -alleged violations of abuse/neglect are defined as situations or occurrences that are observed or reported by staff, residents, relatives, visitors or others but has not yet been investigated; and -staff should report alleged violations of abuse/neglect to the administrator, state agency, adult protective services and other required agencies within 2 hours or no later than 24 hours from the time the incident occurred. C. Review of Resident 10's care plan with an initiated date of 11/20/2021, revealed the resident was identified at risk for elopement related to a diagnosis of dementia, intermittent confusion, attempts to leave the facility, looking for people who are not there and impulsive behaviors with a goal for the resident to not leave the building without an escort. The following interventions were identified; a wander guard (a device attached to a person that sounds an alarm or automatically locks a door to prevent leaving a facility) was attached the resident's right wrist, staff should encourage participation in activities, provide supervision while outside and redirect the resident when the wander guard sounds and [gender] is attempting to leave the building. Review of Resident 10's Elopement Risk Evaluation dated 7/21/22 revealed the following related to the resident's risk of elopement: -the resident had a history of elopement or an attempted elopement while at home; -the resident had a history of attempting to leave the facility without informing staff; -the resident verbalized a desire to go home, packed belongings or stayed near an exit door; -the resident wandered; and -the wandering behavior was likely to affect the safety or well-being of self/others. Review of Resident 10's Nursing Progress Note dated 8/14/22 at 2:47 PM, revealed the resident spent the majority of the shift wandering and pacing in the hallways. Further review indicated the resident had set off the wander guard alarm and was observed outside the facility, at the edge of the front porch near the parking lot. Staff re-directed the resident back into the building. During an interview with the Director of Nurses (DON) on 12/21/22 at 11:55 am, the DON confirmed the incident that was documented in Resident 10's medical record on 8/14/22 at 2:47 PM was an elopement and should have been reported to the DON, administrator and state agency and was not done.

Licensure Reference Number 175 NAC 12-006.09D8b Based on record review and interview, the facility failed to implement recommended nutritional measures to prevent potential ongoing weight loss for Resident 24. The sample size was 15 and the facility census was 27. Findings are: Review of the facility policy Weight Monitoring with a review date of [DATE], revealed the following; -the facility would ensure that all residents maintained acceptable parameters of nutritional status, such as usual or desirable body weight and electrolyte balance, unless the resident's clinical condition or resident preference indicated otherwise, -weight loss was a useful indicator of nutritional status and unintended changes in weight could indicated a nutritional problem, -residents would be weighed weekly unless ordered less frequently, -the Registered Dietitian (RD) would be consulted to assist with interventions, and -the Physician would be consulted to assist with interventions, and -the interdisciplinary team would follow up with weight loss and track until stable. Review of Resident 24's Weight Summary from 11/3/22 through 12/19/22 revealed the following; -on 11/3/22 the resident's weight was 100 pounds -on 11/7/22 the resident's weight was 93 pounds -on 11/11/22 the resident's weight was 92 pounds -on 11/14/22 the resident's weight was 91 pounds -on 11/22/22 the resident's weight was 90 pounds -on 11/25/22 the resident's weight was 88 pounds -on 11/28/22 the resident's weight was 87 pounds (13% of total body weight in 5 weeks) -on 12/19/22 the resident's weight was 87 pounds Review of Resident 24's Minimum Data Set (MDS-federally mandated assessment use to develop the resident's Care Plan) dated 11/7/22 revealed the following; -diagnoses of high blood pressure, irritable bowel syndrome, kidney failure, and malnutrition, -body weight of 100 pounds with no significant weight loss or gain, and -the resident received minimal assistance with bed mobility, transfers, toileting and dressing and supervision with eating, Review of Resident 24's Care Plan with a revision date of 11/18/22 revealed the following; -the resident was at increased nutritional risk due to variable meal intakes, -staff were to encourage 100% consumption of fluids at meals, -offer alternatives to food or drinks refused, -alert the Dietitian and Physician or significant weight loss, and -reweigh for any weight change of greater than or equal to 3 pounds. Review of Resident 24's Progress Notes revealed the following; - on 12/7/22 the Dietitian noted the resident had lost 13.9 pounds since 10/31/22 and recommended switching from Ensure to Boost High Calorie supplement twice daily, and -on 12/19/22 the Dietitian noted the resident had lost 13.5 pound since 10/31/22 and again recommended switching from Ensure to Boost High Calorie supplement twice daily. Review of Resident 24's Medication Administration Record dated 11/22 and 12/22 revealed that Ensure 8 ounces was being given twice daily starting on 11/16/22 and the Boost High Protein supplement was initiated on 12/20/22- (13 days after the initial recommendation by the Dietitian). During an interview on 12/21/22 at 11:00 AM with the Director of Nursing confirmed that Resident 24 had lost 13.5 % total body weight and resident's physician did not respond to an initial request by the facility Dietitian to change supplements, and not until it was addressed again by the Dietitian (13 days later) did the recommended supplementation get implemented.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to ensure that standard of practice regarding personal protective equipment (PPE) for residents on Transmission Based Precautions were in place to protect residents from COVID-19 (a highly contagious virus primarily spread from person to person through respiratory droplets, which can lead to serious illness and even death) for 3 of 3 sampled Residents (Residents 1, 2, and 3) and failed to ensure approved face masks were worn for health care providers which had the ability to affect all residents. The total sample size was 6 and the facility census was 21. Findings are: A. Review of The Center for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality and Oversight Group dated 3/13/20 revealed the following guidance for infection control and prevention of COVID-19: -Facilities should regularly monitor the Center for Disease Control (CDC) website for information and resources. -Prompt detection, triage, and isolation of potentially infectious residents are essential to prevent unnecessary exposures among residents and healthcare personnel. B. Review of Infection Control Assessment and Promotion Program (ICAP) zone recommendations revealed: - The Red Zone was for residents that were either positive or presumptive positive for COVID-19. PPE requirements included gown, gloves, eye protection, and N95 mask (N95 preferred, if no N95, then a surgical mask with a face shield). - The Yellow Zone was for residents that were asymptomatic but had been exposed to COVID-19. PPE requirements included gown, gloves, eye protection, and N95 mask (N95 preferred, if no N95, then a surgical mask with a face shield). - The Grey Zone was for residents that were transferred from the hospital or an outside facility but had no known COVID-19 exposure. PPE requirements included gown, gloves, eye protection, and N95 mask (N95 preferred, if no N95, then a surgical mask with a face shield). - The Green Zone was for asymptomatic residents without any exposure to COVID-19. PPE requirements included a surgical mask and other PPE per standard precautions. C. Review of the Nebraska Department of Health and Human Services Long-Term Care COVID-19 Phasing Guidance revealed if a facility was in Phase 1 the facility needed to provide universal source control and PPE. All facility staff and essential healthcare personnel, regardless of their position, who may interact with residents or enter resident rooms, should wear a surgical/procedural facemask. D. Observations of facility Staff Member-H on 7/15/20 from 9:00 AM to 11:00 AM revealed the staff member walking in the hallways of the building. The staff member wore a cloth face covering. Staff Member-H also held a professional license, which would make it possible that the staff member would need to assist with resident care if an emergent situation was to arise. E. Review of Resident 1's Progress Notes revealed: - On 7/12/20 the resident was noted to be congested with yellow/green sputum and a temperature of 99.0 degrees. - On 7/13/20 an occasional cough was noted and an order was received for a COVID-19 test. - On 7/14/20 at 6:12 AM the resident took fluids poorly and had a temperature of 100.6 degrees and a Tylenol suppository was given. - On 7/14/20 at 3:05 PM the resident's temperature was 101.1 degrees. On 7/15/20 from 10:20 AM to 10:25 AM, Nursing Assistant (NA)-G was observed entering Resident 1's room wearing a surgical mask, face shield, disposable gown, and gloves. F. Interviews with the Director of Nursing (DON) on 7/15/20 from 8:30 AM to 11:00 AM confirmed Resident 1 had been placed in Red Zone isolation due to having symptoms consistent with potential COVID-19 (including an elevated temperature, runny nose, congestion, sneezing, and loss of appetite). Further interview revealed there was a recent positive COVID-19 case in the community so the facility has remained in Phase 1. The DON stated the facility did not have a shortage of PPE and did have N95 masks available but they were not using them at this time as they were saving them. G. Observation of Resident 3 on 7/15/20 at 8:50 AM revealed Resident 3 attempted to leave the resident's room and Registered Nurse (RN)-B immediately intervened and asked Resident 3 to return to the resident's room. NA-G stepped in to help and while RN-B distracted Resident 3, NA-G put on a gown and gloves (a surgical mask was already in place), and assisted Resident 3 back into the room. NA-G did not apply a face shield, goggles, or an N95 mask. H. Observation of RN-B on 7/15/20 at 10:10 AM revealed RN-B responded to Resident 2's call for assistance. RN-B put on a gown and gloves (a surgical mask was already in place). RN-B entered the resident room and conversed with the resident from the bedside. RN-B then removed the gloves and gown inside the resident room, placed the gloves and gown in the trash, exited the room, and used hand sanitizer. Immediately after RN-B exited the room, Resident 2 called from the bed requesting to visit with RN-B. RN-B put on a gown and glove (the surgical mask was already in place) and re-entered Resident 2's room. After conversing with Resident 2 RN-B removed the gloves, and gown, placed the gloves and gown in the trash, exited the room, and used hand sanitizer. RN-B did not apply a face shield, goggles or an N95 mask. I. Interview with the DON on 7/15/20 at 11:00 AM revealed the facility had N95 masks available, but were not requiring N95 mask use by staff during care of residents in the Red Zone, Yellow Zone, or Grey Zone. Staff were using face shields and a surgical mask in the Red Zone and Yellow Zone, but were only using a surgical masks in the Grey Zone (unless an aerosol creating procedure was anticipated).

Licensure Reference Number 175 NAC 12-006.09D2a Based on observation, interview, and record review; the facility failed to implement and to revise and/or develop interventions to promote wound healing and to prevent potential recurrence for Resident 15's pressure ulcer. The sample size was 2 and the facility census was 24. Findings are: Review of Resident 15's Care Plan with a review date of 12/2/19 revealed the resident was at risk for pressure ulcer development related to a history of pressure ulcers. Interventions included wound treatment per physician orders [REDACTED]. Further review revealed the resident had a pressure ulcer to the left inner foot started on 8/6/19 that resolved on 8/23/19. A new open area to the left inner foot started on 8/28/19. Review of Resident 15's Weekly Wound Evaluations revealed: - On 8/28/19 and 9/4/19 the resident continued with a stage 2 area to the left inner foot that measured 0.3 centimeter (cm) by 0.3cm, with an intervention to limit the use of the resident's left shoe until healed. - On 9/11/19, 9/18/19, 10/2/19, 10/9/19, and 10/22/19 the resident continued with a stage 2 area to the left inner foot that measured 0.5cm by 0.5cm. The intervention to limit the use of the resident's left shoe until healed remained in place. There was no evidence to indicate any new/revised interventions were implemented. - On 10/24/19 the residents wound care treatment was changed by the physician. - On 11/6/19 the resident continued with a stage 2 area to the left inner foot that measured 0.5cm by 0.5cm. - On 11/13/19, 11/27/19, 12/4/19, 12/12/19, and 1/1/20 the area to the left inner foot measured 0.2cm by 0.2cm. There was no evidence to indicate any new/revised interventions were implemented. Observations of Resident 15 revealed: - 12/31/19 at 10:20 AM, the resident was in the resident's room seated in the resident's wheelchair with shoes on both feet. - 12/31/19 at 2:18 PM, the resident was in the resident's room with shoes on both feet. - 1/2/20 at 8:22 AM, the resident was in the resident's room with shoes on both feet. - 1/2/20 at 11:35 AM, the resident was in the resident's room with shoes on both feet. - 1/6/20 at 8:24 AM, the resident was in the resident's room with shoes on both feet. Interview with Registered Nurse Consultant -E on 1/2/20 at 11:28 AM revealed the facility used a weekly assessment to look at the wounds healing and to identify any interventions being used. Interview with Nursing Assistant (NA)-D on 1/6/19 at 8:03 AM confirmed the only wound intervention for Resident 15's pressure ulcer was to try and have Resident 15 keep the left shoe off in the resident's room, which didn't always work.

Licensure Reference Number 175 NAC 12-006.05 (16) Based on observation, record review and interviews; the facility failed to assure Resident 23 was safe for the self-administration of medications and to obtain orders for self-administration of medications which had been left at the resident's bedside. The sample size was 1 and the facility census was 24. Findings are: [NAME] Review of the facility policy Self-Administration of Medications (revised 12/12) revealed residents in the facility who wished to self-administer their medications were able to do so, if it was determined they were capable of doing. The policy identified the staff and the physician were to evaluate the resident's mental and physical abilities which included: -decision making capacity; -ability to read and understand medication labels; -comprehension of purpose and proper dosage and administration times; -ability to remove medications from a container, ingest and swallow; and -recognition of risks and adverse consequences of medications. B. Review of a Self-Medication Administration Assessment completed 12/12/19 at 9:07 AM, revealed the resident had expressed an interest in self-administration of medications. The assessment identified the following: -resident unable to state the name, dose, times, strength and frequency of the resident's medications; -resident unable to state if medications required blood pressure or pulse monitoring to determine effectiveness; -resident unable to demonstrate proper storage of medications; and -resident unable to demonstrate ability to properly document the administration of medications. Review of Resident 23's current Care Plan with revision date 12/22/19 revealed the resident had impaired cognition with short term memory loss. In addition, the resident had a history of [REDACTED]. Interventions included education regarding the importance of taking medications, cues, reorientation and supervision as needed and to monitor for changes in cognitive function. An observation of Resident 23's room on 1/2/20 at 9:42 AM revealed a medication cup on the bedside table. The medication cup contained 8 different medications. Resident 23 was seated on the side of the resident's bed with the bedside table in front of the resident. Interview with Resident 23 on 1/2/19 at 10:29 AM revealed the medication cup contained the resident's morning medications. Resident 23 identified the following: -preferred to sleep late and to have a breakfast tray in the resident's room; -staff would frequently leave the resident's morning medications on the resident's bedside table when the resident's blood sugar was tested between 7:00 AM and 7:30 AM; -preferred to take medications after consuming breakfast; and -staff did not observe the resident self-administering the morning medications but would come back to check to make sure the medications were taken or to remind the resident to take if the resident forgot. Review of the resident's Medication Administration Record [REDACTED] -Multivitamin 1 tablet daily; -[MEDICATION NAME] (medication used to treat high blood pressure) 5 milligrams (mg) daily -[MEDICATION NAME] (medication used to treat heartburn) 150 mg daily; -[MEDICATION NAME] (medication for treatment of [REDACTED]. -Vitamin D3 1000 units daily; -Cefdnir (medication used for treatment of [REDACTED]. -[MEDICATION NAME] (medication used for treatment of [REDACTED]. During an interview on 1/2/19 at 10:33 AM, Licensed Practical Nurse (LPN)-C confirmed the resident's 8:00 AM medications had been left in the resident's room for self-administration. Further interview confirmed physician orders for self-administration of these medications had not been obtained.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a (6) Based on record review and interview, the facility failed to notify the attending physician of low blood sugar results for Resident 23 The sample size was 1 and the facility census was 24. Findings are: [NAME] Review of the facility policy for Change in Condition Notification dated 12/14 revealed the facility was to monitor the residents for changes in their condition, to respond appropriately to those changes and to notify the physician of the changes and as directed by the physician. B. Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/12/19 revealed a [DIAGNOSES REDACTED]. Review of a Physician Facsimile (Fax) dated 9/6/19 revealed an order to test the resident's blood sugar 3 times a day and to notify the resident's physician if the resident's blood sugar was less than 60 or greater than 450. Review of the resident's Medication Administration Record [REDACTED] -10/14/19 at 7:30 AM the resident's blood sugar reading was 53; and -10/24/19 at 7:30 AM the resident's blood sugar reading was 54. Review of the Resident's MAR for (MONTH) of 2019 revealed on 11/19/19 at 7:30 AM the resident's blood sugar results were 52. Review of the resident's MAR for (MONTH) of 2019 revealed on 12/27/19 at 5:30 PM the resident's blood sugar reading was 53. There was no evidence Resident 23's attending physician was notified of the low blood sugar results documented on 10/14/19, 10/24/19 and on 11/19/19 at 7:30 AM and on 12/27/19 at 5:30 PM. Interview with the Director of Nurses (DON) on 1/2/20 at 9:02 AM revealed the physician was to be notified any time a blood sugar result was below 60. The DON confirmed Resident 23's low blood sugar results on 10/14/19, 10/24/19 and on 11/19/19 at 7:30 AM and on 12/27/19 at 5:30 PM should have been reported to the attending physician.

Licensure Reference Number: 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to implement, evaluate, and/or revise interventions to prevent ongoing weight loss for Resident 4. The sample size was 2 and the facility census was 24. Findings are: Review of the facility Weight Monitoring policy dated 5/2017 revealed the facility would ensure that all residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. Weights should be documented when they are taken and rounded to the nearest whole pound. The newly recorded weight should be compared to the previous recorded weight. Review of Resident 4's Care Plan with a review date of 10/24/19 revealed the resident was at risk for weight loss. Interventions included monitoring weights weekly. Review of Resident 4's Weights and Vitals Summary revealed; - On 11/22/19 the resident's weight was 169 pounds (lbs), - No weight was documented on 11/29/19, - On 12/6/19 the resident's weight was 156 lbs (a 13 pound weight loss in 14 days), - On 12/8/19 the resident's weight was 151 lbs (a 5 pound weight loss in 2 days), - On 12/11/19 the resident's weight was 150 lbs, - On 12/20/19 the resident's weight was 150 lbs, - No weight was documented on 12/27/19. Review of Resident 4's Progress Notes revealed: - No evidence to indicate any interventions were identified after the resident's weight on 12/6/19. - No evidence to indicate any interventions were identified after the resident's weight on 12/8/19. - On 12/9/19 the resident's physician was notified of weight loss, no new interventions were identified. - On 12/12/19 (after a weight loss of 18 lbs) the physician increased the residents [MEDICATION NAME] (a medication used to treat depression) to try and stimulate the resident's appetite. On 1/2/20 at 11:46 AM Resident 4 was brought to the dining room assist table. The residents supplement was provided with lunch. On 1/6/20 at 8:24 AM Resident 4 was in the dining room eating breakfast. The resident's supplement was provided with breakfast. Interview with the Dietary Manager (DM) on 1/6/20 at 8:33 AM confirmed Resident 4 should be weighed weekly. The DM revealed the DM only reviewed weights monthly though. The DM confirmed there was no documentation of the trial protein shake suggested by the Registered Dietitian. The DM confirmed the resident's supplement was provided with the resident's meals, and could be contributing to poor meal intakes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B Based on observations, record review and interview: the facility failed to prevent the potential for cross contamination as respiratory care equipment was not stored in a sanitary manner for Residents 23 and 9. The facility census was 24 and the total sample size was 3. Findings are: [NAME] Review of Resident 23's current Care Plan with revision date 12/30/19 revealed the resident had a history of [REDACTED]. Interventions included the administration of medications/inhalers/oxygen and nebulizer treatments as ordered, monitoring for signs of respiratory distress and monitoring for changes in level of orientation, increased restlessness and anxiety. Review of Resident 23's Medication Administration Record [REDACTED] -[MEDICATION NAME] (used to treat bacterial infections) 500 mg (milligrams) in the morning for cough and wheezes until 11/2/19; and -[MEDICATION NAME] Solution 0.5-2.5 (3) mg/3 milliliters (ml) [MEDICATION NAME]-[MEDICATION NAME] (medications to relax muscles in the airways and increase air flow to the lungs) via a nebulizer (a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) 4 times a day for cough until 11/3/19. Review of Resident 23's MAR for 12/2019 revealed the following: -12/20/19 Cefdnir (medication used to treat bacterial infections) 300 mg twice a day for cough until 12/30/19; -12/20/19 [MEDICATION NAME] (medication used for the treatment of [REDACTED]. -12/26/19 [MEDICATION NAME] 10 mg once a day for cough until 12/29/19. Observation in Resident 23's room on 12/31/19 at 1:56 PM revealed a nebulizer machine positioned on top of the bed linens of a bed in the resident's room. The bed was currently unoccupied and the resident had been using the bed for storage of the resident's craft items. Tubing and a mask were attached to the machine with the tubing coiled on the top of the bed and the mask draped over the nebulizer machine. There were no plastic bag covers observed in the area. During an observation on 01/02/20 at 9:42 AM, the nebulizer machine remained on the top of the bed linens at the foot of the bed next to the resident's bed. The tubing attached to the machine dangled over the foot board of the bed, coiled directly on the floor and then draped across a bedside table next to the resident's bed. The mask attached to the tubing contained moisture droplets. The elastic band used to secure the mask was encircled on a covered plastic mug which contained water and was positioned on the bedside table. B. Review of Resident 9's current Care Plan with revision date 12/31/19 revealed the resident had [DIAGNOSES REDACTED]. Interventions included administration of antibiotics, [MEDICATION NAME] and nebulizer treatments as ordered, prompt treatment of [REDACTED]. Review of the resident's MAR indicated [REDACTED] -12/23/19 [MEDICATION NAME] 30-600 mg 1 tablet twice a day for cough until 12/28/19; -12/23/19 [MEDICATION NAME] Nebulizer Solution 2.5 mg/3 ml inhale 1 vial via a nebulizer 4 times a day for cough until 12/28/19 -12/31/19 [MEDICATION NAME] 30 mg once a day for cough for 5 days; -12/31/19 Cefdnir 250 mg twice a day for [MEDICAL CONDITION] for 10 days; and -12/31/19 Nebulizer treatment reordered due to continued harsh, non-productive cough and lung sounds with wheezes. Observations on 12/30/19 at 12:51 PM and on 12/31/19 at 10:36 AM revealed 2 nebulizer machines stored side-by-side on top of a bedside stand. Tubing and masks were attached to both of the machines with the tubing and masks coiled on the stand and on top of the nebulizer machines. There were no plastic bag covers observed in the area. Also stored on top of the bedside stand and in a cluttered manner were 2 plastic mugs containing water, 2 candy tins, 2 television remotes and a basket filled with individual pieces of candy. During interview on 01/02/20 at 2:35 PM, the Director of Nursing verified the following: -Residents 23 and 9 were at risk for ongoing respiratory infections and were both currently receiving treatment for [REDACTED].>-Resident 9's roommate was also treated for [REDACTED]. -facility policy was to rinse the nebulizer mask after each treatment, allow it to dry, then store the mask and tubing in a plastic bag; and -respiratory care equipment in Resident 9 and Resident 23's room were not stored in accordance with facility policy and placed the residents at risk for potential cross contamination and continued respiratory infections.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observations, record review and interview; the facility failed to implement assessed fall prevention interventions for 3 (Residents 21, 22 and 23) of 5 residents reviewed for falls and to implement interventions to prevent injuries for 2 (Residents 6 and 134) of 2 residents sampled for accident hazards. The facility census was 32. Findings are: A. Review of Resident 21's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 09/30/18 revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was moderately impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -balance was unsteady during transfers and required physical assist to stabilize; and -history of falls. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident was at risk for falls and for injury related to a fall. The care plan further identified the resident had falls in the resident's room on 9/11/18, 10/12/18 and on 10/15/18. Review of a Nursing Progress Note dated 9/11/18 at 9:20 PM revealed Resident 21 was heard calling out for help in the resident's room. The resident was found on the floor with walker collapsed next to the resident. No injuries were identified. The resident's walker was assessed and it was found that a bolt had come out by the left hand brake. The walker was immediately repaired to assure no further falls related to use of the walker. Review of a Nursing Progress Note dated 10/12/18 at 5:50 AM revealed the resident was calling out for help and staff found the resident on the floor next to the resident's bed. Resident 21 had attempted to self-transfer from the bed to a wheelchair. No injuries were identified. New interventions were identified to check the resident for a urinary tract infection and to adjust the current toileting schedule. Review of a Nursing Progress Note dated 10/12/18 at 10:50 PM revealed the resident's pressure sensor alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) was sounding and the resident was found on the floor next to the bed on the resident's knees. The resident identified the need to get to the bathroom. The resident sustained [REDACTED]. A new intervention was developed to place a TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on the resident at all times. Review of a Nursing Progress Note dated 10/15/18 at 11:30 PM revealed the resident was found on the floor next to the resident's bed. No injuries were identified. A new intervention to keep the resident's bed in the lowest position was identified. Observations of Resident 21 on 11/1/18 revealed the following: -10:57 AM the resident was lying in bed in the resident's room. The resident's bed had not been placed in the low position. -1:34 PM to 2:00 PM the resident was lying on top of the resident's bed with eyes closed. The resident's bed was not in the low position. Interview with the Director of Nursing (DON) on 11/1/18 at 2:04 PM confirmed the resident was at risk for falls and had an intervention for the resident's bed to be in the low position whenever the resident was in bed. During an observation of Resident 21 on 11/6/18 at 7:18 AM the resident remained in bed in the resident's room. The resident's bed had not been placed in the low position. B. Review of Resident 22's MDS dated [DATE] revealed the resident's cognition was moderately impaired. The resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive staff assistance with cares, was frequently incontinent and had 1 fall without injury since the previous assessment. Review of Resident 22's current Care Plan (revision date 10/12/18) revealed the resident was at risk for falls due to lower extremity prosthesis with a [MEDICAL CONDITION] to the left leg. A fall prevention intervention was identified for the resident to have a TABs alarm on at all times and for staff to provide the resident assistance with toileting. Observations of Resident 22 on 11/5/18 revealed the following: -11:39 AM the resident was seated in a wheelchair in the resident's room. No TABs alarm was in place to the resident. -1:28 PM the resident was in the resident's bathroom with the bathroom door closed. The resident did not have the TABs alarm in place and no staff was in the bathroom or in the resident's room to assure the resident's safety. During an interview with the DON on 11/5/18 at 1:30 PM, the DON verified the following regarding resident 22: -history of falls with high risk for ongoing falls; -fall prevention intervention for the resident to wear a TABs alarm at all times; and -the resident should not have been left along in the bathroom without staff supervision. C. Review of Resident 23's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was moderately impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -frequently incontinent of urine; -balance was unsteady during transfers and required physical assist to stabilize; and -history of falls. Review of the resident's current Care Plan with revision date 10/17/18 revealed the resident made attempts to self-transfer despite loss of balance and impaired cognition. In addition, the care plan identified the resident was to have a TABs alarm and pressure sensor alarm on at all times but that the resident had a history of [REDACTED]. The care plan indicated the resident had falls on 10/18/18, 10/22/18 and on 10/23/18. Observations of Resident 23 on 10/31/18 revealed the following: -10:45 AM the resident was in the resident's room and the resident's fall alarms were sounding. The resident had attempted to self-transfer from the resident's recliner. -11:30 AM the resident's fall alarm sounded when the resident attempted to stand from the resident's recliner. -1:45 PM the resident's fall alarms were heard sounding and the resident was observed to be on the floor of the resident's room. Observations of Resident 23 on 11/1/18 revealed the following: -10:24 AM the resident was seated in a wheelchair in the resident's room. The resident's pressure sensor alarm was observed lying on the resident's bed. No pressure sensor alarm was noted to the resident's wheelchair. -12:00 PM the resident was seated in a wheelchair and positioned at a table in the dining room. No pressure sensor alarm was observed in the seat of the resident's wheelchair. -1:00 PM to 2:30 PM the resident was seated in the recliner in the resident's room. The pressure sensor alarm remained on the resident's bed and no sensor pressure alarm was observed to the seat of the resident's recliner. Review of a Nursing Progress Note dated 11/3/18 at 7:45 AM revealed the resident had a fall when the resident was lowered to the floor by staff during a transfer. Review of a Nursing Progress Note dated 11/4/18 at 3:30 PM revealed the resident was found sitting on the floor next to the resident's bed. Interview with the DON on 11/5/18 at 2:35 PM revealed the resident was to have both the TABs alarm and the pressure sensor alarm on at all times. The DON further indicated the resident remained at high risk for falls. D. Review of Resident 134's undated Care Plan revealed the resident was at risk for skin breakdown related to a decrease in overall function. The resident required 1 assist with bathing. Staff were to observe for redness, open areas, scratches, cuts, and bruises, and report any findings to the nurse. Review of a Weekly Wound Evaluation dated 3/8/18 revealed Resident 134 had a skin tear to the resident's right hand measuring 4 centimeters (cm) by 0.1 cm. During an interview on 11/5/18 at 2:10 PM Licensed Practical Nurse (LPN)-F revealed any new skin concern such as a bruise or skin tear should be investigated to determine the cause and then interventions should be implemented to prevent it from happening again. During an interview with the DON on 11/5/18 at 1:20 PM, the DON confirmed an incident report was not completed for Resident 134's skin tear and interventions were not put in place to prevent potential recurrence. E. Review of Resident 6's current undated Care Plan revealed the resident transferred with a full body mechanical lift (a device used to transfer a resident that supports the entire weight of the resident with the use of a sling) with the assistance of 2 staff members. Further review revealed the resident was to wear prevalon boots at all times. Review of an Incident Report dated 7/14/18 revealed Resident 6 was transferred with the full body mechanical lift by 1 staff member from a lounge chair to the resident's wheelchair. After the transfer was completed the staff member noted a 4cm half-moon shaped skin tear to the resident's right hand. There was no evidence to indicate staff members were educated on proper lift techniques. Review of an Incident Report dated 8/6/18 revealed Resident 6 had a bruise to the left outer knee measuring 6cm by 1cm. The bruise was potentially caused during a transfer with the full body mechanical lift. The resident was not wearing the prevalon boots during the transfer. There was no evidence to indicate staff were re-educated to ensure Resident 6's prevalon boots were worn at all times according to the residents Care Plan. During an interview with the DON on 11/6/18 at 10:00 AM, the DON confirmed the full body mechanical lift should be used with 2 staff members and the resident was to wear the prevalon boots at all times. The DON confirmed there was no evidence to indicate training/education was completed with the staff to prevent potential recurrence.

LICENSURE REFERENCE NUMBER 12-006.09C Based on observation, record review and interview; the facility failed to implement care plan interventions for: 1) the prevention of falls/accidents for Residents 6, 21, 22, and 23; 2) the provision of bathing for Residents 21 and 22; 3) the prevention of dehydration for Resident 6; 4) prevention and healing of a pressure ulcer for Resident 32; and 5) provision of Resident 22's walk-to-dine program. The total sample size was 22 and the facility census was 32. Findings are: A. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident was at risk for a decline in Activities of Daily Living (ADL) and at risk for falls. The following interventions were identified: -assure call light within reach at all times; -bed to be kept in lowest position when resident in bed; and -staff to provide the resident 1-2 assist with transfers to/from the bath chair with 2 whirlpool baths to be provided each week. Review of Bathing Documentation (paper record of baths provided) from 10/5/18 through 11/4/18 revealed Resident 21 did not receive a bath twice every week. Documentation indicated the resident received a bath on (MONTH) 5, 9, 12, 19, 23, 26 and on 30, (YEAR) (a total of 7 out of the 9 baths the resident was to have been provided). Observations of Resident 21 on 11/1/18 revealed the following: -10:57 AM the resident was lying in bed in the resident's room. The resident's bed had not been placed in the low position. -1:34 PM to 2:00 PM the resident was lying on top of the resident's bed with eyes closed. The resident's bed was not in the low position. Interview with the Director of Nursing (DON) 11/1/18 at 2:04 PM confirmed facility staff failed to implement the resident's care plan regarding fall prevention interventions and the number of baths the resident was to receive each week. During an observation of Resident 21 on 11/6/18 at 7:18 AM the resident remained in bed in the resident's room. The resident's bed had not been placed in the low position. B. Review of Resident 22's current Care Plan with revision date 10/7/18 revealed the resident was at risk for a decline in ADL ability and identified the resident was at risk for falls. The following interventions were identified: -TABS alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to be on the resident at all times; -staff to provide the resident with extensive assistance with toileting; -staff to provide the resident assist with a walking program (the resident was to be walked to or from meals for a total of 3 times each day); and -staff to provide the resident 1-2 assist with transfers to/from the bath chair with 2 whirlpool baths to be provided each week. Review of Nursing Rehabilitation Documentation (paper record of the number of times each day the staff assisted the resident with ambulation) from 10/7/18 to 11/4/18 revealed Resident 22 was not assisted to ambulate 3 times each day. Documentation indicated the resident was assisted with walking once a day on (MONTH) 7, 10, 15, 18, 19, 25, 27, 29 and 30, (YEAR) and on (MONTH) 2, 3 and 4, (YEAR). Documentation indicated the resident was assisted with walking twice a day on (MONTH) 8, 9, 13, 14, 16, 17, 22, 24, 26, 28, and 31, (YEAR) and on (MONTH) 1, (YEAR) (a total of 36 out 87 times the resident was to be assisted with ambulation). Review of Bathing Documentation (paper record of baths provided) from 10/8/18 through 11/4/18 revealed Resident 22 did not receive 2 baths weekly. Documentation indicated baths were provided on (MONTH) 11, 18, 25, and 31, (YEAR) and on (MONTH) 4, (YEAR) (a total of 5 out of 9 baths that were to have been provided). Observations of Resident 22 on 11/5/18 revealed the following: -8:00 AM the resident was transferred into a wheelchair and the resident was propelled in the wheelchair by staff out to the dining room for the breakfast meal. Resident 22 was not offered an opportunity to walk out to the breakfast meal. -11:39 AM the resident was seated in a wheelchair in the resident's room. No TABs alarm was in place to the resident. -1:28 PM the resident was in the resident's bathroom with the bathroom door closed. The resident did not have the TABs alarm in place and no staff was in the bathroom or in the resident's room to assure the resident's safety. Interview with the DON on 11/5/18 at 2:00 PM verifed the facility staff failed to implement Resident 22's care plan as the resident did not have the TABs alarm on all times, the resident was left alone in the bathroom, the resident was not provided the number of baths the resident's care plan indicated and staff failed to assist the resident with following the walk-n-dine program. C. Review of Resident 23's current Care Plan with revision date 10/12/18 revealed the resident made attempts to self-transfer despite loss of balance and impaired cognition. In addition, the care plan identified the resident was to have a TABs alarm and pressure sensor alarm on at all times. Observations of Resident 23 on 11/1/18 revealed the following: -10:24 AM the resident was seated in a wheelchair in the resident's room. The resident's pressure sensor alarm was observed lying on the resident's bed. No pressure sensor alarm was noted to the resident's wheelchair. -12:00 PM the resident was seated in a wheelchair and positioned at a table in the dining room. No pressure sensor alarm was observed in the seat of the resident's wheelchair. -1:00 PM to 2:30 PM the resident was seated in the recliner in the resident's room. The pressure sensor alarm remained on the resident's bed and no sensor pressure alarm was observed to the seat of the resident's recliner. Interview with the DON on 11/1/18 at 2:35 PM confirmed Resident 23 was to have both the TABs alarm and the pressure sensor alarm on at all times and staff should have followed the resident's care plan to prevent the potential for falls. D. Review of Resident 6's current undated Care Plan revealed the resident transferred with a full body mechanical lift (a device used to transfer a resident that supports the entire weight of the resident with the use of a sling) with the assistance of 2 staff members. Further review revealed the resident was to wear prevalon boots at all times. Review of an Incident Report dated 7/14/18 revealed Resident 6 was transferred with the full body mechanical lift by 1 staff member from a lounge chair to the resident's wheelchair. After the transfer was completed the staff member noted a 4cm half-moon shaped skin tear to the resident's right hand. There was no evidence to indicate staff members were educated on proper lift techniques according to the resident's plan of care. Review of an Incident Report dated 8/6/18 revealed Resident 6 had a bruise to the left outer knee measuring 6cm by 1cm. The bruise was potentially caused during a transfer with the full body mechanical lift. The resident was not wearing the prevalon boots during the transfer. There was no evidence to indicate staff were re-educated to ensure Resident 6's prevalon boots were worn at all times according to the residents Care Plan. During an interview with the DON on 11/6/18 at 10:00 AM, the DON confirmed the full body mechanical lift should be used with 2 staff members and the resident was to wear the prevalon boots at all times. E. Review of Resident 6's current undated Care Plan revealed the resident required 1 assist with eating. The resident had the potential for fluid deficit related to poor intakes. Staff were to encourage the resident to drink liquids of choice at meals and with cares. The resident required liquids to be thickened to nectar consistency. Further review revealed the staff were to ensure the resident had access to nectar thick liquids whenever possible. Review of Resident 6's Nutrition assessment dated [DATE] revealed the category titled Fluid Needs was not filled out. Observations of Resident 6's room on 11/1/18 revealed: - At 10:01 AM, the resident was seated in the resident's wheelchair, no liquids were available in the room. - At 2:01 PM, the resident was asleep in bed, no liquids were available in the resident's room. During an interview with Licensed Practical Nurse (LPN)-F on 11/5/18 at 2:10 PM revealed the resident was on thickened liquids and staff should keep a cup full of thickened water in the resident's room to offer with cares. F. Review of Resident 32's current undated Care Plan revealed the resident had potential and actual impairment to the resident's skin integrity with an open area to the right buttock. Interventions included keeping the resident's feet slightly elevated to keep the resident from sliding down in bed (as the resident preferred the head of the bed to be elevated). The resident was to be re-positioned at least every 2 hours and as needed. Observations of Resident 32 on 11/1/18 from 7:10 AM until 9:27 AM (2 hours and 17 minutes) revealed the resident was seated upright in the resident's wheelchair. Observation of Resident 32 on 11/1/18 at 10:30 AM revealed the resident was resting in bed. The head of the resident's bed was elevated to 90 degrees (per the resident's preference). The resident's feet were not elevated slightly. Observations of Resident 32 on 11/5/18 from 7:06 AM to 9:15 AM revealed the resident was seated upright in the resident's wheelchair. During an interview with Nursing Assistant (NA)-B on 11/5/18 at 9:35 AM, NA-B revealed Resident 32 had been placed in the resident's wheelchair that morning at 6:30 AM and was not transferred out of the wheelchair until 9:15 AM (2 hours and 45 minutes later).

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, interview, and record review; the facility failed to ensure insulin (a medication used to treat diabetes mellitus) was stored within the temperature range recommended by the manufacturer for 4 residents (Residents 1, 30, 25, and 17 ) and failed to ensure insulin pens were dated when opened for 2 residents (Residents 1 and 30). The sample size was 4 and the facility census was 32. Findings are: A. On 11/6/18 at 10:19 AM an observation of the medication refrigerator revealed the thermometer read 22 degrees Fahrenheit (F). Review of the Record of Refrigeration Temperatures dated 4/2018 to 11/2018 revealed frequent temperature readings below 36 degrees F. Review of a document provided by the facility on 11/6/18 titled Insulin in Fridge revealed 4 residents (Residents 1, 30, 25, and 17) had insulin stored in the refrigerator. Interviews with the Director of Nursing (DON) on 11/6/18 from 10:05 AM to 10:15 AM revealed the refrigerator was used to store insulin and various other medications. Further interview confirmed the thermometer read 22 degrees F and insulin should be refrigerated at temperatures between 36 and 46 degrees F. B. Observation of the medication cart on 11/6/18 at 10:10 AM with Licensed Practical Nurse-D revealed 2 of 5 insulin pens were not dated when opened. This included Resident 1's [MEDICATION NAME]and Resident 30's Tresiba insulin. During an interview with LPN-D on 11/6/18 at 10:10 AM, LPN-D confirmed the insulin pens were not dated when opened for Residents 1 and 30. Further interview confirmed the medications should be dated when opened.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and interview, the facility failed to provide nursing staff to provide ambulation assistance for Resident 22 and provision of baths for Residents 21 and 22. 2 of 6 confidential resident interviews and 3 of 6 confidential family interview voiced concerns that there was not enough nursing staff available to meet the resident's needs. The total sample size was 22 and the facility census was 32. Findings are: A. 2 of 6 confidential resident interviews and 3 confidential family interviews conducted on 10/31/18 through 11/6/18 from 09:30 AM until 3:00 PM voiced concerns that there was not enough nursing staff available to meet the needs of the facility residents. Comments regarding staffing included: -residents were not provided baths as often as the residents preferred; -call light response times were frequently 20-30 minutes depending on the day of the week and the time of day; and -difficult to find any staff available in the evenings if need help or just have a question. B. Review of Resident 22's current Care Plan (revised on 10/7/18) revealed the resident was at risk for a decline in Activities of Daily Living (ADL) ability and incontinence. The care plan identified the resident required extensive staff assistance with bathing, transfers, toileting, ambulation and personal cares. The resident had a walking program (the resident was to be walked to or from meals for a total of 3 times each day) and a toileting schedule in place and the resident preferred 2 whirlpool baths a week. Review of Bathing Documentation (paper record of baths provided) from 10/8/18 through 11/4/18 revealed Resident 22 did not receive 2 baths weekly. Documentation indicated baths were provided on (MONTH) 11, 18, 25, and 31, (YEAR) and on (MONTH) 4, (YEAR) (a total of 5 out of 9 baths that were to have been provided). Review of Nursing Rehabilitation Documentation (paper record of the number of times each day the staff assisted the resident with ambulation) from 10/7/18 to 11/4/18 revealed Resident 22 was not assisted to ambulate 3 times each day. Documentation indicated the resident was assisted with walking once a day on (MONTH) 7, 10, 15, 18, 19, 25, 27, 29 and 30, (YEAR) and on (MONTH) 2, 3 and 4, (YEAR). Documentation indicated the resident was assisted with walking twice a day on (MONTH) 8, 9, 13, 14, 16, 17, 22, 24, 26, 28, and 31, (YEAR) and on (MONTH) 1, (YEAR) (a total of 36 out 87 times the resident was to be assisted with ambulation). Observation of Resident 22's morning cares on 11/5/18 from 7:31 AM to 7:55 AM revealed the resident was transferred into a wheelchair, foot pedals were put into place and the resident was propelled in the wheelchair by NA-A out to the dining room for the breakfast meal. Resident 22 was not offered an opportunity to walk out to breakfast. Interview with NA-A on 11/5/18 at 1:00 PM revealed Resident 22 was scheduled to receive 2 baths per week and was to be walked by the staff 3 times a day. NA-A indicated sometimes baths and walking programs did not get completed when staff ran short on time or when not enough staff was available. C. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident required 1-2 staff assist with transfers to and from the bath chair and further revealed the resident was to receive 2 baths a week. Review of Bathing Documentation from 10/5/18 through 11/4/18 revealed Resident 21 did not receive a bath twice every week. Documentation indicated the resident received a bath on (MONTH) 5, 9, 12, 19, 23, 26 and on 30, (YEAR) (a total of 7 out of the 9 baths the resident was to have been provided).

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observation, record review, and interview; the facility failed to maintain Resident 28's dignity related to the use of a gait belt. The sample size was 1 and the facility census was 32. Findings are: Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/17/18 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 (with a score from 0-7 indicating severe cognitive impairment). Review of the facility policy titled Gait Belt dated 8/2015 revealed: - Gait belts were to be used when a resident required assistance with ambulation, - Gait belts should be fastened around the waist/trunk of the resident, - Residents should be transferred with proper body mechanics, and - The gait belt should be removed once the transfer was complete. Observations of Resident 28 from 10/31/18 to 11/5/18 revealed the following: - On 10/31/18 at 10:05 AM, the resident was seated in a recliner in the commons area with a gait belt around the resident's waist. - On 11/1/18 at 10:22 AM, the resident was sleeping in a recliner in the commons area with a gait belt around the resident's waist. - On 11/5/18 from 7:50 AM to 9:02 AM, the resident was seated in a chair at the dining room table. A gait belt remained around the resident's waist the entire time. - On 11/5/18 at 1:10 PM, the resident was seated in a recliner in the commons area, a gait belt remained around the resident's waist. During an interview with the Director of Nursing (DON) on 11/6/18 at 10:00 AM the DON confirmed gait belts should be removed after the transfer was complete.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interview, the facility failed to provide: 1) routine bathing assistance, personal hygiene during toileting cares and ambulation assistance for Resident 22 and 2) routine bathing assistance for Resident 21. The sample size was 4 and the facility census was 32. Findings are: A. Review of the facility policy for Perineal Care with revision date 5/2017 revealed the following procedure for completing personal cares when assisting residents with toileting: -wet wash cloth and apply soap or a perineal cleanser. Pre-packaged perineal wipes may also be used; -start at the urethra and cleanse toward the scrotum; -continue to wash the rest of the perineal area, wiping from front to back, alternating from side to side and moving toward the thighs; and -rinse well and dry the urethral and perineal area, working the same direction until the entire area is clean, soap free and dry. B. Review of Resident 22's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident's cognition was moderately impaired, was frequently incontinent of urine and the resident required extensive staff assistance with transfers, ambulation, toileting, personal cares and bathing. Review of Resident 22's current Care Plan with revision date 10/7/18 revealed the resident was at risk for a decline in Activities of Daily Living (ADL) ability and incontinence. The care plan identified the resident required extensive staff assistance with bathing, transfers, toileting, ambulation and personal cares. The resident had a walking program (the resident was to be walked to or from meals for a total of 3 times each day) and a toileting schedule in place and the resident preferred 2 whirlpool baths a week. Review of Bathing Documentation (paper record of baths provided) from 10/8/18 through 11/4/18 revealed Resident 22 did not receive 2 baths weekly. Documentation indicated baths were provided on (MONTH) 11, 18, 25, and 31, (YEAR) and on (MONTH) 4, (YEAR) (a total of 5 out of 9 baths that were to have been provided). Review of Nursing Rehabilitation Documentation (paper record of the number of times each day the staff assisted the resident with ambulation) from 10/7/18 to 11/4/18 revealed Resident 22 was not assisted to ambulate 3 times each day. Documentation indicated the resident was assisted with walking once a day on (MONTH) 7, 10, 15, 18, 19, 25, 27, 29 and 30, (YEAR) and on (MONTH) 2, 3 and 4, (YEAR). Documentation indicated the resident was assisted with walking twice a day on (MONTH) 8, 9, 13, 14, 16, 17, 22, 24, 26, 28, and 31, (YEAR) and on (MONTH) 1, (YEAR) (a total of 36 out 87 times the resident was to be assisted with ambulation). Observation of Resident 22's morning cares on 11/5/18 from 7:31 AM to 7:55 AM by Nursing Assistant (NA)-A revealed the following: -the resident's soiled disposable urinary incontinence brief was removed and the resident was assisted into the bathroom; -without providing perineal cares, a clean disposable urinary incontinence brief was placed on the resident; and -Resident 22 was transferred into a wheelchair, foot pedals were put into place and the resident was propelled in the wheelchair by NA-A out to the dining room for the breakfast meal. Resident 22 was not offered an opportunity to walk out to breakfast. Interview with NA-A on 11/5/18 at 1:00 PM revealed Resident 22 was scheduled to receive 2 baths per week and was to be walked by the staff 3 times a day. NA-A indicated sometimes baths and walking programs did not get completed when staff ran short on time or when not enough staff was available. NA-A further indicated direct care staff had been trained to complete perineal hygiene on residents whenever incontinent or the residents were toileted and verified failure to complete perineal hygiene for Resident 22 with morning cares. C. Review of Resident 21's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS identified the resident's cognition was moderately impaired and the resident required extensive staff assistance with bathing. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident required 1-2 staff assist with transfers to and from the bath chair and further revealed the resident was to receive 2 baths a week. Review of Bathing Documentation from 10/5/18 through 11/4/18 revealed Resident 21 did not receive a bath twice every week. Documentation indicated the resident received a bath on (MONTH) 5, 9, 12, 19, 23, 26 and on 30, (YEAR) (a total of 7 out of the 9 baths the resident was to have been provided).