Every finding on record at Beatrice Health and Rehabilitation

Licensure Reference Number 175 NAC 12-006.11C The facility failed to ensure hand hygiene was performed in the kitchen in order to prevent the spread of food borne illness. This had the potential to affect all the resident that reside in the facility. The facility census was 55. Findings are: Observation of meal preparation on 4/8/25 at 6:45 AM with Cook-A. Cook-A had gloves on when surveyor arrived. The chili recipe was on the prep table. Cook-A took hamburger out of the packages and placed in a pan and placed on the stove. At 6:49 AM Cook-A performed hand hygiene with soap and water for 13 seconds. Cook-A donned gloves and cut up onion and placed in another pan after measuring. At 6:52 AM Cook-A performed hand hygiene with soap and water for 10 seconds. Cook-A placed 1 can of chili beans, and 3/4 of can of diced tomatoes and put these in the pan, added water, tomato juice, a packet of chili mix, and stirred. At 7:00 AM Cook-A performed hand hygiene with soap and water for 15 seconds. Observation of Cook-A obtaining food temperatures for the South dining room on 4/8/25 at 7:58 am. Cook-A then prepared cold cereal into bowls and placed on counter, put the gallon milk into pan of ice, placed tray lids on cart close to door, opened the steam table pan lids. At 8:03 AM Cook-A applied gloves without hand hygiene and began giving the residents' breakfast plates to the staff to serve. Interview on 4/9/25 at 9:37 AM with the Certified Dietary Manager (CDM) confirmed that the cook should have performed hand hygiene for 20 seconds with soap and water and perform hand hygiene before donning gloves. Record review of the facility's undated Infection Control Prevention and Control Program-Hand Hygiene Policy revealed: The facility considers hand hygiene the primary means to prevent the spread of infection. Use of alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after eating or handling food.

Based on record review and interview, the facility failed to ensure an as needed antipsychotic medication had a 14-day stop date as required for Resident 38. This affected 1 of 5 residents reviewed for unnecessary medication use. The facility census was 55. Findings are: A record review of Resident 38's admission Record printed 04/07/2025 revealed the resident was admitted to the facility on [DATE] and had diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that can cause changes in consciousness, thinking, and behavior), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), arthritis in both knees, anxiety disorder, high blood pressure, an irregular heartbeat, heart failure, and chronic (long-term) kidney disease. A record review of Resident 38's Medication Administration Record (MAR) for February 2025 revealed an order for olanzapine (an antipsychotic medication that may be used to reduce or relieve symptoms of psychosis, such as delusions and hallucinations) 2.5 milligrams (mg) 1 tablet by mouth every 12 hours as needed for insomnia (difficulty sleeping)/delirium (sudden severe confusion due to rapid changes in brain function that can occur with physical or mental illness) until 08/02/2025. This order had a start date of 02/03/2025 and was discontinued on 02/12/2025. Further review of Resident 38's MAR for February 2025 revealed an order for olanzapine 2.5 mg by mouth every 12 hours as needed for schizoaffective disorder (a disorder that is marked by a mix of psychosis and a mood disorder) until 08/02/2025. This order had a start date of 02/12/2025 and was discontinued on 04/01/2025. It was administered four times in February. A record review of Resident 38's MAR for March 2025 revealed an order for olanzapine 2.5 mg by mouth every 12 hours as needed for schizoaffective disorder until 08/02/2025. This order had a start date of 02/12/2025 and was discontinued on 04/01/2025. It was administered seven times in March. A record review of Resident 38's MAR for April 2025 revealed an order for olanzapine 2.5 mg by mouth every 12 hours as needed for agitation (a feeling of aggravation, annoyance, or restlessness), delirium until 08/02/2025. This order was started 04/01/2025 and was current as of 04/08/2025 when the MAR was printed. The medication had been administered once up until 04/08/2025. A record review of a telephone communication between the facility and the Nurse Practitioner (NP) dated 02/12/2025 revealed the order for as needed olanzapine remained unchanged except for a change in diagnosis. A record review of a Visit Note from the NP dated 02/18/2025 revealed documentation that Resident 38 was seen by the NP on 02/04/2025 and on 02/18/2025 with no changes in the as needed olanzapine order. A record review of a telephone communication between the pharmacy and the NP regarding olanzapine dated 03/03/2025 revealed the pharmacy notified the NP that PRN [as needed] antipsychotics cannot exceed 14 days and require direct prescriber evaluation for continuation. The NP recommended to continue the current medications and consult the facility contracted mental health provider. A record review of a Visit Note from the NP dated 03/05/2025 revealed the NP had come to the facility to see Resident 38, but was unable to as the resident had left the facility for an appointment. A record review of a telephone communication between the pharmacy and the NP dated 04/01/2025 revealed the order for as needed olanzapine remained unchanged except for a change in diagnosis. The facility was unable to provide documentation of an in-person visit to Resident 38 by the NP between 02/18/2025 and 04/01/2025. An interview on 04/09/2025 at 1:20 PM with the Director of Nursing (DON) confirmed that as needed antipsychotics ordered as needed should have 14 day stop dates and the resident should have been physically seen and evaluated by the provider prior to renewing the order and further confirmed there was no documentation this had been done for Resident 38.

Licensure reference number 175 NAC 12-006.18(B) The facility failed to ensure hand hygiene was performed during catheter and peri-cares for Residents 28 and 54, failed to ensure wipes were not removed from the wipes container with contaminated gloves for Residents 28 and 54, failed to ensure the drainage catheter bag was kept below the level of the bladder during a transfer for Resident 28, and failed to perform hand hygiene after removal of gloves for Resident 28 to prevent the potential for cross contamination. The facility census was 55. Findings are: A. Record review of Resident 28's Admission Record dated 4/7/25 revealed re-admission to the facility was 6/22/2023. Observation on 4/6/25 at 12:34 PM revealed Resident 28 had sediment in catheter tubing. Observation on 4/07/25 at 10:00 AM Resident 28's urine in catheter tubing is cloudy, mucous with small amount of red tinge. Observation of Resident 28's catheter cares on 4/7/25 at 10:30 AM by Nurses aide (NA)-B and (NA)-C. NA-B and NA-C applied gowns and gloves without performing hand hygiene. NA-B placed a paper towel on the floor, sat the graduate container on the paper towel, and emptied the catheter drainage bag without using goggles or a face shield for protection. NA-B did not perform hand hygiene after emptying the urine into the toilet. NA-B and NA-C took resident's slacks down to ankles and took brief off without performing hand hygiene after. NA-B took 3 cleansing wipes from the wipe container using contaminated gloves and wiped resident's left groin and pubis area groin. NA-B used the other wipe and wiped the right groin with noting some BM on the wipe. NA-B then used the same glove and took out another wipe from the container to wipe right groin again. NA-B took out 3 wipes and cleansed the glans of penis, another wipe for the urethral opening and another for the tubing from urethral opening down tube about 2 inches and did not perform hand hygiene. NA-B and NA-C repositioned resident to [gender] left side. NA-C moved trash can with gloved hands and did not change the gloves. NA-C took wipes from wipe container with contaminated gloves 8 different times and used these wipes to cleanse the back area of the right groin and rectal area. NA-C removed gloves without performing hand hygiene, then assisted NA-B with repositioning resident onto [gender] back and placed a new brief under the resident. NA-B took 2 wipes out of container with contaminated gloves and cleansed the right groin again, then took 2 more wipes out of container with same gloves and continued to wipe right groin. NA-B took 2 more wipes from the container and wiped scrotal area in front, then taped the brief on. NA-B and NA-C removed their gowns and gloves and put in the trashcan. NA-B performed hand hygiene with soap and water for 10 seconds and did not put gloves on. NA-B lifted catheter bag and placed it on the bed which was the same level as the bladder and did not wash hands. Both NA's assisted with putting resident's slacks up and placed lift sling under resident, hooked sling to the Hoyer lift, and placed the catheter hook onto hoyer lift hook which is by resident's head and above bladder. NA-B and NA-C transferred resident into electric wheelchair, took catheter bag down from sling hook area and finished positioning resident. Interview on 4/7/25 at 11:30 AM with NA-B confirmed [gender] should have washed hands for 20 seconds, should not have taken wipes out of the container with contaminated gloves, and not have the catheter bag above the bladder. Interview on 4/7/25 at 11:31 AM with NA-C confirmed [gender] should not have taken wipes out of the container with contaminated gloves, not have the catheter bag above the bladder, and should wash hands after removing gloves. Interview on 4/7/25 at 1:28 PM with the Director of Nursing (DON) confirmed the NA's (NA- B and NA-C) should not have taken wipes out of the container with contaminated gloves and should not have the catheter bag above the bladder. DON confirmed that staff should wash hands after removing gloves, and wash hands for 20 seconds. Record review of Resident 28's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/26/24 revealed: -Section C: BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment) score as follows: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident 28 scored 15 indicating cognitively intact. -Section G: Dependent with all cares, has limitation in both upper and lower range of motion, and uses electric wheelchair. -Section H: Catheter Record review of Resident 28's physician orders dated 4/7/25 revealed: -Catheter Care every shift Date 8/30/2022. -Enhanced Barrier Precautions with High Contact Cares related to Indwelling Catheter every shift - Order Date 1/14/2025. -Monitor Indwelling Catheter for Proper Functioning Every 4 Hours -Order Date 8/30/2022. Record review of Resident 28's Care plan on date 4/7/25 revealed Indwelling Catheter with interventions: -Position catheter bag and tubing below the level of the bladder and away from entrance room door. -Enhanced Barrier Precautions with high contact cares. -Provide catheter care every shift and as needed. Record review of Resident # 28 Diagnosis dated 4/7/25 revealed: Neuromuscular Dysfunction of Bladder, Multiple Sclerosis, Other Reduced Mobility, and Need for assistance with personal care. Record review of Infection Control Prevention and Control Program-Hand Hygiene Policy undated revealed: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standards Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Enhanced Barrier Protection (EBP): expand the use of Personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of Multi-drug Resistant Organisms (MDROs) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). Face protection may also be needed if performing activity with risk of splash or spray. Examples of high contact resident care activities requiring gown and gloves use for Enhanced Barrier Precautions include: Dressing, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use: indwelling urinary catheter. Record review of Catheter Drainage Bag Policy dated 5/2007 revealed: Position the drainage bag below the level of the resident's bladder. Hand washing should be done immediately before and after any manipulation of the drainage bags and/or tubing. Record review of Infection Control Prevention and Control Program-Hand Hygiene Policy undated revealed: The facility considers hand hygiene the primary means to prevent the spread of infection. Use of alcohol-based hand rub containing at least 62% alcohol; or , alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before or after direct contact with residents. Before or after handling an invasive device (e.g. urinary catheter, IV access sites). Before moving from a contaminated body site to a clean body site during resident care. After contact with a resident's intact skin. After contact with blood or bodily fluids. 45484 B. A record review of the facility's undated Perineal Care policy revealed that the basic infection control-concept for pericare is to wash from the cleanest area to the dirtiest area. The policy did not address glove use or application of barrier cream. A record review of the facility's undated Hand Hygiene policy revealed that staff should use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after handling an invasive device (e.g. urinary catheters, IV access sites); Before moving from a contaminated body site to a clean body site during resident care; and After removing gloves. The policy also stated that Hand hygiene is the final step after removing and disposing of personal protective equipment, and that the use of gloves does not replace hand hygiene. A record review of Resident 54's Admission Record printed 04/07/2025 revealed the resident was admitted to the facility on [DATE] and had diagnoses of a fractured right femur (thigh bone), fractures of both bones of the right forearm, chronic (long-term) respiratory failure, heart failure, an irregular heartbeat, and urine retention. A record review of Resident 54's Order Summary printed 04/07/2025 revealed the resident had an indwelling catheter (a flexible tube that drains urine from the bladder to a bag outside the body). An observation on 04/08/2025 at 7:55 AM of catheter and peri-cares (washing the genitals and anal areas) performed by Nurse Aide (NA) D and NA E revealed that both NAs performed hand hygiene and put on gowns and gloves. NA D then prepared the work area and gathered supplies, and both NAs removed the resident's pants and performed hand hygiene and put on clean gloves. NA D then unfastened Resident 54's incontinence brief, got a wipe out of the package with the right hand, moved the wipe into the left hand and picked up the peri wash spray with the right hand to spray it on the wipe, then put the wipe back into the right hand to clean between Resident 54's labia from front to back and discarded the soiled wipe. NA D then with the same soiled gloves, reached back into the package of wipes with the right hand to get a clean wipe, put the clean wipe into the left hand, picked up the peri wash spray with the same soiled glove on the right hand, sprayed the wipe, then put the wipe back into the right hand and wiped between the resident's labia from front to back. NA D with the same soiled gloves reached into the wipes package with the right hand to get another wipe, put the wipe into the left hand and used the right hand to spray the peri wash spray on the wipe, then put the wipe back into the right hand and used it to wipe the catheter tubing from the urethra out. NA D repeated this process two more times to wipe each side of the resident's groin prior to removing their gloves and performing hand hygiene. NA D then put on clean gloves, assisted Resident 54 to roll onto their left side, and removed the resident's soiled brief. The resident had been incontinent of bowel. Without changing gloves, NA D reached into the wipes package with the right hand to get a clean wipe, put the wipe in the left hand, picked up the peri wash spray in the right hand and sprayed the wipe, then put the wipe in the right hand to wipe between the resident's buttocks. NA D then removed the right glove, patted the resident's buttocks dry using a towel with the gloved left hand, then performed hand hygiene and put on new gloves. NA D then tucked a clean brief and soaker pad under Resident 54, and applied barrier cream to the resident's buttocks and peri anal area using the right hand. NA D and NA E assisted Resident 54 to roll over to finish placing the soaker pad and brief, and with the same soiled glove, NA D applied barrier cream to the resident's labia and groin folds using the right hand. An interview on 04/08/2025 at 8:20 AM with NA D confirmed they should not have put their soiled gloves back into the wipes package, and that they should have changed gloves and performed hand hygiene after applying barrier cream to the buttocks and peri-anal area and before applying it to the labia and groin. An interview on 04/09/2025 at 1:20 PM with the DON confirmed that the NA should not have put soiled gloves back into the package of wipes, and that the NA should not have put barrier cream on the buttocks and peri anal area and then on the labia and groin without changing gloves and performing hand hygiene. The DON further confirmed that when performing peri-care, the NA should have gone front to back.

Licensure Reference Number 175 NAC 12.006. 18B Based on observation, and interview; the facility failed to maintain the cleanliness and condition of vents located in rooms 7, 16, 17, 29, 33, 38, 39, 40, 47, 48. This affected a total of 10 rooms. The facility census was 61. Findings are: An observation during an environmental tour on 04/23/2024 at 8:53 AM to 9:15 AM with Maintenance Direcectorrevealed that there was a thick brown buildup of debris located on the outside of vents in rooms: 7, 16, 17, 29, 33, 38, 39, 40, 47, and 48. An interview with Maintenance Director on 04/23/2024 at 9:15 AM confirmed that there was a thick brown buildup of debris located on the outside of vents in rooms: 7, 16, 17, 29, 33, 38, 39, 40, 47, and 48. An interview on 04/23/24 at 1:40 PM with Maintenance Director revealed that there was no policy or procedure for vent checks or cleaning and further revealed no monthly tracking or documentation of vent checks or cleaning had been completed. Maintenance stated that there was an inhouse system on the computer that was used to communicate needs for housekeeping and maintenance and there were no current entries noted in the system regarding cleaning of vents. An interview on 04/23/24 01:45 PM Housekeeping Supervisor (HSK-Sup) confirmed that vents in the resident bathrooms were not on the list to be cleaned or checked.

Licensure Reference Number 175 NAC 12-006.09 D3 Based on observation, interview and record review; the facility failed to maintain indwelling catheter (a tube inserted into the bladder) drainage bag below bladder level during toileting and catheter cares for Resident 39. Facility census was 61. Findings are: A record review of Resident 39s diagnosis list revealed an admitted [DATE] with diagnosis of neuromuscular dysfunction of bladder and overactive bladder. A review of the Indwelling Urinary Catheter Care policy dated 1/2022 revealed that the catheter drainage bag was to be kept below the level of the bladder. An observation on 04/22/2024 at 2:00 PM of Nursing Assistant (NA)-F and NA-E completing catheter cares on for Resident 39 revealed the resident was seated on the toilet in bathroom with the catheter drainage bag positioned on the transfer device.The drainage bag was above the level of residents' bladder and remained there until resident was transferred into wheelchair. The total time the drainage bag was viewed above bladder level was 20 minutes. During an interview on 04/22/2024 at 2:23 PM with NA-F confirmed that the catheter bag was located above Resident 39s bladder level from the time resident was toileted until transfer into wheelchair. During an interview on 04/23/24 at 07:54 AM with the Director of Nursing confirmed the expectation for a catheter drainage bag was for it to be always positioned below bladder level.

Licensure Reference Number 175 NAC 12-006.10D Based on observations, record reviews and interviews; the facility failed to administer the correct medication and give within the time frame prescribed by the physician for 1 (Resident 46) of 3 sampled residents. The facility census was 61. Findings are: Observation on 4/18/24 at 12:30 PM of Medication Aide (MA)-G administering medications to Resident 46 revealed hand hygiene was performed. MA-G then checked the EMAR (a legal record of the medications administered to a patient at a facility by a health care professional) before administration and after when she documented that the medications were given.The medications were given whole in applesauce were: Bisoprolol Fumarate 10 mg QD (every day), Bupropion HCL SR 150 mg QD, Lasix 40 mg QD, Carbidopa-Levodopa 25-250 mg TID, Entresto 24-26 mg BID (twice a day), Gabapentin 100 mg 1 cap BID, Oxybutyrin CL ER 10 mg QD, Potassium CL ER 10 meq 2 tabs QD, Ropinrole HCL 0.25 mg QD, Solifenacin Succ 10 mg QD, Miralax 17 GM QD mixed in water, Apple Cider Vinegar capsule 450 mg 1 cap QD, and Geri-Kot 8.6 mg 1 tab BID. Observation of the EMAR revealed that some of the medications were hightlighted as red in color. Record review of medications order revealed: -Sennosides-Docusate Sodium Oral Tablet 8.6-50 MG Give 1 tablet by mouth two times a day for constipation -Carbidopa-Levodopa Oral Tablet 25-250 MG Give 1 tablet by mouth three times a day for Parkinson's -Entresto Oral Tablet 24-26 MG Give 1 tablet by mouth two times a day for hypertension -Gabapentin Capsule 100 MG Give 1 capsule by mouth two times a day for bilateral lower extremity pain Interview on 4/18/24 at 12:40 AM with MA-G revealed if the medication on the EMAR is red that means it is late. Resident 46 medications were due no later than 11:00 AM and it is was 12:30 PM when they were administered. MA-G further revealed some medications are in a block time that as long as given by 11:00 AM and far enough apart from the next dose. MA-G revealed the reason medications were not given before was because Resident 46 was visiting with [gender] spouse. MA-G stated, I know it's not right, but the medications have enough separation times and some of the medications need to be given at least so many hours apart if they are ordered more than once a day, so as long as they are far enough apart from the next dose. MA-G revealed that if the medications are late, MA-G would tell the charge nurse. Interview on 4/18/24 at 12:17 PM with the Director of Nursing (DON) confirmed that the MA needs to tell the charge nurse if the medications are late and ask for help if needed. They administer the medications on Block times and 8-12-4-8 pm. DON revealed the facility will need to call the Doctor and see if we can get a time change for the medications. Record review of Med Pass Times: -under BID (two times daily) is 7:00 AM-11:00 AM, 3:00 PM-6:00 PM and 7:00 AM-11:00 AM, 8:00 PM-11:00PM -under TID (three times a day) 7:00 AM-11:00 AM, 12:00 AM-3:00 PM, 3:00 PM-6:00 PM and 7:00 AM-11:00 AM, 3:00 PM-6:00 PM, 8:00 PM-11:00PM Interview on 4/23/24 at 8:35 Am with DON revealed that the physician was called on 4/18/24 and was updated on the medication Carbidopa-Levodopa taken late and obtained an order to hold the afternoon dose and give the evening dose in the evening. Record review of Physician Orders Policy revised 01/2018 revealed: It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedure) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. 7) Medications, treatments, and procedures are to be administered per physician order. Record review of Medication Administration Policy dated 05/2021 revealed 2) Medications must be administered in accordance with the written orders of the attending physician. 7) Medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. 13) Prior to administering the resident's medication, the nurse should compare the drug and dosage schedule on the resident's MAR with the drug label.

Licensure Reference Number 175 NAC 12.007. 04D Based on observation, and interviews; the facility failed to maintain mechanical ventilation in residents' bathrooms located in rooms 38, 39, 40, 47, 48. The facility census was 61. Findings are: An observation during an environmental tour on 04/23/2024 at 8:53 AM to 9:15 AM with Maintenance Director revealed that the vents in the following rooms were not functioning: 38, 39, 40, 47, and 48. An interview with Maintenance on 04/23/2024 at 9:15 AM confirmed that vents in the following rooms were not functioning: 38, 39, 40, 47, and 48. An interview on 04/23/24 at 1:40 PM with Maintenance Director revealed that there was no policy or procedure for vent function checks and further revealed no tracking or documentation of vent function checks had been completed. Maintenance Director revealed that there was an in house system on the computer that was used to communicate needs for housekeeping and maintenance and there were no current entries noted in the system regarding nonfunctioning vents. An interview on 04/23/24 1:45 PM Housekeeping Supervisor (HSK-Sup) confirmed that vents in the resident bathrooms were not on the list to be cleaned or checked.

Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, record review and interviews; the facility failed to obtain a physician's order for a CPAP (Continuous Positive Airway Pressuretreatment that uses mild air pressure to keep your breathing airways open) for 1 (Resident 70) of 1 sampled resident. The facility census was 61. Findings are: Observation on 4/17/24 at 9:41 AM revealed a CPAP that was assembled and sitting on bed side table in Resident 70's room. Interview on 4/17/24 at 9:41 AM with Resident 70 revealed [gender] has woren the CPAP every night since admission to the facility. Record review revealed Resident 70's undated Face Sheet revealed Resident 70 was admitted on [DATE]. Record review of the undated Diagnosis Report revealed Resident 70 had a diagnosis of Obstructive Sleep Apnea. Record review of Resident 70's Hospital Admission Physician orders revealed no CPAP orders on 2/19/24. Record review revealed no physician order for a CPAP or the settings and was not on eMAR (a legal record of the medications administered to a patient at a facility by a health care professional). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/23/24 revealed in Section O that the CPAP was not marked. Interview with the Director of Nursing on 4/23/24 at 8:35 AM revealed the physician was called on 4/22/24 and obtained the CPAP order with settings and placed the order on the eMAR. Interview with the Director of Nursing on 4/23/24 at 1:10 PM confirmed the admission physician orders did not have an order for the CPAP and one should have been obtained. Record review of Physician Orders Policy revised 01/2018 revealed: It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedure) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. 6) Medications, treatment or related orders are transcribed in the eMAR, eTAR accurately and verified via the double check system process. 7) Medications, treatments, and procedures are to be administered per physician order.

Licensure Reference Number 175 NAC 12.006019D Based on record reviews, observation, and interviews; the facility failed to ensure that Resident 25 was free from unnecessary medications by attempting a gradual dosage reduction. Sampled resident total 1 of 1. Facility census 61. A record review for Resident 25s face sheet revealed that admission was 05/09/2020. A record review of the undated Diagnosis list for Resident 25 revealed Major Depressive Disorder ( a person with persistently low or depressed mood), Delusional Disorders (one or more firmly held false beliefs that persist for at least a month) , Vascular Dementia with Behavioral Disturbance (changes in memory, thinking and behavior resulting from changes in the brain), Anxiety Disorder, Schizoaffective Disorder ( a combination of symptoms such as mood disorders, hallucinations, mania, and delusions) and, Depression, and Unspecified Psychosis ( an individual that has a psychotic episode, but does not meet any other criteria for a more specific diagnosis). A review of the Minimum Data Set (MDS), (a tool that measures health status of residents in nursing homes) dated 2/26/24 reveals a Brief Interview of Mental Status (BIMS-test is used to get a quick snapshot of how well you are functioning cognitively at the moment) score of 11 which inidcates the Residnet 25 is moderately impaired. No hallucinations or delusions were documented on the MDS. Section GG revealed total dependence to substantial assist for hygiene, dressing, and transfers. Resident 25 was also marked as total dependence to max assist for rolling and position change. A review of Physician's Orders for Resident 25 revealed the following: -Celexa tablet 20 milligrams (mg) give 1.5 tablet by mouth at bedtime for Major Depressive Disorder ordered 8/5/2022. -Risperdal tablets give 0.25 mg by mouth at bedtime related to schizoaffective disorder, ordered 8/7/2022. -Mirtazapine tablet 15mg give 0.5mg tablet by mouth at bedtime for Depression ordered 5/9/2020. - Monitor Episodes: hallucinations and delusions. -Monitor Behavior: sadness, feelings of loss, self-isolation and side effects. A Review of the Medication Administration Record (MAR) revealed Resident 25 had no behaviors, hallucinations, delusions or sign of depression documented for the months of February, March, and April of 2024. A review of Pharmacy Reviews revealed no irregularities or GDRs attempted between the dates of 05/31/2023 and 03/31/24. A review of Interdisciplinary Team (a group of healthcare professionals) notes from 11/22/2023 to 04/16/2024 revealed that Resident 25 was being followed by in house psychiatric physician and that resident has had no target behaviors. A record review of documentation for the in house psychiatric physician revealed there is no documentation to be located since 01/18/2023. A review of the facilities Psychotropic Medications policy dated 12/2023 revealed that patients who use psychotropic drugs receive a gradual dose reduction (GDR) and behavioral intervention, unless clinically contraindicated, to discontinue these drugs. An interview on 04/23/24 at 1:01 PM with the Director of Nursing (DON) confirmed Resident 25 had no behaviors were documented on the MAR for the months of February, March and April of 2024 for Resident 25. An interview on 04/23/24 at 2:50 PM with the DON confirmed that no GDRs has been completed this last year for Resident 25, and no notes from the in house psychiatric physician have been found.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview; the facility failed to perform hand hygiene during wound cares for 1 (Resident 16) of 1 sampled resident, and during catheter cares for 1 (Resident 39) of 1 sampled resident. Facility census was 61. Findings are. A. A review of the undated Infection Control Prevention and Control Program- Hand Hygiene Policy revealed hand hygiene is to be completed at the following times: -before and after contact with residents, -before and after handling an invasive device (a device inserted into a body cavity) such as a urinary catheter (a flexible tube inserted into the bladder), -before moving from a contaminated body site to a clean body site during resident care, -after contact with objects in the immediate vicinity of the resident, -after contact with a Resident's intact skin, and -after contact with blood and body fluids. A review of the Indwelling Urinary Catheter Care policy dated 1/2022 revealed that hand hygiene using soap and water, and putting gloves on should be completed prior to performing catheter cares. B. An observation on 04/22/2024 at 10:04 AM of Registered Nurse (RN)-C completing wound cares on Resident 16 revealed RN-C gathered supplies, including loose gauze for cleaning the wound at the treatment cart located outside of the resident's room without performing hand hygiene. RN-C then sanitized their hands, applied gloves, and touched the treatment cart and the resident's door while entering the room. RN-C turned on the water in the resident's sink, prepared the gauze to cleanse the resident's wound, and turned the water back off with their gloved hands. Without performing hand hygiene or changing gloves, RN-C washed and dried the resident's inner thighs with the gauze, then applied a moisture barrier to the area. RN-C then removed gloves, touched the bathroom door and the countertop next to the sink, then put on another pair of gloves briefly, spoke with resident in doorway of bathroom, then removed the gloves as no cares were performed. No further contact with resident or surfaces. RN-C then performed hand washing was performed for 12 seconds prior to exiting room. RN-C was then in hallway completing an interview. No further surfaces being touched seen. During an interview on 04/22/2024 at 10:15 AM RN C confirmed that gloves were to be changed after cleansing Resident 16 and prior to applying moisture barrier on designated area. RN-C also confirmed that hand hygiene should have been performed after removal of gloves, and that the hand washing was to be completed for 30 seconds instead of the 12 seconds that was performed. C. An observation on 04/22/2024 at 2:00 PM of Nursing Assistant (NA)-F and NA-E completing catheter cares on Resident 39 revealed Resident 39 was seated on the toilet in the room's bathroom. NA-F and NA-E sanitized hands, donned gown and gloves outside of Resident 39's room. NA-E and NA-F then entered Resident 39's bathroom. NA-E positioned the wheelchair to the right side of the Resident 39. NA-F stood in front of Resident 39, and NA-E stood behind the resident assisting to stand. NA-F then obtained a clean wipe, wiping downward on the right side of groin with right hand. NA-F then obtained another clean wipe from the package and wiped downward on the left side of groin with right hand. No change of gloves or hygiene performed. NA-F obtained clean wipe, spread residents' labia (skin folds located between a female's legs) slightly with gloved left hand, and wiped from insertion site of catheter in a downward motion. Clean wipe then obtained another wipe from the package, and with the left-hand held the catheter in place while wiping in a downward motion from catheter entrance site using the right hand. NA-E then obtained a clean wipe and wiped the resident from the vaginal area (area located between bladder and buttocks) to buttocks, and discarded wipe. A clean wipe was obtained from package and the same process completed. The first wipe was noted to have small amount of stool, and the second wipe was without stool. NA-E without performing hand hygiene, obtained barrier cream located on a shelf located behind head and applied to residents' buttocks. NA-E and NA-F then pulled up Resident 39 pants and assisted resident to turn and sit down into wheelchair. NA-E then removed gloves but did not perform hand hygiene prior to exiting room. NA-F then turned to Resident 39's wheelchair with the dirty gloves on, unlocked brakes of wheelchair, and rolled resident backward to tray table in room. NA-F ensured that there was a call light on residents' tray table, then removed gloves and exited room. During an interview on 04/22/2024 at 2:23 PM with NA-F confirmed that gloves were not changed prior to completing care of catheter entrance site after wiping residents' groin. NA-F also confirmed that gloves were not removed and no hand sanitizing post catheter care, and prior to moving the resident from bathroom to tray table. During an interview on 04/22/2024 at 2:25 PM with NA-E confirmed that gloves were not removed prior to touching barrier cream and applying to Resident 39 buttock. NA-E further confirmed that barrier was then replaced on the shelf where retrieved. During an interview on 04/23/24 at 7:54 AM with the Director of Nursing revealed the expectation for catheter care was that hand hygiene is to be performed after groin is cleansed and prior to performing catheter care.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to ensure a provider's order for a fluid restriction was followed for 1 (Resident 2) of 2 residents reviewed. The facility had a total census of 60 residents. The findings are: Record review of Resident 2's Face Sheet, printed 6/14/23, revealed Resident 2 was admitted to the facility on [DATE] with diagnoses that included hyponatremia (a condition that occurs when the level of sodium in the blood is too low - often times a fluid restriction is utilized for treatment, as excess water dilutes the amount of sodium in the blood). Record review of a progress note dated 3/21/23 and written by Resident 2's APRN (Advanced Practice Registered Nurse) revealed the following: -Assessment/Plan of Care: -4. Hyponatremia - noted during hospitalization .continue 1800 mL daily fluid restriction. Record review of Resident 2's March 2023 TAR (Treatment Administration Record) revealed an order for a fluid restriction - 1800mL (milliliters) per 24 hours. Further review of Resident 2's March 2023 TAR revealed Resident 2's fluid restriction was exceeded on the following dates: -3/26/23 - 2800 mL -3/29/23 - 2050 mL -3/31/23 - 2940 mL Record review of Resident 2's April 2023 TAR revealed an order for a fluid restriction - 1800mL per 24 hours. Further review of Resident 2's April 2023 TAR revealed Resident 2's fluid restriction was exceeded on the following dates: -4/1/23 - 1820 mL -4/18/23 - 1880 mL -4/25/23 - 1820 mL -4/27/23 - 2680 mL Record review of Resident 2's May 2023 TAR revealed an order for a fluid restriction - 1800mL per 24 hours. Further review of Resident 2's May 2023 TAR revealed Resident 2's fluid restriction was exceeded on the following dates: -5/3/23 - 2240 mL -5/5/23 - 2129 mL -5/9/23 - 2440 mL -5/10/23 - 2120 mL -5/17/23 - 2680 mL -5/18/23 - 2160 mL -5/19/23 - 2170 mL -5/20/23 - 2400 mL -5/22/23 - 1920 mL -5/23/23 - 2080 mL -5/30/23 - 2680 mL Record review of Resident 2's June 2023 TAR revealed an order for a fluid restriction - 1800mL per 24 hours. Further review of Resident 2's June 2023 TAR revealed Resident 2's fluid restriction was exceeded on the following dates: -6/7/23 - 2960 mL -6/9/23 - 2000 mL -6/11/23 - 1880 mL -6/12/23 - 2480 mL -6/13/23 - 2500 mL Record review of Resident 2's electronic medical record did not reveal any documentation that Resident 2 was refusing to adhere to their fluid restriction or documentation Resident 2's provider had been notified about Resident 2 not following their fluid restriction. Interview on 6/14/23 at 3:40 PM, the DON (Director of Nursing) reported the facility handled resident fluid restrictions by designating a certain amount of fluids for meals, then nursing staffing tracked the remaining allotted fluids. The DON reported this was all documented on the TAR twice daily. The DON stated the facility used to keep a piece of paper for residents on fluid restrictions at the nurses' desk so staff could see what fluids they had already been given for the day but had stopped that process some time ago. Interview on 6/14/23 at 3:58 PM, the DON confirmed no documentation could be located indicating Resident 2 was refusing to follow their fluid restriction or that Resident 2's provider was updated regarding Resident 2 not following their fluid restriction.

Licensure Reference Number 175 NAC 12-006.04D2 Based on record review and interview, the facility failed to employ a qualified dietician on a full time basis or other clinically qualified nutrition professional. This had the potential to affect all 60 residents who reside in the facility. Findings are: Interview on 04/30/23 at 07:25 AM with Cook-G revealed the facility does not have a qualified dietary manager. Interview on 05/01/23 at 10:08 AM with Dietary Aide (DA)-H confirmed the facility does not have a qualified dietary manager and has not for almost one year. Record review of an all staff listed provided by the facility on 4/30/2023 revealed no Dietary Manager. Interview on 5/01/23 at 10:30 AM with the Administrator confirmed that the facility does not have a qualified Dietary Manager or that a Registered Dietician was employed full time.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure food temperatures were maintained to prevent the potentail of foodborne illness which had the potentail to affect 58 out of 60 residents who recieved meals from the kitchen. The facility failed to ensure proper food handling and serving to 2 Residents (Resident 31 and Resident 37) out of 2 sampled residents. The facility identified a census of 60. Findings Are: A) Observation on 04/30/23 at 12:00 PM of the main kitchen revealed the temperature of the food was not taken from the steam table prior to serving residents in the main dining room. Interview on 04/30/23 at 12:30 PM with Cook-G revealed temperatures were not taken prior to the food being served to the residents. Observation on 05/01/23 at 12:15 PM of food temperatures being taken of the last tray from the facility's food cart using the facility's kitchen thermometer revealed; -chicken breast at 100 degrees Fahrenheit -peas at 90 degrees Fahrenheit -garlic buttered noodles 90 degrees Fahrenheit Interview on 05/01/23 at 12:15 PM with Dietary Aide-I confirmed the temperatures of 5/1/2023 12:00 PM meal, prior to placing trays into the food cart for transport, were recorded as follows; -chicken breast at 100 degrees Fahrenheit -peas at 90 degrees Fahrenheit -garlic buttered noodles 90 degrees Fahrenheit A facility test tray meal was recieve on 5/1/2023 at 1:06 p.m. and revealed the following temperatures: -chicken breast at 121 degrees Fahrenheit -peas at 115 degrees Fahrenheit -garlic buttered noodles at 115 degrees Fahrenheit Interview on 5/01/23 at 1:14 PM with Cook-G confirmed the temperature of the chicken breast, peas and noodle temperatures should have been at least 135 degrees. Interview on 5/01/23 at 01:14 PM with Cook-G confirmed that no temperatures of the food had been taken of the food on the steam table prior to being served to the residents in the North Dining Room. Observation on 5/01/23 at 6:30 PM revealed DA-J had brought the steam table back to the kitchen to begin serving food in the South dining room and no temperature checks of the food were completed. 45613 B) Observation on 5/01/23 at 06:40 PM of NA - C (Nurse Aide) revealed NA-C touched Resident 31's cheeseburger with NA-C's bare hands to cut with a knife then handed the cheeseburger to Resident 31 to eat. NA-C did not performan hand hygiene. Observation on 5/01/23 at 06:43 PM of NA - C touched Resident 37's cheeseburger with bare hands to cut with knife then handed the cheeseburger to Resident 37 eat. NA-C did not perform hand hygiene. Interview on 5/03/23 at 2:59 PM with Infection Preventionist- D (IP) revealed staff should not touch resident food with bare hands.

Based on record review and interview, the facility failed to ensure a Level II PASARR (A Level II is necessary to confirm the indicated Mental Illness (MI)/Intellectual Disability (ID) diagnosis and to determine whether placement or continued stay in a Nursing Facility is appropriate) was completed after receiving a new diagnosis of schizoaffective disorder on 5/5/22 for 1 of 1 sampled residents (Resident 15). The facility identified a census of 60. Findings are: Record review of the PASARR Level I (Preadmission Screening and Resident Review that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 12/13/21 contained a diagnosis of Anxiety Disorder with no ID noted. Record review of the diagnosis list for Resident 15 revealed a diagnosis of Schizoaffective Disorder (a mental health problem where you experience psychosis as well as mood symptoms) dated 5/5/22 with no new PASSAR assessment completed. Record review of the policy titled Resident Assessment, MI/MR, Preadmission Screening for with a last revised date of 04/2021 reads as follows; 1. A PASRR shall be completed on every resident upon admission and as needed per RAI (Resident Assessment Instrument used to collect the minimum amount of data to guide care planning and monitoring for residents in a long-term care facility) manual instructions. 2. Based upon assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR. (Mental Illness/Mental Retardation) 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the resident may require. Interview on 5/1/23 at 2:40 PM with Admissions Coordinator-F, revealed a Level II PASARR should have been completed after receiving the Schizoaffective Disorder for Resident 15.

Licensure Reference Number 175 NAC 12-006.09C Based on record review and interview, the facility failed to ensure the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) included interventions for dialysis and for nutrition for 1 resident (Resident 35) of 4 sampled residents. The facility census was 60 at the time of survey. Findings are: Record review of Resident 35's CCP, dated 5/1/23 confirmed the admitted to the facility was on 3/27/2023. Further review revealed dialysis and nutrition interventions were not on the resident's comprehensive careplan. Record review of the facility policy titled Care and Treatment Comprehensive Person-Centered Care Planning, dated 8/2017 revealed the facility shall develop a comprehensive person-centered care plan for each resident for instructions needed to provide effective and person-centered care that meet professional standards of quality care. Interview with the Director of Nursing (DON) on 05/02/23 at 1:13 PM confirmed that dialysis and nutrition interventions were not on Resident 35's CCP.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was stored in a manner to prevent the potential for cross contamination for 2 (Resident 21 and Resident 43) of 2 sampled residents. The facility census was 60. Findings are: A) Observation on 4/30/23 at 12:47 PM of Resident 21's room revealed Resident 21's oxygen (O2) tubing was attached to a portable tank on the back of the wheelchair with the nasal cannula (a device used to deliver oxygen through the nose) touching the wheelchair. Observation further revealed Resident 21 had 02 nasal cannula attached to the oxygen concentrator which was dated 4/23 and the humidifier bottle to be dated 4/16. Observation on 05/01/23 at 8:34 AM of Resident 21's room revealed the O2 tubing for Resident 21 was attached to a portable tank on the back of the wheelchair with the nasal cannula touching the wheelchair. Observation further revealed Resident 21 had 02 nasal cannula attached to the oxygen concentrator which was dated 4/23 and the humidifier bottle to be dated 4/16. Observation on 05/02/23 at 9:20 AM of Resident 21's room revealed Resident 21's O2 tubing was attached to a portable tank on the back of the wheelchair with the nasal cannula touching the wheelchair. Observation further revealed Resident 21 had 02 nasal cannula attached to the oxygen concentrator which was dated 4/23 and the humidifier bottle to be dated 4/16. Record review of the Order Summary printed 5/2/23 for Resident 21 revealed an provider order to change Resident 21's oxygen tubing and clean the oxygen concentrator filter every Saturday night and to sign and date tubing every night shift with a start date of 4/13/22. Record review of the facility policy titled Respiratory Equipment Cleaning with a revision date of 02/2019 reads as follows; B. equipment guidelines: 1. Tubing should be replaced every week 3. Cannulas should be replaced every week D. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretion, mucous, and bacterial growth E. When licensed staff remove treatment tubing will be covered or stored in a bag. Record review of the Respiratory Equipment Cleaning policy does not address humidifier bottles used with oxygen use. Interview on 5/02/23 at 2:29 PM with RN-E (Registered Nurse) revealed the facility expectation and policy was to store oxygen tubing and the cannula when not in use in a bag. RN-E revealed oxygen tubing and humidifer bottles should be change weekly and dated accordingly. B) Observation on 4/30/23 at 2:50 PM of Resident 43's room revealed Resident 43's CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) tubing and mask was lying on the floor beneath the head of the bed. Observation on 5/1/23 at 08:20 AM of Resident 43's room revealed Resident 43's CPAP tubing was lying on the floor beneath the head of the bed. Observation on 5/2/23 at 8:35 AM of Resident 43's room revealed Resident 43's CPAP tubing lying on the floor beneath the head of the bed Record review of the facility policy titled Respiratory Equipment Cleaning with a revision date of 02/2019 reads that Bipap/Cpap attachments will be cleaned with soap and water daily and will be stored clean and dry in a covered bag until next use. Interview on 5/02/23 at 2:29 PM with RN-E revealed the facility expectation and policy was to store CPAP tubing in a bag when not in use. 45613 C) Observation on 5/01/23 at 06:25 PM revealed HK - B (Housekeeper) gathered room [ROOM NUMBER] bedding and held it against HK-B body across the hall to the dirty linen room. Interview on 5/01/23 at 06:27 PM with HK - B confirmed the bedding was held against their clothing and not placed in a bag for transport. Interview on 5/3/23 at 2:59 p.m. with IP-D (Infection Preventionist) revealed the facility did not have a linen transport policy. Further, IP-D revealed dirty linen should not be held against staff clothing.

Licensure Reference Number 175 NAC 12-006.17A Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to prevent the potential spread of COVID-19 as evidenced by the failure to place 1 (Resident 13) resident in transmission-based precautions after admission in accordance with facility policy. The facility also failed to ensure hand hygiene was performed during meal tray delivery to prevent potential cross-contamination between residents in the South hallways. This had the potential to affect all residents residing in the facility. The facility had a total census of 57 residents. The findings are: A. A review of the facility's Infection Control and Prevention Policy - Emerging Infectious Disease: COVID-19, last revised 3/15/22, revealed the following: There are four steps to take to minimize the spread based on community positivity rate, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), LHD (Local Health Department) and ICAP (Nebraska Infection Control Assessment and Promotion Program) guidance precautions and PPE (Personal Protective Equipment) requirements may change: -1. ICAP Zoning (See Color Chart with PPE instructions.) --e. Gray Zone: New Admissions, not up to date with vaccinations. A review of an ICAP colored zoning chart with PPE instructions, last revised 6/9/22, revealed the following: -Gray Zone (Transitional Zone) - Residents that are not up to date on vaccination, without known exposure to COVID-19 who are being transferred from the hospital/ outside facilities are kept in this zone for 7 days if they remain asymptomatic and test negative for COVID-19 at the end of day 7 will be moved to the Green Zone. Required PPE: COVID-19 full PPE (N95 Respirator, eye protection, isolation gown, and gloves). A review of Resident 13's medical record revealed Resident 13 was admitted to the facility on [DATE] and was not up to date on with COVID-19 vaccination. An observation on 9/15/22 at 9:15 AM revealed no signage outside Resident 13's room to indicate any TBP (Transmission-Based Precautions) were in place. A three-drawer plastic cart containing PPE was outside Resident 13's room in the hallway. Further observation at this time revealed NA D (Nurse Aide) entered Resident 13's room wearing a surgical mask and no other PPE to deliver a meal tray. NA D assisted Resident 13 to a position so they could eat, exited Resident 13's room to get some sugar, then reentered Resident 13's room to deliver the sugar to Resident 13. NA D picked up some trash from Resident 13's room, then exited into the hallway. NA D did not perform had hygiene after exiting the room. An observation on 9/15/22 at 12:50 PM revealed NA D entered Resident 13's room wearing a surgical mask and no other PPE to deliver a meal tray. NA D set up Resident 13's meal tray and assisted Resident 13 to a position so they could eat, then exited the room. NA D did not perform hand hygiene after exiting the room. An observation on 9/19/22 at 10:15 AM revealed there was no signage present outside of Resident 13's door to indicate any TBP were in place. There was no longer PPE present in the hallway outside of Resident 13's room. An observation on 9/19/22 at 1:13 PM revealed there was a sign on Resident 13's door indicating they were in a Gray Zone room and PPE was present in a 3 drawer plastic cart in the hallway. In an interview on 9/19/22 at 2:10 PM, the DON (Director of Nursing) confirmed Resident 13 was supposed to be in the Gray Zone, as they were not up to date with COVID-19 vaccination. B. Observations on 9/15/22 from 9:04 AM - 9:18 AM revealed NA D delivered meal trays to residents in the South hallways. NA D delivered a meal tray to Resident 6 and removed dirty dishes from Resident 6's room, placing them on the meal delivery cart. Then, NA D got some sugar off of the cart and delivered it to Resident 6. No hand hygiene was performed. NA D took a meal tray off the cart for Resident 1, set it down in Resident 1's room, then removed dirty dishes from Resident 1's room and placed them on the meal delivery cart. No hand hygiene was performed. Next, NA D delivered a meal tray to Resident 16 and set it up in their room, then exited the room. No hand hygiene was performed. NA D entered Resident 17's room to deliver a menu, then exited and performed hand hygiene. Then, NA D took Resident 8's meal tray into their room and set the tray up on Resident 8's bedside table. NA D removed multiple dirty dishes from Resident 8's room and put them on the meal tray delivery cart. No hand hygiene was performed. Next, NA D delivered meal trays to Residents 5, 18, 12, and 13 in their respective rooms. NA D did not perform hand hygiene in between meal tray deliveries. In an interview on 9/19/22 at 10:33 AM, the DON reported the expectation for hand hygiene in the facility was between every resident contact. The DON confirmed staff should perform hand hygiene in between each resident room when delivering meal trays.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to ensure a broken mechanical lift was not utilized for residents in the South halls. This had the potential to affect 6 residents who utilized the lift. The facility also failed to ensure 2 (Residents 7 and 10) of 3 sampled residents were transferred utilizing the correct sling size The facility had a total census of 57 residents. The findings are: A. An observation on 9/15/22 at 9:01 AM revealed a Hoyer lift (a full-body mechanical lift used to move residents from one point to another) on the South hall. They Hoyer lift was missing the outer covering of the wheel on the back right side. An observation on 9/15/22 at 9:31 AM revealed NA D (Nurse Aide) and RN B (Registered Nurse) utilized the Hoyer lift with the broken wheel to transfer Resident 10 from their wheelchair to their bed. An observation on 9/15/22 at 10:30 AM revealed NA D and NA C utilized the Hoyer lift with the broken wheel to transfer Resident 4 from their wheelchair to their bed. An observation on 9/15/22 at 1:07 PM revealed NA D and NA C utilized the Hoyer lift with the broken wheel to transfer Resident 7 from their wheelchair to their bed. In an interview on 9/1522 at 2:02 PM, the MS (Maintenance Supervisor) reported the facility had two Hoyer lifts, one on each side of the building. The MS confirmed they were aware that one of the Hoyer lifts was missing part of a wheel and that staff were not supposed to be using it right now. The MS stated the process for ensuring broken equipment is not used by staff was the MS took the equipment away and the DON (Director of Nursing) notified the nursing staff that the equipment was not to be used. A review of an undated list provided by the facility titled, Mechanical Lifts, revealed 6 (Residents 4, 6, 7, 8, 10, and 15) residents utilized the Hoyer lift on the South halls. B. A review of the facility's Mechanical Lift Policy, last revised 5/2007, revealed the following: -1. Obtain correct size sling for resident, based on weight and color-coded system. An observation on 9/15/22 at 9:31 AM revealed NA D (Nurse Aide) and RN B (Registered Nurse) utilized the Hoyer lift to transfer Resident 10 from their wheelchair to their bed with a burgundy-colored sling. An observation on 9/15/22 at 1:07 PM revealed NA D and NA C utilized the Hoyer lift to transfer Resident 7 from their wheelchair to their bed with a burgundy-colored sling. Observation at this time revealed a tag on the sling indicating it was a Large. A review of the EZ Way Sling Sizing Chart (from the operator's instructions of the facility's lift), last revised 7/2018, revealed the following: -Green sling - size x-large - weight of patient: 280 - 450 pounds. -Burgundy sling - size large - weight of patient: 190 - 320 pounds. -Beige sling - size medium - weight of patient: 90 - 220 pounds. A review of Resident 10's weight records revealed Resident 10 weighed 98 pounds on 9/15/22. A review of Resident 7's weight records revealed Resident 7 weighed 143 pounds on 9/15/22. A review of an undated list provided by the facility titled, Mechanical Lifts, revealed the following: -Resident 10 - Hoyer Sling - Medium -Resident 7 - Hoyer Sling - Medium

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observations, record review and interview; the facility staff failed to evaluate the ability to safely self administer medications for 2 (Resident 11 and 5) of 2 residents. The facility staff identified a census of 57. Findings are: Observation on 9-15-2022 at 9:57 AM revealed Certified Medication Assistant (CMA) G prepared Resident 11's medication and placed them into a medication cup. CMA G took the medications to Resident 11's room and placed them next to Resident 11 who was up in a chair and left Resident 11's room. On 9-15-2022 at 10:07 AM an interview was conducted with CMA G. During the interview CMA G when asked if Resident 11 had been evaluated for the ability to self administer medications, CMA G reported not being sure if an evaluation to self administer medications was completed. CMA G further reported Resident 11 like staff to leave the medications and Resident 11 would take them later. On 9-19-2022 at 12:17 PM an interview was conducted with the facility Administrator. During the interview the Administrator reported a evaluation to self administer medication had not been completed for Resident 11. B. Record review of a Order Summary Report (OSR) printed on 9-15-2022 revealed Resident 5's practitioner ordered medications that included [MEDICATION(S)] Diskus (medication used to manage symptoms asthma or other respiratory disease) inhaler. Observation on 9-18-2022 at 9:40 AM revealed Resident 5 was in bed awake and had a [MEDICATION(S)] Diskus on a tray table within reach of Resident 5. No staff was with Resident 5 during the observation. On 9-19-2022 at 10:10 AM an interview was conducted with Licensed Practical nurse (LPN) H. During the interview LPN H reported Resident 5 like to have the inhaler at bedside and was not sure if there had been an evaluated for Resident 5 to self administer medications. On 9-19-2022 at 12:17 PM an interview was conducted with the facility Administrator. During the interview the Administrator reported a evaluation to self administer medication had not been completed for Resident 5.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the practitioner of a change in condition for 1 (Resident 3) of 4 sampled residents. The facility staff identified a census of 57. Findings are: Record review of Resident 3's Progress Note (PN) dated 9-05-2022 revealed Resident 3 had [CONDITION(S)] (swelling) to both lower legs and feet. In addition, according to the PN dated 9-05-2022 Resident 3 face was puffy, oxygen tubing had left indentations on the cheeks and Resident 3 had asked why (gender) was so puffy and swollen. According to Resident 3's PN dated 9-05-2022, the [CONDITION(S)] had decreased the prior day. Record review of Resident 3's record revealed there was no indications the facility staff had notified the practitioner and received a response of Resident 3's change in condition. On 9-19-2022 at 2:53 PM an interview was conducted with the Director of nursing (DON). During the interview the DON reported that due to the acute issue, Resident 3's practitioner should have been called and was not.

Licensure Reference Number 175 NAC ,d+[DATE].09D7a Based on interview and record review, the facility failed to implement interventions to help prevent a fall with major injury for 1 (Resident 120) of 10 residents sampled. Total census was 61. Findings are: Record review of the facility's Fall Management System Policy with a revised date of ,d+[DATE] revealed it is the policy of the facility to provide each resident with appropriate assessments and interventions to prevent falls and to minimize complications if a fall occurred. Record review of Resident 120's Progress Notes dated [DATE] through [DATE] revealed Resident 120 had 8 falls on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review of Resident 120's Care Plan with a closed date of [DATE] did not reveal new interventions for the falls on: [DATE], [DATE], [DATE], or [DATE]. Record review of the Minimum Data Set (MDS)(a standardized screening and assessment tool of a resident's health status) dated [DATE], Section G0110 revealed Resident 120 required limited to extensive assistance with all activities. The MDS Section G0300 also revealed Resident 120's balance during transitions and walking was not steady and was only able to stabilize with staff assistance. Section GG0170 revealed the resident required substantial or maximum assistance to sit to stand, bed to chair transfer, and toilet transfer. Record review of Resident 120's Care Plan with a closed date of [DATE] revealed under the Activities of Daily Living (ADL)(daily self-care activities) section revealed the resident requires a 1 person assist with transfers, toileting, repositioning, bathing, personal care, dressing, and eating at times, but in the safety section it revealed an intervention dated [DATE] for therapy to work on sit to stand (a movement to the upright position) positioning. Record review of Resident 120's Care Plan with a Closed Date of [DATE] revealed a Focus of Safety and a Goal of resident will not sustain (undergo or suffer) serious injury through the review date, with the following interventions: - An intervention dated [DATE] of ensure resident is wearing appropriate footwear when transferring or wheeling in a wheelchair - An undated intervention of place gripper socks on resident while in bed - An intervention dated [DATE] to add non-skids strips in front of the bed - An intervention dated [DATE] gripper strips applied on floor in front of bed Record review of the facility's Physician/Nursing Communications dated [DATE] revealed new orders for [MEDICATION(S)] (a medication the improves mental function) take 5 milligram (mg)(a metric measurement) tablet at bedtime, [MEDICATION(S)] (a medication used to treat seizures) take 1 200 mg tablet 2 times per day, and discontinue [MEDICATION(S)] (a medication used to treat seizures) after [MEDICATION(S)] 1st dose is given. [MEDICATION(S)] side effects include diarrhea (loose, watery stools that occur more frequent than usual), frequent urination, difficulty controlling urination, dizziness, confusion, and hallucination (seeing or hearing things that do not exist). [MEDICATION(S)] side effects include confusion, dizziness, and/or unsteadiness. Record review of Resident 120's Care Plan with a closed date of [DATE] did not reveal new Care Plan interventions related to the [DATE] medication change. Record review of the facility's fall investigation dated [DATE] for the [DATE] fall revealed Resident 120 was assisted to the toilet at approximately 01:00 AM, there was no mention of the resident's footwear at that time. Record review of Resident 120's Progress Note dated [DATE] at 04:01 AM revealed at 03:15 AM the resident was heard calling for help. When the Registered Nurse (RN)-C entered the room, Resident 120 was on the resident's left side with the resident's head near the roommate's tray side table base. RN-C documented the resident was wearing dress socks. The Resident stated the resident hit (gender) head. RN-C documented swelling and raised bruise on the left eyebrow. Resident 120's socks were replaced with gripper socks. Record review of [DATE] Progress Note at 11:56 AM revealed Resident 120 complained of back pain from the fall, blood pressure decreased from ,d+[DATE] to ,d+[DATE] and then ,d+[DATE], and did have emesis (vomiting) in the morning. Resident stated the resident did hit (gender's) head. Record review of the Progress note dated [DATE] at 03:27 PM revealed Resident 120 had been transferred to the hospital at 12:58 PM. Record review of Resident 120's Computed Tomography (CT)(a radiology technique used to obtain detailed internal images of the body) Scan dated [DATE] revealed Resident 120 had a moderate, acute (recent) bleed on the right side of the resident's brain. Record review of Resident 120's CT Scan dated [DATE] revealed there was a large interval growth of Resident 120's right sided brain bleeding. Record review of Resident 120's hospital record dated [DATE] revealed the resident had an increased brain bleed and a skull fracture from the fall on [DATE]. Record review of Resident 120's hospital record dated [DATE] revealed the resident died at 03:56 AM Interview with the DON on [DATE] at 02:21 PM confirmed it is the facility's expectation that if the care plan states that non-skid strips should be applied in front of the bed on [DATE] that it would have been done. The DON confirmed that if the staff toileted the resident at 01:00 AM, that the staff member should have ensured the resident was wearing proper footwear, but the resident had dress socks on at the time of the fall. Interview with the DON at [DATE] at 02:46 PM confirmed the gripper strips did not get applied in front of Resident 120's bed until [DATE].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment and Performance Improvement (QAPI) program failed to identify ongoing issues relevant to F580, F610, F684, F692, F726, F760 and implement plans of action to identify and correct the deficient practice. The QAPI program failed to ensure repeated deficiencies at F609, F623, F689 and F880 were corrected and the correction maintained. The facility staff identified a census of 61. Findings are: Record review of the facility Policy/Procedure for Performance Improvement with the subject identified as Quality Assessment and Performance Improvement (QAPI) dated 9-2017 revealed the following information: -Policy: -The facility will establish and implement a Quality Assessment and Assurance Committee, develop a written Quality Assurance and Performance Improvement Plan, which will be reviewed and updated annually, and implement Performance Improvement Project through a data driven and proactive approach. -Purpose: -The purpose of the QAPI Plan and processes is continually assess the facility performance in all service areas, so that systems and process achieve the delivery of person-center care, and which maximizes the individual's highest practicable physical, mental and social well-being. -Procedures: -4. The committee function include, QAPI plan, identifying and prioritizing Performance Improvement Plans (PIP), implement actions to correct quality issues, and monitoring to ensure the corrective action implemented is sustained. -D. Education and Information Sharing: -1. Staff will be educated on QAPI at the time of hire and as needed. -3. QAPI plan and activities may be shared through staff meetings, bulletin boards, etc. On 3-16-2022 at 3:40 PM a interview was conducted with Receptionist J. During the interview receptionist J reported was not positive what QAPI is and that information had not been shared. On 3-16-2022 at 3:40 PM an interview was conducted with Activity Assistant (AA) K. During the interview AA K reported know knowing anything about QAPI. On 3-17-2022 at 6:40 AM an interview was conducted with Nursing Assistant (NA) L. During the interview NA L reported not knowing what QAPI was. On 3-17-2022 at 6:50 AM an interview was conducted with NA M. During the interview NA M reported not knowing what QAPI stands for as NA M didn't go to the meetings. On 3-17-2022 at 7:03 AM an interview was conducted with NA N. During the interview NA N reported wasn't sure what QAPI was and has not been invited to meetings. On 3-17-2022 at 7:40 AM an interview was conducted with the facility Administrator. During the interview the Facility Administrator reported there were not action plans for falls.

LICENSURE REFERENCE NUMBER 12-006.09D7 Based on observation, interviews and record reviews, the facility failed to provide supervision to prevent accident and/or injury related to the elopement (when a patient leaves the facility/hospital when doing so may present an imminent threat to the patient's health or safety) for Resident 1 and the potential elopement risk for 2 residents (Residents 10 and 14). This had the potential to affect 14 residents- identified as at risk for wandering or elopement. The facility census was 68. Findings are: A record review of the demographic information,completed on 12/30/20, revealed Resident 1 had been admitted from home on 02/16/2018 with a diagnosis list that included: Paranoid Personality Disorder, Vascular Dementia with Behavioral Disturbances, Anxiety Disorder and Major Depressive Disorder. A record review of the quarterly MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 09/28/20 revealed Resident 1 had a BIMS ( Brief Interview for Mental Status, an assessment to assess the cognitive function for the elderly) score of 00, which indicated severe cognitive impairment. A record review of the Elopement/Wandering Evaluation dated 9/2/20 indicated Resident 1 made statements related to going home. The evaluation had an answer of no to the question of does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility). The evaluation had an answer of yes to the question does wandering significantly intrude on the privacy or activities of others. The evaluation revealed a question of how does the wandering behavior compare to prior evaluation with an answer of same. The record review revealed the score for this assessment had been listed as high risk for elopement/wandering. A record review of the Comprehensive Care Plan for Resident 1 revealed the following transfer ability: TRANSFER: Independent with transfers; however, does need staff assistance at times. Utilizes W/C for locomotion and can self propel t/o the facility. Date Initiated: 02/16/2018 During an interview on 1/4/21 at 06:30 AM with MA-B confirmed around midnight on 12/26/20, the wanderguard system alarm at the NW exit door had been sounding due to being set off by another resident. MA-B confirmed the staff could not get the alarm to stop sounding and called maintenance in to the facility. An interview on 12/30/20 at 12:10 PM with the Administrator revealed the garage door was unlocked due to the Maintenance Supervisor was at the facility from around 8 pm until after midnight on 12/26/20 to repair the wanderguard alarm on the NW door. A record review on 12/30/20 at 08:00 AM of the 10/11 weather reports for 12/26/20 at 02:00 AM revealed an outside temperature of 24 degrees. The interview on 1/4/21 at 06:30 AM with MA-B revealed it had been cold outside on the night of 12/26/20. The interview revealed Resident 1 was always cold, even in 80 degree weather. MA-B reported that NA-C had called for blankets over the walkie talkie system to be brought to the garage and for the Charge Nurse. MA-B reported that Resident 1 had been warm to touch upon finding and then Resident 1 had been assisted inside the building. An observation on 12/30/20 at 03:05 PM revealed a thermostat set at 60 degrees inside the maintenance office. An observation of the maintenance office on 1/4/21 at 09:30 AM revealed a temperature of 58 degrees The interview on 1/4/21 at 06:50 AM with NA-C confirmed Resident 1 had been found inside the garage in the maintenance office, lying on the floor. 12/26/20 at 02:00 AM; per LPN-K, Resident 1 had been found on garage floor on left side, assisted to wheelchair and taken inside, noted small abrasions to left knee, vital signs stable, warm to touch. An interview with the Administrator on 12/30/20 at 03:05 PM confirmed the distance from the NW dining room door to the garage door is approximately 60 feet. The interview with the Administrator reported the facility had not contacted the police as per facility policy because Resident 1 had been found. An interview on 1/4/21 at 06:30 AM with, MA-B confirmed Resident 1 was not steady with independent ambulation and used the wheelchair most of the time. MA-B confirmed staff had not seen Resident 1 ambulate often. MA-B reported staff used the wheelchair to assist Resident 1 with toileting needs during the night. 12/27/20 at 02:15 AM; (late entry for 12/26/20) Resident 1 had been in the hallway, upset at peer around 11:30 PM , redirected, Resident 1 had made several attempts to exit through the front door with redirection from the MA (Medication Aide) with last attempt being at 1:00 AM, at approximately . 01:55 AM, NA-C, NA-B and LPN-K then began to look for Resident 1 after finding Resident 1's room empty during rounds. Resident 1's wheelchair had been located in front of the exit door in the North dining room. Staff opened exit door, noted alarm had not sounded, and began calling Resident 1's name. LPN-K noted it had been very dark and difficult to see outside. Resident 1 had been located on the floor in the maintenance office in the garage. LPN-K had documented that Resident 1 had been shivering but was still warm to touch. Resident 1 had been wearing long pants, long sleeves and socks. Resident 1 had been covered and assisted back into the wheelchair and back to the building. DON had been notified. 12/26/20 at 09:30 AM; Resident 1's representative had been notified of the elopement and fall. Resident 1's representative had voiced concerns regarding Resident 1's history of increased confusion when taking [MEDICATION(S)] (a medication used for moderate to moderately sever pain). Resident 1 noted to be wandering the halls with repeated attempts to open the West hall exit door with alarms sounding, Resident 1 required 1:1 supervision An interview on 1/4/21 at 06:50 AM with NA-C revealed on the night of 12/26/20 Resident 1 had been restless most of the evening and night hours. NA-C reported that Resident 1 had been exit seeking throughout the night. NA-C reported rounds were being completed and when arrived and found that Resident 1 was not present in their room, NA-C had begun searching for resident. An interview on 1/4/21 at 06:30 AM with MA-B, revealed on the night of 12/26/20, Resident 1 had been restless and roaming the halls most of the night. MA-B reported at 1:45 AM on 12/26/20, Resident 1 was not visible in the halls and staff began searching for Resident 1. The interview with MA-B revealed during the search, MA-B located Resident 1's wheelchair sitting at the North Dining Room exit door and Resident 1 was not in the wheelchair. MA-B confirmed the staff had opened the exit door and called Resident 1's name with no answer. MA-B, confirmed the door alarm had not sounded when MA-B opened the NW dining room door in search of Resident 1. NA-C reported Residents 2, 10, 14 and 15 had displayed exit seeking behaviors during the night shift hours. During the interview with NA-C, confirmed Resident 15 had attempted to open the exit door on the NW hallway at around 7:30-8:00 PM which resulted in the wanderguard alarm to sound. An interview on 1/4/21 at 06:50 AM with NA-C confirmed Resident 1 had been exit seeking and looking for a family member prior to the elopement. NA-C reported staff were not able to reset the wanderguard door alarm and maintenance had been required to come to the facility to fix the alarm. NA-C reported that staff had not been instructed to increase the supervision of Resident 1. NA-C confirmed offering food, fluids, toileting or a distraction of some kind to the wandering residents. NA-C confirmed that Resident 1's wheelchair had been found inside of the North Dining Room exit door. NA-C, MA-B and the Charge Nurse all went to various locations outside of the building to look for Resident 1. NA-C confirmed that the alarm attached to the exit door at the North Dining Room did not sound when opening the door to look for Resident 1. NA-C reported they had slipped on the ice and landed against the external side of the exit door. The interview revealed upon NA-C opening the North Dining Room door to return inside the facility, the alarm on the inside of the door had begun to sound. NA-C had noted that a light had been on inside the garage. NA-C checked the door to the garage and had found it unlocked. NA-C reported a request for blankets and the charge nurse be brought to the garage had gone over the walkie talkie system. NA-C reported that Resident 1 had a temperature of 96.7 upon locating Resident 1 in the garage. During the interview, NA-C confirmed Resident 1 had pants on that were not soiled as to indicate that Resident 1 had crawled from the building to the garage. The interview with NA-C confirmed Resident 1 had been assessed by the Charge Nurse prior to assisting Resident 1 off of the floor. During the interview, MA-B revealed the Charge Nurse was checking other resident rooms in search of Resident 1, while NA-C went to look out in front of the building while MA-B searched outside the back door. MA-B confirmed it had been too dark to see footprints of any kind and MA-B had been using a flashlight during the search for Resident 1. The interview, revealed the light had been on in the garage. MA-B confirmed NA-C had located Resident 1 inside the garage lying on the floor in the maintenance office. The interview with MA-B confirmed Resident 1 had been wearing a long sleeve shirt, pants and socks. 12/26/20 at 11:21 AM; a note had been sent to the APRN (Advanced Practice Registered Nurse) related to Resident 1's increased confusion, elopement and fall, also a request to discontinue Resident 1's [MEDICATION(S)] at the request of Resident 1's representative. 12/26/20 at 1:00 PM; nurse called to the dining room to find Resident 1 on the floor, no injury 12/27/20 at 11:36 AM; Resident 1 wandering, looking for daughter and daughter's baby 12/28/20 at 06:11 AM; a note had been sent to APRN requesting an order to complete a urinalysis due to Resident 1 having 2 falls, exit seeking behavior and increased confusion. 12/28/20 at 07:40 AM; Resident 1 complaining of pain to right extremity, increased pain with ROM (range of motion), grabbing right upper thigh, requiring 2 assist with transfers, bearing no weight to right extremity, order received for a STAT (immediate) x-ray of the right femur and pelvis. A record review of the Elopement/Wandering Evaluation dated 12/30/20 revealed Resident 1 made statements related to going home. The evaluation had an answer of yes to the question of does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility). The evaluation had an answer of yes to the question of does wandering significantly intrude on the privacy or activities of others. The evaluation revealed a question of how does the wandering behavior compare to prior evaluation with an answer of same. An interview on 12/30/20 at 12:10 PM with the facility DON revealed the facility expectation was staff would walk up and down hallways every 30 minutes to monitor resident's safety. An interview on 12/30/20 at 12:10 PM with the DON confirmed on 12/26/20 Resident 1 had eloped. The interview confirmed staff had reported Resident 1 had been seen at 01:30 AM in the hallway. The interview confirmed at 01:55 AM staff had began looking for Resident 1 and had located Resident 1's wheelchair at the exit door in the North dining room. A record review of the facility Policy/Procedure titled Elopement/Wandering dated 06/2018 revealed upon a resident's return after an elopement, staff are to a) complete an assessment to determine if medical attention is required, b) an elopement evaluation will be completed post elopement with follow up documentation for 72 hours and c) the attending physician and resident representative will be notified of resident return and status An interview on 12/30/20 at 2:55 PM with the DON confirmed the resident representative for Resident 1 had not been notified of the 12/26/20 elopement for 7 hours after the elopement and should have been notified sooner. The interview on 12/30/20 at 2:55 PM with the DON confirmed a new elopement assessment should have been completed after the 12/26/20 elopement. An interview on 1/4/21 at 07:30 with the Maintenance Supervisor confirmed the garage door had been left unlocked on the night of 12/26/20, due to being called out to the facility on [DATE] around 8:00 PM to fix the wanderguard door alarm and had remained at the facility working on the alarm until after midnight. The interview confirmed that the Maintenance Supervisor had observed Resident 1 to be restless and roaming the halls around 12:30 AM. The interview with Resident 1's representative on 12/30/20 at 12:30 PM revealed frustration with the facility staff related an inability to get concrete answers related to the elopement. The interview revealed the resident representative had questioned why Resident 1 had not been wearing pajamas as (gender) normally would at that time of night but reported that the facility staff were unable to provide the answers. The representative voiced having conversations with three different staff members but reported not receiving sufficient responses. The representative voiced the staff had been unable to provide the information related to the elopement event to included family notification of the event. The representative for Resident 1 also voiced concerns regarding how Resident 1 had been able to ambulate 60 feet before falling as Resident 1 would barely ambulate 10 feet without falling. B. A record review of the demographic information completed on 12/20/20 revealed Resident 14 had admitted on [DATE] with a primary diagnosis of Alzheimer's disease with behavioral disturbances and Paranoid Personality Disorder. A record review of the quarterly MDS dated [DATE] revealed Resident 14 had BIMS score of 02, indicating severe cognitive impairment. A record review of the facility Elopement Risk Book on 12/30/20 revealed Resident 14 as an elopement risk. The record review of the quartely MDS dated [DATE] for Resident 14, indicated wandering behaviors had not been exhibited. A record review completed on 12/30/20 at 11:00 AM of the Comprehensive Care Plan (CCP- written plan to assist in person-centered care of the resident that meet professional standards of quality care) dated 10/16/20 revealed no goal, problem statement or interventions related to elopement. A record review of the Progress Notes for Resident 14 dated 3/16/20 through 12/30/20 revealed that Resident 14 had been awake and pacing the halls during the night shift on 6 occasions. The record review of the Progress Notes dated 4/16/20 at 04:44 AM revealed Resident 14 had been agitated about not being sure when we were leaving. The record review of the Progress Notes dated 07/02/20 at 10:45 PM revealed Resident 14 had increased anxiety and stated I just need to get out of here. The record review of the Progress Notes dated 09/21/20 at 08:41 AM for Resident 14 revealed an entry a wanderguard placed on resident accidentally and removed. A record review of the Progress Notes dated 10/20/20 at 01:45 AM revealed Resident 14 had been talking about leaving, asking which door to go to and following staff all evening, redirected numerous times without success. An interview on 12/30/20 at 5:30 PM with the DON revealed 4 residents, including Resident 14, within the facility did not have wanderguard bracelets in place. The interview revealed the DON did not consider Resident 14 an elopement risk because Resident 14 had never been seen making attempts to seek and exit. A record review completed on 1/4/21 of the CCP revealed that an elopement goal, problem statement and interventions had been added with a date of 12/30/20. C. An observation on 1/4/21 at 9:50 AM of Resident 10 in their room. Resident 10 stood unattended and transferred from the wheel chair to the bed ambulating 10 steps. Resident 10's wheel chair had a wander guard (a device used to activate door alarms for resident who wander) attached to the back bar of the chair. Located in Resident 10's room was a 4 pronged walking cane, a front wheeled walker and a 4 wheeled walker available for use. An observation on 1/4/21 at 11:01 AM with the DON (Director of Nurses) of Resident 10, sitting in a dining room chair across the hall from (gender's room) and adjacent to a door leading to an outdoor gated area. The wander guard was tested and functioning on the wheel chair located in Resident 10's room. Resident 10 stood unattended and ambulated from the dining area to (gender's) room, inside the room, and back to the dining area approximately 20 foot. An interview on 1/4/21 at 11:20 AM with the DON confirmed Resident 10 was not wearing a wander guard on their person during the observation of the resident in the dining area. The wander guard was on the wheel chair located in the resident room. The DON confirmed Resident 10 ambulated short distances unattended. The DON confirmed the 3 assistive devices in the room were without wander guards and Resident 10 no longer used them. An observation on 1/4/21 at 12:00 PM of Resident 10's room was approximately 10 foot from the dining area. The Resident 10's room was approximately 15 foot from a door leading outside to a gated area. Record review of Resident 10's Elopement/Wandering Evaluation dated 11/01/20 revealed: a score of 12 indicated high risk for Elopement. 1. Diagnosis: dementia 2. Ambulation: ambulatory with an assistive device. 3. Mental status: intermittent confusion. 4. History of elopement: a. No history of elopement, b. Resident 10 made statements about going home. c. Resident 10 was not at risk related to wandering to a potentially dangerous place (stairs or outside of the facility). d. Resident 10's wandering did not intrude on the privacy of others. e. Resident 10's wandering behavior was the same compared to prior evaluation. 5. Days of residence: Longer than 120 days Record review of Resident 10's Quarterly MDS (Material Data Set- a federally mandated assessment used in the development of comprehensive care plans) dated 11/2/20 revealed; Section C: Cognition revealed Resident 10 had a BIMS (Brief Interview for Mental Status- a brief screener that aids in assessing cognitive impairment) Score of 04 indicated severe cognitive impairment. Record review of Resident 10''s Diagnosis dated 11/9/20 revealed unspecified dementia with behavioral disturbances and wandering. Record review of Resident 10's History and Physical dated 12/15/20 revealed: Diagnosis: Dementia without disturbances. Neurological Assessment: (Gender) was confused at baseline. Cognition and Memory: Impaired Assessment and Plan of Care: [CONDITION(S)] without behavioral disturbances, Depression and anxiety, and wandering. Resident 10 was stable. Resident 10 was seen by Mental Health Provider via telehealth and medications were adjusted. Record review of Resident 10's care plan dated 1/13/20 revealed; Elopement Risk o My safety will be maintained and I will not attempt to leave the facility unattended by staff or a family member through the review date. o Check wander guard placement and function every shift. Change per facility policy. My wander guard is on the back of my W/C. o Distract from approaching exit doors by offering pleasant diversions, such as conversation about my baby, coffee, or magazines. o Document wandering behavior and attempted diversion interventions. o I have poor safety awareness and have a history of attempts to leave the facility unattended. ADLs Activities of Daily Living Date Initiated: 07/15/2013 o Will safely perform Bed Mobility, Transfers, Eating, Dressing, Toilet Use, and Personal Hygiene with independence and staff assistance as needed through the review date. Date Initiated: 07/15/2013 o Resident refused staff assistance. Noted to be impulsive and unsteady; however, Resident 10 preferred to be independent with ADLs. (Gender) utilized a W/C for the primary source of locomotion and can self-propel throughout the facility. Resident 10 would ambulate in the room and sometimes outside the room and needed reminders to use (gender's) walker. Date Initiated: 08/26/2020 o Encouraged to use the call light to call for assistance. Most often, Resident 10 would come out of (gender's) room to find staff. The facility failed to provide appropriate/sufficient supervision to prevent accident/injury related to elopement. The Immediate Jeopardy began on 12/25/2020 at approximately 10:00 PM when facility staff notified the maintenance staff the door alarms weren't working. Abatement Plan: The facility will implement a plan to include that all emergency exit doors will be checked for proper functioning every shift for 7 days and then weekly thereafter. The facility will implement the addition of wanderguard alarms on the 3 exit doors within the facility that currently do not have them. The facility will re-educate all staff related to the elopement policy changes prior to their next shift worked. Initially the abatement was partially abated on 12/30/2020 when the facility began educating and training staff regarding elopement. However when the surveyors returned to the building on 1/4/2021 staff were working who had not been trained on elopement so the immediacy was not removed. This was not fully abated until 1/4/2021 when surveyors verified all staff had been trained on elopement.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition to prevent elopement and entry to an unlocked garage and the potentially harmful chemicals and equipment to residents. This had the potential to affect 14 residents. The facility census was 68. Findings are: On 12/30/20 at 09:21AM, an observation of the exit doors completed with RN-F, revealed the SW exit door and SE exit did not close completely once opened. The observation revealed both of the doors remained open approximately an inch or less and would not close without staff pulling the doors shut. The SW door had been equipped with a wanderguard (an alarm system that allows facilities to monitor exit doors to prevent wandering of high-risk residents without assistance) alarm as well as an alarm that sounded when the door was opened. The SE exit door did not have a wanderguard alarm in place. An observation on 12/30/20 at 09:21 AM revealed a sign posted on the NW dining room exit door to ensure the staff pull the door shut to ensure it has latched. An interview on 12/30/20 at 12:05 PM with the Maintenance Supervisor revealed door audits were completed monthly. An interview on 12/30/20 at 12:10 PM with the Administrator revealed it was likely the garage door was unlocked due to the Maintenance Supervisor was at the facility from around 8 pm until after midnight on 12/26/20 to repair the wanderguard alarm on the NW door. An interview on 12/30/20 at 12:45 PM with the Administrator confirmed both the SW and SE exit doors did not close completely without assistance when opened thus not reengaging the alarms. The facility Administrator confirmed the facility had this same problem this past summer when the NW exit door had not closed properly. The Administrator revealed that the door required shaving to close completely and a new closure arm had been placed. The interview revealed that the Maintenance Supervisor had been called to the facility on the evening of 12/26/20 due to the NW wanderguard system not turning off. During the interview, it was revealed that there had been 2 residents roaming the halls on the night of 12/26/20 due to restlessness. The interview confirmed that Resident 1 had eloped through the North dining room door. An observation on 12/30/20 at 3:10 PM confirmed that the facility Maintenance Supervisor had been working on the SW hallway exit door. During the observation, it was discovered that the wanderguard door alarm did not have a green light on to indicate it was functioning. An interview on 12/30/20 at 3:10 PM with the facility Maintenance Supervisor confirmed the wanderguard door alarm at the SW hallway exit door was not functioning. During the interview, the Maintenance Supervisor verbalized a plan to leave from the SW exit door to work on SE exit door despite the wanderguard system not functioning at the SW exit door. An interview on 1/4/21 at 07:30 with the Maintenance Supervisor confirmed the garage door had been left unlocked on the night of 12/26/20, likely due to being called out to the facility on [DATE] around 8:00 PM to fix the wanderguard door alarm and had remained at the facility working on the alarm until after midnight. The interview confirmed that the Maintenance Supervisor had observed Resident 1 to be restless and roaming the halls around 12:30 AM. An observation on 1/4/21 at 07:30 AM revealed the garage door was locked. An observation on 1/4/21 at 09:10 AM revealed that NA-J had been available to open exit doors and ensure proper closing. The observation revealed no problems with SW and SE doors closing appropriately on own, thus re-engaging the door alarms. An interview with the Administrator on 1/4/21 at 09:10 AM revealed the wanderguard door alarm located at the SW exit door had been alarming due to a resident in the adjacent room triggering the alarm. The interview revealed that the alarm had been malfunctioning and new parts had been ordered. F908 The facility failed to maintain all mechanical, electrical and patient care equipment in safe, operating condition. Abatement Plan The facility will implement a plan to include that all emergency exit doors will be checked for proper functioning every shift for 7 days and then weekly thereafter. The facility will implement the addition of wanderguard alarms on the 3 exit doors within the facility that currently do not have them. The facility will re-educate all staff related to the elopement policy changes prior to their next shift worked. This remained unabated until 1/4/2021