Every finding on record at Bertrand Nursing Home

Licensure Reference Number 175 NAC 12-006.11(E) Based on an observation and an interview, the facility failed to store food in a manner to prevent the potential for food born illness. This had the potential to affect all residents who ate out of the kitchen. The facility census was 18. Findings are: An observation on 4/28/25 at 10:17 AM revealed in the stand up refrigerator: - a metal silver bowl with macaroni salad was not labeled or dated, - a metal silver bowl of cut up muskmelons was not labeled or dated. An observation on 4/28/25 at 10:30 AM revealed in the stand up freezer: -a zip lock bag of corn dogs with no opened date on it and ice crystals observed on the corn dogs, -a bag of opened fish sticks with no opened date on them, - a gallon tub of vanilla Ice cream that was opened with no date on it. A review of the Food and Nutrient Services Policy and Procedure Food Safety: Topic Refrigerated Storage Dated: February 2009, Revised August 2017 -All refrigerated items are stored in the original container/packaging or in a container that is fully covered or sealed so as to maintain freshness and quality and prevent cross-contamination -All items are labeled with the common name of the item and dated with the month, day and year when opened or prepared. An interview on 4/28/25 at 11:00 AM with the Dietary Supervisor confirmed that the items listed above had no name (not labeled) or was not dated when opened or prepared and should have been dated and/or labeled.

Based on record review and interview, the facility failed to ensure the Infection Preventionist had the required qualifications prior to assuming the role. This had the potential to affect all residents in the facility. The facility census was 19. Findings are: During an interview on 04/08/2024 at 10:13 AM, the Administrator (ADM) revealed that Registered Nurse (RN) A was the facility's Infection Preventionist (IP-a professional who makes sure the facility's staff and residents are doing all the things they should to prevent the spread of infections). The ADM further revealed that RN A had not completed the Centers for Disease Control (CDC) Nursing Home Infection Preventionist Training Course. The ADM also revealed that the previous IP had left at the end of March 2024, and RN A had assumed the role on 04/01/2024. The ADM provided copies of Certificate of Training CDC Train for RN A for a total of six modules completed: -Module 1-Infection Prevention and Control Program dated 03/28/2024. -Module 2-The Infection Preventionistdated 03/28/2024. -Module 3-Integrating Infection Prevention and Control into the Quality Assurance Performance improvement Program dated 04/02/2024. -Module 4-Infection Surveillance dated 04/02/2024. -Module 5-Outbreaks dated 04/02/2024. -Module 13 -Occupational Health Considerations for the Infection Prevention and Control Program dated 03/28/2024. A review of the CDC website https://www.cdc.gov/longtermcare/training.html revealed the Nursing Home Infection Preventionist Training course consisted of 23 modules and sub-modules. During an interview on 04/11/2024 at 2:20 PM, the DON confirmed confirmed RN A had been working on the Infection Prevention modules through the CDC but was not done.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review, and interview: the facility kitchen staff failed to ensure outdated foods were not available for use. This had the potential to affect all residents in the facility. The facility staff identified a census of 19. Findings are: Observation on 4-17-23 at 9:30 AM with the morning Cook A revealed the following outdated food items: -Cornstarch expiration dates was 5/22. -Creamy rice cereal expiration dates was 6/21. -3 large bag potato chips expiration dates was 2/23. -Champions pizza sauce expiration dates was 11/22. -Baby kidney beans expiration dates was 1/23. -Krispy onions expiration dates was 5/22. -Chili sauce expiration dates was 5/22. -[NAME] dressing expiration dates was 1/23. -Taco shells expiration dates was 9/22. On 4-17-23 at 9:30 AM interview an interview was conducted with Cook A. During the interview Cook A confirmed the food items were outdated and available for use.

Licensure Reference: 175NAC 12-00.09D2b Based on observation, interview, and record review, the facility failed to implement measures to prevent a facility acquired pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident 10. The facility also failed to ensure assessments were completed of the pressure ulcer to promote healing for Resident 10. This affected 1 of 1 sampled residents identified by the facility staff as having facility acquired pressure ulcers. The facility identified a census of 14. Findings are: Observation on 11/30/21 at 07:53 AM of Resident 10 during morning cares revealed that Resident 10 had a nickel size open area to the right heel. When the right sock was removed, Resident 10 complained of pain. Record review of Resident 10's Admission Resident Data Set form dated 7/30/2021 revealed in Section P skin that the resident did not have any pressure ulcers. A note was documented and underlined, feet ok. Section Q Foot problems and Care, was documented as none. Section V Risk for Pressure Ulcers, total score of 13. Record Review of Resident 10's Care Plan revealed a Problem Onset on 8/12/2021 that Resident 10 was at risk for pressure ulcers and skin integrity. Approaches listed that two persons were to assist with repositioning the resident to avoid skin friction/shearing and to place the pressure-reducing device/product on the resident's bed/chair. Resident had a low air loss mattress on their bed that the resident's family bought. There were no pressure ulcer interventions listed related to preventing ankle or feet pressure ulcers. Record review of Resident 10's Weekly Pressure injury Record form dated 10/12/2021 revealed a dark color wound bed. There was no measurements or other wound documentation. There was also no wound measurement or documentation on 10/15/21, 10/22/21, and 10/29/21 on this same Weekly Pressure Injury Record. Record review of a nursing progress note by LPN D (Licensed Practical Nurse) dated 10/12/2021 revealed; noted dark area to right heel 3 cm (centimeters) x 2.5 cm added heel protectors, and foot cradle to bed. Fax sent to provider and left message for family. Record review of fax sent by LPN D on 10/12/2021 revealed; Noted dark area to right heel. 3 cm x 2.5 cm. Add heel protectors, and foot cradle to bed. Will continue to monitor until resolved. Any new orders? yes___ no___? Physician checked no, signed, and returned fax to facility. Nursing note by DON (Director of Nursing) dated 10/14/2021 at 11:32 am revealed Physician here to see elder and no new orders Physician did look at right heel. Family called and updated. Record review of Resident 10's Pressure Ulcer Risk Evaluation form dated 11/3/2021 revealed a total score of 10 (a score of 8 or above represents high risk). Further record review revealed, no other Pressure Ulcer Risk Evaluations had been completed since admission. Record review of Resident 10's MDS (Minimum Data Set, A federally mandated comprehensive Assessment Tool utilized to develop a Residents Care Plan) dated 11/03/2021 revealed that Resident 10 was at risk of developing pressure ulcers/injures, and the resident had one stage 2 facility acquired pressure ulcer. The MDS showed that the interventions in place for Resident 10's pressure ulcer were the following: -pressure reducing device for chai;, -pressure reducing device for bed; -turning/repositioning program; and -nutrition or hydration intervention. On 12/02/21 at 10:50 AM interview with the DON (Director of Nursing) confirmed that staff did not do a full assessment on Resident 10's wound documentation on 10/12/2021, 10/15/2021, 10/22/2021, 10/29/2021, and 11/19/2021. The DON confirmed that on the MDS dated [DATE], the resident was coded as having a pressure ulcer.

Licensure Reference Number: 175 NAC 12-006.11E Based on observation, record review, and interview; the facility failed to 1) maintain food preparation and food storage in a manner to assure food safety and prevent cross contamination; 2) date and label open containers and bags of food; and 3) ensure that the freezer was free from an ice buildup on each shelf. Facility census was 14. Findings are: Observations during the initial tour of the kitchen on 11/29/2021 at 8:17 am, and a tour with the DM (Dietary Manager) on 12/1/2021 @ 10:00 am to 11:30 am, revealed the following: -Beneath the food storage rack in the walk-in pantry there was a mouse trap with a dried piece of cheese attached, a dusty black cloth, debris (leaves, trash, and dirt) and cobwebs. -Food particles on the food mixer, food processor, food prep walls and cupboards. -The facility freezer in the kitchen revealed ice buildup on every shelf. -The vent above the stove and griddle revealed a layer of grease and dust. -The pantry, refrigerator, and freezer revealed an opened gallon of Milk, container of picante sauce, container of Golden Italian dressing, bag of frozen mixed vegetables, bag of macaroni and bag of croutons that weren't labeled or dated. -A sealed bag of Rice Krispy cereal, a zip lock bag of salt and pepper packets and a box of malt o meal were observed on the floor in the walk-in pantry. DA H (Dietary Aide) picked up the above listed items and put on the shelf for use. -Four EcoLab cardboard boxes were observed on the floor next to the refrigerator. -Debris and dried leaves were scattered over 25% of the floor outside the pantry in the kitchen area. -The air conditioner next to the refrigerator revealed a heavy accumulation of debris on the vent. Interview with the DM on 12/01/21 at 11:30 am, confirmed that cleanliness and storage of items was a problem. Record review on 12/1/2021 of PM Cooks Daily Cleaning Schedule and the facility's AM and PM Weekly Cleaning Schedule forms for November 2021 were initialed by staff indicating areas of concern were cleaned either daily or weekly.

Licensure Reference 175 NAC 12-006.07C Based on observation, record reviews, and interviews, the facility failed to have an effective quality assurance program as evidenced by deficient practice identified at F812. This practice had the potential to effect all 14 residents of the facility. A review of Quality Assurance and Improvement Policy dated 11/2017 revealed the following: Leadership will establish and ensure compliance with policies to sustain QAPI (Quality Assurance and Performance Improvement) despite changes in personnel and turnover by development of consistent and sustainable policies and procedures and consistent and sustainable monitoring procedures; Quality Measures including but not limited to: .Pressure Ulcers .; Internal facility monitoring tools including but not limited to: .Infection control surveillance and tracking and trending tools .; and Dietary services including but not limited to: .Food and nutrition sanitation inspections and improvement plans. Observations during the initial tour of the kitchen on 11/29/2021 and continued observations during a tour with the Dietary Manager on 12/1/2021 revealed the following: -a mouse trap with dried cheese attached; -a dusty black cloth, debris and cobwebs; -food particles on the food mixer, food processor, food prep walls and cupboards; -the facility freezer in the kitchen revealed thick ice buildup on every shelf; and -the vent above the stove and griddle revealed a layer of grease and dust. Continued observation of the pantry, refrigerator, and freezer revealed the following items opened and not labeled or dated: -a gallon of milk,-a container of picante sauce,-a container Golden Italian dressing, -a bag of frozen mixed vegetables, -a bag of macaroni and a bag of croutons; -a sealed bag of rice krispy cereal, -a zip lock bag of salt and pepper packets and a box of malt-o-meal were observed on the floor in the walk-in pantry (a dietary aide picked up the above listed items and put them on the shelf for use.) -Four EcoLab cardboard boxes were observed on the floor next to the refrigerator; -debris and dried leaves were scattered over the floor outside of the pantry in the kitchen area; and -the air conditioner next to the refrigerator revealed a heavy accumulation of debris on the vent. An interview on 12/2/2021 with the facility administrator confirmed there were system failures not identified or addressed by the facility including sanitation/cleanliness in the facility kitchen.

Licensure Reference Number: 175 NAC 12- B 175 NAC 12-006.17 Based on observation, interview and record review; the facility failed to implement infection control practices as evidenced by the facility's failure to ensure 1) staff conducted hand hygiene before and after peri-care; and 2) staff COVID education of the facility's COVID protocol was current. Sample size was Findings are: A. Observation on 11/30/2021 from 7:32 am to 7:53 am of Resident 10's morning cares revealed that NA- C (Nurse Aide) completed frontal peri-care on Resident 10. NA-C removed gloves and didn't do hand hygiene. NA-C removed the resident's dirty brief with -NA-C's bare hands. NA-C applied new gloves without hand hygiene, put a new brief on Resident 10, and pulled up Resident 10's pants. NA- C removed their gloves and applied new gloves without conducting hand hygiene and washed Resident 10's face with a wash cloth. Record review of the facility's Hand washing/Hand Hygiene policy revealed that staff should perform hand hygiene either with alcohol based hand rub or wash with soap and water before and after direct contact with a resident, before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. B. Observation on 11/29/21 at 8:15 AM revealed NA-E wearing an isolation gown, N-95 mask and eye protection in the dining room. Interview on 11/29/21 at 8:15 AM with NA-E revealed that the facility was in a light yellow zone so the gown was on in case NA-E came in contact with any residents while serving food and if NA-E did come in contact with any residents, the gown would not need to be changed but hand hygiene would need to be completed. Interview with LPN A (Licensed Practical Nurse) on 11/29/21 at 8:45 AM revealed that everyone in the facility was to wear an N-95 face mask and eye protection at all times. Observation on 11/29/21 at 9:00 AM revealed the facility housekeeper vacuuming the resident halls wearing an N-95 face mask and with eye protection on top of their head, as well as NA- C wearing an N-95 face mask and safety glasses on top of their head while at nurse's station. Interview with the DON (Director of Nursing) on 11/29/21 at 10:00 AM revealed that the PPE (Personal Protective Equipment) protocol is that all staff wear an N-95 mask at all times and eye protection when in close contact with residents. Residents are to wear a face mask when out of their room or in close contact with the staff. Observation on 11/29/21 at 10:15 AM revealed Resident 13 at the nurse's station without mask on speaking to NA-C. NA-C didn't have eye protection on. Interview on 12/21/21 at 3:25 PM with NAF NA-G revealed that they were not sure what protocol or zone the facility should be in but that all staff were to wear eye protection and N-95 masks at all times. Record Review on 12/2/21 of staff education revealed the following: Record review of Agency staff member NAF file revealed that NA-F received education sheets on 6/30/31, which included Facility Map, List of Residents, Emergency Procedures, Abuse and Neglect Policy, Nursing Home & Assisted Living Resident Rights, Quality of Life-Dignity Policy and Assisted Living Resident Service Agreement and a list of COVID-19 policies. No further education was provided after the initial education on 6/30/21 related to infection control procedures related to COVID-19. Record review of Agency staff member NAG's file revealed NA-G did not have any documentation of any infection control procedures related to COVID-19 education in the file. Record review of NA- E's file revealed NA-E had COVID -19 training provided by the facility on 9/24/21. No further education had been provided since 9/24/21. Interview with BOM (Business Office Manager) on 12/2/21 at 10:25 AM confirmed that NA- G did not have any education in their file, NAF did not have any further education since 6/30/21 and NA-E did not have any further education after 9/24/21 related to COVID-19. Record review on 12/2/21 at 10:30 AM of Facility/Family/Staff Updates (a form that was utilized to document notification of any change in COVID -19 guidance related to outbreak) revealed staff notification sections were blank on 11/10/21, 11/15/21, 10/28/21, 10/8/21, and 9/30/21. Interview with the Administrator on 12/2/21 at 2:00 PM confiders that the Facility/Family/Staff Updates form had blanks for staff notification on 11/10/21, 11/15/21, 10/28/21, 10/8/21 and 9/30/21.

Licensure Reference Number 175 NAC 12-006.09D Based on observation, interviews, and record reviews, the facility failed to implement measures for treatment and care provided for one resident (Resident #13.) Sample size included 10 current residents and 2 closed records. Facility census was 14 residents. On 11/29/2021 at 03:15 PM a review of eTAR (electronic Treatment Record) for Resident #13 revealed an order dated 5/21/2021 for Solaris wraps ( .compression garment to reduce swelling .) on AM (morning) and off HS (hours of sleep.) On 11/30/21 at 12:22 PM a review of the Care Plan, printed on 11/30/2021, for Resident #13 revealed the following: Staff to assist me with placing solaris wraps on and off. An observation on 11/29/21 at 09:17 AM of Resident #13 revealed solaris leg wraps were not applied. An obervation on 11/29/21 at 02:56 PM of Resident #13 revealed the solaris wraps not applied. An observation on 11/30/2021 at 12:22 PM revealed solaris leg wraps were not in place for Resident #13. On 11/30/21 at 03:20 PM an observation of and interview with Resident #13 revealed solaris wraps were not in place and verified the solaris wraps had not been applied for a long time. On 11/30/21 03:49 PM, an interview with the Director of Nursing and the facility administrator confirmed the solaris wraps were not in place. The Director of Nursing was not sure the last time the resident wore them.

Licensure Reference Number: 175 NAC 12-0006.09C Based on observation, interviews and record reviews; the facility failed to develop and implement a comprehensive interdisciplinary care plan for pain management for 1 current sampled resident (Resident 10). The facility census was 14 with 10 current sampled residents. Findings are: Observation on 11/30/21 at 07:53 AM of Resident 10 during morning cares revealed that Resident 10 had a nickel size open area to the right heel. When the right sock was removed, Resident 10 complained of pain. NA (Nurse Aid) confirmed that NA-C heard the resident's complaint of pain. Record review on 11/30/2021 of Resident 10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) [MEDICATION(S)] 300 mg by mouth two times a day for pain, and 4) Acetaminophen (A medication used to treat moderate to severe pain) 1000 mg by mouth four times a day as needed for pain/discomfort. Record review of the face sheet for Resident 10 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 10's Care Plan dated 8/12/2021 revealed pain was not addressed on the care plan. Record review of Resident 10's November 2021 eMAR (electronic Medication Administration Record) and eTAR (electronic Treatment Administration Record) revealed that Resident 10 received the following medications for pain relief: 1) [MEDICATION(S)] 200 mg by mouth every day for pain. 2) [MEDICATION(S)] 300 mg by mouth two times a day for pain, and 3) Acetaminophen 1000 mg by mouth four times a day on one day, 11/15/2021. Resident 10 was assessed for signs and symptoms of pain and document concerns at 6:00 am and 6:00 pm every day. Record review of Resident 10's pain evaluation form dated 9/30/2021 revealed: The answer yes was checked for the question; does the resident have any diagnosis(es) which would give reason to believe he/she would be in pain? Interview with the DON (Director of Nursing) on 12/2/2021 at 10:15 am confirmed Resident 10 had pain on 11/30/21 at 07:53 AM. The DON verbalized that they do pain assessments every shift because the resident has pain after Resident 10 receives an iron infusion.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility staff failed to ensure the resident and/or responsible party received a copy of the baseline care plan and ensure that they understood it. This affected 3 of 3 sampled residents (Residents 17, 68 and 2). The facility identified a census of 18 at the time of survey. Findings are: [NAME] Review of Resident 17's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/4/2019 revealed an admission date of [DATE]. Review of Resident 17's Baseline Care Plan dated 9/11/2019 revealed no documentation the care plan was reviewed with and given to Resident 17 or their responsible party. Review of Resident 17's Departmental Notes dated (MONTH) 2019 revealed no documentation a copy of the baseline care plan was given to Resident 17 or their responsible party or that it was reviewed with them. B. Interview with Resident 68 on 12/11/2019 at 2:26 PM revealed they had not received a written copy of their baseline care plan. Review of Resident 68's Baseline Care Plan dated 12/6/2019 revealed an admission date of [DATE]. There was no documentation it was reviewed with Resident 68 or their responsible party or that a copy was given to them. Review of Resident 68's Departmental Notes dated (MONTH) 2019 revealed no documentation a copy of the baseline care plan was given to Resident 68 or their responsible party or that it was reviewed with them. Interview with the DON (Director of Nursing) on 12/16/19 at 1:12 PM confirmed the residents and/or responsible parties had not been given a copy of the baseline care plan. Review of the facility policy Care Plans-Preliminary dated (MONTH) 2006 revealed the following: A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within 24 hours of admission. The preliminary care plan will be used until the staff can conduct the comprehensive assessment develop an interdisciplinary care plan. C. Review of Face sheet revealed Resident 2 was admitted [DATE]. Review of the initial baseline care plan revealed no signatures to indicate Resident 2 or the family representative had received a copy of the initial baseline care plan. Review of the progress notes dated 1/20/19 through 12/20/19 revealed no documentation of Resident 2 or the family representative receiving a copy of the initial care plan. An interview on 12/17/19 at 9:36 AM with the DON (Director of Nursing) revealed the facility had not been giving initial baseline care plans to the residents or family representatives.

LICENSURE REFERENCE NUMBER 12-006.09C1c Based on interview and record review, the facility staff failed to ensure interventions for abnormal heart beat and anticoagulant (blood thinner) use with bleeding risk were included on the comprehensive care plan for Resident 17. This affected 1 of 10 residents whose care plans were reviewed during the survey process. The facility identified a census of 18 at the time of survey. Findings are: Review of Resident 17's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/4/2019 revealed an admission date of [DATE]. Anticoagulant (blood thinner) was received 7 days of the 7 day MDS look back period. Review of Resident 17's Physician's Orders dated (MONTH) 2019 revealed an order for [REDACTED]. Review of Resident 17's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation Resident 17 was receiving the Eliquis as ordered. Review of Resident 17's Care Plan dated 9/26/2019 revealed no documentation of interventions for the abnormal heart beat and use of a blood thinner including bleeding risk. Interview with the DON (Director of Nursing) on 12/16/19 at 2:20 PM confirmed the interventions for bleeding risk were not included on Resident 17's care plan. Interview with NA-A (Nurse Aide) on 12/17/2019 at 10:23 AM revealed they got the information they needed to care for the residents from the resident's care plan. Review of the Nursing (YEAR) Drug Handbook listed the following nursing considerations for Eliquis: monitor patient for bleeding. Discontinue drug if acute pathological bleeding occurs. Alert: promptly evaluate signs and symptom of blood loss. Drug can cause serious potentially fatal bleeding. Monitor patients for neurological impairment (midline back pain, sensory or motor deficits, such as numbness or weakness in lower limbs, bowel or bladder dysfunction). Treat impairment urgently. Patient teaching: tell patient to report all adverse reactions; caution patient that bruising or bleeding may occur more easily. Advise patient to report unusual bleeding. Review of the facility policy Care Plans-Comprehensive revised (MONTH) 2010 revealed the following: Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools before interventions are added to the care plan. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying sources of the problems areas rather than addressing only symptoms or triggers. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: when there has been a significant change in the resident's conditions; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure that 1) cereal bin was labeled and dated. 2) That the steam table was free from rust on the outside and inside of the lids. 3) container of powdered milk was labeled, dated and not sitting on the floor.) This had the potential to affect all 19 residents who ate from the kitchen. The facility census was 19. Findings are: Observation on 9/17/18 at 6:22 PM during the initial kitchen tour revealed the following items: -A plastic container (bin) containing different cereals was not marked or labeled with the date opened. -The lids on the steam table had rust on the outside and inside of the lids. -A gray topped plastic container of powdered milk was not marked with a label of contents or date opened. Interview on 9/18/18 at 9:01 AM with FSS (Food Service Supervisor) confirmed that the powdered milk bin with the gray lid was sitting on the floor and that it was not marked or dated. The cereal bin was not labeled or dated. The steam table pans were rusty.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (5) Based on interview and record review, the facility staff failed to notify the Ombudsman (a person appointed by the state who advocates for residents' rights) when Resident 14 was transferred to the hospital. This affected 1 of 1 sampled residents. The facility identified a census of 19 at the time of survey. Findings are: Review of Resident 14's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 7/18/18 revealed an admission date of [DATE]. Review of Resident 14's MDS schedule revealed Resident 14 was discharged return anticipated 9/17/2018. Review of Resident 14's Nurses Notes for (MONTH) (YEAR) revealed Resident 14 was transferred to the hospital on [DATE]. There was no documentation the Ombudsman was notified Resident 14 was transferred out of the facility to the hospital. Interview with the facility Administrator on 09/19/18 at 3:12 PM confirmed the Ombudsman was not notified when Resident 14 was transferred to the hospital. Review of the facility policy Elder Transfer and discharge date d 7/2017 revealed the following: State Ombudsman must be contacted/consulted regarding a scheduled transfer or discharge.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure sanitization of the dishes and failed to maintain potentially hazardous food at a safe temperature to prevent potential food borne illness. This had the potential to affect the 19 residents who received food from the facility kitchen. The facility identified a census of 19 at the time of survey. Findings are: A. Observation of the kitchen on 8/24/2016 at 8:09 AM revealed incomplete documentation on the dishwasher temperature logs. Record review of the Dishwasher Temperatures log for August 2016 revealed no documentation the dishes had been sanitized on 13 out of the past 23 days. Interview with the DS (Dietary Supervisor) on 8/24/2016 at 8:34 AM confirmed the dishwasher logs were incomplete and staff were to be documenting the dishes had been sanitized daily. Review of the undated facility policy Temperature revealed the following: Policy: To ensure proper temperatures are maintained to assure proper food storage, and proper serving temperatures and that the dishwasher is working properly. Procedures: Record daily the temperature of the dishwasher. The wash temperature must be 150-165 degrees and the rinse must be 180-190 degrees. B. Observation of the lunch meal service on 8/29/2016 at 12:00 PM revealed the DS (Dietary Supervisor), using the facility kitchen thermometer, checked the temperature of the pasta salad sitting on the counter and it was 50 degrees F (Fahrenheit) prior to being served to the residents. Observation of the egg salad sandwiches on 8/29/2016 at 12:26 PM revealed they were in a pan sitting on the counter above the pan of ice but there was no ice touching the pan. The DS checked the temperature of the sandwiches and they were 52 degrees F prior to being served to the residents. Temperature check of a sample tray of food prepared immediately after the conclusion of lunch meal service on 8/29/2016 at 12:40 PM revealed the egg salad sandwich was 69.8 degrees F and the pasta salad was 54.9 degrees F. Taste test of the egg salad sandwich revealed it was not cold. Observation of the dining room on 8/29/2016 at 12:45 PM revealed that Residents 2, 16, 18, and 28 had received the egg salad sandwich and they had all consumed a portion of it. Interview with the DS on 8/29/2016 at 1:06 PM confirmed it was very warm in the kitchen and they should have left the cold sandwiches and salad in the refrigerator until they were ready to serve them. Review of the undated facility policy Temperature revealed the following: -Policy: To ensure proper temperatures are maintained to assure proper food storage, and proper serving temperatures. - Procedures: Record daily the temperature of all meal temperatures. Cold food must be served 41 degrees or colder. Review of the 3/8/2012 version of the Food Code, based on the United states Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: refrigerated, potentially hazardous food shall be at a temperature of 41 degrees F or below when received.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interviews, and record review; the facility failed to maintain cold food temperatures. This affected Residents 2, 16, 18 and 28. The facility identified a census of 19 at the time of survey. Findings are: Observation of the lunch meal service on 8/29/2016 at 12:00 PM revealed the DS (Dietary Supervisor), using the facility kitchen thermometer, checked the temperature of the pasta salad sitting on the counter and it was 50 degrees F (Fahrenheit) prior to being served to the residents. Observation of the egg salad sandwiches on 8/29/2016 at 12:26 PM revealed they were in a pan sitting on the counter above the pan of ice but there was no ice touching the pan. The DS checked the temperature of the sandwiches and they were 52 degrees F prior to being served to the residents. Temperature check of a sample tray of food prepared immediately after the conclusion of lunch meal service on 8/29/2016 at 12:40 PM revealed the egg salad sandwich was 69.8 degrees F and the pasta salad was 54.9 degrees F. Taste test of the egg salad sandwich revealed it was not cold. Observation of the dining room on 8/29/2016 at 12:45 PM revealed that Residents 2, 16, 18, and 28 had received the egg salad sandwich and they had all consumed a portion of it. Interview with the DS on 8/29/2016 at 1:06 PM confirmed it was very warm in the kitchen and they should have left the cold sandwiches and salad in the refrigerator until they were ready to serve them. Review of the undated facility policy Temperature revealed the following: -Policy: To ensure proper temperatures are maintained to assure proper food storage, and proper serving temperatures. - Procedures: Record daily the temperature of all meal temperatures. Cold food must be served 41 degrees or colder. Review of the 3/8/2012 version of the Food Code, based on the United states Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: refrigerated, potentially hazardous food shall be at a temperature of 41 degrees F or below when received.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation and interview; the facility staff failed to 1) store catheter tubing off the floor for Resident 7; 2) store oxygen tubing off of the floor during cares in order to prevent contamination for Resident 2. This potentially involved 2 residents (Residents 7 and 2). The facility census was 19 at the time of the survey. Findings are: A. Observation of Resident 7 on 08/29/2016 at 9:46 AM found the resident sitting in the wheelchair with the catheter tubing resting on the floor under the resident's wheelchair. Observation of Resident 7 on 08/29/2016 at 11:18 AM found the resident sitting in the wheelchair with the catheter tubing laying on the floor under the resident's wheelchair. Interview with the DON (Director of Nurses) on 08/30/2016 at 11:01 AM revealed the catheter tubing was to be stored in the cover bag and not on the floor. A policy for storage of the catheter tubing was not produced. B. Observation of cares for Resident 2 on 08/29/2016 at 11:10 AM by NA-A (Nurse Aide) revealed the nasal oxygen tubing was taken off the resident and landed on the floor in the doorway of the bathroom. Interview with NA-A on 08/29/2016 at 12:19 PM revealed the nasal cannula was not changed after it was on the floor before putting it back on the resident. Interview with the DON on 08/29/2016 at 12:22 PM revealed nasal cannula should have been changed once it was on the floor. It was addressed with the staff at the last inservice.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(1) Based on observation and interviews; the facility failed to fix the marred doors, hang the sagging curtains, replace the cracked wheelchair arm pad, and recaulk the sink. This affected 8 of 19 residents (Residents 1, 16, 14, 9, 23, 6, 8 and 10). The facility census was 19 at the time of the survey. Findings are: A. Tour of the room occupied by Resident 1 on 8/24/2016 at 10:10 AM revealed the bathroom door frame had been chipped at the bottom edge. The curtains in the room were sagging from the curtain rod. B. Tour of the room occupied by Resident 16 on 8/24/2016 at 10:39 AM revealed the wall behind the recliner was gouged. The right arm rest on the resident's wheelchair was cracked and peeling which had become a non-cleanable surface. C. Tour of the room occupied by Resident 14 on 8/24/2016 at 10:53 AM revealed the bathroom door edges were marred and chipped. D. Tour of the room occupied by Resident 9 on 8/24/2016 at 12:33 PM revealed the bathroom door was marred and chipped on both sides of the door. E. Tour of the room occupied by Resident 23 on 8/24/2016 at 12:42 PM revealed the bathroom door was marred and chipped on both sides of the door. F. Tour of the room occupied by Resident 6 on 8/24/2016 at 12:58 PM revealed the drapes were sagging from the curtain rod from missing hooks. G. Tour of the room occupied by Resident 8 on 8/24/2016 at 3:46 PM revealed in the bathroom the sink caulking was broken. The closet doors and room door were marred. H. Tour of the room occupied by Resident 10 on 8/24/2016 at 4:24 PM revealed the closet and room doors were marred. Interview with the Maintenance Supervisor on 08/30/2016 at 9:30 AM revealed the wall behind the recliner needed fixed, the wheelchair arm rest needed replaced, the doors needed fixed, the curtains needed rehung and the sink needed fixed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview and record review; the facility failed to monitor for wheelchair positioning changes and adapt the wheel chair for body alignment for Resident 6. The facility census was 19. Findings are: On 08/24/2016 at 01:29 PM, Resident 6 was observed sitting in the wheelchair with the resident's head and shoulders leaning forward and to the right side. The resident's head and shoulders were not supported by the back of the wheelchair or the adjustable head rest on the wheelchair. On 08/25/2016 at 3:48 PM, Resident 6 was sitting in the wheelchair with squirming noted. The resident was leaning to the right side with the resident's head and shoulders unsupported. On 08/29/2016 at 9:20 AM, Resident 6 was sitting in the wheelchair with the resident's head leaning to the right side. The resident's head, neck and shoulders were not supported by the head rest or the back of the wheelchair. On 08/30/2016 at 10:03 AM, Resident 6 was observed sitting in the wheelchair with the resident's head leaning to the right side and forward. The resident's head and neck were not supported by the wheelchair's head and neck rest. Record review of Resident 6's Occupational Therapy (OT) Progress & Discharge Summary dated 2/26/16 revealed the resident had abnormal posture of Kyphosis (a forward rounding of the back) and leaning to the side while seated. The skilled OT services had included wheelchair seating and repositioning assessment. The resident was discharged from OT due to the family decision to not purchase the custom wheel chair for positioning. Interview with MA (Medication Aide)-B on 08/30/2016 at 11:14 AM revealed that Resident 6 was leaning to the right side and the wheelchair head and neck rest were not providing support to the resident's head and neck. MA-B revealed that the resident daily had this positioning problem. Interview with NHA (Nursing Home Administrator) on 08/30/2016 at 12:39 PM revealed that the resident's wheelchair head rest could be adjusted forward and to the side. The head rest needed adjustment due to how the resident held the resident's head and leaned to the side while in the wheelchair. NHA further revealed that the resident appeared to be leaning more than the resident had been and that the wheelchair was not providing support for the resident's head and neck.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on interview and record review, the facility failed to develop a comprehensive care plan to address urinary tract infection [MEDICAL CONDITION] on Resident 31's care plan. The facility identified a census of 19 at the time of survey. Findings are: Review of Resident 31's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/15/2016 revealed an admission date of [DATE] and UTI in the past 30 days was marked under Active [DIAGNOSES REDACTED].>Review of Resident 31's Admission History & Physical dated 7/9/2016 revealed that Resident 31 was hospitalized from [DATE] to 7/11/2016 with a UTI and had a [DIAGNOSES REDACTED]. Review of Resident 31's care plan dated 7/28/2016 revealed Resident 31 had a history of [REDACTED]. Interview with the DON on 8/30/2016 at 9:42 AM confirmed there was no documentation on Resident 31's care plan addressing the UTI including interventions the staff should have been following. Interview with MA-B on 8/30/2016 at 9:49 AM confirmed that the staff look at the resident's care plan to know what they need to do to take care of them.

Licensure Reference Number 175 NAC 12-006.10A3 Based on observation and interview, the facility staff failed to have the qualifications to handle the oxygen for Resident 2. This had the potential to affect Resident 2. The facility census was 19 at the time of the survey. Findings are: Observation of cares for Resident 2 on 8/29/2016 at 11:10 AM revealed NA-A (Nursing Assistant) removed the oxygen tubing and turned off the oxygen before the resident was transferred to the toilet. Continued observation revealed NA-A ambulated the resident to the resident's bed and allowed the resident to sit on the edge of the bed. NA-A applied the oxygen tubing to the resident nares and turned on the oxygen concentrator. Review of Resident 2's care plan revealed oxygen therapy was to titrate as needed to maintain the oxygen saturation greater that 90%. Also remind the resident to leave on the oxygen as when the oxygen was removed the saturation soared. Interview with NA-A 08/29/2016 at 12:19 PM revealed I am not to do anything with the oxygen like take it off and turn it off but I would rather do that than have to wait for someone to come help. Interview with the DON (Director of Nurses) on 08/29/2016 at 12:22 PM revealed the oxygen was not to be adjusted by a NA should be the MA's (Medication Aides) and/or the nurses. Reference the Basic Nursing Assistant Training Manual revealed oxygen was considered a medication and therefore must be ordered by a physician and administered by a licensed health care professional.