Every finding on record at Blue Valley Lutheran Nursing Home

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure that neurological checks (a series of physical tests that assess the nervous system to monitor for brain injury after a fall) were completed to monitor 1 of 3 residents reviewed (Resident 2) after an unwitnessed fall. This had the potential for resident change in condition to not be identified. The facility census was 32. Findings are: Record review of the undated facility procedure Falls and Neurological Assessments revealed that for unwitnessed falls the policy for required neurological checks to be conducted every 15 minutes x 4, every 30 minutes x 2, every hour x 2, every 2 hours x 2, every 4 hours x 2, then every shift for 72 hours. A set of vital signs (blood pressure, pulse, respirations, temperature) is required for each neurological check. Record review of the Admission Record dated 10/7/24 for Resident 2 revealed that Resident 2 admitted into the facility on [DATE]. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 2 dated 7/28/24 revealed that Resident 2 had 1 fall with major injury since the previous assessment. Record review of the progress note dated 7/18/24 at 6:35 AM for Resident 2 revealed that a neighbor of Resident 2 pressed the call light to alert staff that a loud noise was heard coming from Resident 2's room. Staff observed Resident 2 sitting on their bottom in front of the bathroom sink. Resident 2 was assessed. It was noted that urine was all over the bathroom floor. Resident 2 stated that the resident stood from the toilet and slid down on their butt. Record review of the medical record for Resident 2 revealed no neurological checks were completed for Resident 2 following the resident's unwitnessed fall that occurred on 7/18/24. Interview on 10/7/24 at 3:14 PM with Registered Nurse-B (RN-B) revealed that neurological checks were to be done for all unwitnessed falls and witnessed falls with head injury. Interview on 10/7/24 at 4:29 PM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that no neurological checks were completed for Resident 2 after the resident's fall on 7/18/24. Interview on 10/7/24 at 4:42 PM with the facility Director of Nursing (DON) confirmed that neurological checks were expected to be completed for all unwitnessed resident falls to monitor the resident for a change in condition.

Licensure Reference NUmber 175 NAC 12-006.09D3 Based on Interview and record review the facility failed to ensure the facility bowel management program was followed for 1 (Resident 30) of 1 sampled residents. This affected 1 resident (Resident 30). The facility census was 31. Findings are: A record review of the facility Bowel Management Program which is not a dated document, revealed the following Bowel Movement (BM) protocol: -If no BM, on second day: prune juice breakfast and PRN (as needed) lunch. -If no BM end of day 2: MOM (milk of magnesia - a medication to induce a BM). -May use judgement. May try two doses of MOM and then if no results. -If no BM by last night rounds (04:00 AM to 05:00 AM) of day 3: suppository. A record review of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities to help nursing home staff identify health problems) dated 4/25/2024 for Resident 30 revealed a Brief Interview for Mental Status (BIMS, a brief screening tool that aides in the detection of cognitive impairment) score of 5 indicating severe cognitive impairment. Resident 30 takes antipsychotic (medications are generally used to treat the symptoms of schizophrenia and other psychotic disorders) and an antianxiety (medications used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) medication. The MDS also revealed a diagnosis for Non-Alzheimer's Dementia (several diseases such as Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases.) There is no indication in the MDS that the resident has a diagnosis of constipation. A record review of the Care Plan dated and last revised on 1/24/2024 for Resident 30 revealed a diagnosis of Constipation had been added to Resident 30's Care Plan but had not been addressed in the care plan for interventions, treatments, and expected outcomes. The Care Plan revealed that Resident 30 is cognitively impaired. A record review of the Care Plan last revised on and dated 5/2/2024 for Resident 30 revealed no interventions in place for Resident 30's constipation. A record review of the Physician Orders for Resident 30 revealed an order for Senna-S 8.6/5 mg (milligrams) one tablet daily for constipation which had a start date of 11/16/2023. There is also an order for Milk of Magnesia (MOM, milk of magnesia - a medication to induce a BM) to be given PRN (as needed) for constipation and an order for Bisacolax Suppository (a medication that aides in the relief of constipation) 10 mg to be given PRN with a start date of 11/16/2023 for constipation. A record review of the Follow Up Question reports for April 2024 revealed Resident 30 did not have a BM through the following dates: -On April 1 Resident 30 had a BM. No further BM was documented until April 4. -On April 6 Resident 30 had a BM. No further BM was documented untilApril 9. -On April 9 Resident 30 had a BM. No further BM was documented until April 12. -On April 12 Resident 30 had a BM. No further BM was documented until April 15. -On April 26 Resident 30 had a BM. No further BM was documented until April 30. A record review of the Medication Administration Record for the month of April 2024 revealed Resident 30 received MOM on the following dates: -April 29 on day two per the facility bowel protocol. -April 30 on day three per the facility bowel protocol. A record review of the Follow Up Question reports for the month of May 2024 revealed Resident 30 did not have a BM through the following dates: -On April 30 Resident 30 had a BM. No further BM was documented until May 5. -On May 12 Resident 30 had a BM. No further BM was documented until May 16. -On May 16 Resident 30 had a BM. No further BM was documented until May 20. A record review of the Medication Administration Record for the month of May 2024 revealed Resident 30 received MOM, and Bisacolax suppositories on the following dates: -May 2, day two, per the facility bowel protocol, Resident 30 should have received MOM and didn't. -May 3, day three, Resident 30 recieved MOM. -May 4, day four, Resident 30 recieved MOM. -May 5, day five, Resident 30 received a suppository at 5:00 AM. -May 16, day four Resident 30 received MOM. -May 20, day four, Resident 30 received a suppository at 5:00 AM. -May 24, day two, Resident 30 received MOM. -May 29, day four, Resident 30 received MOM. A record review of Resident 30's Physician Orders dated 5/22/2024 revealed an order to increase the Senna-S 8.6/5 mg to two tablets every morning. A record review of the Follow Up Question reports for June 2024 revealed Resident 30 did not have a BM through the following dates: -On June 5 Resident 30 had a BM. No further BM was documented until June 8. A record review of the Medication Administration Record for the month of June 2024 revealed the resident had not received any PRN medications for constipation whereas according to policy Resident 30 should have received MOM on June 5 and June 6. A record review of the Health Status Notes during the months of April 2024, May 2024, and June 2024 in the Progress notes show that the issues of constipation were not addressed except on the date of 5/21/2024 when the staff had asked the Physician for an order to increase the Senna-S for constipation issues. This order was received and started on 5/22/2024. In an interview on 6/26/24 at 10:40 AM with Registered Nurse-D (RN-D) explains how the facility nurses use the BM Protocol. Night nurses fill out the form so the day shift nurses are able to start the protocol at breakfast as needed. Night nurses fill out who has not had a BM in the last 2 days and then we start the protocol and follow it until we have results. Sometimes the nurses will ask the Nurses' Aides that are working with the patients if they have forgotten to chart any BM's. If they have forgotten or not gotten a BM in the charts, the Nurses' Aides are to enter them right away. The example given was that if a resident had a BM on Sunday, and there was no BM on Monday, then on Tuesday the resident would receive prune juice with meals. Tuesday night if there was still no BM, the resident would receive an ordered dose of MOM. Finally on Wednesday if the resident remained constipated with no results staff are able to give another dose of MOM or give a suppository. Confirmed how to use the BOWEL program, how the staff documents, and that there was no MOM or SUPP done when should have been per the facility policy and procedure. In an interview on 6/26/2024 at 10:55 with Assistant Director of Nursing (ADON). The ADON stated that the BM's are reviewed by the night shift nurses who then fill out the paperwork for the Bowel Protocol. Confirmed that by looking through the MARS and then looking through the BM's that have been charted that this resident should have received multiple different doses of medications on days the facility Bowel program required medication. On these dates and times, no medications were charted. The ADON also confirmed that the Interdisciplinary team reviews the Bowel habits of the residents every week during the risk management assessment. After increasing the Senna in May, the resident has had fewer issues with constipation. Confirmed the facility staff were not following bowel program as the facility policy and procedure directs staff. Confirmed that the information is not contained on the comprehensive patient centered care plans.

Licensure Reference Number 175NAC 1-005.06(A) Licensure Reference Number 175NAC 1-005.06(D) Licensure Reference Number 175NAC 1-005.06(F) Based on record review and interview the facility failed to ensure that the policy for infection control was reviewed and updated annually. This had the potential for the policy to not include current and up to date recommendations for infection control. This had the potential to affect all facility residents. The facility failed to complete catheter and wound cares cares for Resident 26 in a manner to prevent cross contamination. The facility census was 31. Findings are: A. Record review of the Facility assessment dated [DATE] revealed that the services and care offered included Infection Prevention and control. Identification and containment of infections, and prevention of infections. A facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program. Record review of the facility Infection Policy dated 7/2007 revealed that all staff engaged in direct patient care shall be instructed in correct techniques and be familiar with the facility's established infection control policies and procedures. The policy had no documentation of annual review. Interview on 6/26/24 at 4:55 PM with the facility Social Services Director (SSD) confirmed that the facility Infection Policy had not been reviewed and updated annually as required to ensure it was up to date with current infection control standards. 49382 B. Review of a facility policy titled Catheter Care Procedure dated 06/12/2023 revealed to cleanse area by the catheter (which is a tube inserted into the bladder to drain urine) insertion site with a clean wipe. Then, to clean the catheter tubing with alcohol wipes and wiping area closest to the resident body first then away from the body. In an observation completed on 6/26/2024 at 8:21 AM Medication Aide-E (MA-E) was providing catheter cares to Resident 26 while [gender] was lying in the bed. MA-E had gloves on both of [gender] hands and removed a disposable wipe from the package. MA-E dispensed from a plastic pump bottle 2 pumps of a white foam onto the disposable wipe. MA-E then used the disposable wipe to wipe around the tip and down the shaft towards the abdomen of Resident 26's penis. MA-E then used the wipe starting at the tip of the penis to wipe down the catheter tubing away from the resident's body approximately 4 inches down the catheter tubing. MA-E repeated this action using the same section of the disposable cloth 3 times. MA-E then disposed of the cloth into a trash bag. In an interview on 6/26/2024 at 8:50 AM with MA-E, confirmed that a different section of the cloth should have been used for each wipe of the catheter tubing. In an interview on 6/27/2024 at 9:30 AM with the Assistant Director of Nursing (ADON), confirmed the facility policy was to cleanse the catheter tubing with an alcohol wipe not a disposable wipe. C. Review of a facility policy titled Wound Care dated 01/2002 revealed: -Establish a clean field, place all items to be used during procedure on the clean field. -Wash and dry your hands thoroughly. -Loosen tape and remove old dressing, pull the glove over the dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Wash tissue around the wound with antiseptic or soap and water. -Be certain all clean items are on the clean field. Review of a facility policy titled Hand Washing for all Healthcare Workers dated 08/01/2011 revealed under procedure using friction, wash entire surface of hands for 20 seconds. In an observation on 6/26/2024 at 11:21 AM the following was observed during wound care being completed by the facility Infection Control Coordinator (ICC): -The ICC placed a clear plastic medication cup with a piece of white material in it, a pair of silver scissors, a roll of white tape, and an open package containing a dark gray foam material on Resident 12's bedside table. The bedside table was not sanitized or did not contain a barrier prior to ICC placing the wound supplies on the table. -The ICC removed the dressing from Resident 12's right foot. The ICC examined the dressing then placed the removed dressing on top of the scissors laying on the bedside table. -The ICC removed their gloves and performed hand hygiene with soap and water in the resident's bathroom for 5 seconds. -The ICC then placed on gloves on both hands and utilized a white moist cloth and rubbed up and down on Resident 12's right foot wound. -The ICC then used the scissors and cut a piece of the gray foam dressing and placed the gray foam over the wound on Resident 12's right foot. The ICC did not cleanse the scissors prior to cutting the material and placing it over the wound after contaminating the scissors with the removed dressing being placed on top of the scissors. -The ICC removed their gloves and performed hand hygiene with soap and water in the resident's bathroom for 7 seconds. In an interview on 6/26/2024 at 12:10 PM with the ICC, confirmed [gender] did not provide a clean field or sanitize the bedside table prior to placing the wound care items on top of it. The ICC confirmed [gender] placed the removed, soiled dressing on top of the scissors and used the scissors to cut the new dressing material and did not sanitize or clean the scissors prior. The ICC confirmed [gender] did not complete 20 seconds of hand washing.

Licensure Reference Number 175NAC 12-006.04D2 Based on record review and interview the facility failed to ensure that it had a Dietary Manager (DM) that held the required credentials for the position. This affected 29 residents that received meals from the facility kitchen. The facility census was 31. Findings are: Record review of the undated facility Resident Handbook revealed that the Dietary Supervisor (Dietary Manager) and Registered Dietitian are responsible for selecting nutritious meals and that they manage all special diets and offer recommendations for the use of nutritional supplements. Food consumed by residents must be prepared in a licensed kitchen. Record review of the undated facility Licensed Staff list revealed that the facility Dietary Supervisor (Dietary Manager) had no certification number. Interview on 5/25/23 at 8:38 AM with the facility Registered Dietitian (RD) confirmed that the RD is normally in the facility one day a week on Thursdays and can also do some work remotely. The RD confirmed that the RD does not work full-time in the facility. The RD confirmed that the facility Dietary Manager (DM) is not certified as a dietary manager and is taking the certification class. The RD revealed that the DM has been taking the class off and on. The RD revealed that the DM started the class sometime in 2020. The RD revealed that the DM is somewhere in the middle of the class work at this time.

Licensure Reference Number 175NAC 12-006.18B Based on observation, record review, and interview the facility failed to ensure that it maintained the cleanliness of facility lighting fixtures. This affected 24 residents that resided on the 200 hallway. The facility census was 31. Findings are: Record review of the facility Admission Packet Nursing Home Accommodation Rates for 2022-2023 revealed that the facility daily rate includes laundry and housekeeping services. Record review of the undated facility Resident Handbook revealed that the maintenance staff is responsible for the general care and maintenance of the nursing home. Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a safe, clean, comfortable, and homelike environment. The nursing facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 5/24/23 at 8:46 AM in the facility 200 hallway between the great room and the west nurses station revealed that 9 of 9 ceiling lights had dead insects laying in the light covers. The 2 ceiling lights at the 200 hallway west exit both had dead insects laying in the light covers. 8 of 8 ceiling lights in the 200 north hall had dead insects laying in the light covers. 9 of 9 ceiling lights on the 200 south hall had dead insects laying in the light covers. Observation on 5/25/23 between 10:31 AM and 10:47 AM on the facility 200 hallway with the facility Maintenance Supervisor (MS) confirmed that the ceiling lights in the 200 hallways had dead insects in the light covers. The MS revealed that they would look for documentation of scheduled maintenance of the lights that had been performed. Record review of the facility housekeeping checklist titled Procedure for Care of Resident Rooms and Restrooms dated 10/18/07 revealed that lights (halls, rooms, and bathrooms) were scheduled to be cleaned monthly. Interview on 5/25/23 at 11:21 AM with the Maintenance Supervisor (MS) confirmed that housekeeping is scheduled to clean hall lights monthly and monitor them in between. The MS confirmed that this had not been done as the longest tenured housekeeping staff has been here about 6 months and was unaware of this task.

LICENSURE REFERENCE NUMBER 175NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that a review of the baseline (interim) care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was reviewed with the resident/resident representative and failed to ensure that the resident/resident representative was provided a written summary of the baseline care plan as required for 3 of 3 sampled residents (Residents 30, 33, and 34). This prevented the resident/resident representative from identifying additional areas of care required by the resident. The facility census was 31. Findings are: A. Review of Resident 30's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 3/9/2023 revealed an admitted [DATE]. Resident 30 had no BIMS (Brief Interview for Mental Status) score as Resident 30 was rarely/never understood. Resident 30's staff assessment for mental status indicated short term and long term memory problems, severely impaired cognitive skills for daily decision making, and disorganized thinking that was present that did not fluctuate. Review of Resident 30's Care Plan dated 1/4/2023 revealed Resident 30 had a Guardian (a legal guardian is a person who is given authority by a court to act on behalf of a ward and/or to take responsibility for meeting the needs of a ward. Wards are unable to take care of themselves, either due to incapacity or because they are minors). Review of Resident 30's Progress Notes dated 1/3/2023 to 5/25/23 revealed no documentation the baseline care plan was reviewed with Resident 30's personal representative or that a written summary of the baseline care plan was provided to the personal representative. Review of Resident 30's Baseline Care Plan dated 1/3/23 revealed no documentation that is was reviewed with Resident 30 or their personal representative or that a written summary had been provided to them. 41938 B. Record review of the facility Resident Rights dated 2016 revealed the section titled Planning and Implementing Care. The policy revealed that the resident has the right to be informed of and participate in his or her treatment, including the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to his or her medical condition. The resident has the right to participate in the development and implementation of his or her person-centered plan of care. The resident has the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person-centered plan of care. The resident has the right to participate in establishing the expected goals and outcomes of care and any other factors related to the effectiveness of the plan of care. The resident has the right to be informed in advance of changes to the plan of care. The resident has the right to see the care plan, including the right to sign after significant changes to the plan of care. The resident has the right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care. The facility will facilitate the inclusion of the resident and/or representative in the planning process. Record review of the Admission Record dated 5/23/23 for Resident 33 revealed that Resident 33 admitted into the facility on [DATE]. Diagnoses included severe dementia with agitation, anemia (a lack of red blood cells in the body that leads to reduced oxygen flow to the body's organs), and abnormal weight loss. Record review of the Interim Care Plan for Resident 33 dated 1/3/23 revealed that it contained no documentation of review of the interim care plan with the resident/resident representative. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the medical record for Resident 33 revealed no documentation that a review of the interim care plan with the resident/resident representative was completed. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/9/23 for Resident 33 revealed that it was the admission comprehensive assessment for Resident 33. Record review of the Plan of Care progress note for Resident 33 dated 1/12/23 (9 days after Resident 33 admitted into the facility) at 9:58 AM revealed that the initial care plan meeting was held today. C. Record review of the Admission Record for Resident 34 dated 5/23/23 revealed that Resident 34 admitted into the facility on [DATE]. Diagnoses included a fracture of the left femur (upper leg bone), depression, and anxiety. Record review of the Interim Care Plan for Resident 34 dated 1/30/23 revealed that it contained no documentation of review of the interim care plan with the resident/resident representative. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the medical record for Resident 34 revealed no documentation that a review of the interim care plan with the resident/resident representative was completed. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the Minimum Data Set (MDS) dated [DATE] for Resident 34 revealed that it was the admission comprehensive assessment for Resident 34. Record review of the Plan of Care progress note for Resident 34 dated 2/23/23 revealed that the initial care plan meeting scheduled for 2/16/23 (17 days after Resident 34 admitted into the facility) was canceled due to weather. The care plan team reviewed the resident level of care on 2/23/23 (24 days after Resident 34 admitted into the facility). Interview on 5/24/23 at 3:26 PM with the facility Assistant Director of Nursing (ADON) confirmed that the facility was unable to find any documentation that the baseline care plan was reviewed with the resident or resident representative for Residents 30, 33, and 34. Interview with the ADON (Assistant Director of Nursing) on 5/24/23 at 3:52 PM confirmed there was no documentation a written summary of the baseline care plan had been provided to Residents 30, 33, and 34 and/or the resident representatives or that the baseline care plan had been reviewed with the residents or their representatives. The ADON revealed we have not been doing that. The ADON revealed the facility did not have a policy for reviewing the baseline care plan with the residents and/or resident representatives and providing them with a written summary.

Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure that staff did not handle foods with the bare hands to prevent the potential for cross contamination and foodborne illness. This affected 14 residents (Residents 8, 19, 13, 23, 17, 28, 20, 12, 30, 14, 24, 2, 4, and 10). The facility census was 31. Findings are: A. Record review of the Nebraska Food Code dated 7/21/16 section 81-2,272.10* (Preventing Contamination from Hands) revealed: (3) Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. Observation on 5/22/23 at 12:20 PM in the facility kitchen revealed that Dietary Cook-C (DC-C) reached into the package of dinner rolls with the bare hand and removed a dinner roll. DC-C placed the dinner roll on the plate of food on the steam table. Dietary Aide-A (DA-A) delivered the plate of food to Resident 8. Observation on 5/22/23 at 12:20 PM in the facility dining room revealed that Resident 8 picked up the dinner roll from the plate of food. Resident 8 tore the dinner roll in half and buttered the dinner roll. Resident 8 began to take bites of the dinner roll. Interview on 5/25/23 at 8:38 AM with the facility Registered Dietitian (RD) confirmed that bare hands should not be used to handle ready to eat foods. The RD confirmed that gloves or utensils should be used to handle ready to eat foods. The RD was unsure if the facility had a policy. The RD confirmed that the facility is expected to follow the national and state food codes. B. Observation on 5/23/23 at 8:10 AM in the facility kitchen revealed that Dietary Aide-D (DA-D) brought 2 menus into the kitchen and placed them on the shelf of the steam table for Dietary Cook-C (DC-C). DA-D told DC-C that Resident 19 requested a fried egg. DC-C cracked an unpasteurized egg into the frying pan on the stove. DC-C continued to cook the egg to hard yolk consistency and then placed it on a plate. DC-C reached into the loaf of bread package and removed two pieces of bread with the bare hand. DC-C placed them into the toaster. DC-C placed the toast on the plate with the fried egg for Resident 19. Observation on 5/23/23 at 8:22 AM in the main dining room revealed that Resident 19 had eaten half of the toast. C. Observation on 5/24/23 at 11:55 AM in the facility kitchen revealed that Dietary Cook-C (DC-C) plated a meal for Resident 12. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 12. Dietary Aide-A (DA-A) told DC-C that Resident 12 was not in the dining room yet. DC-C placed a sheet of foil over the plate for Resident 12 and placed it into the food warmer. DC-C plated a meal for Resident 13. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 13. DA-A took the meal to Resident 13. DC-C plated a meal for Resident 23. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 23. DC-C plated a meal for Resident 17. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 17. DC-C plated a meal for Resident 28. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 28. DC-C put a plate cover over the plate. DC-C plated a meal for Resident 20. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 20. DC-C put a plate cover over the plate. DC-C placed plate warmers and covers on the cart for East hallway resident meals. DA-A told DC-C that Resident 12 was now in the dining room. DC-C removed the foil covered plate from the food warmer and placed it on the shelf above the steam table. DA-A delivered the plate to Resident 12. The plate contained the dinner roll that DC-C had placed on it with the bare hand. DC-C plated a meal for Resident 8. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 8. DC-C plated a meal for Resident 30. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 30 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 14. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 14 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 24. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 24. DC-C used the bare left hand to reposition the dinner roll on the plate. DC-C sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 19. Resident 19 was in the main dining room. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 19. DC-C plated a meal for Resident 2. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 2 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 4. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 4 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 10. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 10 and sat the plate on the cart for East hallway resident meals. DA-A pushed the cart of East hallway resident meals out of the kitchen. 35043 D. Observation of the facility east unit dining room on 5/22/23 at 12:35 PM revealed MA-E (Medication Aide) sat down next to Resident 24 who was seated at the dining room table and began to feed Resident 24. There was a dinner roll on Resident 24's plate with the other food items. MA-E picked up the roll with their bare hand then put it back onto the plate with the food. MA-E then proceeded to feed Resident 24 the food that was on the plate with the roll MA-E had handled with their bare hand. MA-E then opened the roll and buttered it and fed it to Resident 24.

Licensure Reference Number 175NAC 12-006.17D Licensure Reference Number 175NAC 12-006.17 Based on observation, record review, and interview; the facility staff failed to perform hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection and food-borne illness among patients and health care personnel) during dining which affected 6 of 6 residents who were served food on the east unit, (Residents 10, 2, 24, 30, 4, 14); and the facility failed to maintain urinary catheters (a flexible plastic hollow tube inserted into the bladder to continuously drain urine into a drainage collection bag) to prevent the potential for cross contamination for 1 of 1 sampled residents (Resident 27). The facility census was 31. Findings are: A. Record review of the facility policy titled Hand Washing Procedure dated 8/27/08 revealed that the purpose was to control infection and reduce transmission of organisms. Hand washing should be performed before and after handling residents and after touching dirty areas or utensils. Procedure: Turn on water and wet hands well. Apply soap and work up lather. Using friction, wash entire surface of hands for 20 seconds. Give special attention between fingers, under nails and around wrists. Rinse with hands lowered to allow soiled water to drain from wrists to fingers. Do not touch sink with your hands. Dry hands well. Use new clean dry disposable hand towel to turn off faucet. Observation of the facility east unit dining room on 5/22/23 at 12:16 PM revealed MA-E (Medication Aide) moistened washcloths under the faucet of water in the sink in the dining room then assisted residents with washing their hands and faces. Residents 10, 2, and 4 washed their own faces and hands after MA-E gave them a wet washcloth then MA-E placed the soiled washcloths into a receptacle. MA-E assisted Residents 14, 24, and 30 with washing their faces and hands using the wet washcloths then placing the soiled washcloths into a receptacle. MA-E was observed touching the residents' hands and faces as MA-E was washing them with the wet washcloths. At 12:26 PM MA-E washed their hands for 5 seconds at the sink in the dining room, rinsed their hands under running water, turned the faucet off with their bare hands, then dried their hands with paper towels. There was a cart in the dining room with 6 plates of prepared food that were in insulated plate warmers. MA-E used their thumb to push the plate out of the bottom of the insulated warmer by touching the top of the lip of the plate then took the plates of food to the 6 residents who were seated in the dining room, Residents 10, 2, 24, 30, 4, and 14. All 6 residents were then observed eating the food off the plates that MA-E had handled without performing hand hygiene as required. Interview with the RD (Registered Dietitian) on 5/25/23 at 8:38 AM revealed the facility staff were expected to perform hand hygiene during meal service. 41938 B. Record review of the undated facility policy titled Emptying the Urinary Drainage Bag revealed that the purpose was to keep the inside of the drainage bag sterile to prevent infection. All catheter drainage bags will be emptied following the proper procedure to prevent contamination of the drain system. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 3/30/23 for Resident 27 revealed that Resident 27 had an admitted [DATE]. The MDS revealed that Resident 27 had an indwelling urinary catheter. Observation on 5/23/23 at 10:42 AM in the room of Resident 27 revealed that the resident was in the bed curled up on their left side. The urinary catheter drainage bag sat on the floor under the bed. The urinary catheter bag was folded in half. Observation on 5/24/23 at 10:32 AM in the room of Resident 27 revealed that the resident was in bed. The bed was in low position. The urinary catheter drainage bag was flat on the floor underneath the bed. Observation on 5/25/23 at 9:37 AM at the room of Resident 27 revealed that Nurse Aide-F (NA-F) pulled the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) out of the resident's room. Nurse Aide-G (NA-G) exited the resident room with a soiled garbage bag. Resident 27 was in bed. The bed was in low position and the urinary catheter drainage bag was touching the floor. Interview on 5/25/23 at 9:40 AM with NA-G revealed that staff try to prevent resident urinary tract infections by offering drinks and performing correct catheter care. NA-G revealed that when Resident 27 is in bed the catheter drainage bag is hung from the bed rail. NA-G revealed that the catheter drainage bag should not be touching the floor. Interview on 5/25/23 at 10:09 AM with the facility Assistant Director of Nursing (ADON) confirmed that urinary catheter drainage bags should not be touching the floor due to potential for contamination and infection.

Licensure Reference Number 175NAC 12-006.05(21) Based on observation, record review, and interview the facility failed to ensure that staff served meals in a manner to maintain resident dignity for 1 resident (Resident 8). The facility census was 31. Findings are: Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a dignified existence and be treated with respect and dignity that promotes his or her quality of life, recognizing his/her individuality. The facility must provide equal access to quality of care. Observation on 5/22/23 at 12:04 PM in the main dining room revealed that Dietary Aide-B (DA-B) delivered a meal to Resident 27. Resident 8 (the tablemate of Resident 27) sat at the table and was not served a meal. DA-B delivered a meal to Resident 16 at another table. Resident 16 was alone at their table. Dietary Aide-A (DA-A) delivered a meal to Resident 12 at another table. Resident 12 was alone at their table. DA-A delivered a meal to Resident 25 at another table. Resident 25 was alone at their table. Resident 8 still had not been served a meal. Resident 8 watched as their tablemate (Resident 27) continued to eat their meal. The time was now 12:14 PM. DA-A returned to the dining room with a second helping of ribs for Resident 13. Resident 8 still had not received a meal. Resident 8 continued to watch their tablemate (Resident 27) eat their meal. DA-A asked Resident 8 if they wanted more coffee. Resident 8 refused. Observation on 5/22/23 at 12:18 PM in the main dining room revealed that Resident 27 was finished eating and had consumed 100% of their meal. Resident 8 (tablemate of Resident 27) still had not been served. Resident 8 revealed that they were still waiting for their meal. Interview on 5/22/23 at 12:19 PM with Dietary Cook-C (DC-C) revealed that they were not sure if Resident 8 was going to be a room tray or come to the dining room. DA-A told DC-C that Resident 8 was out in the dining room. Observation on 5/22/23 at 12:20 PM in the facility kitchen revealed that DC-C plated food for Resident 8. DA-A delivered the plate of food to Resident 8. This was 16 minutes after Resident 8's tablemate (Resident 27) had been served. Interview on 5/25/23 at 8:38 AM with the facility Registered Dietitian (RD) confirmed that the expectation is that all residents at a table should be served the meal before serving the next table for resident dignity.

Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, interviews, and record review; the facility failed to ensure 1 (Resident 5) of 2 sampled residents was assisted with ADLs (Activities of Daily Living-dressing, grooming, toileting, bathing) and had the means to obtain assistance if needed. The facility identified a census of 31. Findings are: Record review of the Minimum Data Set (MDS) (a federally mandated assessment used to develop a resident's plan of care) dated 5/4/2023 revealed Resident 5 was admitted on [DATE] with a diagnosis of Schizoaffective Disorder (a mental health disorder) and Section G indicated the resident required extensive assistance with 2 staff members for all Activities of Daily Living (ADL). Record review of Resident 5's Care Plan with a revision date 1/20/23 revealed Resident 5 with a self care deficit problem with an intervention to check and change before/after meals and PRN (as needed) and needs total assistance with bed mobility, transfers, showers, locomotion, dressing, personal hygiene and toileting. Observation on 5/22/23 at 11:22 AM revealed Resident 5 in the wheelchair in the resident's room with a strong odor of bowel incontinence, the call light was located on the floor behind Resident 5, hanging on the oxygen concentrator resting on the floor, out of Resident 5's reach. Resident 5 reached out and asked for help after placing a hand down the soiled brief. Observation on 5/23/23 at 8:00 AM revealed Resident 5 lying in bed flat on the residents back, the call light was located hanging over the oxygen concentrator on the floor, out of Resident 5's reach. Observation on 5/23/23 at 10:25 AM revealed Resident 5 lying in bed in the same position as Resident 5 was in at 8:00 AM, the resident remained in night gown, and the call light was located hanging over the oxygen concentrator on the floor, out of Resident 5's reach. A continuous observation on 5/23/23 from 1:30 PM to 4:10 PM revealed Nurse Aide (NA-I) walked into the residents room at 3:15 PM, and coming out of the room in less than 3 seconds. Nurse Aid (NA-I) did not enter any other rooms on that wing. No other staff member entered the Resident 5's room during this observation period. Staff members were observed gathering in the nurse's office for long periods of time with the door closed during the continuous observation. A continuous observation on 5/24/23 from 8:20 AM to 10:25 AM revealed that at 8:20 AM Resident 5 was in bed in the resident's room with gown on, the call light was located hanging off of the nightstand out of the residents reach. At 9:25 AM an observation revealed staff entering Resident 5's room to provide AM cares, the resident was left in the same position. Observation on 5/24/23 at 2:00 PM revealed that Resident 5 understood the call light use but was not able to manipulate to push the button. Interview with Registered Nurse (RN- H) on 5/24/23 at 2:05 PM revealed the nurse was unsure of who was responsible for determining the type of call light that a resident would use, and that all residents received routine rounding. The interview also revealed that routine rounding meant every two hours and before and after meals. Interview with the Minimum Data Set Coordinator (MDSC) on 5/24/23 at 2:25 PM confirmed that Resident 5 would be able to use a call light and that everyone should have a call light available. A record review of ADL documentation for bowel and bladder incontinence and checking Resident 5 revealed: *5/11/2023 there were 5 episodes of documentation in a 24-hour time period. *5/13/2023 there were 3 episodes of documentation in a 24-hour time period. *5/14/2023 there were 5 episodes of documentation in a 24-hour time period. *5/15/2023 there were 4 episodes of documentation in a 24-hour time period. *5/16/2023 there were 4 episodes of documentation in a 24-hour time period. *5/17/2023 there were 5 episodes of documentation in a 24-hour time period. *5/19/2023 there were 5 episodes of documentation in a 24-hour time period. *5/23/2023 there were 3 episodes of documentation in a 24-hour time period. Interview with the MDS Nurse (MDSC) on 5/24/23 at 9:15 AM confirmed there was no other documentation available for ADL/incontinence cares. The interview also confirmed that check and change routinely indicated that a resident would be checked and changed before and after meals and every 2 hours. A policy review of AM Resident Cares last revised on 11/19/2022 and HS Cares last revised on 1/6/2011 revealed toileting was to be offered with AM and HS cares. Routine rounding and incontinence cares were not addressed in either policy. Interview with the Assistant Director of Nursing (ADON) on 05/24/2023 at 3:25 PM confirmed there was no toileting/ADL policy other than a bowel management policy, and there was no policy for routine rounding.

Licensure Reference Number 175 NAC 12-006.11E Based on observations, interviews, and record reviews; the facility failed to ensure that foods stored in the kitchen walk in freezer were covered without getting air to the food, and food was discarded after the expiration dates. This affected 35 of 39 residents at the facility. The facility census was 41. Findings are: Observation in the kitchen walk in freezer on 3/14/21 at 8:59 AM revealed chicken pieces found in a plastic bag without any date on the package, a box of chicken chunks with breading. The plastic bag was open to the air and was in an open box. Biscuits were setting by some bread had an outdate of 3/8. Residents' refrigerators in the 200 hallway had food and fluids that had been opened and no outdates were written on the items. Spilled food and fluidswere inside the refriderators on 3/16/22 at 10:29 AM. Observation on 3/16/21 at 12:03 PM revealed a large mixer covered with white cloth and a plastic bag. There was a greasy oily substance on the stand and neck of the large mixer. The covering of white cloth and plastic bag was greasy and had chunks of food stuck to it. The 2 timers setting on top of the stove revealed greasy and crusty food items stuck to them. Interview with the DM (Dietary Manager) on 3/16/21 at 12:31 PM revealed the biscuits had been in the freezer, took them out to thaw, and the DM revealed they should be used within 4 days of taking out of freezer. The DM was unsure of what the items with no dates or outdates in freezer were and what time they should be discarded. Record review revealed cleaning of equipment had been completed up until 2/2/22. There was no documentation to show ongoing cleaning after 2/2/22.

Licensure Reference 175 NAC 12-006.18C1; 175 NAC 12-006.17D Based on observation, record review, and interviews; the facility failed to ensure infection control measures were followed to prevent cross contamination related to the delivery of resident clothing, which had the potential to affect all residents. The facility census was 41. Findings are: An observation on 3/16/22 at 10:11 AM of laundry staff passing clean resident clothing revealed the following: -Laundry Aide (LA) J carried resident clothing into rooms [ROOM NUMBER] by holding the clothing against (gender) own clothing. -LA K carried resident clothing into rooms [ROOM NUMBERS] by holding the clothing against (gender) own clothing. -LA I carried resident clothing into rooms [ROOM NUMBERS] by holding the clothing against (gender) own clothing. A review of the policy titled Laundry and Linen dated 5/11/2020 revealed that the delivery of clean linens was not addressed in the policy. An interview on 3/17/22 at 12:02 PM with laundry Supervisor (LS) confirmed that staff should not have been holding clean resident clothing against their clothes during delivery or the clothing and that staff's personal clothing was considered contaminated.

Licensure Reference 175 NAC 12-006.10 Based on record review and interview, the facility failed to follow physician's orders related to blood pressure parameters for 2 residents (5 and 16) out of 10 residents sampled. The facility census was 41. Findings are: A. A record review of Resident 5's active physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if systolic blood pressure (SBP-the top number in a blood pressure) is less than 90. Call the provider if SBP greater than 200. A record review of Resident 5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22 the resident's blood pressure was 83/36 and the [MEDICATION(S)] was given. An interview with the Director Of Nursing (DON) on 3/15/22 at 2:45 PM confirmed that the [MEDICATION(S)] was given on 3/2/22 and 3/14/22 when the blood pressure was outside of the parameters ordered by the physician. The DON further confirmed that the [MEDICATION(S)] should have been held on both occasions. B. A record review of the Order Summary Report dated 3/16/22 for Resident 16 revealed the following order: [MEDICATION(S)] (a medication used to treat high blood pressure and [CONDITION(S)]) Tablet 10 MG (milligram) Give 1 tablet by mouth in the morning for B/P med related to ESSENTIAL PRIMARY) HYPERTENSION (I10) Hold if SBP <90 and DBP <60 A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 03/16/22 at 02:03 PM with the DON, after review of the blood pressure readings and the [MEDICATION(S)] parameters, confirmed that the medication should have been held on 3/16/22 and was not.

Licensure Reference 175 NAC 12-006.09D6 Based on observation, record review, and interview, the facility failed to ensure storage of oxygen tubing and nebulizer kits in a manner to prevent contamination when not in use for 2 Residents (6 & 13) out of 2 sampled. The facility census was 41. Findings are: A. An observation on 03/14/22 at 02:08 PM revealed Resident 13 to have a nebulizer kit still intact and tossed into the cubby area between the closets and also noted to have oxygen tubing connected to the portable oxygen tank and noted to have the nasal cannula resting on the floor. An observation on 03/15/22 at 10:08 AM revealed that the oxygen tubing connected to the portable oxygen tank for Resident 13 was noted to be tossed over the front of wheelchair (w/c) with the nasal cannula resting on the foot pedals of w/c. An observation on 03/16/22 at 01:45 PM revealed the oxygen tubing for Resident 13 was attached to the portable oxygen tank that was on the w/c and noted to be tossed over the foot pedals with the nasal cannula touching the floor. A record review of the facility policy titled Oxygen Concentrator Procedure and dated 8-3-2004 did not address storage of tubing when not in use. A record review of the undated facility policy titled Nebulizer Treatments revealed a step which read keep nebulizer in room by machine in designated container. An interview with the Director of Nursing (DON) on 03/16/22 at 02:03 PM revealed the facility expectation was that oxygen tubing should be placed into the storage bags that should be placed on the back of the wheelchairs when not in use and the nebulizer kits were to be placed in containers in the resident rooms after cleaning following each use. B. An observation of Resident 6's room on 3/14/22 at 2:13 PM revealed Resident 6 had a portable oxygen tank hanging on the back of the wheelchair. The nasal cannula for this tank was wrapped around the handle of the wheelchair. An observation of Resident 6's room on 3/15/22 at 9:47 AM revealed the nasal cannula for the portable oxygen tank hanging on the handle of the wheelchair. An observation of Resident 6's room on 3/16/22 at 10:23 AM revealed the nasal cannula for the portable oxygen tank hanging on the handle of the wheelchair. An interview on 3/16/22 at 10:23 AM with Nurse Aide (NA) H confirmed that the nasal cannula was hanging on the wheelchair handle. NA H further confirmed that the nasal cannula should have been kept in a bag to keep it clean when not in use.

State Licensure Reference 12-006.07. 12-006.07C Based on staff interview, record review and review of the facility policy and procedures, the facility's Quality Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification survey conducted 02/07/19. This was for recited deficiencies in the areas of accuracy of assessments (F641) and infection prevention and control (F880). These deficiencies were recited during the annual recertification and complaint survey conducted on 07/23/20. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. The facility census was 54. Findings are: 1. Cross Refer F641 - The facility failed to code the MDS (Minimum Data Set, a comprehensive assessment used to develop a resident's care plan) to reflect the PASARR (Preadmission Screening and Resident Review) Level II for one of one sampled resident (Resident 15) review for PASARR. During the facility's annual recertification and complaint investigation on 02/07/19 the facility was cited for F641 for failing to accurately code the MDS to reflect the PASRR Level II. The facility's Administrator and Social Worker (SW) were interviewed on 07/23/20 at 1:20 PM. During the interview, the Administrator stated (gender) had started working at the facility in 09/19. The Administrator stated (gender) expected the current areas of concern were in the QA based on the previous survey. The Administrator stated the facility looked at infection control and accidents daily in the morning meetings, weekly in the Interdisciplinary Team (IDT) meetings, and monthly in the QA meetings. 2. Cross Refer F880. The facility failed to assist residents with hand hygiene prior to meal service for residents residing on the East Wing, failed to prevent contamination of a resident's bed linens for 1 of 3 residents (Resident 39) observed and failed to discard open medications that came in contact with the top of the medication cart for 1 of 3 medication passes observed. During the facility's annual recertification and complaint investigation on 02/07/19 the facility was cited for F880 for failing to complete a dressing change in a manner to prevent potential cross contamination. The facility's Administrator and Social Worker (SW) were interviewed on 07/23/20 at 1:20 PM. During the interview, the Administrator stated (gender) had started working at the facility in 09/19. The Administrator stated (gender) expected the current areas of concern were in the QA based on the previous survey. The Administrator stated the facility looked at infection control and accidents daily in the morning meetings, weekly in the Interdisciplinary Team (IDT) meetings, and monthly in the QA meetings.

State Licensure Reference 12-006.17D, 12-006.18C1 Based on observations and staff interviews, the facility failed to assist residents with hand hygiene prior to meal service for residents residing on the East Wing, failed to prevent contamination of a resident's bed linens for 1 of 3 residents (Resident 39) observed and failed to discard open medications that came in contact with the top of the medication cart for 1 of 3 medication passes observed. The facility census was 54. Findings are: 1. Observation in the East Wing dining area on 07/21/20 at 12:00 PM revealed residents being served lunch. Residents requiring assistance were seated at their assigned seat and the meal was placed in front of them. Interview with CNA-B (Certified Nursing Assistant) on 07/21/20 at 12:30 PM confirmed she was assisting residents to the dining room and serving the food. CNA-B stated (gender) did not assist residents with hand hygiene prior to meal service. Interview with the Assistant Director of Nursing (ADON) on 07/21/20 at 12:30 PM indicated the usual routine was to assist residents to toilet as needed and assist the residents with hand hygiene, but confirmed this did not occur prior to meal service. The ADON indicated resident were not assisted as needed to perform hand hygiene prior to meals. 2. Observation on 07/22/20 at 9:15 AM revealed CNA-A (Certified Nursing Assistant) and CNA-C providing personal care to Resident 39. A clean plastic bag was placed on the foot of the occupied bed for the soiled linens to be placed inside. After performing personal care, the bagged linens were placed on the floor while the resident was being repositioned. CNA-C then picked up the bag of soiled linens and placed the contaminated bag on the foot of the resident's bed, contaminating the resident's bedding. Interview with CNA-C on 07/22/20 at 9:30 AM confirmed that items that are on the floor are considered dirty and should not be placed on a clean surface, including the resident's bed. CNA-A and CNA-B stated they did not recall being instructed to not place dirty items on a resident's bed. 3. During an observation of a medication administration pass on 07/21/20 at 9:28 AM, Nurse-A was observed to use hand sanitizer and then open cartridges containing tablets and dispense into a medication cup. 11 pills were dispensed into the cup, when Nurse-A opened the next cartridge with two Potassium Chloride (KCL) capsules that hit the edge of the medication cup and tipped it over. The KCL capsules spilled onto the top of the medication cart. The other pills stayed within the confines of the medication cup. The nurse scooped the KCL capsules with her fingers into the cup and proceeded with the medication pass. On 07/21/20 at 9:47 AM, immediately following the medication administration, an interview was conducted with Nurse-A. The nurse stated (gender) had not cleaned off the top of the medication cart because (gender) had not spilled anything on it. The nurse stated (gender) cleaned the cart at the end of the shift and restocked the cart for the next shift. The nurse indicated this was the procedure the staff followed and thought the previous shift had probably cleaned off the cart and restocked it for the current shift. The nurse was not sure if medications could be administered to a resident if they had spilled and had been picked back up with (gender) hands. On 07/21/20 at 1:19 PM, an interview was conducted with the Infection Control Nurse who stated medications were expected to be discarded if they fell out of the cup. On 07/22/20 at 12:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated it was the expectation that medications be discarded if they spilled out of the cup and new medications should be dispensed. The DON stated the expectation was staff would not touch medications with their hands before dispensing.

State Licensure Reference 12-006.090B Based on interviews and record review, the facility failed to code the MDS (Minimum Data Set, a comprehensive assessment used to develop a resident's care plan) to reflect the PASARR (Preadmission Screening and Resident Review) Level II for one of one resident (Resident 15) reviewed for PASARR. The census was 54. Findings are: Review of Resident's 15 PASARR identification screen, dated 06/05/96, revealed Level II results. Review of Resident's 15 Annual MDS (Minimum Data Set, a federally mandated comprehensive assessment used to develop a resident's care plan), dated on 05/14/20, revealed the resident had the active [DIAGNOSES REDACTED]. Under Section A1500: Is the resident currently considered by the state Level II PASARR process to have serious mental illness and/or intellectual disability (mild intellectual disabilities) or a related condition? The facility had documented no. Review of Resident 15's Face Sheet revealed an admission date of [DATE]. The July 2020 Medication Administration Review included [DIAGNOSES REDACTED]. Interview on 07/23/20 at 10:25 AM with Social Worker-A indicated that Resident 15 was a PASARR Level II. Interview on 07/21/20 at 1:05 PM with the Minimum Data Set Coordinator indicated Resident 15 was a PASARR Level II, and it was an oversight in coding. Interview on 07/21/20 at 1:10 PM with the Director of Nursing indicated that going forward the resident's PASARR level would be verified before coding section A1500 of the full Minimum Data Set (MDS).

State Licensure Reference 12-006.09C1c Based on observations, interviews and record review, the facility failed to develop and implement a resident centered care plan to address behavior monitoring and interventions for one (Resident 26) of 16 residents reviewed for care plans. Finding are: Review of the clinical record for Resident 26 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) (a comprehensive resident assessment tool) with an assessment reference date of 05/28/20, revealed the resident scored 6 of 15 points on the Brief Interview of Mental Status, indicating the resident had significant cognitive impairment. Resident 26 experienced hallucinations and delusions daily. The MDS indicated the resident had physical and verbal behavioral symptoms and rejection of care. It further indicated the behaviors were worse compared to the prior MDS assessment. Review of Resident 26's plan of care revealed the resident had a history of [REDACTED]. Observation of Resident 26 on 07/20/20 at 9:30 AM revealed Resident 26 was coloring while seated next to a nurse in the unit's nursing office. Observation of Resident 26 on 07/20/20 at 11:30 AM revealed the resident was wandering in the hallway. The resident spoke to another resident, demanding they move from the couch in the common area while watching TV. Interview with the Director of Nursing, the Assistant Director of Nursing and the Infection Preventionist on 07/21/20 at 3:30 PM confirmed Resident 26's mood and behaviors as labile, and to some extent, predictable with changes in Resident 26's tone and speech patterns. They confirmed the care plan lacked behaviors to be addressed and specific interventions to be used when the resident displayed behaviors. This placed Resident 26 at risk of experiencing changes in behaviors and ineffective or inconsistent interventions.

Licensure Reference Number 175 NAC 12-006.17A and 12-006.17B Based on observation, interview, and record review, the facility failed to disinfect a Hoyer lift before reuse on another resident (Resident 7) and maintain at least 6 feet distance between residents eating in the dining rooms at meals to prevent the potential spread of COVID-19. The facility reported 50 residents eat in the dining rooms for meals. The facility also failed to screen 91 facility staff members and 1 contracted staff (OT-H) for signs and symptoms of COVID-19 immediately upon entrance to the facility. This had the potential to affect all residents that resided in the facility. The facility had a census of 55 residents. The findings are: Disinfecting Reusable Equipment A. An observation on 6/16/20 at 11:33 AM revealed CNA (Certified Nursing Assistant)-C and CNA-D exiting Resident 6's room. CNA-D was pushing Resident 6 in a wheelchair and CNA-C was pushing a Hoyer lift (an assistive device used to help move residents from surface to surface) out of the room. Continued observation revealed CNA-C pushed the Hoyer lift across the hall and into Resident 7's room and stopped next to Resident 7's bed. In an interview on 6/16/20 at 11:34 AM, CNA-C and CNA-D reported the Hoyer lift was not disinfected prior to reuse for Resident 7. CNA-D stated it was supposed to be disinfected in between use on different residents. In an interview on 6/16/20 at 1:45 PM, the DON (Director of Nursing) and Administrator confirmed the Hoyer lift was supposed to be disinfected before reuse on another resident. A review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment Policy dated 4/7/2020 revealed the following: -Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. -3) Durable Medical Equipment (DME) must be cleaned and disinfected before reuse by another resident. Dining B. Observations of meals on 6/16/20 between 7:56 AM and 12:16 PM revealed the following: -Activity Room dining area had 5 round tables set up with 2 residents observed sitting across from each other at 4 of the 5 tables. -Sunroom dining area had 4 round tables set up with 2 residents observed sitting across from each other at 1 of the 4 tables. -Memory Care dining area had 5 round tables set up with 3 residents observed sitting next to each other at 1 table and 2 residents observed sitting across from each other at 3 of the tables. -Main Dining dining area had 8 round tables and 2 square tables set up with 2 residents observed sitting across from each other at 4 of the round tables and 1 of the square tables. An observation on 6/16/20 at 8:10 AM revealed signage posted outside of the dining areas stated residents are supposed to sit 2 to a table, 6 feet apart. An observation and interview with the Administrator and Maintenance Supervisor on 6/16/20 at 9:15 AM revealed the round tables measured approximately 4 feet in diameter and the square tables measured approximately 3.5 feet across. The Administrator confirmed that would not keep the residents separated by at least 6 feet while dining. Staff Screening C. A review of an email dated 3/23/20 from the Administrator to Facility Department Heads revealed the following: -All employees are to be screened daily for risk of coronavirus infection. It will be your job as department heads to do this to each of your employees daily. You will be given the sheet with the questions to be asked of each employee daily as they prepare to start their shift. You will need to take and record their temperature daily before they start their shift. It will be the responsibility of the office manager to screen and check all office, administration staff, and essential health care staff daily during business hours. It is the responsibility of the charge nurse during non-business hours. -You will be given stickers that the employee is to wear on the front of their shirt that will show that they have been screened for that day. -In absence of the department head (such as weekend or a scheduled day off), in dietarty the responsibility would fall to the assistant dietary manager or the head cook or first cook. All others will fall under the responsibility of the charge nurse. In interviews on 6/16/20 at 9:15 AM and 10:15 AM, RN (Registered Nurse)-A reported staff are screened in their respective department areas in the building. Nursing staff are screened in the nursing office in the memory care unit. In an interview on 6/16/20 at 12:20 PM, CNA-J reported that nursing staff are all screened at the nurses' station in the memory care unit. An observation and interview on 6/16/20 at 12:21 PM with Dietary Staff B revealed the dietary staff screening log was kept in the middle of the kitchen. Dietary Staff B reported dietary staff take their own temperatures upon arrival to work in the kitchen and fill out the screening form. An observation on 6/16/20 at 1:15 PM revealed OT (Occupational Therapist)-H walked in the front door of the facility and to the business office where (gender) was screened by the Office Manager. Observations during this time revealed OT-H walked by 2 residents sitting in the great room on the way to the business office. An observation on 6/16/20 at 1:40 PM revealed CNA-I walked in the front door of the facility and to the business office where (gender) was screened by the Office Manager. Observations during this time revealed CNA-I walked by 1 resident sitting in the great room on the way to the business office. An observation and interview with the ADON (Assistant Director of Nursing) on 6/16/20 at 1:25 PM revealed the screening log for the nursing staff was kept in the nursing office located at the end of the hall in the memory care unit. The ADON reported that staff come to the nursing office when they arrive for their shift and are screened by the charge nurse. In an interview on 6/16/20 at 1:43 PM, the DON stated the Office Manager does staff screening in the business office from 7:30 AM until 4:00 PM and outside of those hours the staff have to go down to the nursing office on the memory care unit to be screened. The DON also reported most of the nursing staff change shifts at 6:00 AM and 6:00 PM. In an interview on 6/16/20 at 1:45 PM, the Administrator and DON confirmed that staff walking through the building and into resident care areas to be screened could be a potential infection control issue. The DON and Administrator also confirmed staff should not be screening themselves.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to provide supervision to prevent falls and injury for Resident 4; failed to ensure resident assistive devices were maintained to prevent a potential accident hazard for Residents 4, 9, 27, 6, and Resident 23 ; and failed to follow care planned fall interventions for Resident 21. This affected 6 of 9 sampled residents. The facility identified a census of 31 at the time of survey. Findings are: A. Review of Resident 4's Review of quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/6/2018 revealed an admission date of [DATE]. Resident 4 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated Resident 4 had severe cognitive impairment. Resident 4 required extensive assistance from staff for bed mobility and transfers. Resident 4 had an active [DIAGNOSES REDACTED]. Review of Resident 4's Morse Fall Scale (a tool used to determine a resident's fall risk) dated 11/26/2018 Revealed Resident 4 had a score of 90 which indicated Resident 4 was at a high risk for falling. Observation of Resident 4 on 2/04/19 at 9:49 AM revealed they had a large hematoma (bruised bump) on the right forehead and a skin tear on the right hand. Resident 4 was hunched over in a wheelchair and did not respond when spoken to. Interview with Resident 4's family member on 2/04/19 at 12:06 PM reported Resident 4 had 15 falls recently and they were unaware of what the facility staff were doing to prevent Resident 4 from falling. Review of Resident 4's Incidents by Incident Type report dated 2/4/19 revealed Resident had 1 witnessed fall on 10/18/18 and 24 unwitnessed falls on 2/14/18, 3/21/18, 4/1/18, 5/11/18, 5/26/18, 5/27/18, 5/30/18, 6/20/18, 6/21/18, 6/30/18, 7/12/18, 7/24/18, 8/26/18, 9/8/18, 9/10/18, 9/19/18, 10/1/18, 10/13/18, 11/29/18, 12/15/18, 12/25/18, 1/8/19, 1/18/19, and 2/2/19. Review of Resident 4's Progress Notes revealed the following: On 4/1/2018 at 10:26 PM Nurse was summoned to resident's room by NA (Nurse Aide). Nurse entered room and observed Resident 4 lying on the floor parallel to their bed. Resident 4 was on their right side with their right elbow bent resting their head in their hand. On 4/8/2018 at 11:11 AM Resident 4 was up and about in pajamas this morning. Staff put clothes in their room and offered to help Resident 4 wash and dress. Resident 4 refused assistance. Resident 4 was observed walking from their room without their walker. Nurse caught up to Resident 4 and walked them back to their room. On 5/11/2018 at 7:30 AM Resident 4 was found lying on floor on their left side in front of the couch. Resident 4's head was pointed west. Legs were bent at the knees. Resident 4 was assisted into aw/c with full body lift and 4 assist of staff. Resident 4 had a 2.5 cm by 2 cm open skin tear to the left forearm near the elbow. Resident 4 complained of hip pain when attempting to bear weight on left leg. Resident 4 was assisted to the hospital in a w/c and with staff. On 5/12/2018 at 2:12 PM nursing staff documented they spoke with nurse at the hospital. Stated Resident 4 had a pelvic fracture and compression fracture of L1 (lumbar vertebrae #1) that was worse. On 5/15/2018 at 2:10 PM Resident 4 returned to the facility. On 5/26/2018 at 8:45 PM Nurse was summoned to Resident 4's room. Observed resident sitting on the fall mat on the floor beside the bed. Resident 4 was leaning back with their back against the bed. Resident 4 had both legs stretched out in front of the. On 5/27/2018 at 11:11 PM Resident 4 was found lying on the fall mat beside the bed. On 5/30/2018 at 2:30 PM Resident 4 was observed on the floor in their room; their feet were pointing toward the west and their head toward the east in front of the recliner. On 6/4/2018 at 6:00 PM Resident 4 was observed sitting in a chair in the lobby with their w/c sitting beside the chair. Nurse checked with all employees and no one had assisted Resident 4 to the chair. On 6/4/2018 at 7:02 PM Resident 4 was observed standing behind their w/c holding onto the handles. On 6/4/2018 at 7:45 PM Medication aide walked by Resident 4's room and observed them sitting on the extended foot end of their recliner. On 6/6/2018 at 12:55 PM Resident 4 was seen transferring self from W/C to the sofa in the lobby. On 6/20/2018 at 4:15 PM Resident 4 was observed leaning with back against the south wall in room east of T.V. stand. Legs were outstretched. On 6/21/2018 at 4:37 PM Nurse walked into Resident 4's room and observed them laying on their back in the middle of the floor with their feet towards the door and a pillow under their head. On 6/24/2018 9:06 AM Resident 4 was attempting to stand without assist. Assisted back into w/c. On 6/30/2018 at 9:26 PM Resident 4 was on the floor hitting their right side of forehead on the floor - quarter size hematoma noted On 7/3/2018 at 6:52 AM Resident 4 had been up unassisted during night and without using call light, used brief found in the bathroom, all lights were turned on and Resident 4 was observed sitting in the recliner. On 7/12/2018 at 10:16 PM Resident 4 was observed lowering self off their bed to the floor and scooting across the floor. On 7/19/2018 at 1:42 PM staff documented C. T. (Computed Tomography) scan of Resident 4's pelvis showed unchanged alignment. Fracture lines showed mild progression in callus formation. On 7/24/2018 at 2:52 AM Twice Resident 4 had self-transferred, ambulating with walker to hall x 1 and going to the recliner x 1, when encouraged to be assisted to bathroom Resident 4 said I cannot do it. Staff assisted with cares and helped Resident 4 back into bed. On 7/24/2018 at 10:56 PM Resident 4 was found lying on the bathroom floor on their left side. On 7/25/2018 at 2:20 AM Skin tear observed on resident's left posterior upper arm. Area cleansed with soap and water. Unable to approximate edges of wound. Measures 2.5 cm by 1 cm. On 7/28/2018 at 1:08 PM Resident 4 had taken self to the bathroom. Staff said Resident 4 was on the toilet talking to self. Staff assisted resident out of the bathroom and into a W/C. On 9/8/2018 at 8:33 PM Resident 4 was found lying in left lateral position, on tile floor, with feet toward bathroom doorway and head towards couch/window, with a folded blanket under their head; Resident 4 was disoriented to date, place, and time; when staff attempted to assist Resident 4 up they exhibited extreme facial grimacing and verbal cursing. Resident 4 was taken to the hospital for evaluation and returned to the facility. On 9/9/2018 at 9:16 PM Resident 4 had self transferred from w/c to recliner, recliner to w/c, or w/c to bed numerous times this shift. Resident 4 was reminded by staff to call for assistance with transfers. On 9/9/2018 at 9:35 PM Resident had torn apart 8 briefs/pull-ups throughout this shift. On 9/10/2018 at 5:50 AM Staff heard a loud boom and entered resident's room. Staff observed resident lying on their right side, facing the door with their head resting on the couch and using their right elbow to hold themselves up. resident sustained [REDACTED]. On 9/19/2018 at 10:03 PM nurse observed Resident 4 in their room on their knees, in front of their recliner, with their body over the seat of the recliner. On 10/1/2018 at 2:45 AM Resident 4 was calling for help. Resident 4 was on the floor in their room in front of the couch, with head toward the window. Did not ring for assist. On 10/13/2018 at 9:49 PM Resident 4 was standing and ambulating across the room without assist. Call light was in place and within reach. On 10/14/2018 at 3:44 PM Resident 4 was observed on the bathroom floor. Resident was lying on their left side with their feet at the base of the toilet and was lying diagonal across the floor with their head against the wall of the room. Pants were down and around their ankles. W/C and walker were in the bedroom. Call light was in place in both Bedroom and BR. Does not give details when asked about the incident. On 10/18/2018 at 11:10 AM Resident 4 was sitting in their w/c in hallway near east wing T.V. area. NA observed Resident lean forward and topple out of w/c. Unable to reach Resident in time. NA reported Resident 4 had hands on forehead and hands hit floor while in front of forehead. Watch caught left forearm causing a 3.5 by 0.3 cm and 3 by 0.3 cm skin tear to left lateral forearm. Resident was kneeling in front of w/c on floor. On 10/29/2018 at 12:16 PM Direct Care staff reported Resident 4 was observed ambulating independently in room. Gait/balance unsteady, is a fall risk. On 10/29/2018 at 12:32 PM Resident 4 kept getting up and walking unassisted. Staff talked to resident about them needing staff assistance. Resident toileted themselves and ripped brief off and threw it on the floor then wore nothing. On 11/6/2018 at 9:14 PM Resident 4 was confused all shift. At 4:00 PM, Resident 4 was found walking in hallway by themselves, stating, I felt like walking. After supper Resident 4 was pacing in their wheelchair up and down hall. On 11/18/2018 at 11:35 AM Resident 4 had ambulated to the bathroom without assistance. Resident 4 did not have the walker or W/C with them. Resident 4 had a BM and had cleaned themselves and some off the floor. Resident 4 was assisted to lunch per W/C. On 11/29/2018 at 10:15 AM Resident 4 observed lying on back on floor in room between end of bed and recliner. Hips were resting on over the bed table base. Head was pointed south-west and feet were outstretched pointing south. Resident 4 had a 3.5 cm skin tear on left posterior hand. On 12/3/2018 at 4:00 PM Resident 4 was observed at walking in the bathroom without a walker. They had been laying down in their bed. Bed was in low position and w/c beside bed with wheels locked. Resident 4 sat in w/c after being toileted. On 12/3/2018 at 9:12 PM Resident 4 was observed sitting in their recliner at this time. They had been in their bed which was in low position. On 12/7/2018 at 11:15 AM Direct Care Staff reported Resident 4 removed their brief, transferred self to the recliner and was incontinent of bladder. Staff assisted Resident 4 with toileting needs, brief applied, and Resident 4 taken to dining room per w/c for Noon Meal. On 12/7/2018 at 9:38 PM Nurse observed the bathroom light on in Resident 4's room. Upon entering nurse observed feces on the floor in front of the recliner and a dirty brief in the garbage and stool in the toilet. Resident was lying in bed without a brief. Room was cleaned up and resident was helped into another brief. On 12/11/2018 at 9:44 PM Nurse observed Resident 4 in the bathroom without their walker with the door closed. Resident was helped with new brief and ambulated back to bed with the walker. On 12/15/2018 at 1:50 PM NA reported resident was hollering, upon entering the room, resident was observed lying on their left side on the floor perpendicular to the bed. On assessment, noted a skin tear to resident's left antecubital (area inside the elbow) 3.5 cm skin tear to left wrist 2.3 cm, abrasion behind left ear 1.5 cm x 0.2 cm and large bruise 45 cm x 6.5 cm extending from residents left thumb to above the left elbow. The nurse asked Resident 4 if they knew how they landed on the floor, they stated, I really don't know. Resident c/o (complained of) generalized pain. Resident assisted off the floor and into their wheelchair via full body lift and 4 assist. On 12/21/2018 at 9:57 PM Resident 4 was observed by nurse sitting on their bed at 7:00 PM without a brief on. Nurse observed it in the garbage in the bathroom. A new brief put on for Resident 4. Resident helped into bed. Nurse observed resident sitting on their couch at (YEAR) without a brief on. It was observed in the bathroom again. Resident attempting to get the tags off a new sweater. Nurse helped and resident asked to put the sweater on. Sweater and new brief were put on and resident was assisted back to bed. On 12/25/2018 at 10:19 PM staff entered Resident 4's bathroom and observed them laying on the floor with feet under the bathroom sink. Resident had shoes and socks on both feet. CNA reported that resident's w/c (wheelchair) had been behind them and when first observed resident was sitting on the floor in front of the w/c, between the sink and w/c. Resident 4 was unable to give statement as to what happened. Resident 4 was assessed for injuries. On the left lateral side of their back Resident 4 had an abrasion measuring 15 cm long by 8 cm wide. On 1/8/2019 at 11:00 AM Nursing observed the resident lying on their left side, head facing towards the bathroom and feet on the fall mat. The fall mat was at an angle from the bed. The resident stated, I don't know what I was trying to get up, just fell out of bed. The resident had 2 skin tears to the left arm, one at the elbow 2.5 x 0.9 cm and one on the underside of the left forearm 2 x 0.5 cm. On 1/18/2019 at 7:16 AM Resident 4 was found lying on the floor of their room beside their bed with their head toward the foot of the bed. Resident 4 was hollering wanting someone to get them up. The floor had urine and BM smeared all over. Their brief was in the bathroom trash can. Their landing strip had been pushed away from the bed. Their left hand and fingers were caked with BM. On 1/18/2019 at 10:12 AM Resident 4 had been up again on their own. Resident 4 was observed in their recliner. On 1/18/2019 at 11:30 AM Resident 4 was up on their own again and put self on the bed. On 2/2/2019 at 10:57 PM, Resident 4 was found on the floor in their room. Resident 4 had an injury to the forehead with a pinpoint open area and a hematoma the size of a walnut. Resident 4 also had two skin tears. #1 area between thumb and index finger in a U shape measuring 3 cm (centimeters). #2 Skin tear to the elbow in a U shape measuring 4 cm. There was no documentation the facility staff had provided the supervision required to prevent Resident 4 from falling 25 times and being injured despite documentation Resident 4 had been observed up on their own and continued to fall. Interview with MA-C (Medication Aide) on 2/06/19 at 9:56 AM revealed the staff were supposed to check on Resident 4 frequently due to a risk for falls. Interview with the DON (Director of Nursing) on 2/07/19 at 9:23 AM revealed they had been discussing alternate fall interventions for Resident 4 but they had not implemented them yet. The facility staff were expected to implement fall interventions to prevent the facility residents from falling. Interview with the facility Administrator on 2/7/19 at 9:23 AM revealed they had been looking at new fall prevention devices and they had received grant money for them but they had not implemented them yet. The facility staff were expected to implement an intervention each time a resident fell to prevent further falls and injury. B. Observation of the toilet risers in the bathrooms belonging to Resident 4 on 2/04/19 at 12:10 PM revealed it was not secured to the toilet. Interview with the facility Administrator on 2/04/19 at 3:21 PM revealed the facility did not have a policy or procedure for monitoring the toilet risers for safety. Therapy staff put them on the toilets and there was no documentation or anything on paper that they were monitored after that. Observation of the toilet riser in Resident 4's bathroom with the facility Administrator on 2/04/19 at 3:47 PM confirmed the toilet riser was not secured to the toilet. Interview with Resident 27 on 2/05/19 at 9:30 AM the facility staff came and secured the toilet riser to their toilet this morning.