Every finding on record at Brookefield Park

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure surfaces in the kitchen were cleaned at a frequency to prevent the accumulation of soil or residue. This had the potential to affect all of the residents receiving food from the kitchen. The facility census was 62. Findings are:Record review of the Food and Drug Association Food Code dated 2022 revealed in 4-602.13 that non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil and residues. In an observation completed on 05/12/2026 at 8:45 AM of the kitchen it was observed that the stainless-steel partition behind the stove and facility steamer had a cloudy yellow-white build up starting approximately 5 inches from the top to approximately 3 feet from the bottom in a downward V spray shape extending down the length of the partition. Record review of a document titled [NAME] Daily Cleaning Schedule dated May revealed no listing for the stainless-steel partition behind the stove and the facility steamer to be cleaned. Record review of a document titled Cooks Weekly Cleaning List and dated April/May revealed no listing for the stainless-steel partition behind the stove and the facility steamer to be cleaned. Record review of a document titled Cooks Monthly Cleaning Schedule and dated May 2026 revealed no listing for the stainless-steel partition behind the stove and the facility steamer to be cleaned. In an interview completed on 05/13/2026 at 10:30 AM with Dietary [NAME] A (DC-A), DC-A confirmed that there was a cloudy yellow-white buildup on the stainless-steel partition located behind the stove and facility steamer. The cook stated that they believed that the Maintenance staff took care of cleaning the stainless-steel partition and was not sure of the frequency. In an interview completed on 05/13/2026 at 10:40 AM with the Maintenance Supervisor (MS), the MS confirmed that there was a yellow-white buildup on the stainless-steel wall behind the stove and the facility steamer. The MS stated that they wipe down the stainless-steel wall every 3 months or so. The MS confirmed that this was not frequent enough to prevent the buildup from occurring.

Licensure Reference Number 175 NAC 12-006.11(D) Based on observation, interview, and record review the facility failed to check the temperature of food items served from the kitchen to ensure they were at a safe and palatable temperature when served for 5 (Resident 4, Resident 17, Resident 55, Resident 7, and Resident 32) sampled residents. The facility census was 62. Findings are:Record review of a facility policy titled Food Temperatures dated 2010 revealed temperatures of food items will be taken and properly recorded for each meal. All hot food items must be held and served at a temperature of or at least 135 degrees Fahrenheit. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. In an observation completed on 05/13/2026 at 12:01 PM Dietary [NAME] A (DC-A) opened and emptied a can of tomato soup into a blue thermal mug. The cook then placed the mug into the microwave and activated the microwave for a time of 1 minute. At the end of the 1 minute the cook removed the mug containing the soup from the microwave placed a plastic lid on top and handed the mug to another staff member to be served to Resident 4. The staff member then served the mug with the soup to the resident. The cook did not check the temperature of the soup after heating it to ensure it was at a safe and palatable temperature prior to serving it to Resident 4. In an observation completed on 05/13/2026 from 12:05 PM, DC-A removed a clear plastic bag containing packaged items from an outside food source from the facility refrigerator. DC-A removed a hamburger and cheese curds from the packaging and placed the items into a rectangle pan and placed the pan containing the items into the facility steamer. At 12:12 PM, DC-A removed the pan containing the items from the facility steamer and placed the food items onto a plate. DC-A then handed the plate to other facility staff who served the plate with the food items on it to Resident 17. DC-A did not check the temperatures of the food items ensuring they were reheated to a safe and palatable temperature prior to serving them to Resident 17. In an observation completed on 05/13/2026 at 12:17 PM, DC-A removed a bowl containing salad from a rectangular container containing ice in the bottom. DC-A then handed the bowl containing the salad to another staff member to be served to Resident 55. The staff member then served the salad to Resident 55. The cook did not check the temperature of the salad to ensure it was at a safe and palatable temperature prior to serving it to Resident 55. In an observation completed on 05/13/2026 at 12:22 PM, DC-A removed a bowl containing salad that was topped with a hardboiled egg from a rectangular container containing ice in the bottom. DC-A then handed the bowl containing the salad topped with a hard boiled egg to another staff member to be served to resident 7. The staff member then served the salad to Resident 7. The cook did not check the temperature of the salad to ensure it was at a safe and palatable temperature prior to serving it to Resident 7. In an observation completed on 05/13/2026 at 12:34 PM, DC-A placed 6 chicken nuggets onto a plate from the steam table using tongs. DC-A then removed a small plastic bowl of grapes and one of cottage cheese from a rectangular container containing ice in the bottom and placed both on the same plate. DC-A handed the plate to another staff member. The staff member served the plate with chicken nuggets, grapes, and cottage cheese to Resident 32. The cook did not check the temperature of the chicken nuggets, grapes, or cottage cheese to ensure they were at a safe and palatable temperature prior to serving them to Resident 32. In an interview completed on 05/13/2026 at 12:45 PM with DC-A, DC-A confirmed that they did not check the temperatures on the tomato soup, hamburger, cheese curds, salads, chicken nuggets, and cottage cheese to ensure they were at a safe and palatable temperature prior to serving them to the residents. In an interview completed on 05/13/2026 at 12:45 PM with the Dietary Manager (DM), the DM confirmed that all items served from the kitchen should have their temperatures checked for safety and palatability. The DM confirmed that DC-A did not check all of the temperatures of food served from the kitchen for safety and palatability and should have.

Licensure Reference Number 175 NAC 12-006.04(G)(ii)Licensure Reference Number 175 NAC 12-006.10(A)(iii) Based on record review and interview the facility failed to ensure that medication aide competency assessments (an evaluation used to verify that a medication aide can safely, accurately, and legally administer medications to residents. It typically includes both a written knowledge test and a practical, hands-on skills demonstration overseen by a licensed healthcare professional) were documented and maintained as required for 1 of 2 medication aides reviewed. The facility census was 62. Findings are:Record review of the Facility assessment dated [DATE] section titled Services Provided Based on Resident Need revealed that the facility will have awareness of any limitations of administering medications. Administration of medications that residents need by route: oral, nasal, buccal (medications placed in the mouth between the gums and the lining of the cheek), sublingual (medications placed underneath the tongue), topical (medications applied on the skin), rectal, inhaled, vaginal, and ophthalmic (medications placed in the eye). The section titled Staff training/education and competencies revealed that staff competencies for medication administration will be assessed during orientation, annually, and as needed. Record review of the facility Competencies for Nursing Assistant, Medication Aide, and Spa Aide dated 12/2018 revealed that competencies will be completed with orientation, annually, and as needed based on performance/facility needs. The list revealed that Medication Administration competency for all routes approved by the facility will be completed for medication aides only. Record review of the untitled and undated facility list of employees revealed that Medication Aide-D (MA-D) had a hire date of 11/11/25. Record review of the facility orientation training checklist dated 3/19/25 revealed that MA-D began orientation on 11/11/25. Record review of the employee file for MA-D revealed that it contained no medication aide competency assessments for MA-D. Record review of the Nursing Staffing Assignments dated from 11/19/25-12/16/25 revealed that MA-D did floor orientation on 11/19/25, 11/20/25, medication aide orientation 11/25/26, medication aide orientation on 11/26/25, 12/11/25, medication aide orientation on 12/12/26, and medication aide orientation on 12/16/25. Interview on 5/14/26 at 11:15 AM with the facility Director of Nursing (DON) revealed that the only medication administration competency assessment for MA-D the facility could provide was a competency assessment for instilling (administering) medication into the eye dated 5/4/26. The DON confirmed that facility medication aides were allowed to administer medications by routes including the mouth, into the eye, into the nose, into the mouth, topically, and rectally. The DON revealed that the facility was to ensure that the medication aide competency all the routes of medication administration are completed during orientation. Record review of the Medication Aide Procedures Checklist Installation Medication (Eye, Ear, and Nose) dated 5/4/26 for MA-D revealed that they type of medication administration observed was marked as Eye. Ear and Nose administration were not marked as being observed. Record review of the Medication Administration Record (MAR, a legal record of the medications administered to a resident at a facility by a health care professional) dated 5/14/25 for Resident 30 revealed that MA-D administered Tylenol 500 milligrams (mg) two tablets by mouth to Resident 30 on 5/9/26. (MA-D had no documented competency assessment to administer oral medications). Record review of the MAR dated 5/14/25 for Resident 22 revealed that MA-D administered Levothyroxine 50 micrograms (a medication used to treat hypothyroid) by mouth; Zyprexa 2.5 mg (a medication to treat mental health behavior) by mouth; and Systane Complete Ophthalmic Solution 1 drop (a liquid medication used to treat dry eyes) in each eye on 5/9/26 to Resident 22. Record review of the MAR dated 5/14/25 for Resident 10 revealed that MA-D administered Donepezil 10 mg (a medication to treat dementia) by mouth; Lexapro 10 mg (an antidepressant medication) by mouth; Melatonin 3 mg (a medication used to assist with sleep) by mouth; Seroquel 150 mg (a medication used to treat mental health behavior) by mouth; Tramadol 50 mg (a pain medication) by mouth; Vicks Baby Rub External Ointment (a topical ointment to relieve cough and congestion) applied to the nostrils topically one time a day; Depakote Sprinkles 125 mg (a medication used to prevent seizures) by mouth; Hydroxyzine 25 mg (a medication used to treat anxiety and allergies) by mouth; Senna Oral Tablet 8.6 mg (a laxative medication used to assist with bowel movement) by mouth; Acetaminophen 1000 mg (a pain medication) by mouth; and Voltaren External Gel (a topical gel to treat pain and joint stiffness) apply to the knees topically on 5/9/26 to Resident 10. (MA-D had no documented competency assessment to administer topical medications). Record review of the MAR dated 5/14/25 for Resident 37 revealed that MA-D administered Latanoprost Ophthalmic Solution (a liquid medication to treat pressure inside the eye) 1 drop into both eyes; Depakote 125 mg by mouth; Tylenol Extra Strength 500 mg by mouth; and Systane Complete Ophthalmic 1 drop into both eyes on 5/9/26 to Resident 37. Record review of the MAR dated 5/14/25 for Resident 14 revealed that MA-D administered Cyclosporine Ophthalmic Solution (an immunosuppressant medication for dry eyes) 1 drop into both eyes; Propranolol 160 mg (a medication to treat high blood pressure) by mouth; Valsartan 160 mg (a medication to treat high blood pressure) by mouth; Tylenol Extra Strength 1000 mg by mouth; and Artificial Tears Ophthalmic Solution (a liquid medication for dry eyes) 1 drop into both eyes on 5/9/26 to Resident 14. Record review of the MAR dated 5/14/25 for Resident 63 revealed that MA-D administered Gabapentin 300 mg (a medication used to treat nerve pain) by mouth; Lorazepam 1 mg by mouth; Melatonin 5 mg by mouth; Rexulti 0.25 mg (a medication used to treat agitation) by mouth; Trazodone 150 mg (an antidepressant medication) by mouth; Memantine 5 mg by mouth; and Vaseline External Gel (an ointment for skin) topically to wound on the back on 5/9/26 to Resident 63. Interview on 5/14/26 at 11:51 AM with the DON confirmed that competency assessments were to be completed during staff orientation. The DON confirmed that the facility had no medication aide competency assessments for oral medication administration or topical medication administration for MA-D orientation. The DON confirmed that the only medication aide competency the facility had for MA-D was the competency for instillation of eye medications dated 5/4/26. Interview on 5/14/26 at 12:02 PM with the DON confirmed that the facility had no documentation of the required medication aide competency assessments from orientation for MA-D.

Licensure Reference Number 175 NAC 12-006.09(D) Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 5) of 5 sampled residents. The facility census was 62. Findings are:Record review of a facility policy titled Timely Completion of MDS Assessments and dated 01/19/2017 revealed the facility would conduct accurate standardized assessment of each resident's functional capacity according to the MDS guidelines per the RAI (Resident Assessment Instrument) Manual. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated 10/2025 revealed coding instructions for N0350 Insulin (a medication used to assist in regulation of blood sugar levels) to enter the number of days during the 7 days prior to the ARD that the resident received insulin injections. To count the number of days insulin injections were received and code the number of days. Record review of Resident 5's Quarterly MDS with an ARD of 02/18/2026 revealed in section N0350 was coded 1, documenting that the resident received an insulin injection during the 7 days prior to the ARD. Record review of Resident 5's Medication Administration Record (MAR) for the month of February 2026 revealed Resident 5 had orders to receive Ozempic (an injectable medication used to help lower blood sugar levels that is not insulin). Resident 5's MAR revealed no documentation that the resident received an insulin injection during the 7-day period prior to the ARD. In an interview completed on 05/12/2026 at 2:45 PM with the MDSC, the MDSC confirmed that Resident 5 did not receive insulin during the 7 days prior to the ARD. The MDSC confirmed that the resident's receiving the Ozempic injection was coded as insulin and should not have been. The MDSC confirmed that the MDS was coded incorrectly.

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 3 of 5 sampled nursing aides (NA) had at least 12 hours of ongoing training. This had the potential to affect all residents residing at the facility. The facility identified a census of 58. Findings Are: A record review of a Facility Assessment for [NAME] Park with a date of 9/1/24-11/21/24 revealed under nursing staffing plans, staff are provided with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through the assessment which include mental health, dementia and infectious diseases. A record review of an untitled and undated document that included a list of employees, their job titles, department, and hire date revealed the following employee hire dates: -NA-H was hired on 06/02/2021. -NA-G was hired on 03/07/2023. -NA-I was hired on 07/07/2020. A record review of a document titled, symplr learning transcript with a date range of 01/29/2024-12/02/2024 for NA-H revealed a total of 6.82 training hours over the prior 12 months. A record review of a document titled, symplr learning transcript with a date range of 03/27/2024-11/24/2024 for NA-G revealed a total of 6.38 training hours over the prior 12 months. A record review of a document titled, symplr learning transcript with a date range of 02/10/2024-12/28/2024 for NA-I revealed a total of 9.69 training hours over the prior 12 months. An interview on 02/18/2025 at 2:40 PM with the Director of Nursing Services (DNS) and Human Resources (HR) confirmed that nursing aides should have at least 12 hours of training each year. The interview also confirmed NA-H, NA-G, and NA-I had not met these requirements in the prior 12 months.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview the facility failed to ensure that refrigerated foods were maintained within the required temperatures to ensure food safety. This had the potential to affect 58 of 58 residents that ate food prepared by the facility kitchen. Findings are: Record review of the Nebraska Food Code, Effective date 7/21/16, 3-202.11 Temperature revealed that refrigerated, Time/Temperature Control for Food Safety (TCS, a method of preventing foodborne illness by controlling the temperature and time of TCS foods. TCS foods are also known as potentially hazardous foods (PHF) including meat, cut or sliced fruits, milk, and dairy products that must be kept at 41 degrees Fahrenheit or below), shall be at a temperature of 41 degrees Fahrenheit (F) or below when received. Observation on 2/18/25 at 9:57 AM in the facility main kitchen revealed that the thermometer inside the walk-in refrigerator displayed a temperature of 44 degrees F. Plastic gallon jugs of milk were on the shelf just inside the door of the walk-in refrigerator. Containers of cottage cheese sat on the shelf above the milk. Two tubes of raw ground beef sat in a gray tub on a bottom shelf. Observation on 2/19/25 at 12:45 PM in the facility main kitchen revealed that the thermometer inside the walk-in refrigerator displayed a temperature of 44 F. Plastic gallon jugs of milk were on the shelf just inside the door of the walk-in refrigerator. Containers of cottage cheese sat on the shelf above the milk. Observation on 2/20/25 at 7:25 AM in the facility main kitchen revealed that the thermometer inside the walk-in refrigerator displayed a temperature of 44 F. Gallon jugs of milk sat on the third shelf and containers of cottage cheese sat on the shelf above the milk. No staff had opened the door and entered the walk-in refrigerator between 7:25 AM and 7:33 AM. The thermometer inside the walk-in refrigerator displayed 43 F when checked at 7:33 AM. Interview on 2/20/25 at 8:36 AM with Dietary [NAME] (DC)-J revealed that DC-J does the recording of refrigerator and freezer temperatures on the temp log but has not yet done them that morning. DC-J confirmed that staff were to record the temperature reading displayed on the thermometer inside of the facility refrigerators and freezers. Observation on 2/20/25 at 9:06 AM in the facility main kitchen DC-J revealed that they would now check refrigeration temperatures. DC-J entered the walk-in refrigerator and read the temperature displayed on the thermometer at 44 F. DC-J recorded the temperature of 44 F on the Fridge/Freezer Temp Log. Gallons of milk sat on the 3rd shelf and containers of cottage cheese sat on the shelf above the milk inside the walk-in refrigerator. Interview on 2/20/25 at 9:08 AM with DC-J revealed that refrigerator temperatures were to be at 40 F or below. This surveyor asked DC-J what actions DC-J would take if refrigeration temperatures were out of range. DC-J revealed that if the temperatures were out of range DC-J would circle the temperature on the temperature log. DC-J revealed that if out of range temperatures continued, the Dietary Manager was notified. Record review of the Fridge/Freezer Temp Log dated February 2025 revealed that 26 of 38 temperatures recorded on the log for the temperature of the walk-in refrigerator were above 41 F. Out of range temperatures recorded on the log were: -On 2/1/25 in the PM the temperature was 42 F, -On 2/2/25 in the AM the temperature was 45 F, -On 2/2/25 in the PM the temperature was 45 F, -On 2/4/25 in the AM the temperature was 45 F, -On 2/5/25 in the AM the temperature was 42 F, -On 2/5/25 in the PM the temperature was 44 F, -On 2/6/25 in the AM the temperature was 45 F, -On 2/6/25 in the PM the temperature was 42 F, -On 2/7/25 in the AM the temperature was 44 F, -On 2/7/25 in the PM the temperature was 42 F, -On 2/8/25 in the PM the temperature was 43 F, -On 2/9/25 in the AM the temperature was 42 F, -On 2/10/25 in the AM the temperature was 42 F, -On 2/10/25 in the PM the temperature was 44 F, -On 2/11/25 in the PM the temperature was 42 F, -On 2/12/25 in the AM the temperature was 45 F, -On 2/12/25 in the PM the temperature was 42 F, -On 2/15/25 in the AM the temperature was 45 F, -On 2/15/25 in the PM the temperature was 42 F, -On 2/16/25 in the AM the temperature was 42 F, -On 2/16/25 in the PM the temperature was 44 F, -On 2/17/25 in the PM the temperature was 43 F, -On 2/18/25 in the PM the temperature was 43 F, -On 2/19/25 in the AM the temperature was 42 F, -On 2/19/25 in the PM the temperature was 44 F, and -On 2/20/25 in the AM the temperature was 44 F. None of the out of range temperatures for the walk-in refrigerator documented on the Fridge/Freezer Temp Log were circled. Observation on 2/20/25 between 9:55 AM and 10:06 AM in the facility main kitchen revealed that there were no staff in the kitchen. The walk-in refrigerator door remained closed during this timeframe. At 10:06 AM this surveyor entered the walk-in refrigerator and closed the refrigerator door. The thermometer inside the walk-in refrigerator displayed a temperature of 44 F. The compressor turned on and the temperature rose to 46 F. Gallons of milk sat on the 3rd shelf and containers of cottage cheese sat on the shelf above the milk inside the walk-in refrigerator. Interview on 2/20/25 at 10:46 AM with the facility Dietary Manager (DM) revealed that refrigeration temperatures were monitored and documented on the temp log twice daily. DM revealed that the DM reviewed the refrigeration temperature logs periodically. DM revealed that the expected temperature for the facility refrigerators was 45 F or below. DM revealed that the freezers were to be at 0 to 10 degrees. Interview on 2/20/25 at 11:29 AM with the facility Registered Dietitian (RD) confirmed that refrigerated temperatures were required to be kept at 40 degrees Fahrenheit or below for food safety. The RD confirmed that approximately 2/3 of the temperatures documented on the February 2025 temperature log for the walk-in refrigerator were above 40 F. Observation with the RD at the walk-in refrigerator in the facility main kitchen confirmed that the thermometer inside the walk-in refrigerator displayed 42 F and was out of range. RD revealed that the DM would complete a work request for maintenance to fix the refrigerator.

Based on record review and interview the facility failed to complete a Level II Pre-Admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability), evaluation for a resident who was identified with a newly diagnosed serious mental illness and psychotropic medication change for 1 (Resident 10) of 1 sampled resident. The facility census was 58. Findings Are: A record review of the undated NE PASRR Provider Portal Frequently Asked Questions (FAQ) document on the website https://nepasrr.acentra.com/wp-content/uploads/sites/26/2024/04/NE-PASRR-Atrezzo-FAQs-1.pdf revealed that if a Level I PASRR was completed prior to resident admission to the facility and then new information is received, the nursing facility should complete a Resident Review for significant change and request a PASRR Level II evaluation and determination. A record review of a PASRR dated 05/02/2024 revealed a Level 1 PASRR was completed for Resident 10 on 05/02/2024. Documentation was present that the resident did not have a diagnosis of serious mental illness and was receiving routine antidepressant and opioid medications. A record review of Resident 10's electronic medical health record revealed Resident 10 was assigned the diagnosis of delusional disorder (a serious mental health condition characterized by persistent, false beliefs that are not based on reality) on 05/09/2024. A record review of Resident 10's electronic medical health record revealed that on 11/14/2024 Resident 10 was prescribed Seroquel (an antipsychotic medication used to treat mental health conditions by assisting to balance chemicals in the brain). In an interview completed on 02/19/2025 at 4:30 PM with the facility Social Services Director (SSD), the SSD confirmed that there was no Level II PASRR completed for Resident 10 reflecting the diagnosis of a serious mental illness or the use of an antipsychotic medication.

Licensure Reference Number 175 12-006.04D2 Based on observations, interviews and record review, the facility failed to have employed a Certified Dietary Manager (CDM). This had the potential to affect all the resident who reside in the facility. The facility census was 61. Findings are: Interview on 11/27/23 at 9:45 AM with the Food Service Supervisor (FSS) revealed that (gender) have been employed since May of 2023 and enrolled in the CDM class since July 2023. The FSS revealed the facility Registered Dietician (RD) comes every 2 weeks for 1 day. Record review of a list of key personal and their License/Certification number revealed the Food Service Supervisor (FSS) was not identified as the CDM. Interview with the facility's administrator on 11/29/23 at 2:04 PM confirmed that the facility does not have a CDM employed. Record review of FSS employment file revealed a copy of Food Handler Essentials Course that that was dated 11/27/23. On 11/30/23 at 9:40 AM an interview with the FSS confirmed that (gender) does not have a bachelor's degree or any other classes/certificates in food service. Dietary Supervisor Job Description undated reviewed. Personal Qualifications: Dietary Supervisors are qualified as a food service supervisor and must be or become a Certified Dietary Manager within one year of hire. Dietary Supervisors have a working knowledge of dietary procedures, related laws, regulations, and guidelines pertaining to hospital and nursing home operations.

Licensure Reference Number 175 NAC 12-007.04D Based on observation, interview, and record review the facility failed to ensure adequate mechanical ventilation in resident's bathrooms for five Residents (#5, #12, #31, #38 and #27). The facility stated census of 61. Findings are: In an observation performed on 11/27/2023 at 1:40 PM Resident #5 and #12's (roommates) bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation performed on 11/27/2023 at 2:11 PM Resident #31 bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation performed on 11/27/2023 at 3:38 PM Resident #38 bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation performed on 11/27/2023 at 3:57 PM Resident #27 bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation on 11/30/2023 at 8:25 AM with Facility Administrator and the Maintenance Supervisor it was verified that residents #5, #12, #31, #27 and #38's bathroom ceiling vents were unable to pull up one square of single ply toilet paper. A strong odor of stale urine was detected upon entering this unit. On 11/30/2023 in an interview with Maintenance Supervisor (MS) at 8:25 AM it was stated that the bathroom vents had been turned off to control the temperature and that MS would go and turn the unit back on at this time. On 11/30/2023 in an interview with MS at 9:10 AM MS stated that that the ventilation unit for that area was not working and MS had notified a service repair individual to come and repair the unit. MS revealed that a monthly check of the bathroom vent on a couple of resident bathrooms per month were completed but did not track or document the bathrooms checked. MS revealed they are made aware of the ventilation system not working by staff alerting them that the temperature has increased in that area. Record review of the undated facility supplied document labeled Direct Supply Tels revealed instructions to inspect exhaust fans for proper operation and clean if necessary, on a monthly basis. Instructions on the form stated to check all exhaust fans in bathrooms to ensure that air flow is sufficient to hold a piece of paper to the vent when operating.

Licensure Reference Number 175 NAC 12-006.18A(1) Based on observation, record review, and interview the facility failed to ensure wheelchairs were clean which affected 3 (Resident 4, 45, and 16) of 3 sampled residents. The facility census was 61. Findings are: A. A review of the admission record for Resident #4 reflected an admitted [DATE]. A review of Resident #4 MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) with the ARD (Assessment Reference Date) of 10/23/2023 reflected Resident #4 used a wheelchair for mobility. A review of Resident #4 current care plan reflected a focus of ADL (activities of daily living) self-care performance deficit related to impaired mobility and cognitive loss. Interventions included Resident #4 is dependent on a wheelchair to move from one place to another. In an observation on 11/28/23 at 10:10 AM Resident #4 was observed sitting in a wheelchair in the resident's room. The observation revealed a black bolstered cushion on left arm rest of wheelchair soiled with dried clear fluid drips to the top and down the outside and front of the cushion. In an observation on 11/29/23 at 8:07 AM Resident #4 was observed sitting in a recliner in the resident's room. The observed black bolstered cushion on left arm rest of wheelchair soiled with dried clear fluid drips to the top and down the outside and front of the cushion. B. A review of the admission record for Resident #45 reflected and admitted [DATE]. A review of Resident #45 MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) with the ARD (Assessment Reference Date) of 10/30/2023 reflected Resident #45 used a wheelchair for mobility. A review of Resident #45 current care plan reflected a focus of ADL (activities of daily living) self-care performance deficit related to stroke with left side being affected and impaired vision. Interventions included Resident #45 is dependent on a wheelchair to move from one place to another. In an observation on 11/27/2023 at 10:20 AM Resident #45 was observed sitting in resident room in the wheelchair. The observation revealed dried brown crusted material to the right front corner of the wheelchair extending down to the seat. Further, the observation revealed small dry yellow brown and white particles on the bottom frame of the wheelchair on both sides. In an observation on 11/28/2023 at 7:51 AM Resident #45 was observed sitting in resident room in the wheelchair. The observation revealed dried brown crusted material to the right front corner of the wheelchair extending down to the seat. Further, the observation revealed small dry yellow brown and white particles on the bottom frame of the wheelchair on both sides and dried fluid drips on the front right side of the wheelchair frame. In an observation on 11/29/2023 at 8:01 AM Resident #45 was observed sitting in resident room in the wheelchair. The observation revealed dried brown crusted material to the right front and back corner of the wheelchair seat extending down to the seat. Further the observation revealed small dry yellow brown and white particles on the bottom frame of the wheelchair on both sides and dried fluid drips on the front right side of the wheelchair frame. C. A review of the admission record for Resident #16 reflected an admitted [DATE]. A review of Resident #16 MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) with the ARD (Assessment Reference Date) of 09/15/2023 reflected Resident #16 used a wheelchair for mobility. A review of Resident #16 current care plan reflected a focus of ADL (activities of daily living) self-care performance deficit related to impaired mobility and cognitive loss. Interventions included Resident #16 is dependent on a wheelchair to move from one place to another. In an observation on 11/28/2023 at 7:44 AM Resident #16 was observed sitting in resident's wheelchair in the hallway. The observation revealed yellow brown crumbs on the frame of the seat of the wheelchair on both sides. Further, the observation revealed dried brown crust stuck to the left front corner of the wheelchair cushion. In an observation on 11/29/2023 at 7:50 AM Resident #16 was observed sitting in resident's wheelchair in resident's room. The observation revealed yellow brown crumbs on the frame of the seat of the wheelchair on both sides. Further, the observation revealed dried brown crust stuck to the left front corner of the wheelchair cushion. In an interview with NA-E (Nurses' Aide) on 11/29/2023 at 9:53 AM NA-E stated if wheelchairs are visibly dirty staff wipe them off immediately. NA-E stated all wheelchairs are cleaned weekly on a rotation for day and night staff. NA-E stated if wheelchair cushion covers are dirty, they are sent to laundry for cleaning, then replaced when return from laundry. In an interview with the DON (Director of Nursing) on 11/29/2023 at 10:05 AM the DON stated wheelchairs are cleaned on a weekly schedule by the night shift nursing staff. The DON stated this is tracked in a book that is kept at the nurse's station. DON stated the facility does not have a wheelchair cleaning policy or procedure. DON unable to provide documentation of Residents #4, #45, and #16's wheelchairs being cleaned in the last 60 days. In a record review of the wheelchair owner's manual for Resident #45 and #16 wheelchairs reflected to clean painted surfaces with a mild soap or detergent. In a record review of the Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Update: May 2019, section labeled Recommendations for Disinfection and Sterilization in Healthcare Facilities, revealed in item four letter c Ensure that, at a minimum, non-critical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly).

Licensure Reference Number: 175 12-006.11E Based on record review, observations, and interview; the facility failed to test the 146 Multi Quat sanitizer solution according to manufacturer's recommendations prior to use when sanitizing surfaces and equipment in the kitchen. This had the potential to cause foodborne outbreak for all residents in the facility. The facility identified a census of 57. Findings are: Interview with Dietary Cook -E (DC-E) on 11/7/22 at 1:50 PM confirmed that the Multi Quat sanitizer solution is used in both kitchens. Interview with the Maintenance Superviser (MS) on 11/7/22 at 1:55 PM confirmed that the facility follows manufacturer's recommendation for the sanitizer solution and this is used as their policy and procedure. Record review of the aide daily cleaning schedule logs for the month of October 2022, revealed the Sanitizer solution testing had not been completed for the entire month. Interview with DA-F on 11/7/22 at 2:38 PM revealed they test the solution like once a week and they are probably not recording it because the top cover is missing. Interview with the MS on 11/7/22 at 2:35 PM confirmed the test strips for the 146 Multi Quat Sanitizer were open and the top cover of the strip case was missing, which is where the color code of the test strips is located. MS stated I'm not sure the test strips are working. Interview with the Dietary Manager (DM) on 11/7/22 at 2:40 PM confirmed the sanitizer solution was not being tested prior to use.

Based on record review and interview the facility failed to ensure that staff Covid-19 testing was completed as required for 3 sampled facility staff to prevent the potential for Covid-19 infection. The facility census was 57. Findings are: A. Record review of the facility Covid-19 Vaccine Mandate Policy and Procedure dated 10/5/22 revealed that all eligible team members are vaccinated against Covid-19 pursuant to applicable federal, state, and local guidelines including regulations issued by the Centers for Medicare and Medicaid Services (CMS). All team members are required to receive vaccinations as determined by CMS unless an exemption is approved and the team member accepts a reasonable accommodation. Team members, who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated against Covid-19. The facility will implement additional precautions to mitigate the transmission and spread of Covid-19 for all staff who are not fully vaccinated for Covid-19 including but not limited to Covid-19 testing once per week. Interview on 11/7/22 at 1:36 PM with the facility Director of Nursing (DON) confirmed that routine staff testing for Covid-19 had changed as of 10/24/22. The DON confirmed that the Covid-19 Vaccine Mandate Policy and Procedure was updated to reflect the CMS changes for staff Covid-19 testing that went into effect on 10/24/22. The DON confirmed that the facility was conducting Covid-19 testing for not up to date staff (staff that had an exemption from being vaccinated for Covid-19 and staff that had not received eligible Covid-19 booster vaccination) two times weekly prior to 10/24/22 to mitigate the transmission and spread of Covid-19. Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Nursing Assistant-A (NA-A) had a facility approved exemption from being vaccinated for Covid-19. NA-A was required to be tested two times a week for Covid-19 prior to 10/24/22. Interview on 11/7/22 at 1:41 PM with NA-A confirmed that NA-A had an exemption from Covid-19 vaccination and was not vaccinated for Covid-19. NA-A revealed that staff not vaccinated for Covid-19, including NA-A, were required to be tested for Covid-19 two times per week prior to 10/24/22. NA-A revealed that starting 10/24/22 NA-A is now only required to be tested for Covid-19 one time per week. Record review of the undated Staff POC (Point of Care) Testing Results (a log of Covid-19 test results for tests performed by the facility) from 9/1/22 to 11/7/22 revealed that NA-A was tested for Covid-19 on 9/2/22 (negative result), 9/8/22 (negative result) (6 days after the previous test on 9/2/22. The only test performed for the week of 9/4/22 through 9/10/22), 9/13/22 (negative result), 9/15/22 (negative result), 9/19/22 (negative result), 9/22/22 (negative result), 9/26/22 (negative result), 9/29/22 (negative result), 10/6/22 (negative result) (7 days after the previous test on 9/29/22. The only test performed for the week of 10/2/22 through 10/8/22), 10/9/22 (negative result) (the only test performed for the week of 10/9/22 through 10/15/22), 10/18/22 (negative result) (9 days after the previous test. The only test performed for the week of 10/16/22 through 10/22/22), 10/24/22 (negative result) (6 days after the previous test), 11/3/22 (negative result). NA-A was not tested for Covid-19 twice per week as required. Record review of the undated Timecard for NA-A revealed that between 9/2/22 (date of previous test for Covid-19) and 9/10/22 NA-A worked on 9/2/22, 9/3/22, 9/4/22, 9/7/22, and 9/8/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 9/4/22 through 9/10/22. NA-A was not tested for Covid-19 two times per week as required the week of 9/4/22 through 9/10/22. Record review of the undated Timecard for NA-A revealed that between 9/29/22 (date of previous test for Covid-19) and 10/8/22 NA-A worked on 9/29/22, 9/30/22, 10/1/22, 10/2/22, 10/4/22, 10/5/22, 10/6/22, 10/7/22, and 10/8/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 10/2/22 through 10/8/22. NA-A was not tested for Covid-19 two times per week as required the week of 10/2/22 through 10/8/22. Record review of the undated Timecard for NA-A revealed that between 10/6/22 (date of previous test for Covid-19) and 10/15/22 NA-A worked on 10/6/22, 10/7/22, 10/8/22 10/9/22, 10/10/22, 10/12/22, 10/13/22, and 10/14/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 10/9/22 through 10/15/22. NA-A was not tested for Covid-19 two times per week as required the week of 10/9/22 through 10/15/22. Record review of the undated Timecard for NA-A revealed that between 10/9/22 (date of previous test for Covid-19) and 10/22/22 NA-A worked on 10/9/22, 10/10/22, 10/12/22, 10/13/22, 10/14/22, 10/18/22, 10/19/22, 10/20/22, and 10/21/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 10/16/22 through 10/22/22. NA-A was not tested for Covid-19 two times per week as required the week of 10/16/22 through 10/22/22. Interview on 11/7/22 at 4:37 PM with the DON confirmed the facility expectation is for unvaccinated staff to be tested for Covid-19 per the facility policy for unvaccinated staff which was two times per week prior to 10/24/22. The DON confirmed the expectation is for all facility staff to be vaccinated for Covid-19 or have an exemption from being vaccinated. B. Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Medication Aide-B (MA-B) received only the 2-dose primary vaccination for Covid-19. MA-B did not receive any booster vaccinations. MA-B was required to be tested two times a week for Covid-19 prior to 10/24/22 to mitigate the transmission and spread of Covid-19. Record review of the undated Staff POC (Point of Care) Testing Results (a log of Covid-19 test results for tests performed by the facility) from 9/1/22 to 11/7/22 revealed that MA-B had no documented Covid-19 testing performed. Interview on 11/7/22 at 1:36 PM with the DON revealed that MA-B was not feeling well so the facility directed MA-B to go get tested at their physician. The DON confirmed that MA-B went to their physician and was found positive for Covid-19 on 10/3/22. Record review of the undated Timecard for MA-B revealed that between 9/1/22 and 11/7/22 MA-B worked in the facility on 9/15/22, 9/16/22, 9/18/22, 9/22/22, 9/23/22, 9/24/22, 9/27/22, 9/30/22, 10/2/22, 10/3/22, 10/9/22, 10/10/22, 10/11/22, 10/13/22, 10/16/22, 10/17/22, 10/18/22, 10/22/22, 10/25/22, 10/26/22, 10/28/22, 10/29/22, 11/1/22, 11/4/22, and 11/6/22 and was available for Covid-19 testing. MA-B was not tested for Covid-19 two times per week as required between 9/1/22 and 10/3/22 (the date that MA-B tested positive for Covid-19). Interview on 11/7/22 at 11:15 AM with the facility Infection Preventionist (IP) confirmed that staff without Covid-19 booster doses were required to test two times per week before the CMS guidance for testing changed. C. Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Nursing Assistant-C (NA-C) received only the 2-dose primary vaccination for Covid-19. NA-C did not receive any booster vaccinations. NA-C was required to be tested two times a week for Covid-19 prior to 10/24/22 to mitigate the transmission and spread of Covid-19. Record review of the undated Staff POC (Point of Care) Testing Results (a log of Covid-19 test results for tests performed by the facility) from 9/1/22 to 11/7/22 revealed that NA-C was tested for Covid-19 on 9/3/22 (negative result), 9/6/22 (negative result), 9/8/22 (negative result), 9/12/22 (negative result), 9/15/22 (negative result), 9/19/22 (negative result) (The only test performed for the week of 9/18/22 through 9/24/22), 9/26/22 (negative result), 9/27/22 (negative result), 9/29/22 (negative result), 10/3/22 (negative result), and 10/6/22 (positive result). Record review of the undated Timecard for NA-C revealed that between 9/15/22 (date of previous test for Covid-19) and 9/24/22 NA-C worked in the facility on 9/15/22, 9/17/22, 9/19/22, 9/20/22, and 9/22/22 and was available for Covid-19 testing. NA-C was only tested on [DATE] for the week of 9/18/22 through 9/24/22. NA-C was not tested for Covid-19 two times per week as required the week of 9/18/22 through 9/24/22. Interview on 11/7/22 at 11:15 AM with the facility Infection Preventionist (IP) confirmed that staff without Covid-19 booster doses were required to test two times per week before the CMS guidance for testing changed.

Licensure Reference Number: 175 NAC 12-006.12B(5) Based on record review and interview, the facility failed to ensure Medication Regimen Reviews (MRR) identified potential unnecessary medications related to prophylactic antibiotic use for 1 of 5 residents reviewed (Resident 5). The facility census was 57. Findings are: Review of Resident 5 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 5's MRR progress notes revealed no notes regarding the rationale for the use of prophylactic antibiotics since 2019. Review of www.webmd.com article dated April 30, 2021 revealed; The biggest concern with prophylactic antibiotics is antibiotic resistance. Antibiotic resistance happens when germs such as bacteria and fungi learn to defeat the antibiotics that previously killed them. Interview on 11/07/2022 at 10:22 AM with the Infection Control Practitioner revealed the pharmacist has not been identifying prophylactic antibiotic use during the MRR process.

Based on record review and interviews, the facility failed to document the clinical rationale in Resident 49's medical record for the use of [MEDICATION(S)] (a medication used to treat anxiety disorders) as needed (PRN) with the order being longer than 14 days. This affected 1 (Resident 49) of 5 sampled residents. The facility identified a census of 57. Findings are: Record review of a Physician order dated 9/26/22 revealed there was no clinical rationale documented for the use of the PRN [MEDICATION(S)] 0.5 mg (milligrams), give 1 tablet by mouth every 12 hours as needed order for Resident 49, the order was written for 180 days. Record review of Resident 49's medication administration record for September 2022, revealed the PRN [MEDICATION(S)] 0.5 mg was administered to the resident 3 times in September 2022. Record review of the facility's Out of Character Response Prevention and Medication Managment policy with a revised date of 1/2017 revealed under Duration that the clincial rationale for continued use of a medication should be documented in the clinical record. Interview with the Assistant Director of Nursing (ADON) on 11/7/22 at 4:40 PM confirmed there was no clinical rationale documented for Resident 49's PRN [MEDICATION(S)] order dated 9/26/22.

Based on record review and interview, the facility failed to follow Antibiotic Stewardship polices [efforts to measure and improve how antibiotics are prescribed by clinicians and used by patients to protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance (when germs like bacteria develop the ability to defeat the drugs designed to kill them)] to review the need of antibiotic use for 2 residents (Residents 5 and 54) to prevent the potential for antibiotic resistance and the potential for adverse antibiotic side effects. The facility census was 57. Findings are: A. Review of Resident 5 Physician orders revealed Resident 5 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/07/2022 at 10:22 AM with the Infection Control Practitioner revealed the pharmacist has not been identifying prophylactic antibiotic use for antibiotic stewardship during the medication regimen review process. Review of a www.webmd.com article dated April 30, 2021, revealed; The biggest concern with prophylactic antibiotics is antibiotic resistance. Antibiotic resistance happens when germs such as bacteria and fungi learn to defeat the antibiotics that previously killed them. Review of the facility policy titled Antimicrobial Stewardship Program revised on 7/28/22 revealed: -The Antibiotic Stewardship Program (ASP) team will regularly review appropriateness of antibiotic courses and make recommendations for adjustment in practice where necessary, establish new or revise existing protocols relevant to appropriate antibiotic prescribing, monitor and report patterns of antibiotic use and resistance - the ASP aims to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. -The goal of the Antimicrobial Stewardship Program is to promote the appropriate us of antimicrobials to maximize treatment outcome and minimize unintended consequences of antimicrobial therapy. The ASP aims to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. Interview on 11/07/22 at 11:58 AM with the Infection Preventionist revealed the Antibiotic Stewardship program has not been tracking prophylactic antibiotic use. B. Resident 54 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) (a Federally mandated process for clinical assessment of residents) dated 10/18/22 revealed a Brief Interview for Mental Status (BIMS) (assessment to identify a resident's cognitive status) score of 15. This indicates this resident is cognitively intact. Record review of Physician Visit Notes revealed Resident 54 was seen on 9/28/22 by Resident 54's physician: The Plan included the following: Resident has some stress incontinence that is chronic. Denies any dysuria (painful urination) or foul odor. Resident has been very concerned about urine for years. The resident wonders if they should have serial UA's (urinalysis assessment) performed to ensure that the resident is not getting repeat infections. The physician discussed that unless the resident is having more symptoms, he does not recommend routine UA's. The physician asked that the resident inform nursing staff if develops any further symptoms. Record review of a Physician Visit/Communication form dated 10/7/22 revealed the Physician was notified that the resident reported having to use an incontinence pad in the residents brief now, and was having new incontinence of urine and frequency. The resident denied pain with urination and was afebrile. Resident requested a UA. No SBAR (a communication tool used to notify the physician of Situation Background Assessment Recommendation), was found. The physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of lab results for the UA dated 10-8-22 revealed negative Nitrates (which can indicate an infection if positive), 3+ Bacteria and White Blood Cells. The Physician ordered [MEDICATION(S)] (an antibiotic used to treat different types of infections) 300 milligram (mg) orally twice a day (BID) for 7 days, without the documentation of the clinical rationale for use. Record review of the UA and culture results dated 10/11/22 revealed the specimen was likely contaminated from uro-genitalia (indicating the specimen that was collected was contaminated from improper cleansing of the female genitalia), and there was a <50,000 colony count of Streptococcus (a bacteria)(cultures that are less than 100,000 and are contaminated are not recommended to be treated). The Physician ordered to continue antibiotic without the documentation of the clinical rationale for use. Review of Electronic Medical Administration Record (EMAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for the month of October revealed [MEDICATION(S)] 300mg BID was taken from 10/8/22 to 10/15/22 for a total of 14 doses. Record review of a Urinary Tract Infection ([CONDITION(S)]) SBAR on 10/20/22 sent to the physician revealed Acute Dysuria (painful urination) alone marked as the only symptom. Recommendations on the SBAR were for the resident to have a UA with culture or an antibiotic. The physician ordered [MEDICATION(S)] (an antibiotic used to treat infections) 875 mg/125 mg orally BID for 7 days. This was ordered without clinical rationale for use. Further review of the SBAR tool for suspected Urinary Tract Infection revealed that there was criteria that was to be followed prior to initiating antibiotics, the criteria on this SBAR tool was incorrect as the resident had been having dysuria off and on for over 3 weeks. Record review of Progress Notes from 10/7/22 to 10/20/22 revealed that the Resident had been having dysuria off and on for over 3 weeks. Record review of EMAR for the month of October revealed [MEDICATION(S)] 875-125 mg BID was taken from 10/21/22 to 10/27/22, for a total of 14 doses. Interview with Resident 54 on 11/02/22 at 09:50 AM, revealed that the resident had been having diarrhea for 3 days and stomach felt gurgly. Interview with Resident 54 on 11/02/22 01:59 PM revealed the resident thinks the loose stools were possibly from the antibiotics. Resident is independent with hygiene toileting and uses prevail wipes for hygiene, and wears incontinent pads. The Resident stated the staff does not assist with toileting or hygiene. Interview with the Infection Preventionist (IP) on 11/08/22 at 08:20 AM confirmed that Resident 54 was on the [MEDICATION(S)] and [MEDICATION(S)] in October for [CONDITION(S)] without clinical rational. Interview with the IP on 11/08/22 at 8:51 AM confirmed there was no further documentation to support the clinical rationale or resident education (specifically for personal hygiene, antibiotic actions and side effects). Record review of the facilities Antimicrobial Stewardship Program with a revised date of 7/28/22 revealed: This multidisciplinary team will regularly review appropriateness of antibiotic courses and make recommendations for adjustment in practice. Interview with the IP on 11/8/22 at 8:51 AM confirmed that the multidisciplinary team did not review appropriateness of this residents' antibiotics. C. Interview on 11/7/22 at 10:19 AM with the facility Infection Preventionist (IP) confirmed that the facility had not reviewed prophylactic antibiotics (antibiotics given as a precaution to prevent, rather than treat, an infection). The IP revealed that the IP plans to visit about it with the Medical Director at the 11/17/22 Quality Assurance meeting. Interview on 11/7/22 at 4:37 PM with the facility Director of Nursing (DON) confirmed that the facility antibiotic stewardship program is to include review of prophylactic antibiotics. The DON revealed that the DON participates as part of the facility antibiotic stewardship committee. The DON confirmed that the antibiotic stewardship committee is to look at prophylactic antibiotic use.

Licensure Reference Number 175NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure that foods were served in a sanitary manner to prevent the potential for foodborne illness. This had the potential to affect all 35 residents on the Cubs and Schibe households. The facility census was 50. Findings are: Interview on 6/22/21 at 1:08 PM at the facility kitchen service galley with the Dietary Manager (DM) revealed that the temperatures of food items are obtained and documented prior to meal service. The DM revealed that the temperatures of food items at the end of meal service are not performed. The DM revealed that the facility had not performed any end of meal service food temperatures since the DM started as the Dietary Manager. The DM confirmed that obtaining temperatures of foods at the end of meal service would verify that the foods remained within the food safety temperature range to prevent foodborne illness. Observation on 6/16/21 at 11:21 AM in the facility kitchen revealed that Dietary Cook-F (DC-F) wet their hands at the sink next to the serving window and applied soap. DC-F scrubbed the hands with soap for 10 seconds and then rinsed and dried the hands. DC-F put on disposable gloves and began to open the steam trays on the steam table using the gloved hands to remove the aluminum foil coverings and the clear plastic wrap coverings. DC-F picked up scoops and placed them into the food steam pans to begin meal service. DC-F grabbed a plate with the gloved hand and the thumb and partial palm on the top of the plate. DC-F placed food items on the plate from the steam pans. DC-F handed the plate to Nursing Assistant-H (NA-H). DC-F plated the foods for the remaining residents and passed them through the service window. Interview on 6/22/21 at 1:08 PM at the facility kitchen service galley with the Dietary Manager (DM) confirmed that when performing hand washing the dietary staff are required to apply soap and scrub their hands with soap for at least 20 seconds before rinsing and drying the hands to prevent foodborne illness. The DM confirmed that staff are expected to perform hand washing prior to putting on disposable gloves and after removing disposable gloves. DM confirmed that staff are not to touch the top of the plates during meal service to prevent foodborne illness.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review; the facility failed to maintain a medication error rate below 5% with 5 errors out of 26 opportunities resulting in a medication error rate of 19.23%. This affected 3 of 7 residents observed, Residents 24, 27, and 101. The facility identified a census of 50 at the time of survey. Findings are: A. Observation of RN-A (Registered Nurse) on 6/21/21 at 11:04 AM revealed RN-A placed a needle and dialed a dose of 8 units of insulin on a pre-filled Novolog (a type of rapid acting insulin) insulin pen. RN-A then injected Resident 24 with the insulin at 11:08 AM. RN-A did not prime the pen after putting the needle on the pen before dialing the dose on the pen and administering the insulin to Resident 24. Resident 24 did not have any food in their room and RN-A did not offer them any food. At 11:16 AM Resident 24 was observed sitting in the dining room at the table. Resident 24 did not have any food or drink. At 11:20 AM Resident 24 received a glass of water and a glass of iced tea. At 11:30 AM Resident 24 received a cup of coffee. Interview with Resident 24 at this time revealed the drinks were unsweetened and had no nutritional value. At 11:45 AM Resident 24 received their food and started eating it at 11:47 AM, 39 minutes after Resident 24 received the insulin which resulted in 2 medication errors for not priming the insulin pen and not having food within the insulin onset parameter. B. Observation of RN-A on 6/22/21 at 7:16 AM revealed RN-A placed a needle and dialed a dose of 17 units of insulin on a pre-filled [MEDICATION(S)] (a type of rapid acting) insulin pen. RN-A then injected Resident 27 with the insulin at 7:18 AM. RN-A did not prime the pen after putting the needle on the pen before dialing the dose on the pen and administering the insulin to Resident 27. Resident 27 did not have any food and RN-A did not offer Resident 27 any food. At 7:32 AM, Resident 27 was observed sitting in their recliner in their room. Resident 27 did not have any food. At 7:54 AM, Resident 27 received a tray of breakfast food in their room, 36 minutes after receiving the insulin which resulted in 2 medication errors for not priming the insulin pen and not having food within the insulin onset parameter. C. Observation of RN-A on 6/22/21 at 7:31 AM revealed RN-A placed a needle and dialed a dose of 25 units of insulin on a pre-filled [MEDICATION(S)] (a type of long acting insulin) insulin pen. RN-A then injected Resident 101 with the insulin. RN-A did not prime the pen after putting the needle on the pen before dialing the dose on the pen and administering the insulin to Resident 101 which resulted in 1 medication error. Interview with the DON (Director of Nursing) on 6/22/21 at 9:46 AM revealed the facility nurses were expected to follow the facility policy and manufacturer's guidelines for priming the insulin pens and the administration of food in the time before the onset of action of the insulin. Review of the facility policy Insulin Administration, Home Care dated November 20, 2020 revealed the following: Rapid-Acting Analogs (aspart, glulisine, lispro) Onset within 15 minutes. Peak 60 minutes. Duration 2 to 4 hours. Nursing Considerations: Administered up to 15 minutes before a meal. Review of the manufacturer's classification for Novolog (insulin aspart) revealed the following: NovoLog® is fast-acting. Eat a meal within 5 to 10 minutes after taking it. [MEDICATION(S)] (insulin lispro): [MEDICATION(S)] is a fast-acting insulin-it helps control the blood sugar spikes that happen naturally when you eat. Review of the facility Prefilled Insulin Pen Competency dated 1/2020 revealed the following: Procedure step 10: To prime the pen, make sure the arrow is in the center of the dose window. 11. Pull the dose knob out in the direction of the arrow until a 0 is seen. 12. Turn the dose knob clockwise until the number 2 is seen. 13. Hold the pen with the needle pointing straight up, tapping the clear cartridge holder so any air bubbles collect near the top. Push the injection button completely using thumb. Keep pressing and continue to hold the injection button firmly. A stream of insulin should come out the tip of the needle.

Surveyor: [NAME], [NAME] LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to provide supervision to prevent falls for Residents 34, 44, and 28. Sample size was 4. The facility identified a census of 50 at the time of survey. Findings are: A. Review of Resident 28's SCSA (Significant Change in Status) MDS (Minimum Data Set) dated 5/4/2021 revealed an admitted [DATE]. Resident 28 had a BIMS score of 9 which indicated moderate cognitive impairment. Resident 28 required extensive assistance of 1 staff person to transfer and use the bathroom. Balance during transitions and walking was not steady. Resident 28 had 2 or more falls with injury since prior assessment. Interview with Resident 28's family on 6/17/21 at 8:59 AM revealed they were concerned about the number of falls Resident 28 has had. The family revealed the only intervention the facility implemented to prevent further falls was the staff reminded Resident 28 to push the call button. The family revealed they were not sure how effective that intervention was as Resident 28 did not remember to call and Resident 28 got up without waiting for help. The family revealed Resident 28 had a fall with a fractured ankle that was broken so severely that a surgeon had to be consulted, and another fall Resident 28's face got all bruised up. The family revealed Resident 28 had another fall a while back and Resident 28 continued to have rib pain so the staff were going to see if Resident 28 needed an x-ray to determine if Resident 28 had any broken ribs. The family revealed Resident 28 resided on the secure unit in the facility. Review of Resident 28's Progress Notes revealed the following documentation of 6 falls with no injury, 2 falls with injury, and 1 fall with major injury: -6/19/2021 09:34 Resident was heard scrambling through the monitor in (resident's) room. Staff went to check on (resident) and (resident) was sitting on (resident) bottom, scooting across the floor from (resident's) chair to the drawer in front of (resident's) bed. -6/16/2021 09:37 Resident had call light on, this nurse entered room to find (resident) sitting on floor with back against chair feet on floor with a bend in legs. Resident assisted off floor with 2 assist, full body lift onto bed. -3/27/2021 21:24 (Resident) was seen sitting on the window side of (resident's) bed in the floor with left foot outstretched in front of (resident) and (gender) right leg curled up behind (resident). (Resident) admits hitting (gender) face on the room heater unit. (Resident) has a 5 cm (centimeter) wide x 8 cm long hematoma to area above right eye. The front side of (resident's) nose has a laceration along its entire length and (resident) has another bruise to the left cheek measuring 2 cm x 1 cm. -3/20/2021 22:08 Heard resident yelling in (resident's) room and upon entering resident on (gender) knees. -3/20/2021 21:30 Observed resident kneeling on (resident) knees by (resident's) nightstand. 2 assist full body lift resident back to bed. -1/20/2021 16:20 Resident observed on bathroom floor lying on back with legs outstretched. Injuries noted to left ankle (swollen and discoloration) and laceration to back of head (measuring 1 cm x 0.2 cm). No shortening or rotation of extremities noted. Lifted to bed per full body lift with 2 assist. Area on back of head cleansed and patted dry, area will be monitored and measured weekly until healed. Family desires to send resident to ER (emergency room ) for additional assessment by provider. ER called at 1621. Verbal note received by Dr. to transfer resident. -1/20/2021 18:59 Resident returns to facility per facility van driver in wheelchair from ER with orders from the PA (Physician's Assistant) for: Bimalleolar (ankle) fracture of left ankle-place in boot. Can remove twice a day to clean and re-wrap ace wrap, otherwise on at all times. (Resident) needs to be completely NWB (Non-Weight Bearing) on that left side. (Resident) is going to be scheduled to follow-up with the orthopedist on 1/29. Continue to monitor for any concerns of neurological changes and notify if concerns. -12/23/2020 09:45 Resident observed lying on (gender) left side on floor at foot of bed. Noted redness to L) (left) inner thumb area 4 cm x 2 cm. -9/17/2020 06:30 Resident turned on call light for assistance. Upon entering bathroom observed resident sitting on the floor with (resident's) back towards (resident') walker. Resident assisted from floor with full body lift and 2 assist to bed. -7/16/2020 18:15 at 1815, resident called us on call light and resident was sitting on butt in the bathroom. Review of Resident 28's Progress Notes revealed the following documentation of Resident 28's attempts to transfer self without calling for assistance: -6/18/2021 17:39 Resident alert, up per usual routine, transfers & ambulates with 1 assist. Makes multiple attempts to transfer and ambulate unassisted and does not utilize call light to call for assist. Resident encouraged to call for assist with transfers & ambulation. -6/17/2021 20:26 (Resident) has made several attempts to self-transfer this evening. Resident reminded to wait for assistance. -6/17/2021 16:42 Resident alert, up per usual routine, transfers & ambulates with 1 assist. Makes attempts to transfer and ambulate unassisted and does not utilize call light to call for assist. Resident encouraged to call for assist with transfers & ambulation. Review of Resident 28's Care Plan dated 6/28/2019 revealed the following: Potential for falls related to history of falls and cognitive loss. Diagnosis of Anxiety Disorder, Hallucinations and Dementia. Bimalleolar fracture of left ankle on 1/20/2021. Interventions included anticipate and meet needs PRN (as needed); audio monitor at bedside; fall risk assessment quarterly and PRN; maintain environment free of clutter and safety hazards; pivot transfers with gait belt and one assist; place items frequently used by resident within easy reach, to avoid resident reaching for items; resident to be offered assistance to bed after meals; restorative program as indicated o Anticipate and meet (gender) needs PRN o Audio monitor at bedside o Fall risk assessment quarterly and PRN o Maintain environment free of clutter and safety hazards o Pivot transfers with gait belt and one assist. o Place items frequently used by resident within easy reach, to avoid resident reaching for items o Resident to be offered assistance to bed after meals o Restorative program as indicated o Therapy to screen and/or evaluate quarterly and PRN for assistive devices, strength, and mobility Review of Resident 28's Morse Fall Scales (a type of assessment used to determine fall risk) revealed the following: 6/19/2021 High Risk for Falling 75.0 3/20/2021 High Risk for Falling 55.0 1/20/2021 High Risk for Falling 80.0 9/17/2020 High Risk for Falling 55.0 8/26/2020 High Risk for Falling 55.0 B. Review of Resident 34's Quarterly MDS dated [DATE] revealed an admitted [DATE]. Resident 34 had no BIMS score as Resident 34 was rarely/never understood. Staff assessment for mental status indicated short term and long term memory problems and severely impaired cognitive skills for daily decision making. Resident 34 required extensive assistance of 2 staff for bed mobility and transfer. Balance during transitions and walking was not steady. Resident 34 had 2 or more falls with no injury and 1 fall with injury since the prior quarterly assessment. Observation of the secure unit on 06/21/21 at 9:04 AM revealed Resident 34 was asleep in a chair that was in the hall by their room. Observed a staff person coming down the hall with the lift and another staff person in a room with a resident out of view of Resident 34. Review of Resident 34's Progress Notes revealed Resident 34 had 11 falls documented on the following dates, 3 with injury: -6/16/2021 18:57 Resident found crawling on floor from (gender) chair to the nurses' station. Assisted resident up with 2 assist full body lift into wheelchair. -5/1/2021 02:10 CNA (Certified Nursing Assistant) took resident to BR (bathroom) and resident thought (gender) was over the toilet and sat before CNA could get (resident) over the toilet. CNA eased resident to the floor. -4/10/2021 12:50 Resident observed on the floor in hallway. Noted an abrasion to (resident's) left knee, bump to (resident's) forehead and abrasion/scrape to (resident's) nose. -2/19/2021 13:45 Resident observed on floor at this time. Resident laughs and states, I was just walking and went down, my legs were tired. Full body mechanical lift utilized to assist resident from the floor to wheelchair. -2/14/2021 12:25 Summoned to hallway by aide. Noted resident lying on back in hallway next to doorway with knees flexed and feet flat on floor with bedside table on abdomen. -2/10/2021 12:45 Summoned by med aide reporting of observing resident standing up and starting to ambulate, assisted back to chair and missed chair, and went down to the ground. Did note resident bumped head on side of bed side table. Did point to the right above ear and noted on (sic) redness or swelling. -1/7/2020 06:30 While walking down the hall heard noise from residents room. When entering resident was observed on floor sitting on bottom with legs in front of (resident) and knees bent. New areas noted to right arm. -8/12/2020 19:00 Resident observed on the floor in (resident) room. Will not leave resident in room in w/c (wheelchair) unattended. -8/1/2020 13:15 Summoned to hallway and noted resident on right side lying on arms with knees bent. Aide reported noted resident on hands and knees and then laid self down on floor. -7/31/2020 23:01 Resident was witnessed standing by the hallway chair and then (resident) went down onto one knee and then the other. (Resident) then leaned forward onto hands. During assessment (Resident) then laid down onto the floor. Hoyer (full body) lift was used to get resident up off of floor. -7/2/2020 18:10 MA came to this nurse and reported that resident was observed on knees next to bed and by the time staff got to bed resident had gotten off floor and up on bed by self. Review of Resident 34's Care Plan dated 4/5/2019 revealed the following: -History and/or has a potential for falls related to diagnosis of CVA, [CONDITION(S)], [CONDITION(S)] and cognitive loss due to Alzheimer's. Poor safety awareness. · Allow additional time for resident to adjust from lying to sitting prior to standing. · Ambulate with gait belt, front wheeled walker and one assist. · Anticipate and meet her needs PRN · Assist her with wheel chair when weak or dizzy. · Assist in day room chair after supper PRN · Assist in straight back chair in day room PRN · Ensure bedside table is cleared after meals as needed · Ensure properly-fitting non-skid footwear worn for ambulation · If resident sleeping in chair offer to lay down in bed. · Maintain environment free of clutter and safety hazards · Nursing staff to guide her to sit down on toilet · Nursing staff to guide her when sitting down in chair as needed · Nursing staff to toilet her after meals · Offer activities when restless · Offer activities when sitting in day room as needed · Offer fluids at night when rounding · Offer life enrichment activities such as photo books after lunch as needed. · Offer toileting when restless as needed · Place items frequently used by resident within easy reach, to avoid resident · Place walker in reach · Provide environment with adequate lighting, free of glare · Provide one on ones when restless · Restorative program as indicated · Take for a walk in w/c when restless · Therapy to screen and/or evaluate quarterly and PRN for assistive devices, · Treat UTI s/s · Utilize 2 assist with transfers PRN · Will not leave resident in her room in her w/c unattended when restless · Maintain her environment free of clutter and safety hazards PRN · Monitor for safety PRN Review of Resident 34's Morse Falls Scales revealed the following: 6/16/2021 High Risk for Falling 75.0 5/19/2021 High Risk for Falling 75.0 5/1/2021 High Risk for Falling 90.0 4/10/2021 High Risk for Falling 80.0 2/19/2021 High Risk for Falling 100.0 2/18/2021 High Risk for Falling 75.0 2/14/2021 High Risk for Falling 90.0 11/7/2020 High Risk for Falling 95.0 9/1/2020 High Risk for Falling 75.0 8/12/2020 High Risk for Falling 80.0 8/1/2020 High Risk for Falling 75.0 7/31/2020 High Risk for Falling 90.0 7/2/2020 High Risk for Falling 55.0 6/11/2020 High Risk for Falling 75.0 C. Review of Resident 44's annual MDS dated [DATE] revealed an admitted [DATE]. Resident 44 had no BIMS score as Resident 44 was rarely/never understood. Staff assessment for mental status revealed Resident 44 had severely impaired cognitive skills for daily decision making. Resident 44 required extensive assistance of 2 staff for transfers. Balance during transitions and walking indicated resident 44 was not steady. Review of Resident 44's Morse Fall Scales revealed the following: 6/1/2021 High Risk for Falling 75.0 3/4/2021 High Risk for Falling 75.0 2/17/2021 High Risk for Falling 60.0 1/28/2021 High Risk for Falling 75.0 12/7/2020 High Risk for Falling 75.0 10/27/2020 High Risk for Falling 75.0 10/18/2020 High Risk for Falling 75.0 9/14/2020 High Risk for Falling 75.0 6/26/2020 High Risk for Falling 75.0 5/30/2020 High Risk for Falling 90.0 5/21/2020 High Risk for Falling 75.0 3/31/2020 High Risk for Falling 75.0 1/15/2020 High Risk for Falling 75.0 11/25/2019 High Risk for Falling 50.0 10/14/2019 High Risk for Falling 75.0 Review of Resident 44's Care Plan dated 7/10/2019 revealed the following: ·Potential for falls related to history of falls, impaired mobility, impaired vision, impaired hearing and cognitive loss. Diagnosis of Alzheimer's Dementia. · Anticipate needs PRN · Assist with toileting (gender) before laying her down in bed PRN · Ensure (gender) has everything (gender) needs before leaving the room · Fall risk assessment quarterly and PRN · Nursing staff to move folding chair after they are done assisting the resident at meals. · Staff to provide activities when restless. · Therapy to screen and/or evaluate quarterly and PRN for assistive devices, strength, and mobility · Use two assist when assisting her out of bed in the mornings. Observation of Resident 44 on 6/17/21 at 2:38 PM revealed they resided on the secure unit in the facility. Review of Resident 44's Progress Notes revealed the following documentation Resident 44 had 4 falls in 4 months and was injured twice: -2/17/2021 18:45 Resident observed setting (sic) on floor leaning against chair. -1/28/2021 09:08 Resident was observed sitting on the floor in (resident's) room. (Resident) was sitting with back against bed and legs extended out in front of (gender). Resident was assessed for injuries, no s/s pain, and scrape to left side of back 4 x 2.8 cm. -10/27/2020 17:27 Resident observed sitting on buttocks on the floor in (resident) room. (Resident's) back was facing the door. -10/18/2020 14:15 Aide summoned nurse to room and observed resident lying on the floor on left side next to bed. Admits to pain to left hand and noted scattered bruises to the back of hand and wrist 21 x 7 cm. Interview with MA-C (Medication Aide) on 06/21/21 at 3:52 PM revealed they worked on the secured unit. MA-C revealed residents who were at risk for falls or elopement needed supervision and redirection. Record review of the facility Room Assignments Resident Roster dated 6/14/2021 revealed 14 residents resided on the secure unit. Observation of the Memory Support secure unit on 6/16/21 at 4:14 PM revealed the following: Resident 37 was up in their room and appeared unsteady. NA-B (Nurse Aide) just come out of a resident's room with the lift at the other end of the unit. Interview with NA-B at this time revealed Resident 37 was not supposed to be up unattended. As NA-B walked down the hall to tend to Resident 37, Resident 35 was observed standing by their room door holding onto the door frame. NA-B asked Resident 35 where their walker was. NA-B went into Resident 35's room and got the walker and gave it to Resident 35 and the resident proceeded to walk around the unit with the walker. NA-B then went and checked Resident 37 who was now seated in the chair in their room with their room door closed. When inquired who was staffed on the unit at that time, NA-B revealed it was just them and the nurse on the unit at that time to care for the residents. At 4:26 PM, Resident 34 was observed crawling on the floor in the hallway between their room and the dining room. No staff were present in the area. Voices could be heard from Resident 15's room with the door closed. Staff were in Resident 15's room and NA-B and LPN-D (Licensed Practical Nurse) were observed lowering Resident 15 into their wheelchair with the lift. When they were informed Resident 34 was crawling on the floor, LPN-D came out of Resident 15's room and waited with Resident 34 as they continued to crawl on the floor down the hall while NA-B finished assisting Resident 15. Interview with LPN-D on 6/16/21 at 4:52 PM revealed they had to use the full lift to get Resident 34 up off the floor. Interview with the DON (Director of Nursing) on 6/22/21 at 9:46 AM revealed the following: A nurse, MA, and NA or sometimes a nurse and 2 nurse aides were staffed on the secured unit. The staff were supposed to call the DON, MDSC (Minimum Data Set Coordinator) or the Life Enrichment staff if they needed help on the unit. The DON revealed no one called them for assistance on 6/16/21 from 4:14-4:52PM while Resident 34was on the floor and the other 2 unsteady residents were observed and when staff were not present. Review of the facility policy Fall Prevention/Management Standard dated 2/2019 revealed the following: Falling is a significant cause of injury and death in our elders. Falls are also the most common cause of non-fatal injuries and hospital admission for trauma. Reducing falls creates a significant challenge and requires interdisciplinary evaluation and intervention. All efforts should focus on minimizing fall risk while maximizing resident dignity and quality life. Each resident will receive adequate supervision and assistance to prevent accidents.

Licensure Reference Number 175NAC 12-006.05(21) Based on observation and interview, the facility failed to ensure resident dignity in the dining room by exposing residents' mechanical lift slings (a fabric device with straps that is placed underneath a resident when a mechanical assistive device is used to transfer a resident with difficulty or the inability to stand up on their own from a seated or lying position) and addressing residents with endearing names. This affected 3 residents (Residents 32, 30, and 33). The facility census was 50. Findings are: A. Observation on 6/16/21 at 11:30 AM in the facility Cub/Schibe dining room revealed that Resident 32 sat in a wheelchair at a dining room table. The resident's mechanical lift sling hung outside of the wheelchair on the resident's left side from the buttock to over the wheelchair back with approximately 5 inches visible. The visible mechanical lift sling hook hung from behind the resident's right shoulder over the back of the wheelchair approximately 14 inches outside the wheelchair. The mechanical lift sling hung visibly outside the wheelchair from the resident's right shoulder all the way down the right side of the resident's torso. Observation on 6/16/21 at 11:30 AM in the facility Cub/Schibe dining room revealed that Resident 30 sat in a wheelchair at a dining room table. The resident's mechanical lift sling hung outside the wheelchair with approximately 5 inches of the mechanical lift sling visible from behind the resident's left shoulder along the back of the wheelchair and all the way down the resident's right side. The mechanical lift sling hooks hung outside of the back of the wheelchair visibly for approximately 7 inches. Observation on 6/17/21 at 7:25 AM in the Cubs/Schibe dining room revealed that Resident 32 sat in a wheelchair at a dining room table. The resident's mechanical lift sling hung outside of the wheelchair with approximately 3 inches visible outside of the back of the wheelchair continuing along the left side of the resident's torso. The visible mechanical lift sling hook hung from behind the resident's right shoulder over the back of the wheelchair approximately 11 inches outside of the wheelchair. Observation on 6/17/21 at 7:25 AM in the Cubs/Schibe dining room revealed that Resident 30 sat at a dining room table in a wheelchair. The mechanical lift sling hung outside the wheelchair with approximately 4 inches visible outside the wheelchair on each side of the resident torso and over the top of the wheelchair back. The mechanical lift sling hooks hung outside the back of the wheelchair visibly for approximately 18 inches. Observation on 6/17/21 at 11:08 AM in the Cubs/Schibe dining room revealed that Resident 32 sat in a wheelchair at a dining room table. The resident's mechanical lift sling hung outside of the wheelchair with approximately 4 inches hanging visibly outside the wheelchair on both sides of the resident's torso and along the top of the back of the wheelchair. A visible mechanical lift sling hook hung over the back of the wheelchair with approximately 14 inches outside of the wheelchair. Observation on 6/17/21 at 11:08 AM in the Cubs/Schibe dining room revealed that Resident 30 sat in a wheelchair at a dining room table. The mechanical body lift sling hung outside the wheelchair on both sides of the resident's torso. The top mechanical lift sling hooks hung visibly over the back of the wheelchair with approximately 18 inches in view outside of the wheelchair. Observation on 6/17/21 at 2:30 PM in the Cubs/Schibe dining room revealed that Resident 30 sat in a wheelchair at table 10 (in the usual position of Resident 24 on the dining room seating chart) playing BINGO. The back of the resident's wheelchair faced the Schibe household. The mechanical lift sling hung visibly outside the wheelchair on both sides of the back of the wheelchair. The mechanical lift sling hooks hung from outside each side of the wheelchair back with approximately 16 inches visible. An unidentified visitor walked around the corner of the kitchen to the dining room on the Schibe household entry side. The visitor looked around at the residents in the dining room playing BINGO. The mechanical lift sling of Resident 30 was visible to the visitor. The visitor then walked toward the Schibe household nurse's station and continued to room [ROOM NUMBER] (room of Resident 6). The visitor knocked on the resident's door and entered the room of Resident 6. Observation on 6/21/21 at 7:48 AM in the Cubs/Schibe dining room revealed that Resident 32 sat in a wheelchair at a dining room table. The mechanical lift sling hung outside the wheelchair on both sides of the resident torso. The visible mechanical lift sling hooks hung outside the back of the wheelchair for approximately 11 inches on each side of the back of the wheelchair. Observation on 6/21/21 at 7:48 AM in the Cubs/Schibe dining room revealed that Resident 30 sat in a wheelchair at a dining room table. The mechanical lift sling hung outside the wheelchair along both sides of the resident's torso. The visible mechanical lift sling hooks hung down out of each side of the back of the wheelchair for approximately 12 inches. Observation on 6/22/21 at 8:23 AM in the Cubs/Schibe dining room revealed that Resident 32 sat in a wheelchair at a dining room table. The mechanical lift sling hung visibly outside of the wheelchair on both sides of the resident's torso. The visible right and left mechanical lift sling hooks hung outside the back of the wheelchair seat behind the wheelchair with approximately 24 inches of each strap showing. Observation on 6/22/21 at 8:23 AM in the Cubs/Schibe dining room revealed that Resident 30 sat in a wheelchair at a dining room table. The visible mechanical lift sling hung outside of the wheelchair on both sides of the resident's torso. The left mechanical lift sling hook hung down behind the wheelchair visibly for approximately 30 inches. The right mechanical lift sling hook hung down behind the wheelchair visibly for approximately 12 inches. Observation on 6/22/21 at 8:25 AM in the Cubs/Schibe dining room with the facility Interim Director of Nursing (DON) confirmed that the mechanical lift slings were visible for both Resident 32 and Resident 30. Interview on 6/22/21 at 8:25 AM in the Cubs/Schibe dining room with the DON confirmed that the mechanical lift slings are to be tucked in so they are not visible to maintain resident dignity. Interview on 6/22/21 at 1:08 PM at the facility kitchen service galley with the Dietary Manager (DM) confirmed that resident mechanical lift slings should be tucked in so that they are not visible for resident dignity. B. Observation on 6/17/21 at 11:47 AM in the Cubs/Schibe dining room revealed that Dietary Staff (DS) carried a plate of food from the kitchen service galley to the table of Resident 33. DS sat the plate on the table in front of Resident 33 and told the resident Here you go dear. Interview on 6/22/21 at 1:08 PM at the facility kitchen service galley with the Dietary Manager (DM) confirmed that staff should not call residents endearing terms such as dear as it is a dignity issue. The DM revealed that the DM would visit with the dietary staff about resident dignity and not using endearing terms.

Licensure Reference Number 175NAC 12-006.09D Based on observation, interview and record review; the facility failed to ensure that the medical provider responded to the consultant pharmacists' request for a Gradual Dose Reduction (GDR) (the periodic physician review of the amount of an antipsychotic medication to consider a decrease in the amount of the medication). This affected 1 resident (Resident 16). This had the potential for Resident 16 to experience adverse health effects. The facility census was 50. Findings are: Record review of the Admission Record for Resident 16 revealed that Resident 16 admitted to the facility on [DATE]. Primary diagnosis is dementia with behavioral disturbance. Additional diagnoses included anxiety, heart failure, and long term drug therapy. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 8/3/20 revealed that Resident 16 had severely impaired cognitive skills (skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. Section I (Active Diagnoses) revealed that Resident 16 had dementia and anxiety disorder. Section N (Medications) revealed that Resident 16 received an antipsychotic (medications used to manage delusions, hallucinations, paranoia or disordered thought) medication, an antianxiety medication, and an antidepressant medication. Record review of the Order Recap Report (a report showing resident medication order details and changes) revealed that Resident 16 had an order for [MEDICATION(S)] (an antipsychotic medication) ordered on 8/1/20. Resident 16 had an active order for [MEDICATION(S)] (an antianxiety medication) ordered on 7/27/20. Record review of the Order Summary (a report of all active physician orders for a resident) revealed that Resident 16 had an order for [MEDICATION(S)] (an antidepressant medication) that was ordered on 7/27/20. Record review of the Nursing 2018 Drug Handbook page 1275 for the medication [MEDICATION(S)] revealed the alert to watch for extrapyramidal effects (medication side effects including continuous muscle spasms or contractions and can include repetitive muscle movements of the face and mouth). Observation on 6/17/21 at 11:01 AM in the resident room revealed that Resident 16 sat in the wheelchair. The resident's eyes were closed. Both of the resident's arms shook underneath the lap blanket. Resident 16's mouth was closed and continual visible movements of the mouth included lateral movement and chewing movement. Record review of the Abnormal Involuntary Movement Scale (AIMS) (a rating scale that was designed in the 1970s to measure involuntary movements that sometimes develop as a side effect of long-term treatment with antipsychotic medications) for Resident 16 dated 8/6/20 revealed that Resident 16 had moderate jaw movements identified. The AIMS did not identify any movements of facial expression. Record review of the Abnormal Involuntary Movement Scale (AIMS) for Resident 16 dated 4/16/21 revealed that Resident 16 had moderate jaw movements identified. The AIMS now identified that Resident 16 had moderate movements of facial expression. The AIMs now identified moderate movements of the lips and the area around the lips. Record review of the Consultant Pharmacist letter to the physician of Resident 16 dated 12/7/20 revealed that Resident 16 had orders for the [CONDITION(S)] medication [MEDICATION(S)] 25 milligrams (an antipsychotic medication) twice daily. The letter revealed that regulations require periodic review and Gradual Dose Reductions if clinically appropriate. The pharmacist requested that the physician evaluate the resident's current medical status and initiate any dosage reductions which may be appropriate. The letter documented the physician's response dated 12/11/21 that the physician did not wish to attempt a dose reduction as it is clinically contraindicated due to clinical worsening. Record review of the Consultant Pharmacist Medication Regimen Review Recommendations dated 1/15/21 revealed a letter to be sent to the physician of Resident 16. The letter revealed that Resident 16 had orders for the [CONDITION(S)] medication [MEDICATION(S)] 25 milligrams (an antipsychotic medication) twice daily. The letter revealed that regulations require periodic review and Gradual Dose Reductions if clinically appropriate. The facility was not able to provide the physician's documentation that a physician reviewed and sent a response to the 1/15/21 request to consider a gradual dose reduction. Record review of the Consultant Pharmacist letter to the physician of Resident 16 dated 1/15/21 revealed that Resident 16 had orders for the [CONDITION(S)] medication [MEDICATION(S)] 0.25 milligrams (an antianxiety medication) three times daily. The letter revealed that regulations require periodic review and Gradual Dose Reductions if clinically appropriate. The pharmacist requested that the physician evaluate the resident's current medical status and initiate any dosage reductions which may be appropriate. The facility was not able to provide the physician's documentation showing that a physician reviewed and sent a response to the 1/15/21 request to consider a gradual dose reduction. Record review of the Consultant Pharmacist letter to the physician of Resident 16 dated 2/19/21 revealed that Resident 16 had orders for the [CONDITION(S)] medication [MEDICATION(S)] 0.25 milligrams (an antianxiety medication) three times daily. The letter revealed that regulations require periodic review and Gradual Dose Reductions if clinically appropriate. The pharmacist requested that the physician evaluate the resident's current medical status and initiate any dosage reductions which may be appropriate. The letter documented the physician's response dated 3/5/21 that the physician did not wish to attempt a dose reduction as it is clinically contraindicated due to clinical worsening. Record review of the Consultant Pharmacist letter to the physician of Resident 16 dated 1/15/21 revealed that Resident 16 had orders for the [CONDITION(S)] medication [MEDICATION(S)] 40 milligrams (an antidepressant medication) once daily. The letter revealed that regulations require periodic review and Gradual Dose Reductions if clinically appropriate. The pharmacist requested that the physician evaluate the resident's current medical status and initiate any dosage reductions which may be appropriate. The facility was not able to provide the physician's documentation that a physician reviewed and sent a response to the 1/15/21 request to consider a gradual dose reduction. Record review of the Consultant Pharmacist Medication Regimen Review Recommendations dated 2/19/21 revealed a letter to be sent to the physician of Resident 16. The letter revealed that Resident 16 had orders for the [CONDITION(S)] medication [MEDICATION(S)] 40 milligrams (an antidepressant medication) once daily. The letter revealed that regulations require periodic review and Gradual Dose Reductions if clinically appropriate. The facility was not able to provide the physician's documentation that a physician reviewed and sent a response to the 2/19/21 request to consider a gradual dose reduction. Interview on 6/22/21 at 4:40 PM with the facility Minimum Data Set Coordinator (MDSC) confirmed that the facility is required to ensure that the physician responded to the requests for gradual dose reductions. The MDSC revealed that the Consultant Pharmacist letters are faxed to the physician and kept at the nurse's station until a response is received from the physician. The MDSC confirmed that the facility was not able to find the physician documentation showing that the physician reviewed the gradual dose reduction requests for the [MEDICATION(S)] requested on 1/15/21, the request for [MEDICATION(S)] on 1/15/21, or the request for [MEDICATION(S)] on 1/15/21 and 2/19/21.

LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D Based on interview and record review; facility failed to assess a change of condition and notify the medical provider to obtain treatment. This affected 1 of 1 sampled resident (Resident 165). The facility identified a census of 65 at the time of survey. Findings are: Record review of Resident 165's Progress Notes revealed Resident 165 was admitted to the facility on [DATE] at 2:45 PM from the hospital. Resident 165 was oriented to person, place, time, situation and Resident 165's breath sounds were clear bilaterally. On [DATE] at 6:51 PM, Resident 165 had an episode in which they choked on a jelly bean and Resident 165 was observed at supper noted to have increased amount of coughing with eating and drinking. Resident 165's family member reported Resident 165 became dusky and lethargic but did not have L[NAME] (Loss of Consciousness). On arrival of nurse resident noted to be listed with head back, loose cough noted . Chest: basilar rales (lung sounds coarse in the bases) bilaterally. O2 (oxygen) 3L (liters)/NC (per nasal cannula) had been in place entire time. O2 sats (Oxygen Level) 94%. No temperature was documented. On [DATE] at 21:54 (9:54 PM) Resident 165's lung sounds were coarse, an abnormal finding. No oxygen level or temperature was documented. There was no documentation the medical provider was notified Resident 165 continued to have coarse lung sounds after choking on the jelly bean at 6:51 PM. On [DATE] at 5:20 AM Nursing entered Resident 165's room and found Resident 165 in bed, cool to touch, no pulse or respirations. Time of death was 0524 (5:24 AM). PA-J (Physician's Assistant) notified, order received to release body. There was no documentation CPR was attempted. There was no documentation Resident 165 was assessed from 9:54 PM to 5:20 AM when they were found deceased . Review of Resident 165's Weights and Vitals Summary printed [DATE] revealed no documentation Resident 165's VS (Vital Signs-temperature, blood pressure, pulse, respirations) were checked after 15:19 (3:19 PM) on [DATE]. Review of Resident 165's Care Plan dated [DATE] revealed Resident 165 had a Code Status of CPR. Attempt Resuscitation. Review of Resident 165's POLST (Physician order [REDACTED]. A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for [REDACTED]. Under the section Medical Interventions: Full Treatment is marked. Primary goal of prolonging life by all medically effective means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. The Selective Treatment options indicated were use medical treatment, IV antibiotics, and IV fluids as indicated. The Comfort-Focused Treatment Options indicated relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of [REDACTED]. There was no documentation the POLST had been changed or revoked prior to Resident 165 being found deceased . Review of Resident 165's Visit/Communication form dated [DATE] at 19:18 PM (7:18 PM) revealed that it was sent to PA-I . The last vitals were taken at 3:18 PM. PA-I wrote on the form on [DATE] that patient expired. There was no documentation PA-I was aware of Resident 165's condition before becoming aware that Resident 165 had expired. Interview with the DON on [DATE] at 10:51 AM revealed Resident 165's Visit/Communication form had been faxed to the medical provider. The DON could not confirm the fax got to the provider at the time it was sent and the DON confirmed it was a concern that it could have sat in the fax machine until someone saw it the next day as it was faxed to the provider after hours. The DON revealed they checked the 24 hour report sheet and there was no documentation of any other assessment or that the provider was notified by phone of Resident 165's condition. The DON confirmed they would expect the nurses to call the provider and not fax and the nurses were expected to do a follow up assessment. The DON revealed the facility did not have a policy or competency for the nurses for potential aspiration care or a potential aspiration protocol after a choking episode. Interview with RN-D (Registered Nurse) on [DATE] at 9:56 AM revealed if a resident choked they would do the [MEDICATION NAME] if needed. RN-D revealed they would assess the resident and notify administration and family. RN-D revealed they would notify the Dr. and see how long they needed to monitor their VS (Vital Signs) and lungs for signs of aspiration. RN-D revealed they would also ask speech therapy to screen them and get speech therapy orders. RN-D revealed they would also put it on the 24 hour report sheet so the on coming nurses know to monitor the resident.