Every finding on record at Brookestone Gardens

Based on observation, record review and interview; the facility failed to ensure the daily posting of nursing hours included the required information. This had the potential to affect all residents. The facility census was 50. Findings are:An observation on 12/10/25 at 2:00 PM revealed, the staff posting titled, Nursing Staff Information form was at the front entrance receptionist desk and was missing the date and the census for the day. An observation on 12/11/25 at 7:25 AM revealed the staff posting titled, Nursing Staff Information form was at the front entrance receptionist desk and was missing the date and the census for the day. An observation on 12/15/25 at 7:20 AM revealed, the staff posting titled, Nursing Staff Information form was at the front entrance receptionist desk and was missing the date and the census for the day. An observation on 12/16/25 at 7:30 AM revealed, the staff posting titled, Nursing Staff Information form was at the front entrance receptionist desk and was missing the date and the census for the day. A record review of the staff posting revealed the facility name, the shift hours, number of team members and staffing hours total. The bottom of the form has a revision date of 9/2025, however missing the date and the census. An interview on 12/16/25 at 10:57 AM with the facility Staff Development Nurse (SDN) confirmed that the requested Nursing Staff Information daily forms did not include the census and were undated. The SDN confirmed that the SDN wrote the dates on the provided copies of Nursing Staff Information forms provided to the surveyors. The SDN revealed that the daily sheets, which include the census are dated and the Nursing Staff Information forms are stapled to them the following day or next business day and filed. The SDN revealed that is how the SDN knew what date to document on each of the forms. Further interviews with the SDN confirmed the staff postings did not have the required documentation.

Licensure Reference Number 175 NAC 12-006.09(F)(i)Based on record review and interview the facility failed to review the required baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) with the resident/resident representative and failed to offer a copy of the summary of the baseline care plan to the resident/resident representative prior to the completion of the comprehensive care plan (a detailed written interdisciplinary comprehensive plan to meet the resident's needs that are identified in the resident's comprehensive assessment covering all of a resident's medical, emotional, and lifestyle health needs) for 6 of 6 residents reviewed (Residents 5, 17, 3, 55, 7, and 40). The facility census was 50.Findings are:Record review of the facility Baseline Care Plan (BCP) Guidelines dated 3.2021 revealed that the baseline guidelines were to be completed per the Nebraska state guidelines which requires them to be completed within 24 hours, rather than the federally mandated 48 hours. An Interdisciplinary team member would review the baseline care plan summary with the resident/representative prior to the completion of the Comprehensive Care Plan (policies of this category are designed to provide coverage for one or more necessary or medically necessary diagnostic, preventative, therapeutic, rehabilitative, maintenance, or personal care services, provided in a nursing home setting) (7 days from when the minimum data set (MDS) (a standardized, comprehensive health assessment tool for residents in Medicare/Medicaid-certified nursing homes, used to capture their health, functional, cognitive, and psychosocial status for care planning, quality improvement, and determining government reimbursement) data was signed). The policy further stated that the signed Care Plan Acknowledgement Form was to be scanned to verify the baseline care plan review was done with the resident/resident representative. The only reason the baseline care plan would not be reviewed and signed would be due to an unplanned discharge. If the resident or the representative prefers not to have a copy of the baseline care plan, this is to be documented in the progress notes and note that the copies were declined. Record review of an undated blank admission Agreement given to all new residents revealed under Services subheading C. Baseline Care Plan. Within 24 hours of your admission, the Facility will develop a baseline care plan. The baseline care plan will include instructions needed to provide you effective person-centered care. The baseline care plan will address, at a minimum, your initial goals based upon you admission orders, physician orders, dietary orders, therapy services, social services, and any applicable pre-admission screening and annual resident review recommendations, if applicable. The facility will provide you and/or your representative with a summary of the baseline care plan prior to the completion of the comprehensive care plan. In an interview with the Social Services Director (SSD) on 12/11/2025 at 11:55 PM it was revealed that when a resident is admitted to the facility, the baseline care plan is completed within 24 hours by the nursing staff. There are others that will add to it as needed, but the baseline care plan is reviewed by the Director of Nursing (DON) who will then use this with the team to create the comprehensive care plan. In a confirmation interview with the DON on 12/11/2025 at 12:15 PM it was revealed that the baseline care plans are completed within 24 hours of arrival of the new resident. The DON then reviews the baseline care plans over a 3 to 7 day period before locking the care plan so no more changes can be made. It is reviewed within that first week of the new resident's entrance. We then complete the resident assessment, complete a comprehensive care plan, schedule a meeting with the resident and/or resident representatives and give them a copy of the care plan at that meeting. The DON confirmed that the family nor the resident receive a copy of the baseline care plan within 24 hours or prior to the first care plan meeting when the comprehensive care plan is discussed. A. Record review of the baseline care plan signed and dated on 02/21/2025 by Resident 5 and co-signed by the Social Services Director (SSD) revealed that Resident 5 was admitted to the facility on [DATE]. The DON signed the baseline care plan on 04/30/2025. The baseline care plan revealed that Resident 5 had diagnoses for malignant neoplasm of the endometrium, postmenopausal bleeding, hypertension, major depressive disorder, osteoarthritis of the knee, glaucoma, and others. The current orders from the physician orders, therapy orders, or treatment orders were not attached to the baseline care plan. The baseline care plan indicated that a copy of the current medication list had been given to the resident. Review of the Care Plan Acknowledgment Form for Resident 5 was signed and dated on 03/05/2025 and co-signed by the SSD. The agreement stated that the Resident's signature indicated there had been a discussion of the plan of care and that the resident was given the opportunity to ask questions and state preferences about the individual resident's care and goals of care. This agreement had a check-marked space that was marked and stated that the resident had been given a copy of the baseline care plan and a copy of current orders and dietary instructions, which included services and treatments to be provided or arranged by the facility and personnel acting on behalf of the facility, and any updated information based on details of the admission comprehensive assessment. Record review of the Progress Notes printed and reviewed on 12/11/2025 for Resident 5 did not reveal any documented entries to show that Resident 5 or the resident representatives were given a copy of the baseline care plan prior to the comprehensive care plan meeting or at the time of the admission. In an interview with the DON on 12/11/2025 at 3:20 PM the DON revealed that the check-marked space the Care Plan Acknowledgment Form for Resident 5 should have been checked for the comprehensive care plan and not have been checked as the baseline care plan. Had this been corrected, this would have revealed that the entire comprehensive care plan had been reviewed. B. Record review of the baseline care plan signed but not dated by Registered Nurse (RN) D and revealed that Resident 17 was admitted to the facility on [DATE]. The DON signed the baseline care plan on 11/16/2025. The baseline care plan revealed that Resident 17 had diagnoses for a fractured upper and lower end of the left fibula and a fractured upper and lower end of the left tibia (both bones of the lower leg). The current orders from the physician orders, therapy orders, or treatment orders were not attached to the baseline care plan. The baseline care plan indicated that a copy of the current medication list had been given to the resident. Review of the Care Plan Acknowledgment Form for Resident 17 was signed and dated on 12/03/2025 by Resident 17 and co-signed by the SSD. The agreement stated that the Resident's signature indicated there had been a discussion of the plan of care and that the resident was given the opportunity to ask questions and state preferences about the individual resident's care and goals of care. This agreement had a check-marked space that was marked and stated this was the initial discussion of the entire comprehensive care plan. Record review of the Progress Notes printed and dated 12/15/2025 for Resident 17 did not reveal any documented entries to show that Resident 17 or the resident representatives were given a copy of the baseline care plan prior to the comprehensive care plan meeting or at the time of the admission. C. Record review of the baseline care plan revealed that Resident 3 was admitted to the facility on [DATE]. The DON signed the baseline care plan on 11/17/2025. The baseline care plan revealed that Resident 3 had diagnoses for cellulitis of the left lower leg, diabetes, pulmonary fibrosis (a lung disease where lung tissue becomes scarred and thickened, making it hard for oxygen to get into your bloodstream, leading to shortness of breath), heart failure, chronic kidney disease, coronary artery disease, a history of transient ischemic attacks (often called a mini-stroke because it's a temporary blockage of blood flow to the brain, causing stroke-like symptoms that usually resolve quickly (minutes to hours) but signal a high risk for a major stroke), among others. The current orders from the physician orders, therapy orders, or treatment orders were not attached to the baseline care plan. The baseline care plan indicated that a copy of the current medication list had been given to the resident. Review of the Care Plan Acknowledgment Form for Resident 3 was signed and dated on 12/03/2025 by Resident 3 and co-signed by the SSD. The agreement stated that the Resident's signature indicated there had been a discussion of the plan of care and that the resident was given the opportunity to ask questions and state preferences about the individual resident's care and goals of care. This agreement had a check-marked space that was marked and stated this was the initial discussion of the entire comprehensive care plan. Record review of the Progress Notes printed and dated 12/15/2025 for Resident 3 did not reveal any documented entries to show that Resident 3 or the resident representatives were given a copy of the baseline care plan prior to the comprehensive care plan meeting or at the time of the admission. D. Record review of the baseline care plan signed but not dated by Registered Nurse (RN) D and revealed that Resident 55 was admitted to the facility on [DATE]. The baseline care plan revealed that Resident 55 had diagnoses of displaced intertrochanteric fracture of the left femur (broken hip. The current orders from the physician orders, therapy orders, or treatment orders were not attached to the baseline care plan. The baseline care plan did not indicate a current medication list had been given to the resident or to the resident representative. The medication list had not been reconciled with the resident of the resident representative. Review of the Care Plan Acknowledgment Form for Resident revealed this to be absent. Record review of the Progress Notes printed and dated 12/11/2205 for Resident 55 did not reveal any documented entries to show that Resident 55 or the resident representatives were given a copy of the baseline care plan prior to the comprehensive care plan meeting or at the time of the admission. In an interview with the DON on 12/11/2025 at 3:20 PM the DON revealed that the Care Plan Acknowledgment Form for Resident 55 had not been completed because there had not been a care plan held to discuss with this resident or with this resident's representative. E. Record review of the facility Baseline Care Plan (BCP) Guidelines dated 3/2021 revealed that the BCP is to be completed within 24 hours. Each resident will only have one BCP per admission. The baseline care plan is locked by the facility designated process owner when the Comprehensive Care Plan is complete. An Interdisciplinary Team (IDT) member/members will review the baseline care plan summary with the resident/resident representative prior to the completion of the Comprehensive Care Plan (a detailed written interdisciplinary comprehensive plan to meet the resident's needs that is required to be completed 7 days from when the MDS Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) is signed). The signed Care Plan Acknowledgement Form is to be scanned into the Miscellaneous tab under the care plan category in the electronic health record to verify Baseline Care Plan review was done with the resident/resident representative. The only reason the BCP summary would not be reviewed and signed by the resident/representative would be due to an Unplanned Discharge. To address medications, services, and treatments the Physician Order Summary will be printed and reviewed with the resident/representative when completing the BCP summary. If the resident/representative prefers to not have a copy of the BCP and Order Summary, document in the progress notes that a copy of the BCP was offered to the resident/representative and the copies were declined. Record review of the undated admission Agreement revealed that the facility will develop a baseline care plan within 24 hours of your admission. The baseline care plan will include instructions needed to provide you effective person centered care. The baseline care plan will address, at a minimum, your initial goals based upon your admission orders, physician orders, dietary orders, therapy services, social services, and any applicable pre-admission screening. The facility will provide you and/or your representative with a summary of the baseline care plan prior to completion of the comprehensive care plan. Record review of the MDS assessment dated [DATE] for Resident 7 revealed that Resident 7 admitted into the facility on 7/15/25. Diagnoses included Stroke, Hemiplegia (paralysis affecting one side of the body), and depression. Record review of the baseline care plan dated 7/23/25 for Resident 7 revealed no documentation of resident or representative signature or that a copy of the baseline care plan was offered or provided to the resident or resident representative. Record review of the progress notes for Resident 7 revealed no documentation that the baseline care plan was reviewed with the resident or resident representative. The progress notes revealed no documentation that a copy of the baseline care plan was offered or provided to the resident or resident representative. Record review of the progress note dated 7/30/25 at 2:48 PM revealed that a care conference was conducted and that Resident 7 attended the conference. The note revealed that the resident representative was invited but did not attend. The note contained no documentation that the baseline care plan was reviewed with the resident. The progress note contained no documentation that a copy of the baseline care plan was offered, provided, or refused. Record review of the Care Plan Acknowledgement Form dated 7/30/25 revealed that the type of care plan discussed was the comprehensive care plan. The acknowledgment form contained no documentation that the baseline care plan was discussed and no documentation that a copy of a baseline care plan was offered, provided, or refused. Interview on 12/15/25 at 2:40 PM with the facility Director of Nursing (DON) confirmed that the facility did not review and offer a copy of the baseline care plan to Resident 7 or their representative as required. The DON confirmed that the first care plan meeting for Resident 7 was on 7/30/25. (15 days after Resident 7 admitted into the facility). F. Record review of the MDS assessment dated [DATE] for Resident 40 revealed that Resident 40 admitted into the facility on [DATE]. Diagnoses included Diabetes, High blood pressure, and anxiety. Record review of the Baseline Care Plan dated 10/8/25 for Resident 40 revealed no documentation of resident or representative signature or that a copy of the baseline care plan was offered or provided to the resident or resident representative. Record review of the progress notes for Resident 40 revealed no documentation that the baseline care plan was reviewed with the resident or resident representative. The progress notes revealed no documentation that a copy of the baseline care plan was offered or provided to the resident or resident representative. Record review of the progress note dated 10/15/25 at 3:30 PM revealed that a care conference was conducted. Resident 40 and their representative were invited to the care conference. Resident 40 did not attend. The representative for Resident 40 attended the conference by phone call. The note contained no documentation that the baseline care plan was reviewed with the resident representative. The progress note contained no documentation that a copy of the baseline care plan was offered, provided, or refused. Record review of the Care Plan Acknowledgement Form dated 10/15/25 revealed that the type of care plan discussed was the comprehensive care plan. The acknowledgment form contained no documentation that the baseline care plan was discussed and no documentation that a copy of a baseline care plan was offered, provided, or refused. Interview on 12/15/25 at 2:40 PM with the facility DON confirmed that the facility did not review and offer a copy of the baseline care plan to Resident 40 or their representative as required. The DON confirmed that the first care plan meeting for Resident 40 was on 10/15/25. (13 days after Resident 40 admitted into the facility).

Based on record reviews and interviews, the facility failed to ensure that all residents were seen by a physician on their initial 30 day visit and at least on every alternate visit as required. This affected 3 (Residents 5, 2, and 7) of 3 sampled residents. The facility census was 50. Findings were: Record review of the facility provided policy for physician services was a copy of the CMS (Centers for Medicare and Medicaid Services) policy F712 dated 10/24/2022. In an interview on 12/11/2025 at 10:53 AM with the Medical Records Director (MR) it was revealed that some residents are seen only by a nurse practitioner or a physician assistant as that is who the residents have chosen to be their primary care provider. Therefore, those residents are only seen by a nurse practitioner or physician assistant for their 30 day and 60 day physician visits. MR revealed that Physician Assistants and Nurse Practitioners are not Medical Doctors or Physicians. MR stated I think I know where we are going with this conversation but wanted more of an explanation. In an interview on 12/11/2025 at 10:55 AM with the Director of Nursing (DON) revealed not knowing that a physician must make the first initial visitation with new residents, and after that, every resident must be seen by a primary physician. There are some residents who do have a nurse practitioner or physician assistant listed as their primary physician. We will make changes to this immediately and list an actual physician in that place. In a confirmation interview on 12/11/2025 at 11:00 AM with the MR, it was confirmed that the residents who have listed the preferred primary provider who is an advanced practice provider such as nurse practitioners and physician assistants have only been seeing those individuals and not being seen by an actual physician or medical doctor. Some of these residents have been seen by a specialist, but those physicians were not seen for complete and total care of these residents like a primary care physician would do. In an interview on 12/11/2025 at 11:40 AM with the Director of Clinical Services (DCS) it was revealed that the facility is supposed to adhere to the regulations of the facility provided policy of CMS F712. A. Record review of the quarterly Minimum Data Set (MDS) (a comprehensive, standardized assessment tool for residents in Medicare/Medicaid-certified nursing homes, used to evaluate their health, functional status, mood, and preferences, driving individualized care plans, tracking quality, and determining payment for services like Medicare Part A skilled nursing stays) dated 10/27/2025 revealed that Resident 2 had been admitted to the facility on [DATE]. Resident 2 had diagnoses of debilitating cardio/respiratory conditions, congestive heart failure, major depressive disorder, hypertension, neurogenic bladder, epilepsy, anxiety, depression, paroxysmal atrial fibrillation (intermittent, irregularly-irregular heart rate), was unsteady on feet, and gastroesophageal reflux disease (heart burn). Resident 2 medications for depression, congestive heart failure, a history of blood clots, and finally another for major depressive disorder. Record review of the Clinical Resident Profile for Resident 2 revealed that an Advanced Practice Registered Nurse was listed as the resident's physician and primary caregiver. Record review of the physician visit from 02/21/2025 60-day visit was completed by an Advanced Practice Registered Nurse (APRN). Record review of the physician visit from 04/22/2025 60-day visit was completed by an APRN. Record review of the physician visit from 06/20/2025 60-day visit was completed by an APRN. Record review of the physician visit from 08/07/2025 visit was completed by an APRN. Record review of the physician visit from 08.20.2025/2025 60-day visit was completed by an APRN. Record review of the physician visit from 10/24/2025 60-day visit was completed by an APRN. B. Record review of the quarterly MDS dated [DATE] for Resident 5 revealed an admission date of 02/21/2025. Resident 5 had diagnoses for medically complex conditions which included cancer, high blood pressure, gastroesophageal reflux disease, thyroid disorder, arthritis, anxiety, depression, macular degeneration, overweight, bicipital tendinitis right shoulder, and allergies among others. Resident 5 took medications to treat anxiety, depression, pain, and infections. Record review of the Clinical Resident Profile for Resident 5 revealed that a Physician Assistant was listed as the resident's physician and primary caregiver. Record review of the initial 30 day physician visit after admission dated 03/20/2025 revealed that Resident 5 was seen by a Physician Assistant (PA). Record review of the 60 day physician visit after admission dated 04/24/2025 revealed Resident 5 was seen by a PA. Record review of the 90 day physician visit after admission dated 05/20/2025 revealed Resident 5 was seen by a PA. Record review of the 60 day physician visit dated 07/22/2025 revealed Resident 5 was seen by a PA. Record review of a physician visit on 08/28/2025 revealed Resident 5 was seen by an APRN Record review of the 60 day physician visit dated 09/23/2025 revealed Resident 5 was seen by a PA. Record review of the 60 day physician visit dated 11/21/2025 revealed Resident 5 was seen by a PA. C. Record review of the undated facility policy titled Physician Services- Physician Visits, Frequency/Timeliness/Alternate NPPs (Non-Physician Practitioners such as a Physician Assistant or Nurse Practitioner) revealed that after resident admission the first physician visit (this includes the initial comprehensive visit) must be conducted within the first 30 days and then at 30 day intervals up until 90 days after the admission date. The physician may not delegate the responsibility for conducting the initial visit. The authority for Non-Physician Practitioners to Perform Visits revealed that Nurse Practitioner may not perform the initial comprehensive visit (30 day visit). Record review of the admission Record dated 12/11/25 for Resident 7 revealed an admission date of 7/15/25. The admission Record documented the Nurse Practitioner as their primary care provider. Record review of the medical clinic office visit note dated 8/20/25 revealed that Resident 7 was at the clinic for their 30 day nursing home visit. The provider completing the 30 day visit was the Nurse Practitioner (NP) and not a physician as required. Record review of the medical clinic office visit note dated 9/30/25 revealed that Resident 7 was at the clinic for follow up from the hospital. The provider completing the visit was the NP. Record review of the medical clinic office visit note dated 10/22/25 revealed that Resident 7 was at the clinic for their 60 day nursing home follow up. The provider completing the visit was the NP. Interview on 12/15/25 at 2:40 PM with the facility Director of Nursing (DON) confirmed that the 30 day initial visit for Resident 7 was completed by the Nurse Practitioner and not by a physician as required.

Licensure Reference Number 175NAC 12-006.18(B) Based on record reviews, observations and interviews, the facility failed to clean and disinfect reusable resident medical equipment between resident use for 4 (Resident 4, Resident 24, Resident 34, and Resident 38) of 14 residents sampled. The facility census was 50. Findings are:A record review of a facility competency for direct care staff titled, Full Body Lift Competency dated 7/2017 revealed that the procedure for using the full body lift #18 states: Wipe all surfaces that come into direct contact with the resident's skin with an approved disinfectant between each resident use whether visibly soiled or not. Heavily soiling may require soap and water scrubbing prior to disinfecting. A record review of a facility competency for direct care staff titled, Sit to Stand Lift Competency dated 7/2017 revealed that the procedure for using the sit to stand lift, #21 states: Wipe all surfaces that come into direct contact with the resident's skin with an approved disinfectant between each resident use whether visibly soiled or not. Heavily soiling may require soap and water scrubbing prior to disinfecting. A record review of a 2025 Skills Competency Fair Checklist for Nurse Aide (NA)-A dated 08/06/25 revealed staff member was checked off for Full Body Lift Competency, Sit to Stand Lift Competency, and Medical Device Disinfection Competency. NA-A and a validator signed the 2025 Skills Competency Fair Checklist on 08/06/25. A record review of a Nurse Aide Competency Checklist for NA-B dated 07/28/25 revealed staff member was checked off for Full Body Lift Competency, Sit to Stand Lift Competency, and Medical Device Disinfection Competency. NA-B, a mentor and an additional staff member, signed the Nurse Aide Competency Checklist on 07/28/25, then validated and initialed on 8/18/25. A record review of a Nurse Aide Competency Checklist for NA-C dated 12/16/25 revealed staff member was checked off on Sit to Stand Lift Competency. NA-C has yet to be checked off on Full Body Lift Competency, or the Medical Device Disinfection Competency. NA-C had not signed the Nurse Aide Competency Checklist, however someone else signed the form on 12/16/25. An interview with the Infection Preventionist (IP) on 12/15/25 at 2:15 PM revealed that all staff are educated and trained during orientation and periodically to clean all reusable resident medical equipment after use. An observation on 12/16/2025 at 7:45 AM NA-A pushed the Sit to Stand into Resident 4's room, additional observations revealed NA-A failed to clean the Sit to Stand. NA-A pushed the lift into the lift enclosure and walked away. An observation on 12/16/2025 at 8:45 AM NA-B pushed the Sit to Stand into Resident 38's room, additional observations revealed NA-B failed to clean the Sit to Stand. NA-B pushed the lift into the lift enclosure and walked away. NA-B went to assist a different resident. The same Sit to Stand was then observed to be taken on 12/16/25 at 9:05 AM by a different Aide NA-A. NA-A pushed the lift into Resident 24's room, additional observations revealed NA-A failed to clean the Sit to Stand. NA-A pushed the lift into the lift enclosure and walked away. An observation on 12/16/25 at 9:00 AM show NA-C pushed the Sit to Stand into the bathhouse to assist with Resident 33 to take a bath. At 9:30 AM, NA-C pushed the Sit to Stand out of the bathhouse and into the lift enclosure. An interview on 12/16/25 at 9:35 AM with NA-C revealed the Sit to Stand did not get cleaned after it was used with Resident 33 in the bathhouse. NA-C stated sometimes we do not get to it or forget. When asked how often it is supposed to be cleaned, NA-C stated after every use. NA-C then cleaned the lift. An interview on 12/16/25 at 10:35 AM with NA-B revealed that sometimes we forget and do not get to clean it, when asked what the process is, NA-B stated the lifts are to be cleaned after every patient. When asked about education or competencies on the process of infection control and cleaning the lifts after resident use, NA-B reveals that management are educating them and others on the process all of the time through group text messaging and on the spot education.

Licensure Reference Number 12-006.05(G)Based on record review and interview, the facility failed to ensure that a PRN (as needed) psychotropic medication had a rationale for use for one of one (Resident 3) sampled resident. The facility census was 50.Findings are:Record review of the admission minimum data set (MDS) (a federally required, standardized health assessment tool for residents in Medicare/Medicaid-certified nursing homes, used to create individualized care plans, track resident status (physical, functional, psychological), ensure quality, and determine payment/reimbursement for services like skilled nursing care) dated 11/21/2025 revealed Resident 3 had been admitted to the facility on [DATE]. Resident 3 had a brief interview for mental status (BIMS) score (a standardized cognitive screening tool used primarily in nursing homes) of 14 and indication of being cognitively intact. Resident 3 did not exhibit any behaviors or tendencies to wander and had no previous MDS to compare behavior symptoms. Resident 3 had diagnoses for anxiety, brief psychotic disorder, muscle weakness, cognitive communication deficit, insomnia, and others. Medications Resident 3 was taking at the time of admission included antipsychotic, antianxiety, hypoglycemic, anticoagulant, antibiotic, and diuretic. Resident 3 had an infected surgical wound of the left foot and used a pressure-reducing cushion for a wheelchair and for a bed, and received wound care and dressings to the left foot. Record review of the working care plan (a detailed, personalized strategy developed by healthcare professionals and the individual (or family) to address all health, personal, and social needs) reviewed on 12/10/2025 revealed Resident 3 had the potential for out-of-character responses related to anxiety, demonstrated by agitation, restlessness, difficulty sleeping, and becoming easily worked up. Also exhibits sexually inappropriate behaviors toward team members, and may present as accusatory, threatening and demanding toward staff.Record review of the November 2025 Medication Administration Record (MAR) revealed that Resident 3 had an order for and was administered; Diazepam (a psychoactive medication used to treat anxiety disorders and muscle spasms among other uses) 5 mg every 6 hours as needed for the diagnosis of anxiety. This order was received on 11/17/2025 at 2:45 PM and discontinued on 11/25/2025 at 11:30 AM. Diazepam 5 mg every 6 hours as needed for muscle spasms with a start date of 11/25/2025 at 11:30 AM and was to be discontinued on 12/04/2025 at 8:27 AM.Record review of the December 2025 MAR revealed an order for Resident 3 for: Diazepam 5 mg every 6 hours as needed for muscle spasms for 6 months with a start date of 12/04/2025 at 8:30 AM and no stop date listed.Record review of the Pharmacy Medication Regimen Review (MRR) (a pharmacy review which ensures all medications are safe, effective, appropriate for the patient's condition, and necessary) completed by the pharmacist on 12/01/2025 revealed the following statement: The resident has an order for PRN (as needed) diazepam. Per CMS (Centers for Medicare and Medicaid Services) regulations, for PRN psychotropic use greater than 14 days, the prescriber must document a clinical rationale in the medical record for continuance of the PRN agent and indicate the duration that the medication should be continued. (F-Tag 605). If continued use is greater than 14 days order is warranted, please provide a clinical rationale as well as duration below. Thank you. Underlined by the pharmacist were the words please provide a clinical rationale. There was no rationale written in the blank space. The duration was indicated by a checkmark for 90 days. The paperwork was signed by the physician and dated 12/3/2025.Record review of a follow-up note to the physician about the MRR completed on 12/01/2025 revealed the following: This resident currently has a PRN (as needed) order for diazepam. Diazepam has a long half-life and an active metabolite which increases the risk of adverse events when used. This medication sis not recommended for use I the geriatric population and is located on the Beers List of potentially inappropriate medications. Please consider a review of the order for diazepam and consider changing to a shorter acting medication. Thank you. Signed by the pharmacist. There was a note from the physician which stated Please continue for now. We will consider this once (Resident 3) moves back to (Resident 3's) assisted living. Signed by the physician on 12/03/2025. The order was reviewed by the nursing staff on 12/03/2025.In an interview with the Director of Nursing (DON) on 12/16/2025 at 12:55 PM it was revealed that the DON did not know why the rationale of the medication had changed from being used for anxiety to now being used for muscle spasms. Confirmed Resident 3 did have the diagnosis of anxiety but there was no diagnosis for muscle spasms. In a confirmation interview with Director of Clinical Services (DCS) who revealed that the Infection Control and Prevention nurse (IP) had received an order from the physician by phone to clarify the orders for the diazepam which indicated as use for Anxiety upon admission and then changed to muscle spasms after text messages exchanged with the physician. DCS confirmed that the pharmacist had asked for documentation of a rationale for the use of the PRN diazepam and that the notices sent to the facility staff in a text message was not the way the facility does this. Secondly the DCS confirmed that the rationale of waiting to review the medication once Resident 3 returned to the assisted living was not a rationale. We have got to work with the doctors to make sure they give us a rationale for these psychotropics.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2)Based on observation, record review, and interview the facility failed to monitor resident pressure ulcers (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) as required for 1 of 1 residents reviewed (Resident 9). This prevented the evaluation of the wound condition progress. The facility census was 50.Findings are:Record review of the facility Skin and Wound Management Standard dated 4/2019 revealed that the routine skin check done by the nurse is added to the electronic treatment record. The Non-Pressure Skin Condition Record (a form for weekly and as needed assessment documentation of the skin condition) is used weekly for all non-pressure skin conditions. The Pressure Ulcer Record (including deep tissue pressure injuries) (a form for weekly and as needed assessment documentation of the pressure ulcer) is used weekly and as needed for all pressure ulcers/injuries. All facility charge nurses will be knowledgeable and involved in preventing, identifying, assessing, treating and documenting all skin and wound conditions. Non-pressure skin conditions will be assessed and measured every 7 days or more frequently if indicated until resolved. Pressure ulcers/injuries will be formally assessed, staged, and measured every 7 days or more frequently if indicated (measure length, width, depth, odor, drainage, pain, wound bed and peri wound appearance). Record review of the admission Record dated 12/11/25 for Resident 9 revealed that Resident 9 admitted into the facility on 7/26/24. Diagnoses included Multiple Sclerosis (A disease where your immune system mistakenly attacks the protective coating on your brain and spinal cord nerves. This damage causes a wide range of unpredictable symptoms like numbness, vision problems, weakness, fatigue, balance issues, and thinking difficulties, affecting how your brain communicates with the rest of your body.) and Functional Quadriplegia (the complete inability to move the arms and legs due to medical conditions). Record review of the Office Visit Wound Clinic note dated 12/4/25 for Resident 9 revealed that Resident 9 sees outpatient wound care for pressure ulcers. The clinic note revealed that the right buttock pressure ulcer is not improving. Apply Critic Aid Clear AF ointment (a medicated ointment containing antifungal medication) four times a day. The clinic note revealed that Resident 9 had dark discoloration to both buttocks with the right buttock wound worse than the left buttock wound. The note revealed Stage 3 pressure ulcer (involves full-thickness skin loss) with deep tissue injury (damage under the skin -purple/red skin) wound. No measurements were documented in the Wound Clinic notes.Observation on 12/11/25 at 8:22 AM outside the room of Resident 9 revealed that Registered Nurse-E (RN-E) set up supplies for the ordered treatment of the pressure ulcers for Resident 9. RN-E and the facility Infection Preventionist (IP) entered the room of Resident 9. Resident 9 was in the bed. IP rolled Resident 9 onto the resident's left side. RN-E removed the brief that Resident 9 wore. Wounds were observed on Resident 9's left and right buttocks. The wound bed on the right buttock was discolored and light to medium dark red in color. Multiple dark reddish purple scab looking areas were scattered within the wound bed. The right buttock wound was approximately 18 centimeters (cm) in length and approximately 11cm in width per visual measurement. The wound had no observed depth. The left buttock wound bed was light to medium dark red in color with multiple reddish purple scab like areas. The left buttock wound was approximately 16 cm in length and approximately 12 cm in width per visual measurement. The wound had no observed depth. The top of the right wound had an irregular shaped area that measured approximately 2 cm in length and approximately 5 cm in width that was a dark reddish purple type scab or eschar (a layer of dead tissue that commonly forms over a wound). RN-E applied Critic Aid Clear AF 2% ointment (a medicated ointment containing antifungal medication) to the wounds on the left and right buttocks of Resident 9 with the gloved hands. Interview on 12/11/25 at 12:33 PM with RN-E revealed that Resident 9 had the pressure ulcer wounds on the buttocks on admission to the facility. RN-E revealed that the Treatment Administration Record (TAR) (a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) has the order to do weekly assessment as a reminder for the nurses to complete the wound assessments weekly. RN-E confirmed that the pressure wounds on the buttocks of Resident 9 are to be assessed weekly and the description of the wound condition and measurements are to be documented on the Non-Pressure Skin Condition Record. RN-E was unsure as to why the weekly documentation of Resident 9's pressure wounds were being documented on the Non-Pressure Skin Condition Record instead of the Pressure Ulcer Record. Record review of the TAR for November 2025 dated 12/16/25 revealed to measure and describe the bilateral buttocks weekly. Complete 2 separate assessment forms, #1: Complete a non-pressure skin condition record for red, open spot to right buttock. #2: Complete a non-pressure skin condition record for red, open areas to left buttock. Include measurements of any open areas/fissures (cracks). Complete weekly every Friday until healed. The completion of measuring the buttocks wounds was documented on the TAR on 11/7/25, 11/14/25, 11/21/25, and 11/28/25.Record review of the 11/7/25 Non-Pressure Skin Condition Record for the right buttock pressure ulcer on Resident 9 revealed that the wound was purple/red in color and measured 15.5 cm in length and 9 cm in width. Record review of the 11/7/25 Non-Pressure Skin Condition Record for the left buttock pressure ulcer on Resident 9 revealed that the wound was purple/red in color and measured 12 cm in length and 6.5 cm in width. Record review of the 11/14/25 Non-Pressure Skin Condition Record for the right buttock pressure ulcer on Resident 9 revealed that the wound was dark red in color and measured 16 cm in length and 8 cm in width. Record review of the 11/14/25 Non-Pressure Skin Condition Record for the left buttock pressure ulcer on Resident 9 revealed that the wound was dark red in color and measured 12 cm in length and 7 cm in width. Record review of the 11/28/25 Non-Pressure Skin Condition Record for the right buttock pressure ulcer on Resident 9 revealed that the wound had redness and has a dark area in the center with a light red around it. The wound measured 8 cm in length and 4 cm in width. The summary note revealed that the skin of the right buttock was assessed per the weekly schedule. Record review of the 11/28/25 Non-Pressure Skin Condition Record for the left buttock pressure ulcer on Resident 9 revealed that the wound had redness and has a dark area in the center with a light red around it. The wound measured 8 cm in length and 2 cm in width. The summary note revealed that the skin of the left buttock was assessed per the weekly schedule. Record review of the TAR for December 2025 dated 12/16/25 revealed to measure and describe the bilateral buttocks weekly. Complete 2 separate assessment forms, #1: Complete a non-pressure skin condition record for red, open spot to right buttock. #2: Complete a non-pressure skin condition record for red, open areas to left buttock. Include measurements of any open areas/fissures. Complete weekly every Friday until healed. The completion of measuring the buttocks wounds was documented on the TAR on 12/5/25 and 12/12/25.Record review of the 12/5/25 Non-Pressure Skin Condition Record for the right buttock pressure ulcer on Resident 9 revealed that the wound on the right buttock was dry skin with no open areas. No measurements were documented on the record. Record review of the 12/5/25 Non-Pressure Skin Condition Record for the left buttock pressure ulcer on Resident 9 revealed that the wound on the left buttock was dry skin with no open areas. No measurements were documented on the record. Record review of the 12/12/25 Non-Pressure Skin Condition Record for the right buttock pressure ulcer on Resident 9 revealed that the wound on the right buttock had dry skin with no open areas. Several scabbed areas are intact and also starting to fall off. No measurements were documented on the record. Record review of the 12/12/25 Non-Pressure Skin Condition Record labeled for the left buttock pressure ulcer on Resident 9 revealed in the Site Description section that right buttock with dry skin no open areas, several scabbed areas are intact and also starting to fall off. (the site description was the description for the right buttock instead of the left buttock). No measurements were documented on the record. Interview on 12/15/25 at 2:40 PM with the facility Director of Nursing (DON) confirmed that a weekly assessment is to be completed by the nurse for both non-pressure skin conditions and for pressure ulcers. The DON confirmed that the weekly assessments are to include documentation of the color, condition, and size of the wound either written or documented per check box on the weekly assessment form. The DON confirmed the assessment form is either the Non-Pressure Skin Condition Record or the Pressure Ulcer Record. The DON confirmed that Resident 9 has a pressure ulcer on the right buttock and on the left buttock that goes through phases of being open and closed. The DON confirmed that the size of the left buttock and right buttock wounds are expected to be documented weekly for Resident 9. Interview on 12/15/25 at 3:26 PM with the DON revealed that the wound care notes for Resident 9 dated 12/4/25 do not contain any measurements of the left buttock or right buttock wound. The DON confirmed that the wound measurements of the right buttock and left buttock wounds for Resident 9 were not documented on 12/5/25 or 12/12/25 as required. The DON revealed that at a weekly meeting the wound documentation is reviewed and education was provided to the nurse that did not document measurements of the wounds on 12/5/25. The DON revealed that the education was not successful and confirmed that no measurements of the wounds were documented on the weekly assessments dated 12/12/25. The DON confirmed that the facility did not have documentation of the left buttock wound assessment for Resident 9 on 12/12/25.

Based on interviews, observation, and record reviews, the facility failed to follow policy and procedures for constipation management and prevention. This affected 1 of 2 residents sampled (Resident 31). The stated facility census was 53. Record review of the facility Bowel and Bladder Management Standard updated on 04/18/2024 defined constipation as difficulty in passing stools or incomplete or infrequent passage of hard stool. The standard states that the care plan should contain the appropriate interventions based upon the interventions for potential risks. Record Review of the Elimination Protocol dated 6/2024 gave specific nursing instructions to review the elimination records of residents and interventions for bowel management and documentation. -Small bowel movements did not count towards the daily elimination. -Day 2; After 48-hour period without a bowel movement (BM); offer 4 ounces of prune juice or natural laxative of resident's choice. The intervention must be recorded in the column below (on the paper). -Day 3; Day shift without a BM; Give 30 milliliters (ml) of milk of magnesia or Miralax (both are medications to relieve constipation) (or medication ordered by their physician) in the morning on the 6 AM to 2 PM shift. Assess bowel sounds, then palpate and document assessment results. Document findings and medication in the Medication Administration Record (MAR). Record in the intervention column on the daily Elimination Protocol sheet. Communicate interventions/results to the oncoming shift for further action if no BM. -Day 3; Evening/Night shift without a BM; Evening/Night charge nurse to assess bowel sounds, palpate and document assessment results before suppository administration. If No Bowel Sounds for the day, call the physician immediately. Give Dulcolax suppository, as ordered, at a time agreeable to the resident. Document on the MAR. Communicate interventions/results to oncoming shift for further action if no BM. Record in Intervention column of the daily Elimination Protocol sheet. -Day 4; All shifts without a BM; If interventions have not been successful; Contact the physician. Advance to enema as ordered and continue with bowel assessments each shift until resolved. Record review of the Minimum Data Set (MDS, part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes to assist in care plans) dated 09/26/2024 revealed that Resident 31 received hospice care, had a BIMS (Brief Interview for Mental Status assessment, which is used to categorize a patient's cognitive impairment) score of 10, meaning moderate cognitive impairment, was continent of bowel, was not on a bowel program, and had diagnoses for Parkinson's disorder, paraplegia, progressive neurological disorder, and difficulty walking. Resident 31 received scheduled and as needed opioid (narcotic) (pain medications). Record review of the Care Plan (a document that outlines a patient's care, including the goals, activities, and who will be involved in care of the resident) revised on 7/12/2024 revealed a potential for alteration in bowel elimination related to narcotic medications, bowels would be managed without complications through the next review date of December 2024, and nursing staff would administer medications per the physician's orders, follow the facility bowel management protocol, and report complications related to bowel elimination. Record review of the Hospice Plan of Care (a document that outlines a patient's care, including the goals, activities, and who will be involved in the resident care) updated on 10/16/2024 revealed that Resident 31 and a family member both verbalized understanding of the risk factors of care that increased the risk of constipation and measures used by Hospice staff to prevent constipation. Interview on 10/28/2024 at 12:20 PM with the family member of Resident 31 revealed that constipation has been an issue. The family member also stated that Resident 31 had gradually become weaker and now received Hospice cares. Interview on 10/28/24 at 1:18 PM with Resident 31 stated I am still having issues with constipation. Resident 31 uses a walker all the time now and no longer walks. Observation on 10/29/2024 at 12:25 when Resident 31 was served a meal there was no prune juice on the food tray. Record review of the Physician Orders printed on 10/29/2024 revealed orders for Milk of Magnesia (400 milligrams (mg)/5 milliliters (ml)) 30 ML daily for constipation, docusate sodium (a medication that works as a stool softener)100 mg capsule 1 capsule twice a day for bowel regulation, bisacodyl suppository (a medication for constipation) 10 mg as needed for constipation, and prune juice 4 ounces (oz) as needed for bowel regulation. Record review of a Bowel Movements (BM) in a 30 day look back period printed on 10/29/2024 for bowel history of Resident 31 revealed the following: -09/30/24; no BM, -10/01/24; no BM, -10/02/24; Resident 31 had a BM, -10/03/24; Resident 31 had a BM, -10/04/24; no BM, -10/05/24; no BM, -10/06/24: Resident 31 had four small BMs, -10/07/24; Resident 31 had a BM, -10/08/24; no BM, -10/09/24; Resident 31 had a BM, -10/10/24; Resident 31 had a small BM, -10/11/24; Resident 31 had a BM, -10/12/24; Resident 31 had a BM, -10/13/24; Resident 31 had a BM, -10/14/24; no BM, -10/15/24; no BM, -10/16/24; Resident 31 had a BM, -10/17/24; no BM, -10/18/24; no BM, -10/19/24; Resident 31 had a BM, -10/20/24; no BM, -10/21/24; no BM, -10/22/24; no BM, -10/23/24; Resident 31 had a BM, -10/24/24; no BM, -10/25/24; no BM, -10/26/24; no BM, -10/27/24; no BM, -10/28/24; Resident 31 had a BM, -10/29/24 no BM. Record review of the October 2024 MAR/TAR (medication administration record/treatment administration record) for Resident 31 revealed no documented administration of prune juice. The MAR/TAR also revealed Resident 31 received a new order for milk of magnesia 400 milligrams (mg)/5 milliliters (ml) and administered 30 ml daily for constipation with a start date of 9/28/2024. Resident 31 received Dulcolax sodium capsules 100 mg twice daily for constipation. Resident 31 received a bisacodyl suppository 10 mg on October 2, 11, 13, 16, 19, 23, and 27 for constipation. There was no documented suppository given on 10/26/24. Record review of the medical records for Resident 31 did not reveal any physician communication with the physician about constipation. Interview with LPN-F (Licensed Practical Nurse-F) on 10/30/24 at 11:40 AM: Spoke about the Elimination Protocol on day 2, residents get whatever is ordered which is usually prune juice. On day 3 we give the resident milk of magnesia, or the physician ordered medication, if there are still no results. The nurse charts the medication on the MAR/TAR and then follows up throughout the shift. If the resident has had no results, the nursing staff will give this information to the oncoming staff for the next shift. On day four of no BM, staff nurses will give the resident a suppository after we assess the resident bowel sounds, and double check with our nurses' aides to be certain there was not a BM that didn't get charted so we do not give something unnecessarily. The nurse then has to write a nursing progress note. If there are no bowel sounds or if the resident complains of abdominal pain if no BM for several days or if the stuff we are doing simply is not working, we have to call the doctor. We also will reach out when necessary to see if the physician wants to have anything else specifically added to the orders. The nurse will not usually call the doctor unless the resident is having pain or there are no bowel sounds, which is not exactly what the elimination protocol says to do. Interview with the DON (Director of Nursing) on 10/30/2024 at 02:40 PM who confirmed that the bowel and elimination protocols for management and prevention were not followed as written for residents who have constipation.

Licensure Reference Number 175NAC 12-006.09(H)(vi)(3)(d) Based on observation, record review, and interviews, the facility failed to follow the manufacturer's instructions for insulin administration for 1 of 2 residents observed (Resident 24) to prevent the potential for hypoglycemic reaction. The facility census was 53. Findings are: Record review of the Fiasp FlexTouch (insulin aspart injection) (a fast acting insulin) product insert (manufacturer's instructions for use) dated 09/2022 revealed the section titled Dosage and Administration. Item 2.2 Route of Administration Instructions revealed the instructions to inject Fiasp at the start of a meal or within 20 minutes after starting a meal. Record review of the Admission Record for Resident 24 dated 10/29/24 revealed that Resident 24 admitted into the facility on [DATE]. Diagnoses included diabetes. Record review of the Care Plan dated 10/28/24 for Resident 24 revealed that Resident 24 has the potential for abnormal blood sugars related to diabetes. Interventions included to monitor blood sugar and administer insulin as ordered. Report any signs and symptoms of hypoglycemia (low blood sugar): sweating tremor, high heart rate, paleness, nervousness, confusion, slurred speech, lack of coordination to the charge nurse. Record review of the Order Summary Report (a listing of all physician orders for a specific resident) for Resident 24 dated 10/29/24 revealed a physician order for Fiasp insulin injection before meals. Observation on 10/29/24 at 11:51 AM in the room of Resident 24 revealed that Resident 24 sat in a wheelchair. Registered Nurse-H (RN-H) confirmed the blood sugar reading of 258 for Resident 24. RN-H confirmed that the physician order for Fiasp insulin for Resident 24 was to receive 6 units of insulin to be given for a blood sugar reading of 258. RN-H removed a Fiasp Insulin pen from the medication cart. RN-H applied the needle to the pen and turned the dial to 2 units and pushed the plunger to prime the needle. RN-H turned the dial on the insulin pen to the ordered 6 units of insulin. RN-H entered the room of Resident 24 and administered the insulin into the right upper arm of Resident 24. The time was 11:53 AM. RN-H did not offer Resident 24 a snack or juice. RN-H provided no instructions to Resident 24. Resident 24 was assisted to the dining room by an unidentified staff member and placed at a table in the dining room. Observation on 10/29/24 at 12:00 PM in the facility dining room revealed Resident 24 seated in the wheelchair at a dining room table with a cup of coffee and a glass of dark brown liquid. Resident 24 revealed that the glass contained diet coke. Interview on 10/29/24 at 12:07 PM with Dietary Aide-I (DA-I) confirmed that Resident 24 received diet coke and coffee. Observation on 10/29/24 from 12:00 PM to 12:27 PM in the dining room revealed that Resident 24 received no caloric intake and only had the cup of coffee and glass of diet coke available for consumption. Observation on 10/29/24 at 12:27 PM in the dining room revealed that Dietary Aide-J (DA-J) delivered a plate with a hot dog on a bun to Resident 24. Resident 24 told DA-J it was not what the resident ordered. DA-J carried the plate back to the kitchen. DC-J returned to Resident 24 at 12:30 PM with a menu and clarified what Resident 24 wanted for lunch. Resident 24 remained at the table with only the cup of coffee and glass of diet coke. Resident 24 had consumed approximately 1/4 of the diet coke. Observation on 10/29/24 at 12:39 PM in the dining room revealed that DA-J carried a plate of food to Resident 24. The plate contained a hamburger on a bun, potato salad, and a bowl of mandarin oranges. DA-J sat the plate on the table in front of Resident 24. Resident 24 immediately took a couple of bites of the hamburger. This was 46 minutes after RN-H administered the fast acting insulin to Resident 24. Resident 24 had not received any caloric intake for 46 minutes after the fast acting insulin was administered. Record review of the Treatment Administration Record (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) for Resident 24 dated 10/29/24 revealed that RN-H documented the administration of the 6 units of Fiasp insulin for Resident 24 occurred at 11:51 AM (48 minutes before Resident 24 received any caloric intake). Interview on 10/30/24 at 4:12 PM with Registered Nurse-K (RN-K) revealed that the nurse is expected to ensure that a resident receiving fast acting insulin receives nutrition (caloric intake) within 15 minutes of administration. RN-K revealed that RN-K administers fast acting insulin just before the resident goes to the dining room to get nutrition. RN-K revealed that staff should let dietary know that the diabetic is in the dining room. RN-K confirmed that no juice or snack is given from the treatment cart after insulin administration to a resident. Interview on 10/30/24 at 4:38 PM with the facility Director of Nursing (DON) confirmed that residents receiving fast acting insulin are required to receive nutrition with caloric value within 15 minutes of the insulin administration to prevent complications of low blood sugar. The DON confirmed that the coffee and diet Coke provided to Resident 24 did not have caloric value. Interview on 10/31/24 at 9:38 AM with Registered Nurse-H (RN-H) revealed that RN-H ensures a resident receives something with caloric value after insulin administration by telling them to get a cup of juice when they get to the dining room. RN-H revealed that if the resident appeared to need immediate caloric intake the RN-H would get them their meal in the dining room.

Licensure Reference Number 175NAC 1-005.06 Licensure Reference Number 175NAC 12-006.18 Based on observation, interview, and record review; the facility failed to ensure that oxygen administration supplies were monitored and replaced for 1 of 1 residents observed (Resident 41) to prevent the potential for respiratory infection. The facility census was 53. Findings are: Record review of the facility document titled Facility assessment dated [DATE] revealed that resident care needs include infection prevention and control. Specific care practices include identification and containment of infections and prevention of infections. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 41 dated 10/3/24 revealed that Resident 41 admitted into the facility on [DATE]. The MDS revealed that Resident 41 receives oxygen therapy while a resident in the facility. Record review of the Care Plan dated 10/28/24 for Resident 41 revealed that Resident 41 has altered respiratory function and requires oxygen. The care plan lacked interventions to replace the oxygen administration tubing and nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) for Resident 41. Record review of the Order Summary Report (a listing of all physician orders for a resident) for Resident 41 dated 11/1/24 revealed that it contained a physician's order for oxygen at 2 to 4 liters per minute to be given by nasal cannula. The Order Summary lacked interventions to replace the oxygen tubing and nasal cannula for Resident 41. Record review of the Medication Administration Records (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) and Treatment Administration Records (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) for Resident 41 for the months of February 2024-September 2024 dated 10/30/24 revealed that Resident 41 received oxygen daily. The MARs and TARs lacked interventions to replace the oxygen tubing and nasal cannula for Resident 41. Observation on 10/28/24 at 12:24 PM in the room of Resident 41 revealed a light blue oxygen concentrator (a medical device that concentrates the oxygen from room air and delivers it to a patient needing supplemental oxygen) with oxygen tubing and a nasal cannula in an undated blue infection control pouch. A humidification bottle with a 10/31/27 manufacturer outdate had no opened date on the bottle. There was no date on the oxygen tubing or the nasal cannula. Observation on 10/29/24 at 7:39 AM in the room of Resident 41 revealed that Resident 41 was in bed as Registered Nurse-H (RN-H) administered medications to Resident 41. The nasal cannula was in place on Resident 41 and had no date on it. The humidification bottle had no open date documented on it. The oxygen tubing had no date documented on it. The oxygen concentrator was operating and the oxygen flow rate was set at 2 liters per minute. Observation on 10/30/24 at 8:05 AM in the room of Resident 41 with the facility Director of Nursing (DON) revealed that the oxygen tubing was connected to the oxygen concentrator and the tubing had not been dated, the humidification bottle was not dated, and the blue infection control pouch was not dated. Interview on 10/30/24 at 8:05 AM with the facility DON confirmed that the oxygen tubing, cannula, and infection control pouch of Resident 41 were not dated. The DON confirmed that the humidification bottle is not dated with an open date. The DON revealed that oxygen tubing, nasal cannula, and infection control pouches were expected to be changed (replaced) weekly on Thursday nights by the night shift. The DON confirmed that the oxygen tubing and cannula are expected to be changed out weekly. The DON revealed that the weekly changing of the oxygen administration supplies is documented on the monthly cleaning schedule with staff initials to document completion. The DON revealed that the staff are not dating the oxygen supplies when it is changed out. The DON revealed that the DON observed that the oxygen supplies were set out to know that the oxygen supplies were being changed out. Record review of the untitled and undated monthly cleaning log provided by the DON revealed that it contained the instructions for Thursdays: Change out all respiratory bags, tubings including nebulizer masks and mouthpieces- infection control bags (on concentrators, portable tanks- change bags on wheelchairs). The log contained a box to initial completion of changing the respiratory administration supplies on the date it was performed. The monthly cleaning log did not list the residents receiving oxygen. Interview on 10/30/24 at 8:10 AM with the DON confirmed that there is not a cleaning schedule log for individual residents. The cleaning log is for all residents receiving oxygen on the hall and is documented as a whole. The DON revealed that there is one monthly cleaning log for the 400 hall and one monthly cleaning log for the 300 hall. The DON confirmed that there is no individual resident documentation that the oxygen supplies were changed out weekly for each specific resident as required. Interview on 10/30/24 at 4:28 PM with the DON confirmed the facility had no documentation of individual resident oxygen being replaced for any residents. The DON confirmed that the facility had no documentation that the oxygen supplies were replaced weekly as required for Resident 41.

Based on record review and interview the facility failed to ensure that staff testing for Covid-19 was completed as required for 3 of 3 sampled staff to prevent the spread of Covid-19. The facility census was 53. Findings are: A. Record review of the facility policy titled Covid-19 Vaccine Mandate Policy and Procedure dated 11/18/21 revealed that the facility will implement additional precautions to mitigate (prevent or reduce) the transmission and spread of Covid-19 for all staff who are not fully vaccinated for Covid-19 including but not limited to: regular testing two times per week. Interview on 9/15/22 at 1:48 PM with the Infection Preventionist (IP) confirmed that the facility follows the Covid-19 Vaccine Mandate Policy and Procedure dated 11/18/21. The IP confirmed that routine Covid-19 testing is performed on staff that are unvaccinated against Covid-19 and staff that are not up to date for Covid-19 vaccination. The IP confirmed that the definition of staff that are not up to date are staff that have not received all of the current recommended Covid-19 boosters. The IP confirmed that the expectation for staff that are unvaccinated against Covid-19 and for staff that are not up to date for Covid-19 vaccination is for them to be tested two times per week. The IP revealed that a staff list is used to monitor that staff are tested as expected for Covid-19. The IP revealed that staff requiring Covid-19 testing know that the scheduled testing for Covid-19 is on Monday and Thursday each week. The IP revealed that the staff requiring Covid-19 testing make sure they come in to test on Monday and Thursday or make sure that they are tested before their next work shift to make sure they are tested two times per week. Record review of the undated Covid-19 Staff Vaccination Status provided by the facility revealed that Dietary Aide-E (DA-E) received the primary Covid-19 vaccination but had not received the recommended booster vaccination. DA-E was not up to date for Covid-19 vaccination. DA-E was required to test for Covid-19 two times per week. Interview on 9/14/22 at 11:32 AM with DA-E confirmed that DA-E was vaccinated for Covid-19 but had not received any Covid-19 booster vaccinations. DA-E confirmed that DA-E was required to test two times per week for Covid-19. DA-E confirmed that DA-E tested positive for Covid-19 on 8/13/22. Record review of the facility Abbott BinaxNOW Covid-19 Ag Card Internal Controls and Testing Logs (a form for recording test results for Covid-19 point of care rapid tests) dated from 6/30/22 through 9/14/22 revealed that DA-E had no documented testing between 6/30/22 and 7/12/22. DA-E was tested for Covid-19 on 7/12/22 (negative result); 7/14/22 (negative result); 7/21/22 (negative result) (7 days after previous test); 7/28/22 (negative result) (7 days after previous test); 8/1/22 (negative result); 8/4/22 (negative result); and 8/11/22 (negative result) (7 days after previous test). Record review of the undated Timecard for DA-E revealed that between 7/1/22 and 7/11/22 DA-E worked on 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/6/22, 7/9/22, 7/10/22, and 7/11/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required the week of 7/4/22. Record review of the undated Timecard for DA-E revealed that between 7/11/22 and 7/25/22, DA-E worked on 7/11/22, 7/12/22, 7/13/22, 7/14/22, 7/15/22, 7/17/22, 7/19/22, 7/21/22, 7/22/22, 7/23/22, 7/24/22, and 7/25/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required during the week of 7/18/22. Record review of the undated Timecard for DA-E revealed that between 7/21/22 and 8/1/22 DA-E worked on 7/21/22, 7/22/22, 7/23/22, 7/24/22, 7/25/22, 7/26/22, 7/27/22, and 7/28/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required during the week of 7/25/22. Record review of the undated Timecard for DA-E revealed that between 8/1/22 and 8/12/22 DA-E worked on 8/5/22, 8/6/22, 8/7/22, 8/10/22, 8/11/22, and 8/12/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required the week of 8/8/22. Interview on 9/14/22 at 7:36 AM with the Facility Administrator (FA) confirmed that the expectation for staff requiring to be tested for Covid-19 is that they are tested two times per week. B. Record review of the undated Covid-19 Staff Vaccination Status provided by the facility revealed that Medication Aide-D (MA-D) received the primary Covid-19 vaccination but had not received the recommended booster vaccination. MA-D was not up to date for Covid-19 vaccination. MA-D was required to test for Covid-19 two times per week. Interview on 9/14/22 at 11:19 AM with MA-D confirmed that MA-D was vaccinated for Covid-19 but had not received any Covid-19 booster vaccinations. MA-D confirmed that MA-D was to be tested two times per week for Covid-19. MA-D confirmed that MA-D tested positive for Covid-19 at home on 8/20/22. MA-D revealed that MA-D returned to the facility for Covid-19 testing on 8/25/22 and tested positive for Covid-19. Record review of the facility Abbott BinaxNOW Covid-19 Ag Card Internal Controls and Testing Logs dated from 6/30/22 through 9/14/22 revealed that MA-D was tested for Covid-19 on 7/5/22 (negative result); 7/11/22 (negative result); 7/14/22 (negative result); 7/18/22 (negative result); 7/21/22 (negative result); 7/25/22 (negative result); 8/1/22 (negative result) (7 days after the previous test); 8/5/22 (negative result); 8/11/22 (negative result); 8/15/22 (negative result); 8/18/22 (negative result); 8/25/22 (positive result); 8/28/22 (negative result); 9/9/22 (negative result). Record review of the undated Timecard for MA-D revealed that between 7/4/22 and 7/14/22 MA-D worked on 7/4/22, 7/5/22, 7/6/22, 7/8/22, 7/9/22, 7/10/22, 7/11/22, 7/12/22, 7/13/22, and 7/14/22 and was available for Covid-19 testing. MA-D was not tested for Covid-19 two times per week as required the week of 7/4/22. Record review of the undated Timecard for MA-D revealed that between 7/25/22 and 8/1/22 MA-D worked on 7/27/22 and 7/28/22 and was available for Covid-19 testing. MA-D was not tested for Covid-19 two times per week as required the week of 7/25/22. Record review of the undated Timecard for MA-D revealed that between 8/1/22 and 8/15/22 MA-D worked on 8/1/22, 8/2/22, 8/3/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/9/22, 8/10/22, 8/12/22, and 8/15/22 and was available for Covid-19 testing. MA-D was not tested for Covid-19 two times per week as required the week of 8/8/22. C. Record review of the undated Covid-19 Staff Vaccination Status provided by the facility revealed that Nursing Assistant-C (NA-C) received the primary Covid-19 vaccination but had not received the recommended booster vaccination. NA-C was not up to date for Covid-19 vaccination. NA-C was required to test for Covid-19 two times per week. Record review of the facility Abbott BinaxNOW Covid-19 Ag Card Internal Controls and Testing Logs dated from 6/30/22 through 9/14/22 revealed that NA-C was tested for Covid-19 on 6/30/22 (negative result); 7/8/22 (negative result) (8 days after the previous test); 7/14/22 (negative result); 7/19/22 (negative result); 7/21/22 (negative result); 7/25/22 (negative result); 7/28/22 (negative result); 8/1/22 (negative result); 8/2/22 (negative result); 8/8/22 (negative result); 8/19/22 (positive result). 8/22/22 (positive result); 8/25/22 (positive result); and 8/26/22 (negative result). Record review of the undated Timecard for NA-C revealed that between 8/8/22 and 8/19/22 NA-C worked on 8/8/22, 8/9/22, 8/10/22, 8/11/22, and 8/12/22 and was available for Covid-19 testing. NA-C was not tested for Covid-19 two times per week as required the week of 8/8/22.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E LICENSURE REFERENCE NUMBER 175 NAC 12-006.11C Based on observation, interview, and record review; the facility failed to ensure staff served meals to residents in a manner to prevent potential cross-contamination and the facility failed to ensure potentially hazardous foods were cooked to prevent the potential for food-borne illness. This affected 4 residents (Residents 44, 30, 32, and 33). The facility identified a census of 53 at the time of survey. Findings are: A. Observation on 9/12/22 at 11:50 AM revealed DA (Dietary Aid)-E putting a thumb on each plate as the plates were being served. Observation on 9/12/22 at 11:55 AM revealed AD (Activities Director) with a thumb on each dessert plate as the plates were being served. Observation on 9/12/22 at 12:00 PM revealed DC (Dietary Cook)-L with a thumb on each dessert plate as they were being set in the window to be served to the residents. Observation on 9/12/22 at 12:00 PM revealed DC-M with a thumb on each plate as they were being filled with food and then set in the window to be served to the residents. Observation on 9/12/22 at 12:10 PM revealed three coffee cups served with pureed food with straws. No beverages are served to Resident 44. NA (Nursing Assistant)-K was repeatedly touching the end of the straw with an un-gloved hand to place food in Resident 44's mouth. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-301.11 Preventing Contamination by employees 81-2,272.10*(Replaces 2013 Food Code 3-301.11 (B), (C), (D) and (E) Preventing Contamination from Hands). 1. Food employees shall wash hands as specified in the Nebraska Pure Food Act. 2. Food employees shall be trained to wash hands 3. Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. This may be accomplished with the use of suitable utensils such as deli tissue, spatulas, tongs, single use gloves, or dispensing equipment. 4. Food employees not serving highly susceptible populations may contact exposed ready-to-eat food with their bare hands if they have washed their hand as specified in the act prior to handling the food. B. Observation on 9/12/22 at 9:43 AM of eggs in both refrigerators revealed there were no pasteurized (treated with mild heat to eliminate pathogens and extend shelf life) eggs in the facility. Interview on 09/12/22 at 9:45 AM with the DM (Dietary Manager) revealed there were no pasteurized eggs in the facility at this time. The farm fresh eggs that were in the facility were used for baking and used for the residents sometimes if there is no pasteurized. Observation on 9/13/22 at 8:15 AM revealed Resident #30 had ordered an over-easy egg with bacon and toast and was dipping the toast in the runny egg. Resident #30 ate 100% of the breakfast. Observation on 9/13/22 at 8:15 AM revealed Resident #32 ordered one over-easy egg and toast and was dipping the toast in the runny egg. Resident #32 ate 100% of the breakfast. Observation on 9/13/22 at 8:16 in the kitchen revealed a container full of eggs from the refrigerator sitting next to the stove. The eggs had no pasteurized stamping on them and one had multiple cracks in it. These were the eggs used for the made-to-order eggs for the residents breakfast. Interview on 9/13/22 at 8:30 AM with DC (Dietary Cook)-M confirmed that the eggs used for breakfast were not pasteurized. DC-M stated that the eggs do not have a P stamped on them like pasteurized eggs usually do and the package does not say pasteurized on it. Observation on 9/13/22 at 9:30 Resident #23 had ordered two over-easy soft eggs served with toast, sausage with gravy and oatmeal. Resident #23 ate one egg and everything else that was ordered for breakfast. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food serve sanitation practices, revealed the following: 3-202.13 Shell Eggs A. Egg Products shall be obtained pasteurized. C. Interview with the PDC (People Development Coordinator) who oversaw the dietary department on 9/15/22 at 11:30 AM revealed the facility staff were expected to carry plates of food from the bottom and not touch drinking surfaces of the straws and glasses. The PDC revealed the facility had been having issues with obtaining pasteurized eggs. The PDC confirmed the staff should not have been serving soft cooked/undercooked eggs to the residents that were not pasteurized. Review of the facility policy Proper Ways to Serve Food dated 2008 revealed a diagram showing a thumb on the plate was wrong and carrying a glass, or touching the drinking surface with the hands, and handling utensils by the use surface was wrong. Review of the undated untitled facility policy revealed the following: The purpose of this policy is to ensure all products made and/or served in this facility containing eggs or egg products are made by utilizing proper sanitation, food handling practices, and pasteurized shell eggs or liquid pasteurized eggs to prevent the outbreak of foodborne illnesses. Guidelines: Pasteurized shell eggs or liquid pasteurized eggs will be utilized for requests for undercooked eggs. All unpasteurized eggs will be cooked until yolks and whites are firm. D. Observation on 9/13/22 at 8:10 AM in the facility [NAME] Dining Room revealed that Resident 32 sat at a table. The plate on the table had soft cooked eggs. Resident 32 poked the yoke of an egg with a fork and dipped a half slice of toast into the runny egg yolk and took a bite of the toast. Observation on 9/13/22 at 8:10 AM in the facility [NAME] Dining Room revealed that Resident 30 sat at the table with Resident 32. Resident 30 had a plate with soft cooked eggs on the table in front of the resident. Resident 30 poked the yolk of an egg with a fork and the yoke ran over the white of the egg. Observation on 9/13/22 at 8:33 AM in the [NAME] Dining Room revealed that Resident 32 ate all of the breakfast meal. Observation on 9/13/22 at 8:33 AM in the [NAME] Dining Room revealed that Resident 30 ate all of the breakfast meal. Interview on 9/13/22 at 8:33 AM with Resident 32 confirmed that the resident ate all of the breakfast meal and enjoyed the eggs. Interview on 9/13/22 at 8:33 AM with Resident 30 confirmed that the resident ate all of the breakfast meal.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility failed to prevent potential cross contamination by failing to perform hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) for 20 seconds, failing to perform hand hygiene before donning and after doffing gloves during medication administration for 1 of 5 residents observed (Resident 25); failing to perform hand hygiene, change gloves, and cleanse a wound before applying a dressing for 4 of 4 residents observed (Residents 25, 40, 155 and 28); failing to perform hand hygiene and change gloves during catheter care for 1 of 1 residents observed (Resident 40), failing to perform hand hygiene between going in and out of resident rooms which affected 4 residents (Residents 45, 47, 40, and 32); and failing to ensure laundry delivery was conducted to prevent the potential for cross-contamination which affected 3 residents (Residents 4, 45, and 47). The facility identified a census of 53 at the time of survey. Findings are: A. Observation of LPN-G (Licensed Practical Nurse) on 9/14/22 at 9:27 AM revealed they prepared medications to administer to Resident 25 via PEG tube (A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). LPN-G crushed each medication and mixed them with water separately. LPN-G had gloves on when LPN-G pushed the pills out of the bubble packs. LPN-G removed the gloves and did not do hand hygiene before LPN-G poured each pill into the pill crusher pouches and poured them into the medication cups. As LPN-G was preparing the medications, LPN-G donned a pair of gloves, removed 1 glove and then put another glove on the same hand without doing hand hygiene in between. LPN-G then put each cup of medication into a bin. LPN-G removed the gloves and did hand hygiene with ABHR (alcohol based hand rub) then took the bin into Resident 25's room and put a paper towel down on the table and put the bin on top of it. LPN-G then went into the bathroom and turned the water on. LPN-G put soap onto their hands from the dispenser on the wall and lathered them for 2 seconds. LPN-G then rubbed their hands together under running water for 20 seconds. The soap was no longer visible after 2 seconds. LPN-G turned the faucet off with a paper towel and donned gloves. Resident 25 was in bed. LPN-G removed the glove from their right hand then without doing hand hygiene, LPN-G used that hand to touch the bed control to raise the bed and head of the bed then LPN-G donned a new glove on that hand without doing any hand hygiene. LPN-G exposed Resident 25's abdomen by pulling the blanket and top sheet down and pulling Resident 25's gown up and handled the PEG tube with the gloved hands. The tube was inserted into Resident 25's abdomen through the skin. LPN-G inserted a 30 ml (milliliter) syringe into the PEG tube and aspirated the stomach contents. LPN-G then put the syringe into the PEG tube port and flushed the tube via gravity with water. LPN-G poured each medication into the tube and flushed the tube with water via gravity in between. LPN-G then poured water into the tube and put the [MEDICATION(S)] nutritional formula into the tube, poured more water in and removed the syringe and put the cap into the port. At 9:51 AM, LPN-G removed the gloves and donned a new pair without doing hand hygiene. LPN-G opened a toothette (a stick with a swab sponge on it used to do oral care) and poured some mouthwash into an emesis basin. LPN-G dipped the toothette into the mouthwash and did oral care by swabbing Resident 25's mouth. LPN-G put the basin on the stand and removed their gloves and donned new gloves without doing hand hygiene. The PEG tube dressing supplies were observed lying on the counter of the built in dresser in front of the stereo. LPN-G removed the soiled drain sponge and silver dressing from around the PEG tube site on Resident 25's abdomen. There was serous drainage on the dressings. LPN-G then used the same gloved hands and picked up a gauze sponge off the counter, opened the package, took the sponge out of the package, picked up a bottle of wound cleanser and sprayed the wound cleanser on the sponge and cleaned around the site which LPN-G did twice by handling the bottle of wound cleanser and the gauze sponges with the soiled gloves. LPN-G then got a pair of scissors out of the bathroom and cut the silver dressing after opening the package and taking the dressing out of the package by handling it with the same gloved hands. LPN-G laid the silver dressing on Resident 25's gown. Using the same gloved hands, LPN-G opened a package of cotton swabs, picked up a tube of [MEDICATION(S)] (medicated) ointment and squeezed some onto the swabs. LPN-G then swabbed the area around the PEG tube under the flange with the [MEDICATION(S)] ointment. LPN-G touched the flange and the PEG tube with the same gloved hands. Using the same gloved hands, LPN-G picked up the dressing off of Resident 25's hospital gown, cut a slit in it with the scissors that were laying on the counter and not on a barrier, and placed it around the PEG tube insertion site in Resident 25's stomach under the flange. Using the same gloved hands LPN-G opened a package of drain sponges, used the same gloved hands to handle the drain sponge and placed it over the silver dressing under the flange of the PEG tube. LPN-G then removed their right glove and held it in their left hand, used the right hand to take a permanent marker out of their pocket, and wrote the date on the drain sponge. LPN-G used the same ungloved hand to reposition the PEG tube and cover Resident 25 up with the blanket/sheet. LPN-G did not do any hand hygiene after LPN-G removed the glove. LPN-G then removed the glove on the left hand and used their right hand to lower the bed by handling the control with their bare hand. LPN-G did not do any hand hygiene after LPN-G removed the other glove. LPN-G then put the opened silver dressing back into the drawer in the bathroom and used their right hand to take a permanent marker out of their pocket and marked on the bottle of [MEDICATION(S)] that was sitting on the bathroom counter. LPN-G then went back out into Resident 25's room and picked up the bin with all of the used cups, took it into the bathroom, and rinsed the cups in the sink and put them on a towel in the bathroom. LPN-G then put the bin on the bathroom counter and did not clean it. LPN-G then washed their hands for 10 seconds under running water. There were no paper towels, so LPN-G used one of the hand towels that was on the bar in the bathroom to dry their hands. LPN-G then took the trash out of the can by handling the bag and put it on the floor. LPN-G pulled a trash can liner out of the can and put the towel in it and tied it and laid it on the floor. LPN-G then pulled up a trash can liner with their bare hands, tied a knot in it, and used it to line the trash can. LPN-G used their elbow to open the room door. LPN-G then did hand hygiene with ABHR. LPN-G put on 1 glove and took a disinfectant wipe out of a container on the cart and cleaned the table the medications were on in Resident 25's room but did not clean the scissors or the counter with the dressing supplies on it. LPN-G then removed the glove with the wipe in it and put the same glove back on and took the emesis basin with the mouthwash in it into the bathroom and rinsed it out in the sink. LPN-G then removed the glove, and without doing hand hygiene, took the bottle of [MEDICATION(S)] formula off the bathroom counter and put it on top of the treatment cart and took the trash and linen bags out of the room and down the hall. Review of the facility policy Lippincott Procedures-Enteral feeding tube exit site care, gastrostomy and jejunostomy dated 9/15/22 revealed the following: Remove and discard your gloves, perform hand hygiene, put on a new pair of gloves. Completing the procedure: Remove and discard your gloves. Perform hand hygiene. B. Observation of Resident 40 on 9/14/22 at 12:28 PM revealed Resident 40 was resting in bed on their back with their pants down. Resident 40 had an indwelling urinary catheter (a tube inserted and left in the bladder to drain urine). RN-F (Registered Nurse) donned gloves and used a wet washcloth to wipe the front of Resident 40's perineum (an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), including the catheter insertion site at the urinary meatus (external urinary opening). RN-F then removed their gloves and put another pair on. RN-F did not do hand hygiene between glove changes. RN-F then dried Resident 40's perineum with a hand towel and there was blood on it. RN-F took off their gloves and put new ones on without doing any hand hygiene. NA-H (Nurse Aide) assisted Resident 40 to roll over in bed onto their side exposing their backside. RN-F took a [MEDICATION(S)] (a type of dressing) sacral (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) dressing out of the package. Resident 40 had numerous open areas on their sacrum and coccyx (tailbone) and there was thick white paste like cream on the entire area. RN-F did not clean Resident 40's open areas, backside/bottom area or wipe the cream residue off. RN-F put the dressing on over the cream residue and did not wash Resident 40. RN-F took the gloves off and put on a new pair without doing hand hygiene. RN-F and NA-H helped Resident 40 roll back over onto their back. RN-F sprinkled medicated powder onto Resident 40's groin areas. RN-F rubbed the powder onto the groin areas. RN-F removed their gloves and put on a new pair and did not do hand hygiene in between. RN-F and NA-H then put a brief (a type of incontinent product) on Resident 40 and repositioned Resident 40 by touching Resident 40's body and linens. With the same gloved hands, RN-F got a graduate, paper towel, and alcohol wipe out of the bathroom, placed the graduate on the floor on the towel and emptied the catheter bag into the graduate. RN-F wiped the spout before putting the drain tube back into the holder on the catheter bag. RN-F then took the graduate into the bathroom and emptied it. Review of Resident 40's TAR (Treatment Administration Record) for September 2022 revealed documentation the zinc paste and skin barrier had been applied to Resident 40's open areas on buttocks and surrounding skin at 8:00 AM on 9/14/22 and the treatments had been discontinued on 9/14/2022. Review of Resident 40's Progress Notes revealed documentation Resident 40 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/14/22, the MD (Medical Doctor) ordered the Sacral [MEDICATION(S)] dressing to buttocks and to discontinue the zinc paste and aloe-[MEDICATION(S)] cream. On 8/8/22 it was documented the pressure areas on the coccyx showed no improvement. The areas measured: upper right buttock 1.5 cm (centimeters) x (by) 1.7 cm. Under that pressure area there was another area that measured 2.8 cm x 2 cm. On the left buttock there was a .2 cm x .2 cm open area. On 7/6/2022 it was documented Resident 40 had an open area to the right buttock measuring .5 cm x .6 cm. On 4/5/2022 it was documented Resident 40 had a 0.5 x 0.5 cm circular open area to the left buttock. Interview with the DON (Director of Nursing) on 9/15/22 at 9:00 AM revealed the staff should have cleaned the open areas on Resident 40's coccyx and sacrum before applying the dressing. C. Observation of Resident 155 on 9/13/22 at 1:11 PM revealed Resident 155 was resting in bed. MA-I (Medication Aide) and MA-J were in the room and both of them donned gloves. MA-I wiped Resident 155's perineum front side with a pre-moistened wipe. MA-I and MA-J then pulled a brief up over Resident 155's perineum and fastened it. MA-I took the trash out of the can by Resident 155's bed that had the soiled wipes in it and took the trash and the soiled linen into the bathroom. MA-I put the bag of trash onto the bathroom counter next to the sink. MA-I then removed their gloves and washed their hands in the bathroom sink for 7 seconds. MA-I then walked out into Resident 155's room and took a liner out of the trash can and pulled it up in the can. MA-J then went into the bathroom and washed their hands for 7 seconds and used their bare hand to turn off the faucet. MA-J then went out into Resident 155's room and moved Resident 155's eye glasses that were laying on the counter. MA-I put the linen into a trash bag they had taken out of the trash can and tied it. MA-I picked the trash bag up off the bathroom counter and walked out into Resident 155's room with both bags and touched the bed control with the same hands they had used to handle the trash bags and lowered the bed. Interview with the DON on 9/15/22 at 9:02 AM revealed the expectation was for staff to wash hands a full 20 seconds and do hand hygiene before donning and after doffing gloves. The DON revealed the staff should use enough hand sanitizer to completely wet their skin and rub their hands together until dry. The DON revealed gloves were not to be used in place of hand hygiene and should have been changed when they are soiled. Review of the facility Donning and Doffing Competency dated 3/2021 revealed the following. Donning (putting on the equipment): Perform hand hygiene. Put on gloves. Doffing (taking off the gear): Remove gloves. Perform hand hygiene. Review of the facility Hand Hygiene Competency dated 12/2019 revealed the following: Hand Hygiene Using Antimicrobial Soap and Water: Check for paper towels before starting hand hygiene procedure. Turn on water and wet hands. Apply soap. Using friction, rub hands together. Clean under and around nails/jewelry and between fingers. Wash up onto wrists. Lather and rub hands together for a full 20 seconds. While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. (These areas are always considered soiled.) Do not shut off water. Leave it running. Dry hands well with paper towels. When finished drying hands, discard paper towel and use a clean paper towel to shut off water faucet. Discard paper towel. When to wash hands: Before eating and drinking; before each resident contact; after sneezing, coughing or blowing your nose; after using the restroom; after touching a resident or handling their belongings; whenever hands are soiled; after any contact with body fluids; after handling contaminated items (linens/garbage/briefs, etc.); before and after gloving; whenever indicated. Hand Hygiene Using Hand Sanitizer: When can hand sanitizer be used: Hands should be free of dirt or organic material. If visibly soiled, use soap and water. Duration of entire procedure: 20 to 30 seconds. If carrying hand sanitizer in your pocket, apply sanitizer to your hand then immediately place the bottle back in your pocket with your free hand. Your pocket and the hand sanitizer bottle are considered dirty. Examples: before/after direct contact with resident; preparing or handling medications; after contact with resident's intact skin; after contact with inanimate objects, such as medical equipment in resident' room or vicinity; after removing gloves or between changing gloves. Procedure: How to Hand Rub: apply a palmful of the product in a cupped hand, covering all surfaces. Rub hands palm to palm. Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once dry, your hands are safe. D. 09/13/22 01:20 PM Observation on 9/13/22 at 1:20 PM revealed Resident #28 was having a dressing change on a small healing pressure ulcer. RN (Registered Nurse)-N was in the room with two aids who were helping to reposition the resident. The aids assisted the resident to roll onto the left side and RN-N applied gloves after doing hand hygiene with ABHS (Anti-Bacterial Hand Sanitizer) and undid the brief on the right side and observed the area on the inner top right buttock. RN-N was interviewed and said the resident came back to the facility with the these skin issues. Rolling the dirty brief on itself and toward the left hip of the resident, RN-N then removed the gloves and did ABHS and donned a new set of gloves and applied Calazinc cream (prevents and relieves skin irritation associated with wet, cracked skin) to the pressure area and removed the gloves then obtained a new brief and opened and applied gloves, rolled, tucked and removed the old brief and replaced it with the new one. RN-N used a wipe over and over to peri area and applied the brief. Both the aids removed their gloves and washed with soap and water and left the room. RN-N removed gloves and emptied the trash then proceeded to wash with soap and water. Observation on 9/13/22 at 1:30 PM revealed NA (Nursing Assistant)-O washed hands for 15 seconds. Observation on 9/13/22 at 1:40 PM revealed RN-N washed hands for 8 seconds. Review of the facility Hand Hygiene Competency dated 12/2019 revealed the following: Hand Hygiene Using Antimicrobial Soap and Water: Check for paper towels before staring the hand hygiene procedure. Turn on the water and wet the hands. Apply the soap. Using friction, rub hands together. Clean under and around nails/jewelry and between fingers. Wash up onto wrists. Lather and rub hands together for a full 20 seconds. While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. (These areas are always considered soiled.) Do not shut off the water. Leave it running. Dry hands well with paper towels. When finished drying hands, discard the paper towel and take a clean paper towel to shut off the water faucet. Discard the paper towel. When to wash hands: Before eating and drinking; before each resident contact, after sneezing, coughing or blowing your nose; after using the restroom; after touching a resident or handling their belongings; whenever hands are soiled; after any contact with body fluids; after handling contaminated items (linens/garbage/briefs, etc.); before and after gloving; whenever indicated. Hand Hygiene Using Hand Sanitizer: When can hand sanitizer be used: Hands should be free of dirt or organic material. If visibly soiled, use soap and water. Duration of entire procedure: 20 to 30 seconds. If carrying hand sanitizer in you pocket, apply sanitizer to your hand then immediately place the bottle back in your pocket with your free hand. Your pocket and the hand sanitizer bottle are considered dirty. Examples: before/after direct contact with resident.; preparing or handling medications; after contact with resident's intact skin; after contact with inanimate objects, such as medical equipment in resident's room or vicinity; after removing gloves or between changing gloves. Procedure; How to Hand Rub: apply a palmful of the product in a cupped hand, covering all surfaces. Rub hands palm to palm. Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once dry, your hands are safe. E. Record review of the undated facility document titled Clean Linen revealed that only those with clean hands may access clean linen. Record review of the facility policy titled Hand Hygiene Competency dated 12/2019 revealed the section titled Hand Hygiene Using Hand Sanitizer (alcohol-based hand rub (ABHR)). The section revealed that the duration of the entire procedure is 20-30 seconds. The procedure revealed that a palmful of the product should be applied to the cupped hand. Interview on 9/15/22 at 1:48 PM with the Infection Preventionist (IP) confirmed that the use of hand sanitizer is included in the Hand Hygiene Competency and that staff are expected to follow the steps of the competency. Observation on 9/14/22 at 9:47 AM on the facility [NAME] Hall revealed that Laundry Assistant-B (LA-B) removed a pair of pants on a hanger from the laundry cart. LA-B carried them into the room of Resident 4. LA-B exited the room of Resident 4 and did not perform hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel). LA-B pulled the laundry cart down the hallway towards the nurse's station. LA-B placed a small amount of alcohol-based hand rub (ABHR) on the tip of the hand and rubbed the hands together for 5 seconds. LA-B removed clothing on hangers and a folded laundry item from inside the laundry cart. LA-B carried the clothing into the room of Resident 45. LA-B exited the room of Resident 45 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B did not perform hand hygiene. LA-B removed clothing on hangers and folded laundry from inside of the laundry cart. LA-B carried the clothing into the room of Resident 47. LA-B exited the room of Resident 47 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B did not perform hand hygiene. LA-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 40. LA-B exited the room of Resident 40 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B applied a small amount of ABHR to a hand and rubbed the hands together for 3 seconds. LA-B removed clothing on hangers from inside the laundry cart. LA-B carried the clothing into the room of Resident 32. LA-B exited the room of Resident 32 carrying used empty clothes hangers. LA-B grabbed additional empty used clothes hangers that were on the handrail outside the room of Resident 154. LA-B carried the used empty clothes hangers to the laundry cart and hung them on the rack inside of the laundry cart. LA-B applied ABHR to a hand and rubbed the hands together for 10 seconds. Interview on 9/15/22 at 9:19 AM with the facility Director of Nursing (DON) confirmed that when utilizing alcohol-based hand rub (ABHR) the staff are to place a palmful of the sanitizer on the palm of the hand and wet the entire hands. The DON confirmed that the staff are to rub the hands with the ABHR until dry. The DON confirmed that staff are expected to perform hand hygiene after exiting the resident's room including during laundry delivery. F. Record review of the undated facility document titled Clean Linen revealed that only those with clean hands may access clean linen. Clean linen will be held away from the employee's uniform. Observation on 9/14/22 at 9:47 AM on the [NAME] Hall revealed that Laundry Assistant-B (LA-B) removed a pair of pants on a hanger from the laundry cart. LA-B held the hanger up at head level with the pants resting against LA-B's shirt as LA-B carried them into the room of Resident 4. LA-B exited the room of Resident 4. LA-B pulled the laundry cart down the hallway towards the nurse's station. LA-B removed clothing on hangers and a folded laundry item from inside the laundry cart. LA-B held the folded laundry item against LA-B's shirt. LA-B carried the clothing into the room of Resident 45 with the folded laundry held against LA-B's shirt. LA-B exited the resident's room carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B removed clothing on hangers and folded laundry from inside of the laundry cart. LA-B carried the clothing into the room of Resident 47 with the folded laundry held against LA-B's shirt. LA-B exited the room of Resident 47 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. Interview on 9/15/22 at 9:19 AM with the facility Director of Nursing (DON) confirmed that staff are to keep clean laundry from touching their uniform. The DON confirmed that the DON saw the staff delivering laundry with the clean laundry against their uniform. The DON revealed that the DON corrected it.

Licensure Reference Number: 12-006.05 21 Based on observation, interview and record review; the facility failed to ensure residents remained covered to protect resident dignity and failed to assist residents in a dignified manner for 1 resident (Resident 44). Census was 53. Findings Are: Observation on 09/12/22 at 10:15 AM revealed Resident #44 was sitting in the wheelchair with the lift pad underneath and the straps still pulled between the legs and without a brief on. Resident #44 had a blanket at the knees, fully exposed. Observation on 9/12/22 at 12:10 PM revealed three coffee cups served with pureed food with straws and no beverages were served to Resident #44. NA (Nursing Assistant)-K was assisting the resident to eat without talking to the resident and without taking any breaks between drinks of food. No fluid drinks were offered. NA-K repeatedly touched the end of the straw to place it in the resident's mouth. Interview with MA-P on 9/14/22 at 4:45 PM revealed residents have the right to be covered and not exposed, at all times. Interview with MA (Medication Aide)-P on 9/14/22 at 4:50 PM revealed when assisting a nonverbal resident to eat it is best to talk with the resident and ask them what they like the taste of, and if they want more of something. Even if a resident cannot talk a person will still be able to tell what is needed. Talk with them, not at them. Record review of the facility policy titled Getting To Know Us Resident Policies dated 12/2020 revealed the section titled Resident Rights. The Resident Rights section revealed: All residents have the right to a dignified existence, self-determination, and communication inside and outside the facility. The facility wants to ensure that residents are treated with dignity and respect in all interactions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure a written summary of the baseline care plan (a written plan required to be developed within 24 to 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was provided to the resident/resident representative within the required timeframe for 3 residents (Residents 31, 46, and 41) of 7 residents reviewed. This prevented the resident/resident representative from identifying additional care concerns for inclusion in the care plan. The facility census was 53. Findings are: A. Review of Resident 31's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/3/2022 revealed an admitted [DATE]. The CAA (Care Area Assessment) completion date and care plan completion date was 8/5/2022. Review of Resident 31's Baseline Care Plan dated 7/27/2022 revealed no documentation a written summary was offered to Resident 31 and/or their PR (Personal Representative). The signature line for resident or PR acknowledgement of the baseline care plan was blank. Review of Resident 31's Initial Care Plan revealed a date initiated of 8/05/2022. Review of Resident 31's Progress Notes dated 8/10/2022 revealed the IDT (Interdisciplinary Team-the facility team responsible for the development of the care plan) met for the initial care team meeting with the resident. The Baseline care plan and copy of orders was declined which was 5 days after the completion of the CAA and initial care plan. There was no documentation a written summary of the baseline care plan was offered to Resident 31 or their PR prior to the completion of the initial care plan. B. Review of Resident 46's Admission MDS dated [DATE] revealed an admitted [DATE]. The CAA completion date and Care Plan completion date was 4/27/22. Review of Resident 46's Baseline Care Plan dated 4/7/22 revealed the resident and representative signature area was blank. Review of Resident 46's Initial Care Plan revealed it was initiated 4/8/22. Review of Resident 46's Baseline Care Plan Acknowledgement Form dated 5/4/22 revealed the baseline and Initial care plan was marked and signed by Resident 46 and their PR on 5/4/22, 7 days after the Care Plan completion date, 27 days after the admitted , and 26 days after the initial care plan was initiated. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed the care plan completion date (item V0200C2) must be either later than or the same date as the CAA completion date (item V0200B2), but no later than 7 calendar days after the CAA completion date. Review of the facility policy Baseline Care (BCP) Guidelines dated 3/2021 revealed the baseline care plan was to be completed per state guidelines. An IDT member (s) will review the baseline care plan summary with the resident/representative prior to the completion of the Comprehensive Care Plan (7 days from when MDS is signed). C. Record review of the facility policy titled Baseline Care Plan (BCP) Guidelines dated 03/2021 revealed that the baseline care plan is to be completed per state guidelines (within 24 hours in Nebraska). An Interdisciplinary Team member/members (a group of health care professionals with various areas of expertise who work together toward the goals of the resident) will review the baseline care plan summary with the resident/representative prior to the completion of the Comprehensive Care Plan (the written interdisciplinary comprehensive care plan detailing how to provide quality care for a resident. The Comprehensive Care Plan must be completed within 7 days of completion of the resident's comprehensive assessment). The signed Care Plan Acknowledgement Form is to be scanned into the resident's electronic health record to verify that the baseline care plan review was done with the resident/resident representative. The policy revealed that the only reason that the baseline care plan summary would not be reviewed and signed by the resident/resident representative would be due to an unplanned discharge. If the resident/representative prefers not to have a copy of the baseline care plan, document in the progress notes that a copy of the BCP was offered to the resident/representative and the copies were declined. Record review of the Admission Record dated 9/13/22 for Resident 41 revealed that Resident 41 admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record revealed that Resident 41 had a power of attorney for healthcare (a resident representative). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 8/12/22 for Resident 41 revealed that it was the admission assessment (a comprehensive assessment) for Resident 41. Record review of the Baseline Care Plan for Resident 41 revealed that the baseline care plan was completed on 8/9/22. Record review of the Care Plan Acknowledgement Form for Resident 41 revealed that the type of care plan was not identified. The reason for discussion or viewing of the care plan was left blank. The form contained the signature of the resident representative for Resident 41 with a date of 8/17/22. The form contained the signature of the facility Social Services Director (SSD). The Care Plan Acknowledgement Form did not contain documentation that a baseline care plan review with the resident/resident representative occurred. Record review of the progress note dated 8/17/22 at 3:24 PM for Resident 41 revealed that a care plan meeting took place with the Interdisciplinary Team and the resident's child. The progress note contained no documentation that a review of the baseline care plan summary was completed with the resident/resident representative. The progress note contained no documentation that a copy of the baseline care plan was provided to the resident/resident representative or if a copy of the baseline care plan was offered and refused. Interview on 9/15/22 at 2:30 PM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that the resident's baseline care plan is initiated on admission to the facility. The MDSC confirmed that during the initial care plan meeting the resident/resident representative are to be provided with a copy of the baseline care plan. The MDSC revealed that you always find out things during the meeting with the resident/resident representative that require the care plan to be fine-tuned. The MDSC confirmed that the resident/resident representative sign the Care Plan Acknowledgement form. The MDSC confirmed that a progress note documenting that a copy of the baseline care plan was provided to the resident/resident representative is to be completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure Resident 40 was offered pain medication prior to potentially painful procedures. This affected 1 of 1 sampled residents. The facility identified a census of 53 at the time of survey. Findings are: Review of Resident 40's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/1/22 revealed an admitted [DATE]. Resident 40 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 40 was cognitively intact. Resident 40 required extensive assistance from staff with ADLs (Activities of Daily Living including bed mobility, transfer, toilet use, dressing, bathing, and personal hygiene). Resident 40 had an indwelling urinary catheter (a tube inserted into and left in the bladder to drain urine). Resident 40 had pain occasionally rated at a 6 on a 0-10 pain scale, with 10 being the worst pain. Resident 40 had pressure ulcers present that were not present upon admission. Observation of Resident 40 on 9/14/22 at 12:28 PM revealed Resident 40 was lying in bed in their room. RN-F (Registered Nurse) and NA-H (Nurse Aide) were in the room. RN-F reported Resident 40 did not like to lay down due to issues with pain. Resident 40 had a urethral (the tubular passage through which urine is discharged from the bladder to the exterior of the body) urinary catheter. Resident 40's perineum (an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), urinary meatus (external urinary opening) and groins were very red. RN-F used a wet washcloth to wipe Resident 40's urinary meatus and perineum. The washcloth had a rough surface and Resident 40 hollered out in pain ouch and oh and winced when RN-F wiped Resident 40. RN-F then dried Resident 40's meatus and perineum with a hand towel which also had a rough surface and after RN-F wiped Resident 40, there was bright red bloody drainage on the towel. Resident 40 hollered out in pain and winced when RN-F dried Resident 40's perineum and meatus with the hand towel. NA-H then took pre-moistened wipes and wiped Resident 40's groins. Resident 40 winced every time NA-H wiped Resident 40's groins. Resident 40 was observed writhing and squirming around in bed and complaining of pain while Resident 40 was lying in bed. NA-H then assisted Resident 40 to roll over to their left side in bed and Resident 40 winced and hollered out in pain. There were numerous open areas on Resident 40's coccyx (tailbone) and sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis). RN-F removed a dressing from a package and applied it to the open areas on Resident 40's sacrum and coccyx. RN-F and NA-H assisted Resident 40 to roll back over in bed onto their back and Resident 40 hollered out in pain ouch and oh. MA-Q (Medication Aide) then brought a bottle of [MEDICATION(S)] (a medicated powder used to treat rashes caused by yeast) powder and RN-F sprinkled it onto Resident 40's red groin areas. RN-F rubbed the powder onto Resident 40's groin area and Resident 40 hollered out with pain. NA-H revealed Resident 40 did not like to lay down in bed because it caused Resident 40 discomfort. Review of Resident 40's MAR (Medication Administration Record) for September 2022 revealed order for acetaminophen (Tylenol pain reliever) 650 mg at bedtime and every 4 hours as needed for pain. There was no documentation any acetaminophen was administered to Resident 40 for pain before Resident 40 was assisted into bed and catheter care, pressure ulcer care, and perineal care were provided. The last documentation the acetaminophen was administered was at 9:00 PM on 9/13/2022, over 15 hours prior to the procedures. Interview with Resident 40 on 9/15/22 at 9:50 AM revealed Resident 40 did not like to lay down in bed as it caused them pain. Resident 40 revealed it hurt to lay down in bed and they had slept in their recliner for [AGE] years. Interview with the DON (Director of Nursing) on 9/15/22 at 9:00 AM confirmed Resident 40 did not like to lay down in bed and often refused perineal care which resulted in pressure ulcers and a sore perineal area. The DON revealed the staff should have used a soft wipe instead of the washcloth when they cleaned Resident 40 and they should have offered Resident 40 something for pain prior to the procedure. Review of the facility Skin and Wound Management Standard dated 4/2019 revealed the following: Pain related to pressure ulcers should be consistently assessed and addressed for all residents with pressure ulcers.

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 2 medication errors out of 37 opportunities which resulted in a medication error rate of 5.41%. This affected 2 of 6 residents observed, Residents 25 and 18. The facility identified a census of 53 at the time of survey. Findings are: A. Observation of Resident 25 on 9/14/22 at 9:27 AM revealed LPN-G (Licensed Practical Nurse) prepared medications to administer to Resident 25 via PEG tube (A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). LPN-G poured medication into a medication cup to the 10 ml (milliliter) mark on the cup from a bottle labeled acetaminophen 160 mg (milligrams) per 5 ml; administer 10.15 ml (325 mg) per PEG tube TID (three times a day). The medication cup had hash marks every 5 ml after the 10 ml mark and did not have marks to measure .10 ml or .05 ml. LPN-G did not draw up the .15 ml using a syringe after they poured the 10 ml in order to ensure the exact amount of acetaminophen was administered which resulted in 1 medication error. LPN-G then administered the acetaminophen to Resident 25 via PEG tube. B. Observation of Resident 18 on 9/14/22 at 11:16 AM revealed LPN-G dialed 2 units on a [MEDICATION(S)] insulin pen holding the pen sideways, pushed the plunger on the pen, then dialed 20 units on the insulin pen. The instructions on the insulin pen read administer 20 units before meals. LPN-G then took the cap off the insulin pen and put a needle on the pen then administered the insulin to Resident 18. LPN-G did not prime the insulin pen after the needle was attached to the insulin pen to ensure it was primed which resulted in 1 medication error for not ensuring the ordered dose of insulin was administered. Review of the facility policy Prefilled Insulin Pen Competency dated 1/2020 revealed the following: Attach the capped needle onto the end of the pen by turning it clockwise until tight. To prime the pen, make sure the arrow is in the center of the dose window. Pull the dose knob out in the direction of the arrow until a 0 is seen. Turn the dose knob clockwise until the number 2 is seen. 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. Interview with the DON (Director of Nursing) on 9/15/22 at 4:23 PM confirmed LPN-G should have attached the needle to the insulin pen before priming to ensure the ordered amount of insulin was administered and LPN-G should have measured the exact amount of acetaminophen liquid.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interview and record review; the facility failed to provide food to the residents that maintained nutritive value for residents receiving pureed diets. This had the potential to affect 4 residents (Resident # 17, Resident # 9, Resident # 6 and Resident # 32) receiving pureed diets. The facility failed to serve food at a safe serving temperature that prevents foodborne illness to all resident receiving food from the kitchen with exception of one resident ( Resident # 10) who received a tube feeding (a device that's inserted into the stomach through the abdomen and used to supply nutrition when a person has trouble eating) for nutritional needs. The facility census at the time of the survey was 44. A. Review of the menu for 4/15/2021 revealed the food service for pureed diets consisted of: Pureed Salisbury steak Pureed Hash brown Casserole Pureed Glazed Carrots Alternate menu was: Pureed Chicken Alfredo Over Fettuccini Pureed Broccoli Pureed Green Beans Pureed Banana Cake with Cream Cheese Frosting Bread Beverage Observation on 4/15/21 at 11:15 AM revealed the DC-K (Dietary Cook) was pureeing the carrots that were on the pureed menu. The DC-K placed 5 slotted spoons full of carrots into the blender and DC-K checked the consistency of the carrots. The DC-K then removed the lid and turned on the cold water tap and placed a full blender container of tap water into the carrots in the blender. The DC-K then blended the carrots and checked the consistency DC-K then turned on the cold water tap and placed another container of tap water from the faucet at the sink into the cap of the blender. The DC-K did not measure the tap water. The water decreased the flavor of the food and waters down the nutritional value. An interview on 4/15/21 at 11:47 AM with RDC (Registered Dietician Consultant) revealed that the expectation was for the cooks to wash hands for 20 seconds following the instructions on the wall above the hand washing sink. The cooks are to scrub their hands, wrist and arms rinse and dry hands between tasks. RDC confirmed that pureed food items were to be processed with broths from meats and the juices the vegetables were cooked in as thinning agents. B. On 4/15/21 at 12:58 PM observation of the test tray revealed the temperatures of the food as: The Chicken Alfredo was 123.4 degrees Fahrenheit and the Broccoli was 144.9 degrees Fahrenheit. The Chicken Alfredo was cold and the noodles were soggy and over cooked. The noodles had a pasty texture to them. The Chicken Alfredo was mixed into the Fettuccini noodles and not placed over Fettuccini noodles with was not attractive or appetizing. Broccoli had a good flavor however the texture was soggy and over cooked. An interview on 4/15/21 at 3:26 PM with the RDC (Registered Dietician Consultant) revealed and confirmed that the DC-K and DC-L failed to perform hand hygiene per facility policy and failed to serve food at a safe serving temperature according to the Food Temperatures policy. Review of the undated Food Temperatures policy revealed it was the policy of the facility to record food temperatures daily to ensure food was at the proper serving temperatures(s) before trays are assembled. Hot foods will be held at 135 degrees Fahrenheit or greater. Ready-to-eat foods that require heating before consumption should be taken directly from a sealed container or an intact package from an approved food processing source and heated to at least 135 degrees Fahrenheit for holding for hot service. On 4/19/21 at 11:00 AM a interview with Resident 23 revealed that the food over the weekend was cold and was never serve hot.

Based on observation, interview and record review; the facility failed to ensure dietary staff handled plates and bowls of food to prevent the potential for cross contamination which affected 17 residents (Residents 25, 15, 16, 31, 5, 6, 35, 18, 44, 29, 97, 12,14, 30, 7, 33, and 40); and the facility staff failed to perform hand hygiene per facility policy when serving and working with foods in the kitchen and after touching their PPE (Personal Protective Equipment (PPE) (protective clothing such as disposable gloves, gowns, face masks, and face shields worn to help prevent the spread of germs) which had the potential to affect all 43 residents receiving food from the facility kitchen with the exception of one resident (Resident 10) receiving tube feeding (a device that's inserted into the stomach through the abdomen and used to supply nutrition when a person has trouble eating) nutrition. The facility census was 44 at the time of the survey. Findings are: A. Observation on 4/15/21 at 10:20 AM of DC-K (Dietary Cook) preparing the ground meat of Salisbury steak revealed the DC-K had 9 residents that have a ground meat diet and 4 residents that are on a pureed diet. DC-K placed 9 steaks that resembled meat balls into the Robo Coupe and added beef broth from the steak as a thinning agent. The DC-K then washed her hands for 13 seconds. DC-K washed DC-K hands but not the wrist or arms per posted instructions above the hand washing sink. The DC-K then obtained a blender and pureed 5 steaks into the blender that resembled meat balls and used broth to thin the meat to pureed consistency. The DC-A covered the pans of the ground and pureed meat and placed them into the warmer to keep heat consistency. B. Observation on 4/15/21 at 11:37 AM of another cook DC-L who served the food prepared by DC-K revealed DC-L washed DC-L's hands for 20 seconds in the hand washing sink but did not scrub the wrist or arms. DC-L received a special order of a [MEDICATION(S)] Sandwich. The DC-L whet to the refrigerator touched the contaminated outside door handle and removed a container of [MEDICATION(S)] mixture. The DC-L then went to the counter and removed a 1/4 loaf of bread. The DC-L went to the glove box passing by the hand washing sink and applied a glove to the DC-L's right hand without washing DC-L's hands. DC-L prepared the sandwich and gave the sandwich on a plate to the aide who covered it with Aluminum foil. DC-L then washed DC-L's hands for 20 seconds after making the sandwich but did not scrub the wrist or arms with soap and water per the posted instructions above the hand washing sink. An interview on 4/15/21 at 11:47 AM with RDC (Registered Dietician Consultant) revealed that the expectation was for the cooks to wash hands for 20 seconds following the instructions on the wall above the hand washing sink. The cooks are to scrub their hands, wrist and arms rinse and dry hands between tasks. C. Record review of the facility provided document titled Proper Ways to Serve Food dated 2008 revealed that there's a right way and a wrong way to carry utensils and serve food. Doing it the wrong way can contaminate food and make people ill. Illustrations revealed the right way to carry a plate is with the thumb and fingers underneath the plate. The wrong way to carry a plate is with the thumb on the top (food side) of the plate. The illustration for carrying a glass revealed the wrong way is grasping the glass over the top of the glass with the palm over the top of the glass. The illustration for carrying a cup revealed the wrong way to carry the cup is holding the cup with a thumb or finger inside of the cup. Observation on 4/14/21 at 12:11 PM in the facility dining room revealed that Dietary Staff-F (DS-F) carried two plates from the kitchen service galley and placed one plate on the table in front of Resident 26. DS-F carried the second plate of food to Resident 25 with the thumb on the eating surface of the plate and placed it on the table in front of the resident. Observation on 4/14/21 at 12:16 PM in the facility dining room revealed that DS-F served a plate of food to Resident 15 with the thumb on the eating surface of the plate. Observation on 4/14/21 at 12:26 PM in the facility dining room revealed that DS-F served a plate of food to Resident 16 with the thumb on the eating surface of the plate. Observation on 4/14/21 at 12:29 PM in the kitchen serving galley revealed that DS-F picked up a round serving tray from the bottom shelf of the wire storage rack. DS-F picked up a small dish of dessert by placing the hand over the top of the dish to pick it up and placed it on the round serving tray. DS-F picked up 4 additional dishes of dessert by placing the hand over the top of each dish as DS-F placed each of them on the serving tray. DS-F carried the tray into the north wing of the dining room. DS-F picked up a desert dish off the tray with the thumb inside the dish and the index finger on the outside rim of the dish and sat it on the table in front of Resident 31. DS-F went to the table of Resident 5 and picked up a desert dish off the tray with the thumb inside the dish and the index finger on the outside rim of the dish and sat it on the table in front of Resident 5. DS-F went to the table of Resident 6 and picked up a desert dish off the tray with the thumb inside the dish and the index finger on the outside rim of the dish and sat it on the table in front of Resident 6. DS-F went to the table of Resident 35 and picked up a desert dish off the tray with the thumb inside the dish and the index finger on the outside rim of the dish and sat it on the table in front of Resident 35. DS-F went to the table of Resident 18 and picked up a desert dish off the tray with the thumb inside the dish and the index finger on the outside rim of the dish and sat it on the table in front of Resident 18. Observation on 4/14/21 at 12:35 PM in the kitchen service galley revealed that DS-F stood at the food service counter in the kitchen serving galley. DS-F touched the N95 face mask (a respiratory protective mask designed to protect the wearer from respiratory diseases. The outside surface of the mask is considered to be contaminated) with the right hand with the palm covering the front of the mask and moving the mask up and down. DS-F touched the protective goggles and repositioned them. DS-F did not perform hand hygiene. DS-F grabbed a plate of food over the food service counter with the thumb of the right hand on the food surface of the plate. DS-F obtained a piece of aluminum foil and covered the plate of food with the foil. DS-F wrote the resident name on the foil and placed the plate on the bottom shelf of the 3 shelf cart. DS-F touched the mask with the right hand with the palm over the mask surface. DS-F did not perform hand hygiene. DS-F placed a covered bowl of soup on the bottom shelf of the 3 shelf cart. DS-F pushed the 3 shelf cart out of the serving galley. The foil covered plate on the bottom shelf of the 3 shelf cart had the name of Resident 44 written on it. DS-F pushed the cart to the facility [NAME] Neighborhood. Nursing Assistant-I (NA-I) pushed the 3 shelf cart down the 300 hall of the [NAME] Neighborhood and delivered the meal plate from the bottom shelf to Resident 44. NA-I delivered the covered bowl of soup to Resident 38. Observation on 4/15/21 at 12:26 PM in the facility dining room revealed that Dietary Staff-G (DS-G) carried a tray of desert dishes containing cake from the kitchen service galley into the dining room. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 29. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 97. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 12. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 14. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 30. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 7. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 33. DS-G picked up a desert bowl from the tray with the thumb inside of the bowl and placed the bowl on the table in front of Resident 40. Interview on 4/20/21 at 9:43 AM in the facility dining room with Dietary Staff-F (DS-F) confirmed that plates of food should be handled with the fingers and thumb underneath the plate. DS-F confirmed that the thumb should not be on the top of the plate next to the food. DS-F confirmed that bowls of food should not be picked up by placing the hand over the bowl. DS-F confirmed that a bowl of food should be handled by the sides of the bowl so that the fingers and thumb are not near the food in the bowl. DS-F confirmed that bowls of food are served by grabbing the outside of the bowl only. DS-F confirmed that the thumb or fingers should not be placed on the inside of the bowl next to the food. Interview on 4/20/21 at 9:52 AM in the Director of Nursing (DON) office with the facility DON confirmed that the expectation is for staff to perform hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting germs among patients and health care personnel) after touching the Personal Protective Equipment (PPE) (protective clothing such as disposable gloves, gowns, face masks, and face shields worn to help prevent the spread of germs) the staff is wearing. The DON confirmed that included touching of the N-95 mask and goggles.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility staff failed to perform hand hygiene during in room meal service which affected 5 of 5 residents observed (Residents 14, 33, 28 29, and 30); failed to perform G-tube (gastrostomy tube-a tube inserted into the stomach for the purpose of administering food, fluids, and medication) site care, G-tube feeding, and G-tube medication administration in a manner to prevent potential cross contamination by placing G-tube site dressing change items, G- tube feeding supplies, and G-tube medication administration supplies on a soiled surface which affected 1 of 1 sampled residents, Resident 10; failed to perform catheter care in a manner to prevent potential cross contamination by failing to change gloves and perform hand hygiene when indicated during catheter (a tube placed into the bladder to drain urine) care for 1 of 1 sampled residents, Resident 10; and failed to ensure staff wore the required Personal Protective Equipment (PPE) (protective clothing such as disposable gloves, gowns, face masks, and face shields worn to help prevent the spread of germs) when performing Covid-19 Point of Care (POC) rapid testing to detect Covid-19 infection to prevent the potential for cross contamination which had the potential to affect all of the facility residents. The facility identified a census of 44 at the time of survey. Findings are: A. Observation of Unit 1 on 4/14/21 at 12:06 PM revealed an unidentified dietary staff person pushed a cart of food down the hall to the unit. There were plates, bowls, and cups on the cart and the plates and bowls were covered with foil and there were lids on the cups. MA-C (Medication Aide) then took the cart and pushed it down the hall and passed the food. At 12:07 PM, MA-C did not do hand hygiene after pushing the cart down the hall. MA-C then took a plate, bowl, glasses of liquid, and silverware off the cart in the hall to Resident 14 and setup the items on Resident 14's table and cut Resident 14's food with the silverware. There was food on the plate and in the bowl. MA-C then went into the bathroom and washed their hands for 8 seconds. MA-C then went back out to the cart in the hall and took a plate and bowl of food, cups of fluids, and silverware to Resident 33 and helped Resident 33 set up the items on the table. MA-C touched the plate, bowl, cups, silverware and the table MA-C put the items on which were all covered. The plate and bowl had foil on them which MA-C removed with their hands by handling the plate and the bowl and the cups had lids which MA-C also removed with their hands by handling the cups. MA-C then went into the bathroom and washed their hands for 8 seconds. At 12:12 PM, MA-C took food to Resident 28 in the same manner. MA-C then did ABHR for 2 seconds after MA-C set up Resident 28's food items by handling the items. MA-C then took a plate and bowl of food, cups of fluid, and silverware to Resident 29 and handled the table and placed the items on the table. MA-C then did hand hygiene with ABHR for 2 seconds. MA-C then took a plate and bowl of food, cups of fluids, and silverware to Resident 30 and handled all items. MA-C handled the plates, bowls, cups and silverware for each residents then MA-C put the items down on the tables and removed the foil from the plates and bowls and the lids from the cups and unwrapped and handled the silverware. None of the residents were wearing masks and MA-C was within 3 feet of them as MA-C put the items on the tables in front of the residents. All of the residents were observed touching the items after MA-C had handled them. Review of the facility policy Hand Hygiene dated May 15, 2020 revealed the following: The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Therefore, hand hygiene is the single most important procedure in preventing infection. To protect a patient from health care-associated infection, hand hygiene must be performed routinely and thoroughly. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as [CONDITION(S)] and bacillus anthracis) is strongly suspected or proven, and after using the restroom. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, non-intact skin, or wound dressing (if hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment. Implementation: hand washing: Wet your hands and wrists with warm water and apply soap from a dispenser. Work up a generous lather by vigorously rubbing your hands together for at least 20 seconds. Hand sanitizing: apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all of the product has dried (usually about 30 seconds). Review of the facility Hand Hygiene Competency dated 12/2019 revealed the following: Procedure Step: Hand hygiene using antimicrobial soap and water: Turn on water and wet hands. Apply soap. Using friction, rub hands together. Lather and rub hands together for full 20 seconds. When to wash hands: before each resident contact; after touching a resident or handling their belongings; whenever hands are soiled; after contact with body fluids; after handling contaminated items (linen/garbage/briefs, etc); before and after gloving; whenever indicated. Hand hygiene using hand sanitizer: When can hand sanitizer be used: hands should be free of dirt or organic material; if visibly soiled, use soap and water; duration of entire procedure: 20 to 30 seconds. If carrying hand sanitizer in your pocket, apply sanitizer to your hand then immediately place the bottle back in your pocket with your free hand. Your pocket and the hand sanitizer bottle are considered dirty! Examples: before/after direct contact with residents; preparing or handling medications; after contact with residents' intact skin; after contact with inanimate objects, such as medical equipment in resident's room or vicinity; after removing gloves or between changing gloves. Procedure/How to Hand Rub: Apply a palm full of the product in a cupped hand, covering all surfaces. Rub hands palm to palm. Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palms and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once dry, your hands are safe. Interview with the DON (Director of Nursing) on 4/19/21 at 4:26 PM revealed it was the expectation the staff follow the 20 seconds for lather when washing their hands and to rub the hands together and put enough hand sanitizer on for a 20 second scrub. B. Review of Resident 10's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/19/2021 revealed an admitted [DATE]. Resident 10's staff assessment for mental status indicated short term and long term memory problem and severely impaired cognitive skills for daily decision making. Resident 10 required extensive assistance of 2 staff with bed mobility and was dependent with all other ADLs (Activities of Daily Living-dressing, transfer, bathing, toilet use). Resident 10 had a feeding tube and an indwelling catheter. Review of Resident 10's Order Summary Report dated 4/15/2021 revealed the following orders: Urinary catheter 20 FR (French) W(with)/30 CC bulb placed 7/21/2020. Nursing order: Cleanse G-tube site with wound cleaner, pat dry and apply drain sponge BID (twice a day) and as needed. Apply barrier cream BID PRN (as needed) two times a day for G-tube site care with an order date of 1/01/2021. [MEDICATION(S)] 1.5 Cal Liquid (Nutritional Supplements) Give 237 milliliter via G-Tube four times a day every 6 hours with an order date of 8/19/2020. Review of Resident 10's TAR (Treatment Administration Record) for April 2021 revealed the following undated order: Catheter care: clean insertion site and tubing twice daily every day and night shift. Observation of LPN-A (Licensed Practical Nurse) on 4/15/21 at 9:30 AM revealed they prepared the following medications for Resident 10 by crushing the tablets and mixing them all together in one glass and then pouring the liquids into the same cup: 1. [MEDICATION(S)] 10 ml (milliliter) liquid per GT (gastrostomy tube) BID (twice a day) (50 mg/5 ml) 2. [MEDICATION(S)] 100 mg (milligram) per GT QD (every day)-crushed 3. [MEDICATION(S)] 250 mg per GT QD-crushed 4. [MEDICATION(S)] 5 mg per GT QD-crushed 5. [MEDICATION(S)] 75 mg per GT QD-crushed 6. [MEDICATION(S)] 25 mg 1/2 tab per GT BID-crushed 7. Multivitamin 1 tablet per GT QD-crushed 8. NaCl ([MEDICATION(S)]) 1 GM tablet per GT QD-crushed 9. KCL (Potassium Chloride) 10 MEQ 7.5 ML per GT QD (20 mEq/15 ml liquid) 10. FeSO4 (Ferrous Sulfate) 7 ml per GT QD (liquid) 11. Geritussin (guaifenesin) 10 ml (200 mg) per GT Q 6 hours (100 mg/5 ml). 12. Silpap liquid (acetaminophen) 10.25 ml (325 mg) per GT TID (three times a day) Observation of LPN-A on 4/15/21 at 9:42 AM revealed LPN-A walked into Resident 10's room with the cup of medication. LPN-A pulled an OTB (over the bed) table over to Resident 10 who was sitting in their recliner. LPN-A did not clean the OTB table and there was visible soil on it. LPN-A placed the cup of medications on the table then went into the bathroom and poured [MEDICATION(S)] 0.9 % from a bottle into a plastic cup. LPN-A placed a large syringe that LPN-A had picked up from a towel on the counter in the bathroom and placed it on the table with some gloves, a bottle of dermal wound cleanser, a package of gauze sponges, and a package with a split sponge. LPN-A also placed a bottle of [MEDICATION(S)] 1.5 cal 8 ounces on the table. LPN-A donned gloves and checked placement of the tube with aspiration and auscultation using the syringe that had been laying on the table. At 9:46 AM, using the syringe, LPN-A then used gravity to flush the tube with about 50 cc of the [MEDICATION(S)], poured in the medications, flushed the tube with [MEDICATION(S)] solution again, poured in the [MEDICATION(S)], flushed the tube again with the [MEDICATION(S)] and clamped the tube and reconnected it to the tube secure taped to Resident 10's abdomen. LPN-A then removed the gloves and washed their hands. LPN-A donned another pair of gloves that had been laying on the table and removed the soiled dressing from around the G-tube site. LPN-A donned a different pair of gloves that had been laying on the table and sprayed a gauze sponge that had been laying on the table with dermal wound cleanser and cleaned around the G-tube site. LPN-A changed gloves and put the split sponge around the site and taped it in place and marked it with the date. The gloves and the split sponge had been laying on the table with the visible soil on it. C. Observation of Resident 10 on 4/19/21 at 3:06 PM revealed LPN-A and NA-B (Nurse Aide) assisted Resident 10 with perineal (an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum)/catheter care. Resident 10 was resting in bed in their room. LPN-A washed their hands and retrieved a pack of pre-moistened wipes. NA-B was on the other side of Resident 10 and was wearing gloves. LPN-A then donned gloves and lowered Resident 10's blanket and brief. Resident 10 had an indwelling urinary catheter present. With gloved hands, LPN-A used the pre-moistened wipes to clean Resident 10's perineum and catheter. LPN-A used 3 wipes to complete the perineal/catheter care. LPN-A did not change their gloves after they completed the perineal/catheter care and touched Resident 10's hands and clothing. LPN-A and NA-B then repositioned Resident 10 onto their right side by touching Resident 10 and their clothing and the turn sheet that was under Resident 10. With gloved hands, NA-B wiped Resident 10's back side with a pre-moistened wipe then removed the soiled brief. Wearing the same gloves they had used to wipe Resident 10's bottom and remove the soiled brief, NA-B put a clean brief under Resident 10 and LPN-A and NA-B both touched Resident 10's clothing and the turning sheet. NA-B then removed their gloves and did not do hand hygiene. LPN-A and NA-B then positioned Resident 10 to their back and with the same gloved hands, LPN-A pulled the clean brief up between Resident 10's legs. Resident 10 was observed grabbing LPN-A's hands and touching their gloves. LPN-A touched Resident 10's arm, turn sheet, shoulder, pillow and blanket with the same gloved hands. NA-B also handled Resident 10's blanket with the same hands without doing hand hygiene after removing the gloves. Without doing hand hygiene, NA-B then touched the bed control and lowered Resident 10's bed after LPN-A pulled the blankets up over Resident 10 with the same gloved hands. Interview with the DON (Director of Nursing) on 4/19/21 at 4:11 PM revealed the facility did not have a written policy for cleaning surfaces. The DON revealed the expectation was for staff to ensure the surface was clean and place a barrier down to put the supplies on. The DON revealed it was their expectation that if going from a dirty procedure to a clean procedure or when gloves were soiled, the staff were expected to change their gloves and perform hand hygiene. Interview with the DON on 4/19/21 at 4:31 PM revealed it was their expectation the gloves would be changed after they were soiled and from moving from a soiled task to a clean task. The DON agreed the staff should have changed their gloves and completed hand hygiene after they did catheter/perineal care and removed the soiled brief for Resident 10. Review of the facility policy Hand Hygiene dated May 15, 2020 revealed the following: The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Therefore, hand hygiene is the single most important procedure in preventing infection. To protect a patient from health care-associated infection, hand hygiene must be performed routinely and thoroughly. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as [CONDITION(S)] and bacillus anthracis) is strongly suspected or proven, and after using the restroom. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, non-intact skin, or wound dressing (if hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment. Implementation: hand washing: Wet your hands and wrists with warm water and apply soap from a dispenser. Work up a generous lather by vigorously rubbing your hands together for at least 20 seconds. Hand sanitizing: apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all of the product has dried (usually about 30 seconds). Review of the facility Hand Hygiene Competency dated 12/2019 revealed the following: Procedure Step: Hand hygiene using antimicrobial soap and water: Turn on water and wet hands. Apply soap. Using friction, rub hands together. Lather and rub hands together for full 20 seconds. When to wash hands: before each resident contact; after touching a resident or handling their belongings; whenever hands are soiled; after contact with body fluids; after handling contaminated items (linen/garbage/briefs, etc); before and after gloving; whenever indicated. Hand hygiene using hand sanitizer: When can hand sanitizer be used: hands should be free of dirt or organic material; if visibly soiled, use soap and water; duration of entire procedure: 20 to 30 seconds. If carrying hand sanitizer in your pocket, apply sanitizer to your hand then immediately place the bottle back in your pocket with your free hand. Your pocket and the hand sanitizer bottle are considered dirty! Examples: before/after direct contact with residents; preparing or handling medications; after contact with residents' intact skin; after contact with inanimate objects, such as medical equipment in resident's room or vicinity; after removing gloves or between changing gloves. Procedure/How to Hand Rub: Apply a palm full of the product in a cupped hand, covering all surfaces. Rub hands palm to palm. Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palms and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once dry, your hands are safe. D. Record review of the facility provided Abbott Binax NOW Covid-19 Ag Card (a Point of Care rapid test for Covid-19) Training Checklist dated 9/2020 revealed that the user acknowledges to wear appropriate personal protective equipment and gloves when running each test and handling patient specimens. The section titled Specimen Collection, Storage, and Handling revealed the step: Perform Hand Hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) and don (put on) gloves, N-95/KN-95 (a respiratory protective mask designed to protect the wearer from respiratory diseases), gown, and Face Shield. Observation on 4/19/21 at 1:45 PM in the facility lab office revealed that Licensed Practical Nurse-D (LPN-D) wore an N95 mask and goggles. A knock was heard on the outside door adjacent to the lab. LPN-D performed hand hygiene with ABHR and put on disposable gloves. LPN-D took a test swab to the outside door and opened the door. Nursing Assistant-J (NA-J) stood outside the facility and LPN-D placed the swab into the left nostril of NA-J and rotated the swab in a circular fashion 5 times. LPN-D removed the swab from the left nostril of NA-J and inserted it into NA-J's right nostril and rotated the swab in a circular fashion 5 times. NA-J departed and LPN-D closed the door and returned into the lab office. LPN-D opened an Abbott POC test card and placed 6 drops of the reagent into the hole on the card. LPN-D inserted the test swab into the test card and rotated the swab 3 times. LPN-D sealed the test card closed and wrote the name of NA-J on the outside of the test card. LPN-D removed the gloves and performed ABHR. A knock was heard on the outside door. LPN-D wore an N-95 mask and goggles. LPN-D put on disposable gloves and went to the door with a test swab. Essential Care Giver-Y (ECG-Y) was outside the door when it was opened by LPN-D. LPN-D placed the swab into the left nostril of ECG-Y and rotated the swab in a circular fashion 5 times. LPN-D removed the swab from the left nostril and inserted it into ECG-Y's right nostril and rotated the swab in a circular fashion 5 times. ECG-Y departed and LPN-D closed the door and returned into the lab office. LPN-D opened an Abbott POC test card and placed 6 drops of the reagent into the hole on the card. LPN-D inserted the test swab into the test card and rotated the swab 3 times. LPN-D sealed the test card closed and wrote the name of ECG-Y on the outside of the test card. LPN-D removed the disposable gloves and performed ABHR. Observation on 4/19/21 at 1:53 PM in the facility lab office revealed that LPN-D heard a knock on the outside door adjacent to the facility lab office. LPN-D wore an N95 mask and goggles. LPN-D performed hand hygiene with ABHR and put on disposable gloves. LPN-D went to the door with a test swab. Essential Care Giver-Z (ECG-Z) was outside the door when it was opened by LPN-D. LPN-D placed the swab into the left nostril of ECG-Z and rotated the swab in a circular fashion 5 times. LPN-D removed the swab from the left nostril and inserted it into ECG-Z's right nostril and rotated the swab in a circular fashion 5 times. ECG-Z departed and LPN-D closed the door and returned into the lab office. LPN-D opened an Abbott POC test card and placed 6 drops of the reagent into the hole on the card. LPN-D inserted the test swab into the test card and rotated the swab 3 times. LPN-D sealed the card closed and wrote the name of ECG-Z on the outside of the test card. LPN-D removed the disposable gloves and performed ABHR. Interview on 4/20/21 at 8:43 AM in the Director of Nursing (DON) office with Licensed Practical Nurse-D (LPN-D) confirmed that LPN-D wore an N95 mask, gloves, and goggles while performing Covid-19 point of care testing on 4/19/21. LPN-D confirmed that a face shield and gown should also have been worn during testing. LPN-D and the DON confirmed that during Covid-19 test swab collection the staff performing the test is to wear a gown, face shield, N95 mask, and gloves.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review; the facility staff failed to maintain a medication error rate below 5% with 26 errors for 30 opportunities with a medication error rate of 86.67% by failing to administer medications within the required time frame for 3 of 4 residents observed (Residents 10, 41 and 14) and failing to administer G-tube medications per standard of practice for 1 of 1 sampled residents, Resident 10. The facility identified a census of 44 at the time of survey. Findings are: A. Review of Resident 10's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/19/2021 revealed an admitted [DATE]. Staff assessment for mental status indicated short term and long term memory problem and severely impaired cognitive skills for daily decision making. Resident 10 required extensive assistance of 2 staff with bed mobility and was dependent with all other ADLs (Activities of Daily Living-transfers, dressing, bathing, toilet use, locomotion). Resident 10 had a feeding tube. Review of Resident 10's Order Summary Report dated 4/15/2021 revealed the following orders: Nothing by Mouth diet (NPO) texture with an with an order date of date of 07/24/2020 Acetaminophen Liquid Give 325 mg (milligram) via PEG-Tube (a type of G-tube) three times a day with an order date of 12/21/2020 [MEDICATION(S)] Tablet 100 MG Give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-Tube with an order date of 7/24/2020 [MEDICATION(S)] Tablet 5 MG Give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-Tube with an order date of 07/24/2020. [MEDICATION(S)] Tablet 250 MG ([MEDICATION(S)] Axetil) Give 250 mg via PEG-Tube in the morning with an order date of 07/27/2020 [MEDICATION(S)] Tablet 75 MG Give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-Tube with an order date of 07/24/2020. [MEDICATION(S)] Sodium Liquid 50 MG/5 ML (milliliter) Give 10 ml via PEG-Tube two times a day with an order date of 07/24/2020. [MEDICATION(S)] Sulfate Liquid Give 7 ml via PEG-Tube one time a day with an order date of 03/30/2021 [MEDICATION(S)] Liquid 100 MG/5 ML Give 200 mg via GTube four times a day with an order date of 07/24/2020 [MEDICATION(S)] Tablet 25 MG Give 12.5 mg via PEG-Tube two times a day. Crush and administer via PEG-Tube with an order date of 07/24/2020 Multivitamin Tablet (Multiple Vitamin) Give 1 tablet via PEG-Tube one time a day for supplement. Crush and administer via PEG-Tube with an order date of 07/24/2020 [MEDICATION(S)] Solution 20 MEQ (milliequivalents)/15 ML (10%) Give 7.5 ml via PEG-Tube one time a day with an order date of 07/24/2020 Sodium Chloride Tablet 1 GM Give 1 tablet via PEG-tube one time a day. Crush and administer via PEG-Tube with an order date of 07/24/2020 Review of Resident 10's TAR (Treatment Administration Record) for April 2021 revealed documentation of the following medications and administration times for Resident 10: [MEDICATION(S)] Tablet 100 MG give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-tube at 0800 (8:00 AM) [MEDICATION(S)] Tablet 5 MG give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-Tube at 0800 [MEDICATION(S)] Tablet 250 MG ([MEDICATION(S)] Axetil) Give 250 mg via PEG-Tube in the morning at 0800 [MEDICATION(S)] Tablet 75 MG give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-Tube at 0800 [MEDICATION(S)] Sulfate Liquid Give 7 ml via PEG-Tube one time a day 0800 Multivitamin Tablet (Multiple Vitamin) Give 1 tablet via PEG-Tube one time a day. Crush and administer via PEG-Tube at 0800 [MEDICATION(S)] Solution 20 MEQ/15 ML (10%) give 7.5 ml via PEG-Tube one time a day at 0800 Sodium Chloride Tablet 1 GM give 1 tablet via PEG-Tube one time a day for electrolyte replacement. Crush and administer via PEG-Tube at 0800 [MEDICATION(S)] Sodium Liquid 50 MG/5 ML give 10 ml via PEG-Tube two times a day at 0800 [MEDICATION(S)] Tablet 25 MG give 12.5 mg via PEG-Tube two times a day crush and administer via PEG-Tube at 0800 Acetaminophen Liquid give 325 mg via PEG-Tube three times a day at 0800 [MEDICATION(S)] Liquid 100 MG/5 ML give 200 mg via G-Tube four times a day at 0800 Observation of LPN-A (Licensed Practical Nurse) on 4/15/21 at 9:30 AM revealed they prepared the following medications for Resident 10 by crushing the tablets and mixing them all together in one cup and then pouring the liquids into the same cup: 1. [MEDICATION(S)] 10 ml liquid per GT (gastrostomy tube) BID (twice a day) (50 mg/5 ml) 2. [MEDICATION(S)] 100 mg per GT QD (every day)-crushed 3. [MEDICATION(S)] 250 mg per GT QD-crushed 4. [MEDICATION(S)] 5 mg per GT QD-crushed 5. [MEDICATION(S)] 75 mg per GT QD-crushed 6. [MEDICATION(S)] 25 mg 1/2 tab per GT BID-crushed 7. Multivitamin 1 tablet per GT QD-crushed 8. NaCl (Sodium Chloride) 1 GM tablet per GT QD-crushed 9. KCL ([MEDICATION(S)]) 10 MEQ 7.5 ML per GT QD (20 mEq/15 ml liquid) 10. FeSO4 ([MEDICATION(S)] Sulfate) 7 ml per GT QD (liquid) 11. Geritussin ([MEDICATION(S)]) 10 ml (200 mg) per GT Q 6 hours (100 mg/5 ml). 12. Silpap liquid (acetaminophen) 10.25 ml (325 mg) per GT TID (three times a day) Interview with LPN-A on 4/15/2021 at 9:30 AM confirmed they had mixed all of Resident 10's medications together in the same cup. Observation of Resident 10 on 4/15/2021 at 9:46 AM revealed LPN-A administered the medications from the cup to Resident 10 through their G-tube, 46 minutes after the latest time the medications were to be administered. LPN-A mixed all of the medications together in the same cup and administered them to Resident 10 through their G-tube and they were administered 46 minutes after the standard leeway time (an hour on each side the medication is ordered to be given) which resulted in 12 medication errors. Interview with the DON (Director of Nursing) on 4/19/21 at 4:20 PM revealed it was their expectation that the medications would be given individually and not given as a mixture. Review of the facility policy Gastrostomy tube drug instillation, long-term care dated May 15, 2020 revealed the following: After verifying proper tube placement, flush the tube with at least 15 ml of purified water. Administer the medication using a clean enteral (intestinal) syringe. Flush the gastrostomy tube again with at least 15 ml of purified water, taking into consideration the resident' fluid volume status. Repeat the procedure for each additional prescribed medication. Interview with the DON on 4/20/21 at 8:48 AM revealed the facility staff were expected to administer the medications within the time frame they were ordered. Review of the facility document Medication Aide Procedure Checklist dated 2017 revealed the following: Provide the medications according to the five rights (the right patient, the right drug, the right time, the right dose, and the right route). B. Record review of the Admission Record for Resident 41 revealed that the resident admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 4/19/21 at 9:26 AM on the facility [NAME] Neighborhood revealed that Registered Nurse-H (RN-H) reviewed the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-H placed the [MEDICATION(S)] into a medication cup. RN-H placed the [MEDICATION(S)] in the medication cup. RN-H entered the room of Resident 41 and gave the medication cup to the resident. Resident 41 swallowed the [MEDICATION(S)] and the [MEDICATION(S)]. The medications were administered 26 minutes late. C. Record review of the Admission Record for Resident 14 revealed that the resident admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 4/19/21 at 9:34 AM on the facility [NAME] Neighborhood revealed that Registered Nurse-H (RN-H) reviewed the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-H removed the scheduled medications from the medication cards and placed them into a medication cup. RN-H revealed that [MEDICATION(S)] 17 Grams was scheduled to be given to Resident 14. RN-H poured the [MEDICATION(S)] powder into a plastic glass and then added water to the glass and stirred it to mix it up. RN-H entered the room of Resident 14 and assisted the resident to take the medications from the medication cup. Resident 14 drank some of the [MEDICATION(S)] and swallowed the pills. Resident 14 drank the remainder of the [MEDICATION(S)]. The medications were administered 34 minutes late.