Every finding on record at Brookestone Meadows Rehabilitation and Care Center

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to implement interventions to manage pain during wound care for 1 (Resident 24) of 5 residents sampled for pain control. The facility identified a census of 128 residents. Findings are: Record review of a facility policy entitled Skin and Wound Management Standard dated revised 04/2019 identified that the following were examples of non-pressure skin conditions: -Venous insufficiency ulcers. The policy defined venous insufficiency ulcer as an open lesion of the skin and subcutaneous tissue of the lower leg. They are reported to be the most common of the vascular ulcer and may be difficult to heal, may occur on and off for several years and may occur after relatively minor trauma. The ulcer may have a moist, granulating wound bed, may be superficial and may have minimal to copious drainage unless the wound is infected. The resident may experience pain which may be increased when the foot is in the dependent position such as when the resident is seated with feet on the floor. - 4. Pain. Pain related to non-pressure skin conditions should be consistently assessed and addressed for all residents with non-pressure related skin changes/condition. Non-pharmacological interventions and/or pain medications should be given prior to treatments when appropriate and prn (as needed). Pain should be addressed with each assessment and prn. Record review of Resident 24's Clinical Census report revealed that Resident 24 was admitted to the facility on [DATE], was discharged to the hospital on 03/19/25 and was readmitted to the facility on [DATE]. Record review of Resident 24's Diagnoses List obtained from the physician order sheet dated 04/01/25 revealed diagnoses that included: squamous cell carcinoma of the skin of the right lower limb, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity and venous insufficiency (chronic) peripheral. Record review of Resident 24's Admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 03/17/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. The MDS manual identified the following range of scores for indications of cognitive impairment:13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. The MDS identified that Resident 24 required substantial to maximum assist with lower body dressing, received scheduled pain medications, received prn pain medications, received non-pharmacological interventions for pain, had occasional pain which occasionally affected sleep, therapy activities and day to day activities. The MDS identified the resident identified a numerical pain rating of 6. (The Numeric Pain Rating Scale is a tool used to measure intensity of pain from 0 to 10 where 0 means no pain and 10 represents the most intense pain imaginable. It helps healthcare providers assess and manage a resident's pain). The MDS identified Resident 24 had 2 venous stasis ulcers present and had non-surgical dressings applied other than to feet. Record review of Resident 24's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) dated 03/11/25 revealed Resident 24 was at risk for alteration in comfort related to osteoarthritis, right hip nailing and wounds. Goals included Resident 24 would verbalize adequate pain relief of pain or ability to cope with incompletely relieved pain. Interventions for pain management included the following: - Assess need for preventive pain measures prior to ADL's (activity of daily living), treatments, exercise, etc. - Avoid unnecessary stress and strain on joints. - Meds as per MD (medical doctor) order, offer prn meds if non-verbal cues present. - Non-pharmacological interventions e.g. repositioning, warm/cold compresses, lighting change, music, 1:1 visits, w/c rides etc. - Position with pillows (devices as ordered) to promote comfort. - Review for pain medication efficacy. Record review of Resident 24's Pain Assessment completed at the time of admission on 03/11/24 revealed that pain was present, with occasional frequency, had an effect on therapy activities and day to day activities, and the resident gave a numeric rating for pain of 5. Record review of an Operative Report dated 03/19/24 for Resident 24 revealed that the resident had a debridement procedure [the surgical removal of dead or infected tissue from a wound to promote healing] of the right leg wounds x 5 wounds, up to subcutaneous tissue and fascia [fibrous tissue in the body] and Acell wound matrix [supports wound healing by facilitating tissue regrowth) and layer application along with wound vacuum (wound vac, a device that applies suction to a wound to remove excess moisture and aide in healing] placement. The wound sizes were identified as 5 cm (centimeters) x 5 cm, 3 cm x 2 cm, 1 cm x 1 cm, 7 cm x 3 cm and 1 cm x 3 cm. The operative report also revealed Resident 24 had a debridement procedure to the left leg wound x 1wound, up to subcutaneous tissue and fascia and Acell wound matrix and layer application along with wound vac placement. The wound size was identified as 2 cm x 2 cm. Record review of Resident 24's Hospital Clinic Summary dated 03/20/25 identified the following information and physician orders: - Problems: Traumatic open wound of left and right lower legs with delayed healing, Venous stasis ulcers of both lower extremities. - Surgical records: Allograft application skin graft lower debridement lower extremity bilateral 03/19/25, possible Acell application to bilateral legs - Discharge orders: Do not change wound vac dressing. First dressing change to be done at wound care clinic in 1 week, keep wound vac at 125 mmHg (millimeters of mercury), see wound clinic in 1 week for wound vac change. - Acetaminophen 500 mg (milligrams) 2 tabs q (every) 6 hours prn (as needed) pain mild. - Oxycodone 5 mg cap 1 by mouth every 4 hours as needed pain x 7 days. Record review of Physician Orders dated 04/01/25 revealed an order for a wound vac set at 125 mmHg with bilateral drains to both lower legs present. The wound vac was applied on 03/20/25. Observation on 03/26/25 at 1:13 PM revealed Resident 24 seated in a recliner in the resident's room. A wound vacuum was present and was set at 125 mmHg as directed per physician orders with bilateral drains to both lower legs present. Interview on 03/26/25 at 1:13 PM with Resident 24 revealed the resident reported that ulcers were present on both lower legs and the resident had a lot of pain in the legs. Record review of a Physician Communication Form dated 3/25/25 revealed the following information: Since having wound vac placed patient has had an increase in pain to BLE (bilateral lower extremities) accompanied with weakness and affected ADLs (Activities of Daily Living, tasks related to personal care, such as dressing, eating, and mobility). Ulizing (SP, utilizing) prn pain meds. I feel patient would benefit from something stronger. This nurse/wound nurse reported to vascular there is an odor, redness and warmth to BLE on 03/24/2025 vascular wants to keep appointment for 3/27/2025. New orders received included: - Stop Tylenol 1000 mg q (every) 6 hours prn - Start Tylenol 1000 mg TID (Three times a day) - Start Tramadol 50 mg PO TID with APAP (Tylenol) Record review of Resident 24's Medication Administration Record (MAR) dated March 2025 revealed the resident received the following medications for pain: - Received scheduled Tylenol 1000 mg TID every day. - Received scheduled Tramadol (pain medication) 50 mg every day. - Received prn Oxycodone on the following days: - 3/22/25 for a pain rating of 7. - 3/24/25 x 2 for pain ratings of 9 and 10. - 3/25/25 for a pain rating of 9. - 3/27/25 x 2 for pain ratings of 10. - 3/29/25 for a pain rating of 4. - 3/31/25 at 12:03 PM (This immediately after the observation of a dressing change for a pain rating score of 7). Observation on 3/27/25 at 10:36 AM revealed Resident 24 was seated in a recliner in the residents room. The resident stated the pain is much better now that they took that thing off (wound vac). Interview on 03/27/25 at 10:40 AM with Registered Nurse (RN)-D revealed Resident 24 had just returned from a visit at the wound care clinic, and they had removed the wound vac at the visit. RN-D stated the wound care clinic was going to fax over new orders for wound care for Resident 24. Interview on 03/27/25 at 12:19 PM with Licensed Practical Nurse (LPN) wound care nurse -A revealed that new orders had been received for wound care for Resident 24. LPN-A reported the wraps for wound care would start on Monday 03/31/25. Observation on 03/31/25 at 8:39 AM revealed the resident was seated in a recliner in the resident's room. The resident had wraps present on both lower legs. The resident stated the pain is ok but was still present in the legs. Record review of a nursing note dated 03/27/25 at 11:01 AM revealed the following information: Note Text: Patient returned from Wound Clinic appointment. Wound vac was removed. New dressings to BLE. No orders received. Call made to wound clinic and VM (voicemail) left for them to call back with order changes. Next appointment 4/2/2025 @1100 and 4/9/2025 @1100. Transportation slip created. Record review of a nursing note dated 03/27/25 at 12:09 PM revealed the following information: Note Text: Received orders from Methodist Wound clinic at this time. Patient was evaluated by Vascular MD (medical doctor) while at appointment today. New orders are as follows: Please send Resident 24 with [gender] Wound VAC to [gender] next visit in one week (April 2nd) in case they want to replace then. 1. DC (discontinue) previous wound care Orders. Wound Care 3 times weekly. 2. Remove dressings 3. Clean wounds with mild soap and water 4. Cleanse with Wound Cleanser of choice 5. Nonstick of choice to all wounds and denuded skin. Mepitel [a type of wound contact layer that does not adhere to the moist wound so it can be easily removed without damaging the skin, potentially reducing pain during wound care treatment] was used in office today. 6. Hydrofera Blue [a brand of antibacterial foam dressing used for managing wounds to help maintain a moist wound environment to promote healing] Transfer to all wounds 7. Apply CoFlex [a two layer compression system that provides therapeutic compression to manage venous disease and associated edema] compression wraps to Bilateral lower legs. Please use Zinc, patient does not tolerate calmoseptine. 8. Continue oral antibiotic until completion per hospital. 9. Patient to follow up in one week. Call sooner with any questions or concerns. Call placed to (gender) son to update on new orders from appointment today. Observation of wound care for Resident 24 on 03/31/25 between 11:00 AM and 12:00 PM revealed LPN-A and RN-B used hand sanitizer and donned gowns in the hallway outside Resident 24's room per infection control protocol for enhanced barrier precautions [used to reduce transmission of organisms during high contact care activities for the resident]. LPN-A knocked, received permission from the resident to enter and both staff entered Resident 24's room. Resident 24 was seated in a recliner in the resident's room. LPN-A had wound care supplies and placed the supplies on the bedside table on a clean towel and all items were in sterile packages. LPN-A donned gloves, cleaned a pair of scissors with a sanitizer wipe, placed them on the clean drape and assisted the resident to transfer and lay down in the bed. Both staff members performed hand hygiene 20 seconds and donned clean gloves. RN-B placed a clean drape underneath the resident's legs on the bed and removed the resident's socks. LPN-A cut the exterior wrap dressings off the right leg and the left leg by cutting the dressings on the front of Resident 24 shin's. LPN-A began to lightly pull the dressing away from the skin in the right leg as RN-B held the resident's leg so LPN-A could get underneath the leg to remove the wrap dressings. As the dressings were being pulled away from the skin on the right leg, the resident exhibited signs of pain with grimacing and moaning and tried to pull [gender] leg away. Resident 24 stated Oh my that hurts and moaned while trying to move about in the bed. Resident 24 lifted (gender) right leg higher and tried to pull away from the nurse. The resident continued to moan, move about on the bed and verbally expressed pain, Ouch it hurts continuously throughout the removal of the dressings to the right leg. About halfway through the removal of the dressings on the right leg at 11:28 AM, LPN-A stopped, took off the gown and gloves, used hand sanitizer and left the room. LPN-A stated I am going to get some saline to try to soak the dressings to make them easier to remove. LPN-A returned to the room with a clean gown in place. LPN-A performed hand hygiene, donned gloves and proceeded to soak the dressings to the right leg in saline as they were being removed. During the rest of the removal of the dressings, after they were soaked with saline, the resident continued to moan and express verbal moans and facial grimacing. At one point, during the removal of the dressings to the right leg, RN-B went to resident, held [gender] hand and told the resident to squeeze [gender] hand and the resident did this. The same process was then completed for the dressing change to the left leg. The resident continued to moan, move about on the bed and verbally expressed pain, Ouch it hurts continuously throughout the removal of the dressings to the left leg. After the dressings were removed from both the right and the left leg, LPN-A and RN-B went into the resident's bathroom and washed hands for 20 seconds. During that time, the resident used [gender] hands to wipe away tears from [gender] eyes. LPN-A and RN-B donned clean gloves. LPN-A washed the wounds to both legs with soap and water while RN-B lifted the resident's legs. During this treatment to the wounds, the resident moaned and stated, Oh that stings and moved the right leg around in pain. LPN-A expressed to the resident that it was almost over and that the application of wound cleanser would sting. LPN-A and RN-B removed their soiled gloves, performed hand hygiene in the resident's bathroom for 20 seconds and donned new gloves. LPN-A sprayed the wounds with wound cleanser and wiped them down while RN-B held the resident's legs up. During that treatment, the resident continued to moan and move about in pain and stated again It stings. Oh ouch oh oh oh. LPN-A and RN-B removed their soiled gloves, performed hand hygiene in the resident's bathroom for 20 seconds and donned new gloves. LPN-A applied several Mepitel dressings to cover all the wounds on the right leg and then several Hydrofera Blue dressings to cover all wounds on the right leg. LPN-A then wrapped the right leg with a CoFlex compression wrap. While the wraps were being applied, Resident 24 continued to moan and say Oh my it hurts. The same process was then completed for the dressing change to the left leg. While the dressings were being removed from the left leg and wraps were being applied, Resident 24 continued to moan and say Oh my it hurts. After the treatment was completed, the resident asked LPN-A if (the resident) could get a pain pill right away. LPN-A stated (gender) would check with the medication aide to see when a pain pill could be given. Interview at 03/31/25 at 11:58 AM with Resident 24 revealed, when asked if the staff had given the resident a pain pill prior to the start of the treatment, the resident stated no, I got my regular medications this morning around 8. Resident 24 confirmed that no pain medication had been received prior to the beginning of the treatment. Interview on 03/31/25 at 12:00 PM with Medication Aide (MA)-C confirmed that Resident 24 had a prn oxycodone pain medication available for use as needed and this had not been given prior to the start of the treatment. MA-C confirmed that the last prn dose of oxycodone was provided to Resident 24 on 3/29/25 for a pain level of 4. Interview on 03/31/25 at 12:00 PM with LPN-A confirmed that no PRN pain medication had been provided to Resident 24 prior to the start of the treatment. LPN-A stated this was the first time [gender] had seen the wounds after the wound vac came off and had no idea the resident would be in so much pain with the treatments. LPN-A confirmed Resident 24 should have been premedicated for comfort and confirmed Resident 24 exhibited both physical, nonverbal signs of pain (moaning, grimacing, squeezing staff hands, moving around in bed) and verbal expressions of pain during the treatment. Interview with LPN-A on 03/31/25 at 1:05 PM confirmed that LPN-A could have stopped the treatment and gotten Resident 24 pain medication and then could have came back to complete the dressing change after the medication had taken effect. LPN-A confirmed this was not done. Interview on 04/01/25 at 8:07 AM with Resident 24 revealed, at the time of the dressing change on 03/31/25, the resident stated [gender] pain rating was a 10 with 10 being the worst possible pain. The resident stated an acceptable level of pain was 0 and the resident wanted no pain with the treatments. The facility was unable to provide additional information prior to exit on 04/1/24 related to pain management for Resident 24.

Licensure Reference Number 12 NAC 12-006.11(E) 2017 Nebraska Food Code 2-301.14 Based on observations, interviews, and record reviews; the facility failed to implement hand hygiene practices between glove changes during meal service to prevent the potential for food borne illness. This had the potential to affect 31 residents who ate foods from the neighborhood satellite kitchen. The facility identified a census of 128. The findings are: Record review of a facility provided document entitled Hand Hygiene Competency dated revised 12/2019 revealed: -When to wash hands: -Before and after gloving. -Whenever indicated. Record review of the Nebraska Food Code 2-301.14 dated 2017 revealed the following: -Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: -(H) Before donning gloves to initiate a task that involves working with food. Continuous observations on 03/27/2025 from 11:40 AM to 12:28 PM in the Calamus neighborhood kitchen revealed Culinary Assistant (CA)-E donned gloves without performing hand hygiene and measured the temperature of pork roast with a thermometer. CA-E cleaned the thermometer with an alcohol pad, doffed gloves, and without performing hand hygiene donned new gloves. CA-E measured the temperature of chicken breasts, cleaned the thermometer with an alcohol pad, and doffed gloves. Without performing hand hygiene, CA-E donned new gloves, measured the temperature of the corn casserole, cleaned the thermometer and doffed gloves. Without performing hand hygiene, CA-E donned new gloves measured the temperature of green beans, cleaned the thermometer and doffed gloves. Without performing hand hygiene, CA-E donned new gloves, measured the temperature of the two-gram sodium diet chicken, cleaned the thermometer, and doffed gloves. Without performing hand hygiene, CA-E donned new gloves, measured the temperature of the two-gram sodium diet pork roast, cleaned the thermometer, and doffed the left glove. Without performing hand hygiene, CA-E donned a new left glove and proceeded with dining room service. During meal service, CA-E prepared a single serving of ranch dressing which soiled the left glove. CA-E doffed the left glove, without performing hand hygiene donned a new left glove and continued with meal service. An interview on 03/27/25 at 12:57 PM with CA-E confirmed that hand hygiene was not performed between glove changes and should have been. An interview with the Registered Dietitian (RD) on 04/01/2025 at 1:05 PM revealed the facility did not have a policy regarding hand hygiene but followed the hand hygiene competency.

Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview and record review, the facility failed to ensure beard restraints were used during meal preparation and service to prevent food borne illness. This had the ability to affect 127 of the 129 residents that reside at the facility. The facility census was 129. The findings are: Record Review of the facility's undated policy titled Hygienic Practices revealed that food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, linens and unwrapped single service and single-use articles. An observation on 03-11-2024 at 10:43 AM of the Culinary Service Director (CSD) revealed [gender] was cooking in the kitchen. The CSD had a mustache and goatee and was not wearing a beard restraint while stirring chili at the free-standing soup kettle. An observation on 03-11-2024 at 10:50 AM of Cook-B revealed [gender] was cooking in the kitchen. Cook-B had a beard and was not wearing a beard restraint while deep frying chicken fritters. An observation on 03-11-2024 at 12:00 PM of Cook-A revealed [gender] was serving lunch in the Long Pine dining room. Cook-A had a mustache and beard and was not wearing a beard restraint while plating food for lunch service. An observation on 03-12-24 at 9:13 AM of Cook-C revealed [gender] was cooking in the kitchen. Cook-C had a beard and was not wearing a beard restraint while stirring sauce at the free-standing soup kettle. An interview with the Registered Dietician (RD) on 03-06-2024 at 7:40 AM revealed that all residents in the facility except 2 eat food prepared in the facility kitchen. An interview with the CSD on 03-12-24 at 9:19 AM confirmed beard nets were not being used. An interview with the Registered Dietician (RD) on 03-12-2024 at 9:25 AM confirmed beard nets should be worn if facial hair is present.

Licensure Reference Number 175 NAC 12-006.09D6 Based on observation, record review and interviews, the facility failed to aspirate to determine patency of a peripherally inserted central catheter (PICC) for 1 (Resident 178) of 3 sampled residents. The facility identified a census of 129. The findings are: Record review of Resident 178's discharge orders dated 3/5/24 revealed the resident recieved recent treatment at the hospital for an infection in left knee wound (prosthetic joint infection). Record review of Resident 178's physician's orders dated 3/05/24 revealed the following order: -Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 10 millilieters (mL) intravenously two times a day related to Infection and Inflamattory reaction due to internal left knee prosthesis, subsequent encounter. The order revealed to flush each lumen of PICC line before and after medication administration and/or every 12 hours while not in use. An observation on 3/12/24 at 10:20 AM, of Registered Nurse (RN)-D preparing to flush Resident 178's PICC Intravenous (IV) Line revealed RN- D performed hand hygiene and applied gloves. RN-D then completed the hub scrub with an alcohol wipe for 30 seconds and attached the Normal Saline syringe and completed a 10 mL flush. RN-D failed to aspirate (draw back) for a blood return to check for patency (correct placement) prior to completing the Normal Saline flush. RN-D then removed the syringe from hub, scrubbed the hub with an alcohol wipe for 30 seconds, and applied a new cap. RN-D completed hand hygiene after removing gloves. An interview on 3/12/24 at 10:30 AM with RN-D confirmed that the RN-D did not complete a patency check (pull back for blood) with this procedure for the flushing. An interview on 3/12/24 at 10:45 AM interview with Assistant Director of Nursing (ADON) -E confirmed the facility policy states that PICC patency is to be checked prior to flushing procedure. A record review of the facilities Intravenous Policy and Procedure for Administration of Intravenous (IV) Fluids/medications guidelines (Policy 9.10) created by Senior Care Pharmacy, last review 01/21 revealed under #7 letter A on page 1 to, Confirm patency of the vascular access device (VAD) prior to infusion via a brisk blood return and absence of resistance when flushing as well as absence of signs and symptoms of complications. A record review of the facilities IV Policies and Procedures for Flushing and Locking of a Venous Access Device (VAD) (Policy 9.9) created by Senior Care Pharmacy revealed on page 2, under Procedure-Flushing: #5 Slowly inject 1-2ml of sodium chloride into VAD, noting resistance or sluggishness of flow, and slowly aspirate until brisk blood return is obtained. Then slowly inject remainder of sodium chloride flush. #5b states, Inability to flush or absence of a blood return from CVAD requires further investigation about the cause (mechanical problem, fibrin/thrombosis over VAD tip, extravascular tip location). A record review of the Standard of Practice for the power PICC manufacturers recommendations page 1, Power injection procedure #3-Aspirate for adequate blood return and vigorously flush the catheter with the full 10ml of sterile normal saline WARNING: Failure to ensure patency of the catheter prior to power injection studies may result in catheter failure.

Licensure Reference Number 12-006.18E4 Based on observations, interviews, and record review, the facility failed to secure hazardous chemicals in two open-air kitchens. This deficient practice had the potential to affect the 66 residents that resided on Waters/Longpine and Calamus/Lodgepole halls. The facility census was 120. Findings are: An observation on 10/29/2021 at 4:00 PM revealed an unattended spray bottle with a red liquid on a cart in the Calamus/Lodgepole dining room. Further observation revealed two entrances to the dish room in the Calamus/Lodgepole open-air kitchen, which was adjacent to the dining room. Both doors to the dish room were propped open. Two detergent dispensers were just inside the doorway of one entrance; one connected to a red liquid, and one connected to a green liquid. No staff or residents were observed in the area at the time, but residents could access this area at any time. An observation on 10/29/2021 at 4:05 PM of the Waters/Longpine open-air kitchen revealed three spray bottles with a red liquid and a gallon of bleach on the shelves in the dishwashing room. There were two open entrances to the dish room, and no staff were present in the kitchen or dining room. Further observation revealed two detergent dispensers were just inside the doorway of one entrance; one connected to a red liquid, and one connected to a green liquid. No residents were observed in the area at the time, but residents could access this area at any time. In an interview on 10/29/2021 at 4:15 PM, the Food and Nutrition Services Director (FNSD) stated there were main doors closing off all access to each open-air kitchen, but they never used them. The FNSD then stated the red liquid was a Quat Sanitizer and the green liquid was a detergent for mopping the floors. The FNSD stated they did not shut the doors to the dish room during the day or night; they were always open and accessible. When kitchen staff were not present in the kitchen, the nursing staff monitored the dish rooms and they had not had any issues with residents wandering or accessing the chemicals. The FNSD then stated there was no risk if a resident were to ingest the red sanitizer because they used it on food contact surfaces, so it should be no different if they ingested it. The FNSD stated bleach should be locked up and should not be in the dish room. The FNSD stated it would not be good if a resident ingested bleach or the mop detergent. The FNSD stated they did not know why they did not shut and lock the doors to the dish room when no one was present. In an interview on 10/29/2021 at 4:30 PM, the Maintenance Director stated the facility may have used the primary doors to close off access to the open-air kitchen when not in use the first year the building was open, but they never used them now. The Maintenance Director then stated they could lock up the chemicals in a housekeeping closet if they needed to be locked up. In an interview on 10/29/2021 at 4:45 PM, the Director of Nursing (DON) stated that the back portion of the open-air kitchens contained the dishwasher, the food preparation area, and the area that held the dirty dishes. The DON stated that the facility kept the doors open during the day. The DON was unaware if any chemicals were in the area in question. The DON stated that if chemicals were in the area, they would be accessible to residents, and it would be detrimental to them [the residents]. When asked if the risk to the residents would be minimized if the doors were shut when staff were not present, the DON stated, Yes. In an interview on 10/29/2021 at 5:10 PM, the Administrator stated the doors in the open-air kitchens were open all the time, and the Administrator was unable to verify if the doors were closed during the evening or night shift. The Administrator stated the area in the open-air kitchens contained the dishwasher and the garbage area for cleaning. The Administrator stated that there were cleaning chemicals in that area. To their knowledge, no resident had ever gone into the area, but anyone would have access if the doors were open. The Administrator stated that the doors should remain shut when staff were not present. In an interview on 10/29/2021 at 5:50 PM, the Administrator stated they had no policy on securing chemicals making them inaccessible to residents. Instead of a policy, they went by the Safety Data Sheets (SDS). A review of the undated SDS for Oasis 146 Multi-Quat Sanitizer revealed, Harmful if swallowed, causes severe skin [CONDITION(S)] and eye damage, and store locked up. This was the red liquid that was observed. A review of the undated SDS for Sanitizing Wash n Walk revealed, Harmful in contact with skin or if inhaled, may cause an allergic skin reaction, causes serious eye damage. Keep out of reach of children. This was the green liquid that was observed. A review of the undated SDS for Clorox Healthcare Bleach Germicidal Cleaner revealed, Avoid contact with eyes, skin, and clothing. Do not eat, drink or smoke when using this product.

Based on observations, interviews, document review, and facility policy review, the facility failed to monitor and record medication refrigerator temperatures daily for two (Nemaha and Elkhorn) of four medication rooms reviewed for medication storage. This deficient practice had the potential to affect the 23 residents who resided on Nemaha and Elkhorn. The facility census was 120. Findings are: A. A review of the Elkhorn medication refrigerator temperature log, dated October 2021, revealed the following temperatures were recorded: - On 10/03/2021, 34 degrees Fahrenheit (F) - On 10/06/2021, 35 degrees F - On 10/11/2021, 34 degrees F - On 10/23/2021, 40 degrees F - On 10/24/2021, 40 degrees F - On 10/26/2021, 31 degrees F All other dates between 10/01/2021 and 10/29/2021 were blank. A further review of the temperature log revealed, Temperature for medication refrigerator should be between 36 degrees F and 46 degrees F. If temperature is not adequate, notify appropriate individuals for repair and remove contents to another refrigerator for storage. Document action taken on this sheet. There was no documented actions taken on the temperature log for the temperatures logged below 36 degrees F. An observation on 10/29/2021 at 9:35 AM revealed the medication room's refrigerator thermometer was 29 degrees F. The following medications were stored in the refrigerator: - Two pens of [MEDICATION(S)] 1.5 milligrams (mg)/0.5 milliliter (mL) - Six Ultra Transport Medium (UTM) RT specimen collection kits for COVID-19 - Three intravenous (IV) Cephazolin 2 grams (gm)/50 mL - One [MEDICATION(S)] 5 mL vial - Two [MEDICATION(S)] injections 5/0.1 mL During an interview on 10/29/2021 at 9:40 AM, Registered Nurse (RN) A stated the medications in the medication refrigerator needed to be stored between 36 degrees F and 46 degrees F. RN A stated the night shift nurse was responsible for checking and logging the medication refrigerator's temperature and did not know why staff were documenting temperatures outside of that range. RN A stated it was important to store medications in the required temperature range because if they were not, the medications may not work properly or could cause harm to a resident. RN A stated they would put in a maintenance request and move the medications to another refrigerator. During an interview on 10/29/2021 at 10:30 AM, the Director of Nursing (DON) stated they did not know what the medication room's refrigerator required temperature range should be. The DON then asked the Infection Control Preventionist what the medication room's refrigerator required temperature range should be. The Infection Control Preventionist stated they would have to look up what the required temperature range should be. The DON further stated the night nurse was responsible for checking the medication refrigerator temperature and logging it on the log. It was important to ensure medications were stored in the required temperature range so medications could be administered to residents safely. If medications were stored outside of the required temperature range, they should be replaced. The DON then stated the required temperature range for the medication refrigerator was on the posted temperature log, and the nurses should know the required range. The DON stated there were four medication room refrigerators. During an interview on 10/29/2021 at 3:00 PM, the Administrator stated they expected nursing to be in compliance with monitoring medication refrigeration temperatures. Temperatures logs should be complete and accurate. During an interview on 10/29/2021 at 6:30 PM, RN E stated they were on the night shift, and the night shift nurses were responsible for checking the temperature of the medication refrigerators and documenting them on the temperature log. The required temperature range was listed at the bottom of the log. RN E further stated they always did it when on the night shift. If the temperature was outside of the 36 degrees F to 46 degrees range, they would let maintenance know so they could look at it. RN E then stated they did not know why the temperature log was not completely filled out, or why staff were documenting above or below the appropriate temperature range. It was important to complete the log with the correct temperature to keep resident medications safe to use. A review of the facility's policy titled, Medication Storage and Utilization Policy, dated 03/2019, revealed, Medications requiring refrigeration or storage at temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow for temperature monitoring. Temperature of medication storage refrigerators will be monitored and recorded daily to ensure proper storage. B. A review of the Nemaha medication refrigerator temperature log, dated October 2021, revealed the following temperatures were recorded: - On 10/01/2021, blank - On 10/02/2021, 32 degrees F - On 10/03/2021, 32 degrees F - On 10/04/2021, 32 degrees F - On 10/05/2021, 32 degrees F - On 10/06/2021, 34 degrees F - On 10/07/2021, 32 degrees F - On 10/08/2021, 31 degrees F - On 10/09/2021, 35 degrees F - On 10/10/2021, 34 degrees F - On 10/11/2021, 32 degrees F - On 10/15/2021, 32 degrees F - On 10/19/2021, 32 degrees F - On 10/20/2021, 32 degrees F - On 10/21/2021, 32 degrees F - On 10/22/2021, 33 degrees F - On 10/23/2021, 34 degrees F A further review of the temperature log revealed, Temperature for medication refrigerator should be between 36 degrees F and 46 degrees F. If temperature is not adequate, notify appropriate individuals for repair and remove contents to another refrigerator for storage. Document action taken on this sheet. All other dates between 10/01/2021 and 10/29/2021 had appropriate temperatures logged between 36 degrees F and 46 degrees F. There was no documented actions taken on the temperature log for the temperatures logged below 36 degrees F. An observation on 10/29/2021 at 9:50 AM revealed the medication room's refrigerator's thermometer was 38 degrees F. The following medications were stored in the refrigerator: - Seven vials of [MEDICATION(S)] inhalation suspension 590 milligrams (mg)/8.4 milliliters (mL) - One [MEDICATION(S)] 5 mL vial - One [MEDICATION(S)] injection 5/0.1 mL - One syringe of Ceftraxone, 2 gm - One [MEDICATION(S)] 100/mL pen During an interview on 10/29/2021 at 9:55 AM, Registered Nurse (RN) C stated they thought the medication, lab specimen, and food refrigerators needed to be kept less than 40 degrees F. RN C further stated it was important to store medications in the required temperature range because if they were not, the medications could go bad and not work properly. During an interview on 10/29/2021 at 10:30 AM, the Director of Nursing (DON) stated they did not know what the medication room's refrigerator required temperature range should be. The DON then asked the Infection Control Preventionist what the medication room's refrigerator required temperature range should be. The Infection Control Preventionist stated they would have to look up what the required temperature range should be. The DON further stated the night nurse was responsible for checking the medication refrigerator temperature and logging it on the log. It was important to ensure medications were stored in the required temperature range so medications could be administered to residents safely. If medications were stored outside of the required temperature range, they should be replaced. The DON then stated the required temperature range for the medication refrigerator was on the posted temperature log, and the nurses should know the required range. The DON stated there were four medication room refrigerators. During an interview on 10/29/2021 at 3:00 PM, the Administrator stated they expected nursing to be in compliance with monitoring medication refrigeration temperatures. Temperatures logs should be complete and accurate. During an interview on 10/29/2021 at 6:30 PM, RN E stated they were on the night shift, and the night shift nurses were responsible for checking the temperature of the medication refrigerators and documenting them on the temperature log. The required temperature range was listed at the bottom of the log. RN E further stated they always did it when on the night shift. If the temperature was outside of the 36 degrees F to 46 degrees range, they would let maintenance know so they could look at it. RN E then stated they did not know why the temperature log was not completely filled out, or why staff were documenting above or below the appropriate temperature range. It was important to complete the log with the correct temperature to keep resident medications safe to use. A review of the facility's policy titled, Medication Storage and Utilization Policy, dated 03/2019, revealed, Medications requiring refrigeration or storage at temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow for temperature monitoring. Temperature of medication storage refrigerators will be monitored and recorded daily to ensure proper storage.

Based on observations, interviews, and document review, the facility failed to monitor and record nourishment refrigerator temperatures daily for two (Niobrara and Elkhorn) of four nourishment refrigerators reviewed for food storage. This deficient practice had the potential to affect the 20 residents who resided on these two halls. The facility census was 120. Findings are: An observation on 10/29/2021 at 9:20 AM revealed the nourishment refrigerator on Niobrara had a temperature of 44 degrees Fahrenheit (F). There were two individual yogurt containers, three Glucerna shakes, and one Ensure stored in the refrigerator. During an interview on 10/29/2021 at 9:22 AM, Registered Nurse (RN) A stated the nourishment refrigerator should be below 40 degrees F and confirmed the temperature was 44 degrees F. RN A stated the yogurts would be thrown away because they were not stored under 40 degrees F. RN A stated it was important to store food that required refrigeration under 40 degrees F to prevent foodborne illness. A review of the Niobrara nourishment refrigerator's temperature log, dated October 2021, revealed the following temperatures were recorded: - On 10/03/2021, 46 degrees F - On 10/05/2021, 44 degrees F - On 10/06/2021, 42 degrees F - On 10/07/2021, 42 degrees F - On 10/09/2021, blank - On 10/11/2021, blank - On 10/12/2021, blank - On 10/14/2021, 42 degrees F - On 10/21/2021, 42 degrees F - On 10/22/2021, 42 degrees F - On 10/23/2021, 46 degrees F - On 10/24/2021, 42 degrees F - On 10/25/2021, 46 degrees F - On 10/26/2021, 46 degrees F - On 10/27/2021, 46 degrees F - On 10/28/2021, 48 degrees F - On 10/29/2021, 46 degrees A further review of the temperature log revealed, Temperature should be 40 degrees F or below. If temperature is not adequate, notify appropriate individuals for repair and remove contents to another refrigerator for storage. Document action taken on this sheet. All other dates between 10/01/2021 to 10/29/2021 had appropriate temperatures logged below 40 degrees F. There was no documented action taken on the temperature log for the temperatures logged above 40 degrees F. A review of the Elkhorn nourishment refrigerator's temperature log, dated October 2021, revealed the following: - From 10/01/2021 to 10/03/2021, the dates were crossed off because no residents were on the hall - The dates from 10/04/2021 to 10/26/2021 were blank - On 10/27/2021, 36 degrees F - On 10/28/2021, 36 degrees F During an interview on 10/29/2021 at 9:50 AM, Licensed Practical Nurse (LPN) E stated the night shift nurse was responsible for checking and documenting the temperature of the nourishment refrigerator. LPN E then stated they did not know why the temperature log was mostly blank. LPN E stated it was important to monitor the refrigerator's temperature because if foods were stored above the required temperature range, they could start to grow bacteria and make people sick. During an interview on 10/29/2021 at 10:30 AM, the Director of Nursing (DON) stated the night nurse was responsible for checking and logging the nourishment refrigerator's temperature. The temperature log had written on it that the nourishment refrigerator temperature must be below 40 degrees F. The DON stated it was not safe to eat foods if they had not been refrigerated below 40 degrees F. If some food was stored above 40 degrees F it could start to grow bacteria and make people sick. During an interview on 10/29/2021 at 10:50 AM, the Registered Dietitian (RD) stated food refrigerators must be kept at 40 degrees F or below to safely store potentially hazardous foods. If potentially hazardous foods were stored above 40 degrees F, they could cause foodborne illness if individuals ate them. The RD expected the nourishment refrigerators to be kept 40 degrees F or below, and the temperature logs to be complete to ensure adequate monitoring. During an interview on 10/29/2021 at 3:00 PM, the Administrator stated they expected nursing to be in compliance with monitoring nourishment refrigeration temperatures. Temperatures logs should be complete and accurate. During an interview on 10/29/2021 at 6:30 PM, Registered Nurse (RN) E stated they were on the night shift, and the night shift nurses were responsible for checking the temperature of the nourishment refrigerators and documenting on the temperature log. The required temperature range was below 40 degrees F, and it was listed at the bottom of the log. RN E further stated they always checked temperatures when on the night shift. If the temperature was above 40 degrees F, they would let maintenance know so they could look at it. RN E then stated they did not know why the temperature log was not filled out. RN E stated it was important to complete the log with the correct temperature so resident foods were stored safely and did not grow bacteria. A review of an in-service, dated 10/26/2021, revealed, Attention nurse/medication aide nights: please make sure you are documenting the temperature for the refrigerators in supplement room and medication room every night. During an interview on 10/29/2021 at 11:45 AM, the RD stated they followed the Centers for Medicare and Medicaid (CMS) guidelines when monitoring temperatures for potentially hazardous food storage. A policy was requested. A review of the undated regulation provided to the surveyor by the facility revealed, Potentially hazardous foods must be maintained at or below 41 degrees F. Monitoring food temperatures and functioning of the refrigeration equipment daily.

Based on observations, record review, and interviews, the facility failed to ensure the morning meal was offered to one (Resident 3) of five residents reviewed for nutrition. This failed practice had the potential to affect the 36 residents located on Lodge Pole Hall and Calamus Hall who received meals from the halls' designated satellite kitchen. The facility census was 120. Findings are: The facility admitted Resident 3 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score to be a nine out of 15, which indicated the resident was moderately cognitively impaired. A review of Resident 3's care plan, with a revision date of 10/21/2021, revealed the resident was at risk for potential impaired nutritional status. Interventions included the resident's likes and dislikes related to food. The care plan had no documentation related to the resident's preference of being bathed before meals. For restorative dining, staff were to obtain the resident's menu selection and offer an alternative meal and find food that the resident was willing to try. In an observation and interview on 10/26/2021 at 12:22 PM, Resident 3 was lying in bed and was asked by the surveyor if they had been served lunch yet, since the resident was dining in their bedroom. Resident 3 stated that they never received breakfast and wanted breakfast instead of lunch. The surveyor asked to verify if Resident 3 did not receive breakfast, and again, Resident 3 stated they did not receive breakfast that morning and they were starving. There were no staff in the resident's room with the resident at the time of this observation and interview. In an interview on 10/26/2021 at 12:59 PM, Certified Nursing Assistant (CNA) A was asked if all meal trays had been delivered to the hall, and CNA A stated all the lunch trays had been served in the dining room and to those residents who dined in their rooms. The surveyor asked if Resident 3 received a noon meal tray. At that time, CNA A got on their walkie-talkie system and asked the other two CNAs assigned to that hall if they had provided Resident 3 with their meal tray. CNA C came over the walkie-talkie and stated they had not given the resident a meal tray and there was no response from CNA B. In an interview and observation on 10/26/2021 at 1:02 PM, CNA B was asked if they provided Resident 3 with a breakfast or lunch meal tray. CNA B stated they thought another CNA provided the meal tray to the resident. CNA B stated, I guess [Resident 3] didn't get any breakfast. CNA B went to the satellite kitchen and got a lunch tray for Resident 3 and then delivered it to Resident 3's room. The resident's head of the bed was against the same wall as the door, which made the resident face the widow and unable to see who entered the room. The refrigerator was located against the wall by the door. CNA B stated they would put the resident's lunch meal in the resident's personal refrigerator and give it to the resident after the resident received their bath from hospice. CNA B did not acknowledge Resident 3 when the CNA entered the room with the meal tray. As CNA B placed the food in the refrigerator, the surveyor asked CNA B to ask Resident 3 if the resident wanted to eat. CNA B, again, stated the resident preferred to eat after their bath and started to walk to the door to leave. CNA B was asked again to at least offer the meal to the resident, and CNA B then asked if Resident 3 wanted to eat before their bath, and the resident stated, Yes, I haven't even had breakfast yet and I'm starving. Resident 3 asked what food was being served for lunch, and CNA B got the food out of the refrigerator and advised the resident of the meal. Resident 3 stated they did not want the lunch meal and requested a waffle, sausage, and juice instead. CNA B asked if Resident 3 wanted to save the lunch for later, and Resident 3 stated, No. CNA B placed the food back inside the refrigerator and left the room. Within a few minutes, CNA B brought the resident the requested breakfast. When asked who completed the meal tickets for Resident 3, CNA B stated they did not know. In an interview on 10/26/2021 at 1:04 PM, CNA C stated they did not provide Resident 3 with breakfast or lunch and that they were providing a shower during the breakfast time. When asked who completed the meal tickets for Resident 3, CNA C stated they did not know. In an interview on 10/26/2021 at 1:08 PM, CNA A stated they did not provide Resident 3 with a breakfast tray. CNA A stated the CNAs working the hall were responsible for passing the meal trays. When asked why Resident 3 did not get a breakfast or lunch tray, CNA A stated they did not know. When asked who completed the meal tickets for Resident 3, CNA A stated they did not know. In an interview on 10/26/2021 at 1:10 PM, Dietary Aide (DA) A stated that they only provided meal trays based off the meal tickets they received from the CNAs. When asked who served the breakfast meal, DA A stated that the Dietary Manager (DM) had to fill in for breakfast for that satellite kitchen due to being short staffed. In an interview on 10/26/2021 at 1:15 PM, the DM stated they had to fill in as a dietary aide that morning and had to go back and forth between the satellite kitchen and the main kitchen. The DM stated that both the nursing staff on the floor and the dietary staff were responsible for ensuring all residents were served a meal tray. When asked how they were made aware that everyone had been served breakfast that morning, the DM stated, I asked the floor staff if everyone had been given a plate, and they said everybody had been served. Generally, breakfast tends to run over the set breakfast times. The DM stated when a resident was not served their meals, it could lead to weight loss and malnutrition. After the interview with the DM, Resident 3 was observed eating breakfast and had eaten 75% of their meal and was still eating. The hospice aide was sitting outside of the resident's room until the resident finished their meal. A progress note written by Assistant Director of Nursing (ADON) B was reviewed. The progress note was created on 10/26/2021 at 4:49 PM, and had an effective date and time of 10/26/2021 at 1:10 PM. ADON B indicated Resident 3 requested to have breakfast after their bath that day and the resident ate breakfast closer to lunch time and was not hungry for their lunch. The note indicated the resident requested staff to save their lunch and staff placed it in the resident's personal refrigerator. In an interview on 10/28/2021 at 10:50 AM, the Registered Dietician (RD) stated the facility used a ticketing system that created a ticket for every resident, unless they were NPO (nothing by mouth). Each perforated page had the resident's name, hallway, room number, diet, any adaptive equipment needed, and allergies listed for breakfast, lunch, and dinner. The RD stated that each unit was responsible for the residents on their hall. The nursing staff were to pick up the tickets at the satellite kitchen, take the tickets to the resident's room, and review what was on the ticket with the resident. Then, the CNA takes the ticket back to the satellite kitchen, and the kitchen staff prepared the food based off the tickets received. The RD stated, The dietary aide only serves what the nursing staff provides them on the ticket. The RD stated that sometimes there were residents who did not wish to eat during the breakfast time from 7:30 AM to 9:00 AM, and the dietary staff could provide the resident with a meal, but that process was prompted by the CNA and nursing staff. The RD stated that Resident 3 had a particular way of doing things. The RD stated that the resident preferred to sleep in, and a family member brought in assorted items that the resident liked, and the staff would heat the food up for the resident. The RD stated that if a resident missed meals, it could lead to weight loss and other concerns. The RD stated, Every resident should be given the opportunity to choose on the menu and when and what they want to eat, and it should be done at breakfast, lunch, and dinner. There should be a check-and-balance system with the meal tickets. The RD stated there was a meal ticket printed for Resident 3 but could not speak of where it went. In an interview on 10/28/2021 at 11:10 AM, the Director of Nursing (DON) stated the facility had open dining, and breakfast could be from 7:30 AM to 9:00 AM, and lunch was from 11:30 AM to 1:00 PM. The DON stated if a resident ate in their room for the designated meal, the CNAs were responsible for picking up the tickets from the satellite kitchen, and then they go to the resident's room with the tickets and have the residents fill them out with their preference. Then, the tickets are taken back to the kitchen for dietary staff to prepare the room tray. When asked who was responsible for ensuring all residents were served a meal tray, the DON stated the responsibility was between the nurses and aides; they follow up to make sure everyone is fed. The DON stated when the concern of the resident not being fed breakfast or lunch was brought to their attention by the surveyor, the DON interviewed staff, and the resident had a bath that day and preferred to eat after their bath. The DON was told the resident was not provided a meal tray until 1:02 PM, and the DON stated, It was much later than usual. The DON was asked why the meal trays were not offered to the resident, regardless of the resident's preference, which could change, and the DON stated that the surveyor needed to speak with ADON B. In an interview on 10/28/2021 at 11:20 AM, ADON B stated the resident preferred to have breakfast after they received their bath. The surveyor asked if the resident had to wait until after 1:00 PM to be offered breakfast due to wanting to eat after a bath, and ADON B again stated it was the resident's preference. ADON B stated that the progress note written on 10/26/2021 was written after ADON B interviewed staff on the resident's hall. In an interview on 10/29/2021 at 9:59 AM, the Administrator stated that it was the resident's choice when they wanted to eat. When asked what the expectations were of the staff regarding residents' meals, the Administrator stated the residents should receive what was on their meal ticket and staff should have good communication to ensure all residents received a meal tray. There was no policy and procedure made available during the survey regarding the serving of residents' meals.

Licensed Reference Number 12-006.09D6 Based on observations, record review, and interviews, the facility failed to ensure a nebulizer treatment was monitored for completion for one (Resident 102) of one resident reviewed for respiratory care. This failed practice had the potential to affect three residents located on Calamus Hall who received physician-ordered aerosol treatments. The facility census was 120. Findings are: The facility admitted Resident 102 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score to be a 13 out of 15, which indicated the resident was cognitively intact. A review of Resident 102's care plan, with a revision date of 08/07/2021, indicated the resident was at risk for altered respiratory function related to chronic obstructive pulmonary disease, oxygen dependence, pulmonary [CONDITION(S)], pleural effusion, [CONDITION(S)], aspiration risk, and inability to sleep in bed related to shortness of breath. An intervention listed was to provide breathing treatments as ordered. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to inhale orally four times a day for chronic obstructive pulmonary disease. The start date was 10/24/2021. In an observation on 10/27/2021 at 2:06 PM, Resident 102 was lying in bed, with their eyes closed. The resident had on a nebulizer mask that appeared to have an empty nebulizer reservoir, in which the liquid medication went. The nebulizer machine was currently turned on and running. There was a medication cart sitting outside of the resident's room, but there was not a nurse nearby. In an observation and interview on 10/27/2021 at 2:14 PM, Licensed Practical Nurse (LPN) B walked up to the medication cart outside of Resident 102's room and was asked when they started the resident's nebulizer treatment. LPN B stated they started the treatment at 1:00 PM. LPN B was asked if they stayed with the resident during the administration of the medication, and LPN B stated they asked the resident's preference if they preferred the mask treatment or the handheld treatment. LPN B then checked on the resident after fifteen minutes. LPN B stated that they had not removed the resident's nebulizer mask or turned the machine off because they just came back to the cart to administer Tylenol to the resident, and they did not want to wake the resident to remove the mask. LPN B stated that they did not stay near the resident's room during the nebulizer treatment and did not stay with the resident or around the resident's room while the treatment was completed. LPN B stated that they finished passing medications to other residents while the treatment was being completed. An interview was attempted with Resident 102 on 10/27/2021 at 3:01 PM, but the resident declined to be interviewed. In an interview on 10/27/2021 at 3:04 PM, the Director of Nursing (DON) was asked how nursing staff were to provide nebulizer treatments, and the DON stated the nurse should follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that prior to the COVID-19 pandemic, the nurse would stay with the resident but due to COVID-19, the nurse left the room due to it being an aerosol procedure. After the treatment was complete, the nurse should assess the resident and clean the equipment used. The DON was asked if a nebulizer treatment should be on a resident for over an hour, and the DON replied, No. The DON stated the nurse should be aware of how much time had elapsed, so they knew when to check on the resident. In an interview on 10/29/2021 at 9:57 AM, the Administrator was asked what their expectations were regarding the steps a nurse should follow when administering a nebulizer treatment, and the Administration stated they would assume the nurse would follow the order and monitor the resident. A review of the Instructions for Use for [MEDICATION(S)]-[MEDICATION(S)] Solution, a pamphlet located inside the resident's medication box, indicated the treatment should last approximately five to fifteen minutes. A review of the facility's Nebulizer Medication Administration procedure, with no revision date listed, indicated nursing staff should .17. Remove the mouthpiece when all medication inhaled. 18. Turn off the compressor. 19. Repeat vital signs, if indicated. 20. Assist the resident with oral care .

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on record reviews and interviews; the facility staff failed to implement a fluid restriction for 1 (Resident 50) of 4 sampled residents. The facility staff identified a census of 121. Findings are: Record review of a physician's orders [REDACTED]. Record review of Resident 50's Treatment Administration Record (TAR) for May 2020 revealed the facility staff documented Resident 50 fluid intake as follows: -5-01-2020, 1750 ml. -5-03-2020, 1612 ml. -5-08-2020 2050 ml. -5-09-2020, 2310 ml. -5-10-2020, 1550 ml. -5-11-2020, 1360 ml. -5-14-2020, 1400 ml. -5-16-2020, 1210 ml. -5-17-2020, 2260 ml. -5-22-2020, 1990 ml. -5-23-2020, 2030 ml. -5-24-2020, 1240 ml. -5-25-2020, 1520 ml. -5-26-2020, 1210 ml. -5-29-2020, 1380 ml. -5-30-2020, 1330 ml. -5-31-2020, 2050 ml. Record review of Resident 50's TAR for June 2020 for the fluid restriction revealed the following information: -6-05-2020, 1540 ml. -6-06-2020, 1600 ml. -6-07-2020, 1925 ml. -6-12-2020, 1300 ml. -6-13-2020, 1530 ml. -6-14-2020, 1600 ml. On 8-19-2020 at 4:50 PM an interview was conducted with the Facility Director of Nursing (DON), During the interview, the DON confirmed the fluid restriction was not followed as ordered by Resident 50's practitioner.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to evaluate skin breakdown as a pressure ulcer, failed to prevent additional pressure ulcers and failed to obtain changes in treatment when the condition of the pressure ulcer declined for 1 (Resident 10) of 3 sampled residents. The facility staff identified a census of 118. Findings are: A. Record review of the facility policy and procedures for Skin and Wound Management Standards (SWMS) dated 4-2019 revealed the following information: -Definitions: -Pressure Ulcer/Injury: -A pressure ulcer/injury is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. -Avoidable/Unavoidable Pressure Ulcers: -Avoidable means the resident resident developed a pressure ulcer and the facility did not do one or more of the following: Evaluated the residents conical condition and pressure ulcer risk factor, define and implement interventions that are consistent with the resident needs, resident goals and recognized standards of practice, monitored and evaluated that impact the interventions and revise the approaches as appropriate. -Pressure ulcer stages: - Deep Tissue Pressure Injury (DTPI), Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. -Unstageable is full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough ( yellow, tan, gray, green or brown tissue that is dead) and/or eschar (tan, brown or black) in the wound bed. B. Record review of Resident 10's Non-Pressure Skin Condition Record sheet (NPSCRS) dated 4-10-20 revealed Resident 10 admitted to the facility on [DATE]. Further review of Resident 10's NPSCRS dated 4-10-20 revealed the facility staff identified Resident 10 as having a red blanchable ( According to the National Database of Nursing Quality Indicators for Pressure Ulcer Training, Module 1, Blanchable is when color return immediately with release of pressure. Such as taking a finger and pressing on skin and releasing) area to the left heel and a bandage was applied. Record review of Resident 10's NPSCRS dated 4-24-20 revealed Resident 10 was evaluated with an area to the left heel that measured 2 centimeters (cm) by 2 cm. According to the information on Resident 10's NPSCRS dated 4-24-20 , Resident 10 had a non blanchable area to the left heel and was purple in color with the progression of the wound evaluated as deteriorated. Record review of Residents 10's medical record that included progress notes and practitioners orders revealed there was not evidence Resident 10 left heel ulcer had been re-evaluated for the possibility of a need to change treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident 10's NPCRS dated 4-28-20 revealed Resident 10 area to the left heel measured 1.5 cm by 2.0 cm and was blanchable. Record review of Resident 10's NPSCRS dated 5-8-20 revealed Resident 10 was evaluated with a left heel abrasion that measured 0.6 cm by 0.5 cm and .appeared grayish in color. Record review of Resident 10's medical record that included progress notes and practitioner orders revealed there was not a re-evaluation of the development of the ulcer appearing grayish in color or changes in interventions to prevent further deterioration in the ulcer. Record review of Resident 10's NPSCRS dated 5-15-20 revealed resident 10 had a scab/redness noted to the L (left) heel that measured 1 cm by 1 cm with redness measuring 2 cm with thearea left open to air. Record review of Resident 10's medical record that included progress notes and practitioner orders revealed there was not a re-evaluation of the development of the ulcer with development of a scab area. Record review of Resident 10's NPSCRS dated 5-22-20 revealed Resident 10 was evaluated with a scab/purple area to the left heel that measured 2 cm by 1.6 cm, an increase in size of the ulcer from the NPSCRS dated 5-15-20. Record review of Resident 10's medical record that included progress notes and practitioner orders revealed there was not a re-evaluation of the treatment, interventions or casual factors. Record review of Resident 10's NPSCRS dated 5-29-20 revealed Resident 10 was evaluated with a open area to the left heal that measured 2 cm by 2 cm with a depth of 0.5 cm with drainage with the ulcer identified as deteriorating. Record review of Resident 10's progress note dated 6-02-2020 revealed Resident 10 was admitted to the hospital after a schedule appointment. Review of Resident 10's electronic record revealed Resident 10 returned to the facility on [DATE]. Record review of a Pressure Ulcer sheet dated 6-03-2020 revealed the left heel ulcer was unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) and was facility acquired. C. Record review of Resident 10's Progress Notes (PN) sheet dated 7-22-20 revealed Resident 10 was evaluated with a .scabbed area to outside of right heel. Review of Resident 10's medical record that included progress notes, practitioner orders and practitioners visits revealed there was no evidence the facility had evaluated the casual factor of the development of the ulcer, or requested a treatment. Record review of a Wound Center (WC) progress note for Resident 10 revealed on 7-30-2020 Resident 10 was assessed as having a new wound to the right lateral malleolus and the right lateral plantar aspect of the foot. According to the WC progress note for Resident 10 dated 7-30-2020, the plantar wound appeared to be a deep tissue pressure injury and the left Achilles (same area being identified as left heel by facility staff). Record review of a Pressure Ulcer Record (PUR) dated 7-31-20 revealed in the Progress Note Summary section Resident 10 had a new pressure area to the plantar surface of the right foot. According to Resident 10's PUR dated 7-31-2020 the new pressure ulcer was found at Resident 10's appointment with the Wound Clinic. Observation on 8-04-2020 at 7:10 AM of pressure ulcer treatment by the facility Wound Nurse (WN) revealed Resident 10 had a pressure ulcer to the upper part of the left heel into the Achilles area that measured approximately 2.3 cm by 2.0 cm with whitish gray tissue coving the wound base. Observation of the right foot ulcers revealed Resident 10 had a black area that was measured by the WN to be 2.8 cm by 1.7 cm to the plantar and 1 cm round to the right Malleolus. On 8-04-2020 at 9:00 AM an interview was conducted with the facility WN. Review of Resident 10's NPSCRS sheet dated 5-08-2020, 5-15-2020,5-22-2020 and 5-29-2020 was completed with the WN revealing the following : D. During the interview and review, the facility WN confirmed gray skin to the left heel area would indicate a change as identified on the NPSCRS dated 5-08-2020. E. During the interview and review, the facility WN reported a scab would be necrotic tissue and was a change in condition of the ulcer as identified on the NPSCRS dated 5-15-2020. The facility WN further reported not sure if the treatment had been changed as the WN was not involved at this point and was not notified. F. Review of Resident 10's NPSCRS sheet dated 5-22-2020 indicated the ulcer had deteriorated and the facility WN reported not being aware if a request for a treatment changed was completed as the WN had not been notified. G. The facility WN confirmed Resident 10's NPSCRS dated 5-29-2020 revealed the left heel ulcer was open, had drainage and the condition of the wound had deteriorated. H. The facility WN confirmed during the interview on 8-04-2020 at 9:00 am Resident 10's left heel should have been identified as a pressure ulcer. On 8-04-2020 at 10:40 AM a interview was completed with the facility WN was conducted. During the interview the facility WN reported there was not a treatment change requested and should have been when Resident 10's ulcer condition declined on 5-15-2020 and on 5-22-2020. On 8-04-2020 at 11:30 PM a follow up interview was completed with the facility WN. During the interview the WN reported since Resident 10's ulcer was on the heel, the ulcer should have been evaluated as pressure as the ulcer was on a bony prominence.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.01C3a(6) Based on record review and interview; the facility staff failed to notify the practitioner and responsible family member of deterioration of a pressure ulcer for 1 (Resident 10) of 3 sampled residents. The facility staff identified a census of 118. Findings are: Record review of Resident 10's Non-Pressure Skin Condition Report Sheet (NPSCRS) dated 5-8-20 revealed Resident 10 was evaluated with a left heel abrasion that measured 0.6 cm by 0.5 cm and .appeared grayish in color. Further review of Resident 10's NPSCRS dated 5-08-20 revealed the sections to document if the practitioner and family members were notified were blank. Record review of Resident 10's NPSCRS dated 5-15-20 revealed resident 10 had a scab/redness noted to the L (left) heel that measured 1 cm by 1 cm with redness measuring 2 cm with thearea left open to air. Further review of Resident 10's NPSCRS dated 5-15-20 revealed the practitioner and family were notified on 4-10-2020. This was prior to the change of the development of the scab/redness noted to the L (left) heel that measured 1 cm by 1 cm with redness measuring 2 cm with thearea left open to air noted on the NPSCRS dated 5-15-2020. Record review of Resident 10's NPSCRS dated 5-22-20 revealed Resident 10 was evaluated with a scab/purple area to the left heel that measured 2 cm by 1.6 cm, an increase in size of the ulcer from the NPSCRS dated 5-15-20. Further review of Resident 10's NPSCRS dated 5-22-2020 revealed the sections to notify the practitioner and family were blank. Record review of Resident 10's NPSCRS dated 5-29-20 revealed Resident 10 was evaluated with a open area to the left heal that measured 2 cm by 2 cm with a depth of 0.5 cm with drainage with the ulcer identified as deteriorating. Further review of Resident 10's NPSCRS dated 5-29-2020 revealed the section for notification of family was blank. On 8-04-2020 at 10:40 AM an interview was conducted with the facility Wound Nurse(WN). During the interview the facility WN confirmed the Resident 10's practitioner and responsible party had not been notified of the deterioration of the left heel ulcer on 5-08-2020,5-15-2020 and 5-22-2020 and should have been. In addition, the facility WN confirmed Resident 10's responsible party had not been notified of the deterioration of the left heel ulcer on 5-29-2020.

Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure bathroom vents were in working order. This had the potential to affect 6 residents, (Residents # 87, 27, 22, 24, 26, and 7). The facility census was 130. Findings are: Observation on 11/13/18 at 1:30 PM revealed that vents in bathrooms of (Residents 87, 27, 22, 24, 26, and 7.) were not working. Observation on 11/14/18 at 10:00 AM revealed that vents in bathrooms of (Residents 87, 27, 22, 24, 26, and 7.) were not working. Interview on 11/14/18 at 2:01 PM with the head of maintenance confirmed that the ventilation system was not working on the 1200 wing (Lodgepole) of the facility. This affected (Residents 87, 27, 22, 24, 26, and 7).

Based on observation and interview the facility failed to store food items in a sanitary manner. This affected two of the five kitchens observed. Findings include: During initial tour of the main kitchen conducted on 09/18/2017 at 8:15 a.m. with Cook Staff M the following observations were made: In the dry storage area, there were 13 brown bananas on a metal tray. At least one of the bananas had withered and underneath the bananas was a large amount of brown liquid. Stored on the floor was a medium sized cardboard box containing approximately 40 bags of corn chips. There was a large plastic bin containing 4 quarts of rice; the scoop was stored inside the plastic bin containing the rice. The scoop handle was in contact with the rice and a potential cross contaminant. In the freezer, there was a 10 pound bag of sausage links and a 5 pound bag of breaded chicken open to the air and not dated. During interview conducted at that time Cook Staff Letter M verified these observations. During observation conducted on 09/19/2017 at 11:28 a.m. in the kitchen located on Lodgepole Hall, one refrigerator contained multiple slices of bacon that were uncovered and undated. During interview conducted at that time the Dietary Manager Staff L verified the observation and stated the bacon should have been covered and dated.

Based on record review and staff and resident interview the facility failed to post a prominent and accessible notice regarding the availability of the survey report for the public and residents. Findings include: Interview with Resident #231 on 9/19/2017 at 10:15 a.m. revealed he had been the resident council president in the facility for 1.5 years. He stated he attends and manages the resident council meetings. He stated in all the meetings that he had led over the past 1.5 years the subject of the location of where the annual survey report was located had never been shared. He stated there are facility staff present in every meeting and they have never informed residents of where they can view the survey report. He stated he would like, and would like other residents, to be made aware of what was found during the annual inspection. Observation of the 3 main entrances in the facility revealed only one entrance had the survey report posted. The 2 entrances with no evidence of survey results posted also failed to have a sign to indicate the results could be found at the main entrance. Interview with alert Residents #257 and #170 on 9/19/2017 4:26 p.m. revealed they attend most resident council meetings and they had never heard the staff present at the meetings speak about location of the survey results and they were not aware of where the survey results were located. Interview with the Administrator and the Director of Nursing on 9/20/2017 at 8:30 a.m. revealed they only have the survey results posted at the main entrance. They verified family and other visitors enter all three entrances in the facility and not just the main entrance. They verified those families and visitors who enter the facility through the East and West entrance would never see the survey results. They verified there is no signage posted at any other entrance to direct residents residing on the neighborhoods as to where the survey results are posted.

Based on clinical record review and staff interview the facility failed to ensure one resident was comprehensively assessed for a significant weight loss. This affected one of 22 residents reviewed in the Stage 2 sample (Resident #304). Findings include: Review of resident #304's clinical record conducted on 09/19/2017 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Weights and Vitals Summary revealed the following weights were obtained: 04/06/2017 144 pounds 04/10/2017 138.2 pounds 04/13/2017 137.8 pounds 04/17/2017 137.6 pounds 04/20/2017 134 pounds Review of the 14 Day Minimum Data Set (MDS) assessment with a reference date of 04/20/2017 revealed that the resident's weight was documented as 143 pounds in Section K0200B. The resident was discharged home on[DATE]. During interview conducted on 09/19/2017 at 11:20 a.m. Dietitian Staff P verified that on 04/20/2017 the resident had weighed 134 pounds as documented on the Weights and Vitals Summary. She also verified that on the 14 Day MDS dated [DATE] section K 0200B the resident's weight was documented as 143 pounds instead of the actual weight of 134 pounds. Dietitian Staff P stated that due to the incorrect coding on the 14 Day MDS dated [DATE] section K0200B the resident was not identified as having experienced a significant weight loss and therefore no action had been taken at that time. During interview conducted on 09/19/2017 at 12:00 p.m. Registered Nurse Staff D verified the 14 Day MDS assessment dated [DATE] section K0200 was not coded with the correct weight of 134 pounds.

Based on interviews and record review the facility failed to implement the plan of care for 1 of 22 residents in the stage 2 sample (Resident #262) who was non-weight bearing status and required extensive assistance and the support of two staff members for all transfers. Findings include: Resident #262 was admitted to the facility on [DATE] and has multiple [DIAGNOSES REDACTED]. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed that resident #262 required extensive assistance with transfers and the support of 2 plus persons' physical assistance. The resident was also coded as, not steady and only able to stabilize with human assistance. Under the section entitled cognitive patterns, the resident was coded as being oriented to day, month and year with her recall ability determined to be intact. The resident's plan of care was also reviewed with an admission date of [DATE] and in part revealed the following focus area, goals and interventions: Focus: ADL self-care performance deficit related to right patellar tendon rupture with right knee ligament extensor mechanism reconstruction. Goal: Will improve current level of function in ADL's (Activities of Daily Living) through the review date, with a target date of 11/24/2017. Interventions: Resident requires extensive assistance and the support of two persons physical assistance with transfers, toilet use, bathing, and bed mobility. The care plan intervention also indicated that the resident was NWB (non-weight bearing) status to RLE (Right Lower Extremity) and that the, brace to RLE to remain locked and in extension at all times. A second area of focus on the care plan indicated that the resident, has potential for falls related to decline in mobility ROM (range of motion) restrictions, impaired balance. The care plan goal indicated that resident #262 would be free from injury resulting from a fall through the review date. A review of the physician's orders [REDACTED]. A review of the x-ray report dated 9/14/2017 was conducted and revealed in part, Impression: Inferior patellar fracture with diastasis, minimally increased. Comparison August 22, 2017, July 13, 2017. Technique: AP and lateral views of the right knee Under the section of the report entitled 'Discussion' the report read in part, [MEDICATION NAME] inferior fracture, with minimal improvement of diastases compared to 7/13/2017 exam, but with slight increase of diastases since 8/22/2017 exam, which possibly may be related to difference in position. Persistent osseous irregularity and fragmentation near the tibial tuberosity, with fixation screw in place. Right total knee arthroplasty without hardware complication. [MEDICAL CONDITION] calcifications. I have participated in the interpretation of these images and approved this report. This report was acknowledged by resident # 262's surgeon on 9/18/2017 at 14:48. An interview was conducted with resident #262 on 9/18/2017 at 11:13 a.m. The resident conveyed that a male nurse aide CNA (W) nearly dropped her on Monday, September 11, 2017 while trying to transfer her from her recliner chair to her wheelchair. Resident #262 conveyed that she was supposed to have two staff members to transfer her from the recliner chair to her wheel chair, but this time instead of having two nurse aides, only one CNA, (W) transferred the resident by himself using a gait belt. The resident stated, He was trying to hold on to me with a gait belt. She reported that as he was attempting to lift and pivot her from recliner to the wheelchair her right foot slipped under the chair as he was turning and pivoting her to the wheelchair. The resident also stated that her right knee twisted as he pivoted her to the wheelchair. The resident continued and expressed that during the transfer her right knee started twisting which caused her to experience some pain. The resident did not recall the name of the nurse aide, although she was able to provide a description of CNA (W). The resident also conveyed that CNA (W) was not wearing his name badge at the time. The resident stated that nurse aide (W) no longer provides care for her and she was told by someone that he no longer worked at the facility. The resident also shared that her family member came in later and asked, Mom, what's wrong? She shared her account of what had happened during the transfer. The resident conveyed that her family member went to speak with the nurse (X) who knew nothing about the incident. The resident stated that the facility ordered an X-ray of her right knee after the incident which indicated that everything was, pulled apart that they had fixed during her recent knee surgery (right patellar tendon rupture with right knee ligament extensor mechanism reconstruction). She said she had been told that, whatever was attached has now been completely pulled apart and is unattached. They are going to have to re-do it, she said. The resident looked at her calendar on the wall and shared that they are planning for her to have surgery again on October 12, 2017. The resident also shared near the end of the interview that she was supposed to have two staff members to transfer her, but also shared that the physical therapy staff had just started transferring her with just one therapist as well. She says she did not understand how they could have just one person transfer her when the doctor said she should have two especially since she was not supposed to have pressure or bear weight on the right foot or right leg. An interview was conducted with CNA (A) on 9/19/2017 at 11:33 a.m. CNA (A) revealed that she had only been working at the facility for about a week. She Stated she always transfers the resident with two staff members present. The nurse aide conveyed that they will receive a report from the nurse on the unit as well as a shift to shift report from another nurse aide in order to know how to transfer a resident. CNA (A) also communicated that the nurse aides have access to the care plans and Kardexes on the unit. CNA (A) said the care plans and Kardexes indicate if they are to use 1 or 2 staff members to transfer the resident. CNA (A) also shared that the resident has never fallen to her knowledge since she has been here. She conveyed that they use a gait belt on the resident's right lower extremity (RLE) which is non- weight bearing and a second gait belt around the waist of the resident to transfer the resident. The CNA described the process indicating that the one CNA holds the resident's leg with the gait belt to keep it from touching the floor and applying pressure. The other staff person (CNA or nurse) lifts the resident from the bed or chair with the second gait belt which is around the waist of the resident and then pivots her to the wheelchair. The nurse aide said, It would be hard to transfer her (Resident #262) with one person as she is pretty heavy. An interview was conducted on 9/19/2017 at 11:33 a.m. with another nurse aide CNA (B) who routinely provided care for resident #262. Nurse aide (B) conveyed that she has always transferred the resident with two staff members assisting. The nurse aide also said that the therapy staff will let them know if there are changes. CNA (B) used the CNA care plans and the CNA Kardexes to demonstrate how the staff knows whether a resident requires one or two persons to assist the resident. An interview was also conducted with the assessment nurse (D) on 9/19/2019 at approximately 12:15 p.m. The assessment nurse provided copies of the CNA look back report form dated 9/10/2017 and 9/11/2017 which is the same day of the transfer incident referenced by resident #262. The assessment nurse (D) shared that the look back report demonstrated activities of daily living support provided by the CNAs. The assessment nurse (D) said the CNAs code what support they provide, but nurse (D) could not explain why on the same day, 9/11/2017, CNAs provided the support of two staff members at 10:27 a.m. and the support of one staff person at 16:21 p.m. The assessment nurse said they (CNAs) don't get to decide whether to use 1 or 2 persons for transfer. She said it would be up to the Therapist. A follow-up interview was conducted with the administrator on 9/19/2019 at 2:00 p.m. The administrator also said that nurse aide (W) was terminated for lying about the incident, when he stated that the incident never occurred during the initial interview. The administrator described the incident as, transferring the resident inappropriately. The administrator also stated that nurse aide (W) confessed when he was informed of the Speech Therapist's account of the incident. (The Speech Therapist had been in the room at the time of the incident and witnessed the transfer.) The administrator stated that nurse aide (W) was terminated on Friday, September 15, 2017. The administrator also shared that nurse aide (W) had conveyed that he was told in shift to shift report that the resident had been upgraded to a 1-person transfer, but said the nurse aide should have verified the resident's transfer status with the nurse and the care plan. The administrator confirmed during this same interview that Resident #262 should've had two staff members participate in the transfer of Resident #262 at the time of the incident, but was only transferred by one person which was nurse aide (W). She confirmed that the resident's plan of care indicated that the resident was a, two-person transfer at the time of the incident on September 11th, 2017. An interview was conducted on 9/19/2017 at 2:40 p.m. with the physical therapist (S) assigned to care for resident #262. The therapist stated that she is the primary physical therapist for this resident and that it is not her expectation that the resident should be or should have been transferred with only one staff member. The physical therapist stated, I wanted them to use a pivot transfer and two persons would have been a lot safer. The therapist did confirm that the resident was in between a one person and two persons assist for transfers, but stated that was only for therapists. The therapist said she had not conducted any care-giver training for staff to use only one person to transfer the resident. The physical therapist (S) said, My plan of care on September 11th would have said 2 persons assist for transfers. Therapist (S) conveyed further that, Resident #262 was not upgraded by me to be a one person assist on the 11th. I was off on that day. My weekly progress notes on September 5th the week before and the following week of September 13th still said she required 2-persons limited assistance. When we as therapist try to transfer with one person assisting that's just for us, as therapists, but the caregivers should still use the amount of assistance that is noted on the resident's care plan. Once we upgrade the resident, we conduct caregiver training and complete the ADL Cheat sheet. We notify the MDS coordinator and they notify nursing. The therapist said she had not upgraded this resident's status and she still required 2 staff persons for transfer on 9/11, the date of the incident. The Physical Therapy Director (Q) was also present during the interview. The Physical Therapy Director stated that it has been made clear that staff should follow the care plan for transfers.

Based on interviews and record review the facility failed to safely transfer 1 of 22 residents in the stage 2 sample (Resident #262), who was non-weight bearing status and required extensive assistance and the support of two staff members for all transfers. Findings include: Resident # 262 was admitted to the facility on [DATE] and has multiple [DIAGNOSES REDACTED]. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed that resident #262 required extensive assistance with transfers and the support of 2 plus person's physical assistance. The resident was also coded as not steady and only able to stabilize with human assistance. Under the section entitled cognitive patterns, the resident was coded as being oriented to day, month and year with her recall abilities intact. A review of the plan of care with an admission date of [DATE] was reviewed and in part revealed, Focus: ADL self-care performance deficit related to right patellar tendon rupture with right knee ligament extensor mechanism reconstruction. Goal: Will improve current level of function in ADL's (Activities of Daily Living) through the review date, with a target date of 11/24/2017. Interventions: Resident requires extensive assistance and the support of two persons physical assistance with transfers, toilet use, bathing, and bed mobility. The care plan intervention also indicated that the resident was NWB (Non-Weight Bearing) status to RLE (Right Lower Extremity) and that the brace to RLE to remain locked and in extension at all times. A second area of focus on the care plan indicated that the resident has potential for falls related to decline in mobility ROM (range of motion) restrictions, impaired balance. The care plan goal indicated that resident #262 would be free from injury resulting from a fall through the review date. A review of the physician's orders [REDACTED]. The interdisciplinary and skilled nursing progress notes were also reviewed from the date of admission on 8/25/2017 through 9/18/2017. The progress notes consistently noted the resident as being alert and oriented times 3 (oriented to person place and time). The progress notes also consistently noted that resident #262 required extensive assistance of 2 (persons) with stand and pivot transfers. The skilled nursing progress notes revealed the following entries in part, as related to the resident's cognitive status, and transfer status: 8/25/2017 at 3:20 p.m.: Arrived via wheelchair from hospital .extensive assist with transfers; 8/25/2017 at 9:37 p.m.: Alert and oriented x3 .Extensive assist of 2 with stand and pivot transfers; 8/26/2017 at 8:49 p.m.: Alert and oriented x3 .Transfer with extensive assist of 2 to stand and pivot NWB RLE; 8/28/2017 at 10:00 a.m.: alert, pleasant and oriented x4 . Patient transfers X 2 extensive assist; 8/29/2017 at 11:32 p.m.: Patient alert and oriented x4; 8/31/2017 at 8:54 p.m.: Alert and oriented times three .extensive assist of 2 for transfers NWB to RLE; 9/02/101 at 02:20 a.m.: Alert and oriented x3 with pleasant affect .Transfers extensive 2-assist; 9/04/2017 at 8:26 p.m.: Alert and oriented x3 .Transfers with extensive assist of 2, stand and pivot. NWB to RLE; 9/06/2017 at 10:42 p.m.: A&O; 9/07/2017 at 9:07 p.m.: Extensive 2x assist for transfers to w/c (wheelchair); 9/08/2017 at 10:17 p.m.: Transfers to w/c with 2x extensive assist; 9/09/2017 at 8:11 p.m.: extensive 2x assist for transfers to w/c; 9/10/2017 at 9:54 p.m.: Alert and oriented x3 .Stand and pivot transfers with extensive assist of 2; 9/11/2013 at 8:22 p.m.: Alert and oriented x3; 9/12/2017 at 9:52 p.m.: A&O for assessment .Extensive 2x assist for transfers to w/c; 9/13/2017 at 10:30 a.m.: . she is assist of 2 at this time; 9/13/2017 at 11:03 p.m.: .Transfers 2x assist; 9/14/2017 at 08:01 a.m.: .Pt stood with 2 assists, one staff member holds RLE while standing during transfer due to pt. (patient) unable to Not bear weight (status); 9/14/2017 at 09:22 a.m.: (Late entry for September 11, 2017 at 5 p.m.) . family member notified that this nurse educated daytime CNA (Certified Nursing Assistant) that patient is to be 2 assist transfers until therapy can clarify transfer status'; 9/14/2017 at 09:34 a.m.: .patient notified that education done with staff and staff notified that patient needs to have 2 assists when transferring; 9/14/2017 with an untimed entry: (Late entry for September 12, 2017 approximately 9 a.m.) . Spoke with therapy about patient's transfer status and patient and daughters concerns and it was decided that patient would continue to require 2 assists with transfers until further notice. This nurse educated staff that patient to remain 2 assists with transfers and is NWB to RLE; 9/14/2017 at 9:58 p.m.: . A&O for assessment .denies pain, 2 x assists for transfers to w/c; 9/5/2017 at 9:48 p.m.: Alert and oriented x3. Extensive assist of 2 with stand and pivot transfers with 2; 9/16/2017 at 9:38 p.m.: Alert and oriented times 3 .; 9/18/2017 at 12:10 p.m:, .Pt is A&O x3 and denies any pain at this time; 9/18/2017 at 12:31 p.m.: Received fax with new appointment for pre-op visit .Pt will be having a revision R knee extensor mechanism reconstruction with surgeon on 10/12/2017 ; 9/18/2017 at 10:16 p.m.: Ext (extensive) 2x assist for transfers to w/c; The following nursing progress notes addressed the status of the resident's right patellar tendon rupture with right knee ligament extensor mechanism reconstruction: 9/14/2017 at 09:49 a.m.: (Late entry for September 12, 2017 in late afternoon) .Received call from surgeon's (V) office. Nurse called to check up on patient. This nurse verbalized patient concerns with transfers and notified that right leg slipped during transfer last evening. Patient not exhibiting or complaining of any increased pain .This nurse requested that x-ray be performed at appointment to ensure patient and daughter that RLE is without further injury; 9/14/2017 at 12:07 p.m.: Received call from nurse at surgeon's (V) office. Nurse stated patient's extensor mechanism failed. Pt will need surgery. 9/14/2017 at 1:23 p.m.: Pt returned from ortho appointment .no new orders, nothing written on referral form. Patient toileted x2. This nurse held RLE to maintain NWB to RLE while CNA stabilized patient when transferring. NWB applied to RLE during this transfer, nurse had to use significant amount of strength to keep RLE from touching down. RLE remained off ground .; A review of the x-ray report dated 9/14/2017 was conducted and revealed in part: Impression: Inferior patellar fracture with diastasis, minimally increased. Comparison August 22, 2017, July 13, 2017. Technique: AP and lateral views of the right knee. Under the section of the report entitled, 'Discussion' the report read in part, Diastatic inferior fracture, with minimal improvement of diastases compared to 7/13/2017 exam, but with slight increase of diastases since 8/22/2017 exam, which possibly may be related to difference in position. Persistent osseous irregularity and fragmentation near the tibial tuberosity, with fixation screw in place. Right total knee arthroplasty without hardware complication. Atherosclerotic calcifications. I have participated in the interpretation of these images and approved this report. This report was acknowledged by resident #262's surgeon on 9/18/2017 at 14:48. An interview was conducted with resident #262 on 9/18/2017 at 11:13 a.m. The resident conveyed that that a male nurse aide CNA (W) nearly dropped her on Monday, September 11, 2017 while trying to transfer her from her recliner chair to her wheelchair. Resident #262 conveyed that she was supposed to have two staff members to transfer her from the recliner chair to her wheel chair, but this time instead of having two nurse aides, only one CAN, (W) transferred the resident by himself using a gait belt. The resident stated, He was trying to hold on to me with a gait belt. She reported that as he was attempting to lift and pivot her from recliner to the wheelchair her right foot slipped under the chair as he was turning and pivoting her to the wheelchair. The resident also stated that her right knee twisted as he pivoted her to the wheelchair. The resident continued and expressed that during the transfer her right knee started twisting which cause her to experience some pain. The resident did not recall the name of the nurse aide, although she was able to provide a description of CNA (W). The resident also conveyed that CNA (W) was not wearing his name badge at the time. The resident stated that nurse aide (W) no longer provides care for her and she was told by someone that he no longer worked at the facility. The resident shared that her family member came in later and asked, Mom, what's wrong at which time she shared her account what had happened during the transfer. The resident conveyed that her family member went to speak with the nurse (X) who knew nothing about the incident. The resident stated that several days later she was eating in the dining room and one of the people (Name unknown) who works with administrator took her back to her room to interview her about the incident. She said the head administrator also came in later as well as during the interview, but then left. The resident shared that they ordered an X-ray of her right knee after the incident which indicated that everything was, pulled apart that they had fixed during her recent knee surgery (right patellar tendon rupture with right knee ligament extensor mechanism reconstruction). She said she had been told that, whatever was attached has now been completely pulled apart and is unattached. They are going to have to re-do it, she said. The resident looked at her calendar on the wall and shared that they are planning for her to have surgery again on October 12, 2017. The resident conveyed that a speech therapist (R) had been in the room at the time of the transfer incident, but did not assist her or the nurse aide during the transfer, but informed the resident that she would write up whatever was necessary regarding the incident. The resident also shared near the end of the interview that she was supposed to have two staff members to transfer her, but also shared that the physical therapy staff had just started transferring her with just one therapist as well. She says she did not understand how they could have just one person transfer her when the doctor said she should have two especially since she was not supposed to have pressure or bear weight on the right foot or right leg. The resident shared that she had some pain at the time of the incident, but does not have any pain today, although it does start hurting sometimes at night. The resident also conveyed that they (the facility staff) are supposed to have a meeting today 9/18/2017 at 3:30 p.m. to discuss this incident with her family member. She said she had been told by the physical therapist that she should be present for the meeting as well. An interview was conducted with CNA (A) on 9/19/2017 at 11:33 a.m CNA (A) revealed that she had only been working here for about a week. She stated she always transferred the resident with two staff members present. The nurse aide conveyed that they receive a report from the nurse on the unit as well as a shift to shift report from another nurse aide in order to know how to transfer a resident. CNA (A) also communicated that the nurse aides have access to the care plans and Kardexes on the unit. CNA (A) said the care plans and Kardexes indicate if they are to use with 1 or 2 staff members to transfer the resident. CNA (A) also shared that the resident has never fallen to her knowledge since she has been here. She conveyed that they use a gait belt on the resident's RLE which is non- weight bearing and a second gait belt around the waist of the resident to transfer the resident. The CNA described the process indicating that the one CNA holds the resident's leg with the gait belt to keep it from touching the floor and applying pressure. The other staff person (CNA or nurse) lifts the resident from the bed or chair with the second gait belt which is around the waist of the resident and then pivots her to the wheelchair. The nurse aide said, It would be hard to transfer her (Resident #262) with one person as she is pretty heavy. An interview was conducted on 9/19/2017 at 11:33 a.m. with another nurse aide CNA (B) who routinely provided care for resident #262. Nurse aide (B) conveyed that she has always transferred the resident with two staff members assisting. The nurse aide also said that the therapy staff will let them know if there are changes. CNA (B) used the CNA care plans and the CNA Kardexes to demonstrate how the staff knows whether a resident requires one or two persons to assist the resident. An interview was also conducted with the assessment nurse (D) on 9/19/2019 at approximately 12:15 p.m. The assessment nurse provided copies of the CNA look back report form dated 9/10 2017 and 9/11/2017 which is the same day of the transfer incident referenced by resident #262. The assessment nurse (D) shared that the look back report demonstrated activities of daily living support provided by the CNAs. The assessment nurse (D) said the CNAs code what support they provide, but nurse (D) could not explain why on the same day, 9/11/2017, CNAs provided the support of two staff members at 10:27 a.m. and the support of one staff person at 16:21 p.m. The assessment nurse said they (CNAs) don't get to decide whether to use 1 or 2 persons for transfer. She said it would be up to the Therapist. The assessment nurse also shared that as of today, 9/19/2017 the resident's status is now Weight bearing as tolerated. She said the surgeon wrote a new order, but was previously non-weight bearing status up until today. An interview was also conducted with the director of nursing (DON) (E) on 9/19 2017 at 12:17 p.m. The DON conveyed that she was aware of the transfer incident on 9/11/2017 and shared that Resident #262 had conveyed to her that her foot had slipped underneath the chair and she had felt a little bit of a jolt. A follow-up interview was conducted with both administrator (U) and DON (E) on 9/19/2019 at 2:00 p.m. The DON shared that she first became unaware of the incident on September 13th when the resident's family member called in the concern to one of the facility social workers. The DON denied having knowledge that the family member had mentioned anything about the resident's knee twisting during the transfer process, but said the family member was more concerned about the resident having 2 staff to transfer the resident instead of just one. The DON also stated that they have completed the 5-day investigation and submitted the report to DHHS on 9/18/2017 regarding this incident. The DON and administrator both conveyed they were not made aware of the incident from anyone until September 13th. The DON further conveyed that the Speech Therapist, (R) did not report this incident sooner because she thought someone else had already reported the incident. She went on to say that the nurse aide initially denied anything happened with the resident when interviewed on the 9/13/17. But after the daughter called the facility, the Speech Therapist confirmed the incident had occurred and they re-interviewed nurse aide (W) who acknowledged that the therapist's account of the incident was correct. The administrator conveyed that nurse aide (W) was terminated. The administrator described the incident as, transferring the resident inappropriately. The administrator also said that nurse aide (W) was terminated. The administrator also stated that, 'it is not clinically possible to say why the resident's hardware malfunctioned. She went on to say that the resident is not in pain and is at her same baseline with pain and ADL's as she was before the incident. The administrator also shared that nurse aide (W) had conveyed that he was told in shift-to-shift-report that the resident had been upgraded to a 1-person transfer, but said that the nurse aide should have verified the resident's transfer status with the nurse and the care plan. The administrator confirmed during this same interview that Resident #262 should've had two staff members participate in the transfer Resident #262 at the time of the incident, but was only transferred by one person which was nurse aide (W). She confirmed that the resident's plan of care indicated that the resident was a, two-person transfer at the time of the incident on September 11th, 2017. A follow-up interview was conducted with Resident #262 again on 9/19/2017 at 2:25 p.m. The resident repeated the same account of the incident as she had on the previous day. She also denied that staff used a walker for any part of the transfer on 9/11/2017. She said, He had a hold of my gait belt on my right leg and he had the gait belt around my waist. Additionally, the resident stated that she initially had knee replacement survey back in September of 2016 and then recently before this admission had surgery again on 8/22/2017 to re-attach her patellar tendon. An interview was conducted on 9/19/2017 at 2:40 p.m. with the physical therapist (S) assigned to care for resident #262. The therapist stated that she is the primary physical therapist for this resident and that it is not her expectation that the resident should be or should have been transferred with only one staff member. The physical therapist stated, I wanted them to use a pivot transfer and two persons would have been a lot safer. The therapist did confirm that the resident was in between a one person and two persons assist for transfers, but stated that was only for therapists. The therapist said she had not conducted any care-giver training for staff for one person transfers for the resident. The physical therapist (S) said, My plan of care on September 11th would have said 2 persons assist for transfers. The therapist provided copies of her therapy treatment notes which were dated for the week beginning 9/05/2017 and for the week beginning 9/13/2017. For the week dated 9/05/2017, the resident's current level of transfer status was noted as, The patient performs all functional transfers with MAX assist of 1, moderate assist of 2 (26-75% assist of 2 people needed .). The following entry was noted under the section entitled, Patient/ Care Giver Training, Caregiver education continued with safe functional pivot transfers with NWB L LE with 2 Limited Assist/proper hand /foot placement using FWW (front wheeled walker). For the week beginning on 9/13/2017, the resident's current level of transfer was noted as, The patient performs all functional transfers with moderate assist (2), (26-75% assist with 2 people needed .) The caregiver training section of the progress report on 9/13/2017 indicated, RE education continued with safe functional pivot transfers NWB using FWW needs 2 Limited assist. Therapist (S) conveyed further that Resident #262 had not been upgraded to be a one person assist on the 11th. She stated that she had not been working in the facility on that date. She added that her weekly progress notes on September 5th, the week before and the following week of September 13th still said the resident required 2-persons limited assistance. She added that, when the therapists transfer with one person assisting that's just for the therapists, but the caregivers should still use the amount of assistance that is noted on the resident's care plan. Once we upgrade the resident's transfer status, we conduct caregiver training and complete the ADL Cheat sheet. We notify the MDS coordinator and they notify nursing. The therapist stated she had not upgraded this resident's status and she still required 2 staff persons for transfer on 9/11, the date of the incident. An interview was conducted with the speech therapist (R) on 9/20/2017 at 9:00 a.m. She denied knowing anything about the resident having her knee twisted during the transfer. She stated she was not thinking about the incident as an injury that would need to be reported, as she had her back turned and heard the resident say, my foot, my foot or something like that when she turned around. She said the resident was seated in the wheel chair when she turned around and a portion of her foot was observed still under the recliner chair that the resident had been sitting in. She said once the male aide pulled the resident's wheelchair back, the resident's foot came out from under the recliner, stating that only about 'a third or less' of her foot was under the chair at the time. The Speech Therapist referred to her written statement and conveyed that she did not tell the resident that she would write up a statement at the time of the incident on September 11th because she didn't think there was an injury. Rather, she had told the resident on 9/14/17, after the family member had contacted the facility administrator regarding the 9/11/17 incident. The speech therapist conveyed that she handed the resident her walker during the transfer, and denied that the resident had fallen during the incident. A concurrent interview was also conducted on 9/20/17 at 9 a.m. with the Physical Therapy Director (Q) who was present with the Speech Therapist. The Physical Therapy Director stated that it has been made clear that staff should follow the care plan for transfers. She voiced that the family member had made a strong connection to the incident and the cause of the injury during the resident's recent care plan meeting. A follow-up interview was conducted with the administrator and DON on 9/20/2017 at approximately 12:15 p.m. The administrator shared that she was first made aware of the transfer incident when the family member called into the facility on [DATE] requesting that the facility pay for the transportation services to the doctor's appointment for the x-ray and follow-up appointment with the surgeon. The administrator stated that it was during that call that she first became aware of the allegation and started the facility's investigation into the matter. The administrator stated that she decided to report the incident to Adult Protective Services and the Department of Health and Human Services because during this call the family member also described the incident as a fall. The administrator stated that their findings did not support that the resident had fallen, but rather that the front portion of the resident's foot was caught under the recliner chair. Multiple attempts were made to interview the resident's family member without success. As resident #262 was wearing a knee brace at the time of the transfer on September 11th attempts were also made to interview the resident's physician, surgeon (V), to determine if it were possible for this incident to have caused the ligament extensor mechanism reconstruction to fail, but those calls were not returned either.

Based on observation and staff interview the facility failed to ensure nurse staffing data was posted daily. Findings include: During initial tour conducted on 09/18/2017 at 9:00 a.m. the nurse staffing data posted by the entrance located near Lodgepole was dated 09/15/2017. During interview conducted at that time with Registered Nurse Staff N verified the nurse staffing data posted had not been updated since Friday 09/15/2017.

Based on interview and record review, the facility failed to provide a list of services and items that would and would not be charged once Resident 161 became eligible for medicaid. Sample size was 1 and the facility census was 121. Findings are: Interview on 11/29/16 at 8:54 AM with Resident 161's Power of Attorney (POA) revealed that information of items covered and items not covered was not provided upon Resident 161's eligibility for Medicaid. Record review of Resident 161's Electronic Medical Record (EMR) revealed that Resident 161 was admitted to the facility on [DATE] with Medicare as the payment source. Record review of Resident 161's EMR revealed eligibility of Medicaid began on 10/01/16. Interview on 12/01/2016 at 10:23:40 AM with the facility Business Office Manager (BOM) that review of Medicaid covered and non covered items was not reviewed with resident or family when the resident became eligible for Medicaid. It was reviewed at admission but no other time. Interview on 12/01/2016 at 1:17:41 PM with the facility Administrator revealed that the facility did provide information upon application for Medicaid. The facility did not provide Resident 161's POA a list of items covered and not covered upon Medicaid eligibility.