Every finding on record at Brookestone Village

Based on interview and record review, the facility failed to ensure that 1 (Resident 1) of 3 sampled residents' representative's preference of female caregivers only was honored. The facility census was 130. Findings are:A record review of the facility's Resident Rights dated 05/19 revealed the resident had the right to designate a legal representative who can make choices about care and to make choices about aspects of your life in the facility that are significant to the resident. The resident had the right to choose activities, schedules, health care and health providers.A record review of Resident 1's Clinical Census dated 03/23/2026 revealed that Resident 1 was admitted to the facility 12/12/2025. A record review of Resident 1's Medical Diagnosis dated 03/23/2026 revealed the resident had diagnoses that included Major Depressive Disorder and Cognitive Communication Deficit (problems communicating caused by a cognitive impairment).A record review of Resident 1's Physician's Order Sheet And Progress Notes dated 03/20/2021 revealed the physician documented the resident had previously undocumented Dementia.A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/04/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 7 of 15 which indicated the resident was severely cognitively impaired (confused). The resident was independent with eating, required supervision or touching assistance with oral and personal hygiene (cleaning), substantial/maximal assistance with upper body dressing, bathing was not attempted, and the resident was dependent on staff for toileting hygiene, lower body dressing, and footwear. The resident was substantial/maximal assistance with mobility and transfers. A record review of the facility's submitted Level I (roman numeral one) Screen Preadmission Screen and Resident Review (PASARR) For Serious Mental Illness (SMI) and/or Intellectual Disability (ID) or Related Conditions submitted documentation dated 01/08/2026 revealed Resident 1 had a diagnosis of Dementia (confusion)/Neurocognitive Disorder (decline in mental function), Alzheimer's Disease, or Organic Disorder (mental or cognitive decline) and had a diagnosis of Dementia or Neurocognitive Disorder that was considered advanced, primary, or late stage. A record review of Resident 1's admission Agreement dated 12/12/2025 revealed the contact information for the resident was a family member and the relation to the resident was the Responsible Party. The signature pages had the Responsible Party/Legal Representative listed as the resident's representative and signed and dated by the resident's responsible party. The resident was provided with the Resident's [NAME] of Rights.A record review of Resident 1's Representative Signatures and Responsible Party Acknowledgement signed by the resident representative and dated 12/12/2025 revealed the responsible party had been identified by the resident to be responsible for handling certain matters on behalf of the resident. A record review of the facility's Investigation Report dated 03/14/2026 revealed the allegation of sexual abuse had been investigated and the permanent steps that were put into place to prevent reoccurrence (happening again) included Resident 1 would only be cared for by female caregivers. A record review of Resident 1's Progress Notes dated 03/23/2026 revealed on 03/13/2026 the nursing assistant (NA) provided perineal cares (peri)(cleaning of the genital and anus area). After leaving the room, the resident started screaming and crying and the nurses went into the room and the resident told the staff a man came into the room and inappropriately touched and groped (feel or fondle for sexual pleasure) Resident 1. The staff tried to calm the resident down and assured the resident that the NA would not come back into the room. On 03/13/2026 at 2:27 PM the Progress Notes revealed the staff contacted the resident's representative about the incident and agreed the resident would have female only caregivers. A record review of Resident 1's Care Plan Report with an admission date of 12/12/2025 revealed an intervention of FEMALE ONLY CAREGIVERS created 03/13/2026. A record review of Resident 1's Clinical Physician Orders page dated 03/23/2026 revealed under the Care Profile section there were Special Instructions that included FEMALE ONLY CARE GIVERS. A record review of the facility's Nursing Staffing Assignments dated 02/25/2026 - 03/29/2026 revealed the following in Resident 1's unit: - 03/12/2026 night shift - NA-B was the only NA scheduled and was a male. - 03/13/2026 night shift - Registered Nurse (RN)-A was the only RN scheduled and was a male. - 03/17/2026 night shift - NA-B was the only NA scheduled and was a male. - 03/19/2026 day shift - NA-C was the only NA scheduled and was a male. - 03/19/2026 night shift - NA-B was the only NA scheduled and was a male. - 03/21/2026 day shift - NA-C was the only NA scheduled and was a male. A record review of NA-B's Previous Pay Period and Current Pay Period timecards dated 03/01/2026 - 03/21/2026 revealed NA-B worked: - 03/11/2026 from 10:24 PM to 03/12/2026 at 6:30 AM. - 03/12/2026 from 10:24 PM to 03/13/2026 at 6:43 AM. - 03/17/2026 from 10:24 PM to 03/18/2026 at 6:40 AM. - 03/19/2026 from 10:24 PM to 03/20/2026 at 6:41 AM. A record review of RN-A's Last 30 day timecard dated 02/21/2026 - 03/21/2026 revealed RN-A worked 03/13/206 from 6:27 PM to 03/14/2026 at 6:52 AM. In an interview on 03/24/2026 at 7:25 AM, NA-C, a male NA, confirmed the resident had been female caregivers only for about a week now and NA-C did not take care of Resident 1. In a telephone interview on 03/23/2026 at 2:38 PM, NA-B, a male NA, confirmed NA-B was the NA involved in the sexual abuse allegation on 03/13/2026 and NA-B had provided care to the resident when NA-B worked on 03/17/2026 - 03/18/2026 and 03/19/2026 - 03/20/2026. In a telephone interview on 03/23/2026 at 2:57 PM, RN-A, a male RN, confirmed RN-A did provide cares to Resident 1 on the night shift that started 03/13/2026. In a telephone interview on 03/24/2026, Resident 1's resident representative revealed that following the allegation of sexual abuse, the facility contacted the resident's representative, and they agreed that an intervention would be that the resident would have no male caregivers. The resident's representative confirmed it was the preference of the resident's representative that the resident does not have male caregivers. In an interview on 03/24/2026 at 11:51 AM, the Director of Nursing (DON) confirmed male caregivers should not have provided cares for Resident 1 as per the Special Instructions, Care Plan, and Resident 1's representative's preferences.

Licensure Reference Number 175 NAC 12-006.18Based on observation, interview and record review, the facility failed to ensure a staff member wore a face shield or goggles in a droplet/contact isolation room, failed to restrict sharing of communal food items, and failed to ensure a staff member disinfected goggles between resident rooms in droplet/contact isolation to prevent cross contamination. The facility staff identified a census of 122.Findings are:Record review of an e-mail from an Infection Preventionist at the Nebraska Infection Control Assessment and Promotion Program (ICAP) to the Infection Preventionist and Assistant Director of Nursing (ADON) A at the facility dated February 18, 2026, at 3:20 PM revealed the following list of immediate prevention actions to follow regarding a Norovirus (a highly contagious virus that causes gastroenteritis, leading to vomiting, diarrhea, and stomach cramps) outbreak : -Ill residents should be isolated in contact precautions (gown, gloves, and mask and protective eyewear (due to aerosols produced with vomiting) until 48 hours after vomiting and diarrhea has ended.-Facility should use a disinfectant with claim against norovirus-Facility should encourage frequent hand hygiene-- Alcohol based hand rub can be used, but soap and water hand hygiene is preferred after providing care for isolated residents.-Consider stopping dining room service and group activities temporarily, to limit transmission of illness.-Nebraska Department of Health and Human Services (DHHS) has a great Norovirus toolkit: Norovirus Outbreak Toolkit for Healthcare. This toolkit addresses most infection prevention concerns, in an easy-to-use reference check-list format A. An observation on 2/18/26 at 10:23 AM revealed signage on the door of resident room [ROOM NUMBER] which stated the resident was in Droplet/Contact PrecautionsSTOP Droplet/Contact Precautions: Everyone Must: Donning (put on) order: Hand sanitize, gown, mask, face shield or goggles, glovesDoffing (take off) order: Gloves, face shield or goggles, gown, mask, hand sanitizeDisinfect face shield/goggles with D1 plus wipes before entering another room. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. An observation on 02/19/2026 10:23 AM revealed Medication Aide (MA) J donned a mask, gloves, gown and goggles and entered resident room [ROOM NUMBER]. MA J exited resident room [ROOM NUMBER] at 10:29 AM and proceeded to the next resident room with eyewear/goggles on top of their head without disinfecting. An interview with MA J on 02/19/2026 at 10:31 AM revealed that MA J did not think they needed to clean/disinfect goggles between residents. In an interview with ADON A on 02/19/2026 at 10:42 AM confirmed they would expect the eye wear to be cleaned/disinfected between residents. B.Record review of a Norovirus Outbreak Toolkit dated October 2023 page 3, section Food Service and Dining revealed the facility shouldRestrict sharing of communal food items and food brought from outside the facility or prepared by residents An observation on 2/19/26 at 10:25 AM revealed signage on the door of resident room [ROOM NUMBER] which stated the resident was in Droplet/Contact PrecautionsSTOP Droplet/Contact Precautions: Everyone Must: Donning (on) order: Hand sanitize, gown, mask, face shield or goggles, glovesDoffing (off) order: Gloves, Face shield or goggles, gown, mask, hand sanitizeDisinfect face shield/goggles with D1 plus wipes before entering another room. Use dedicated or disposable equipment. An observation on 02/19/2026 at 10:25 AM revealed Nursing Assistant (NA) K donned gown, gloves and mask and entered resident room [ROOM NUMBER] carrying a plastic tray. An observation of NA K on 2/19/26 at 10:34 AM revealed NA K exited resident room [ROOM NUMBER] with a tray containing 7 plates of individually wrapped single donuts. In an interview on 2/19/26 at 10:38 AM NA K confirmed they forgot to put on a face shield. NA K confirmed they had entered a contact/droplet isolation room carrying a tray with individually wrapped donuts. NA K confirmed they did not know if that consisted of a breach of contact/droplet isolation procedure. In an interview on 02/19/2026 at 10:42 AM with ADON A confirmed the NA K should have worn a face shield and the tray of donuts should not have been taken into an isolation room. ADON A confirmed this was a breach of contact/droplet isolation.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure injury for 1 (Resident 58) of 1 sampled resident. The facility census was 122. Findings are:A record review of the facility's Skin and Wound Management Standard with a revised date of 04/2019 revealed each resident would be assessed for their risk for developing a pressure ulcer/injury and each high-risk area would have an individualized care plan to address each risk area, and interventions implemented immediately to avoid development of a pressure ulcer. A record review of Resident 58's Clinical Census dated 02/24/2026 revealed the resident was admitted to the facility on [DATE] to room [ROOM NUMBER]-A and transferred to room [ROOM NUMBER]-A on 01/27/2026. A record review of Resident 58's Order Summary Report dated 02/24/2026 revealed the resident had diagnoses of Nondisplaced Intertrochanteric Fracture of the Right Femur (right hip fracture), Presence of Orthopedic Joint Implant (joint bone replacement), Peripheral Vascular Disease (blood flow disorder most commonly affecting the legs), Lymphedema (fluid build-up in arms or legs), and Foot Drop, Left Foot (nerve injury that causes difficulty lift front part of left foot). A record review of Resident 58's admission Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/27/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 10 which indicated the resident was moderately cognitively impaired (confused). The resident was independent with eating and oral hygiene (cleaning), required partial/moderate assistance with upper body dressing, and personal hygiene, required substantial/maximal assistance with bathing and footwear and lower body dressing. The resident required partial/moderate assistance with sit to lying positioning and lying to sitting on the side of the bed, substantial/maximal assistance with rolling left and right, and was dependent on staff for sit-to-stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The resident was at risk of developing a pressure ulcer/injury and the resident did have 1 stage I pressure ulcer (wound), 1 unstageable pressure (severe wound) injury, and surgical wound at the time of the assessment. A record review of the facility's Braden Scale For Predicting Pressure Sore Risk * - V 2 dated 01/22/2026 revealed Resident 58 was chairfast (couldn't bear weight and must be assisted into chair), the resident's mobility was very limited, and the resident had a potential problem with friction and shear (skin probably slides against other surfaces with movement). The Resident's score was 17 which indicated the resident was at risk for developing a pressure injury. A record review of Resident 58's Progress Note dated 01/22/2026 revealed the resident's skin condition was assessed on admission and did not reveal any concerns with the skin except edema (excess fluid in the arms or legs) was noted. A record review of Resident 58's Daily Skilled Documentation - V 9 dated 01/23/2026 revealed normal skin color with a surgical wound and no notable changes to the skin integrity (intact and undamaged). A pressure-reducing device was being used for chair and bed. A record review of Resident 58's Daily Skilled Documentation - V 9 dated 01/24/2026 revealed normal skin color with a surgical wound and notable changes to the skin integrity of the right hip surgical wound. A pressure-reducing device was being used for chair and bed. A record review of Resident 58's Daily Skilled Documentation - V 9 dated 01/25/2026 revealed normal skin color with a surgical wound and no notable changes to the skin integrity. A pressure-reducing device was being used for chair and bed. A record review of Resident 58's Daily Skilled Documentation - V 9 dated 01/26/2026 at 9:00 AM revealed normal skin color with a surgical wound and no notable changes to the skin integrity. A pressure-reducing device was being used for chair and bed. A record review of Resident 58's Progress Note dated 01/26/2026 at 5:38 PM revealed Registered Nurse (RN)-M was called to the spa (bath/shower room) by the Nursing Assistant who observed an area to the left heel. RN-M observed the left heel and the resident had a large fluid filled blister that measured 3 centimeters (cm) by (x) 2.8 cm. The blister was dark red and purple in color and was not open. The resident was educated not to wear shoes, only gripper socks and Prevalon boots to protect the left heel. An air mattress was also ordered. A record review of Resident 58's Pressure Ulcer Record - V 1 dated 01/26/2026 revealed it was marked that the resident's pressure ulcer was marked as community acquired even though the date of onset was 01/26/2026. The pressure ulcer was marked as an unstageable (full thickness tissue loss) pressure ulcer that was 3 cm x 2.8 cm in size. Specialty interventions needed was a specialized air mattress and positioning device of Prevalon boot. A record review of the facility's New Pressure Ulcer incident report dated 01/26/2026 revealed that Resident 58's left heel [NAME] a large fluid filled blister that measured 3 cm x 2.8 cm. An assessment was completed by RN-M and the resident was educated not to wear shoes until healed, and Prevalon boot while in bed. Predisposing (underlying) factors were gait imbalance (difficulty walking) and footwear type. Other information revealed history of left foot drop and extended period of time lying on the floor after a fall before Emergency Medical Services arrived with pressure on heel and the surgery at the hospital. A record review of Resident 58's Tasks list dated 02/24/2026 did not reveal a turning and repositioning task or other pressure reducing interventions tasks until 01/26/2026 when the task to ensure the resident had a Prevalon boot (thick boot designed to keep the pressure of the heel) to the left heel and float right heel while at rest was put in place. A record review of Resident 58's Care Plan Report with an admission date of 01/22/2026 did not reveal a focus area or interventions were initiated until 01/26/2026 for the potential impairment (damage) to skin. On 01/26/2026 the facility added the interventions of encourage good nutrition, elevate legs when resting, float heels using pillows or offloading boots as needed, and keep skin clean and dry and apply lotion to dry skin. A record review of the facility's Work Order Number (#) 38477 dated 01/26/2026 revealed a work order was placed for the resident to have an air mattress on 01/26/2026 and it was completed 01/27/2026. An observation on 02/19/2026 at 9:56 AM revealed Resident 58 was sitting in a wheelchair in the resident's room with both heels directly on the footrests of the wheelchair. An observation on 02/23/26 at 7:00 AM revealed RN-N completed wound care on Resident 58's left heel. The left heel had a intact (not open) partially fluid filled blister that was purple in color. RN-N painted the blister with betadine (brownish-red antiseptic), applied a new sock, edema wraps, and gripper socks to both of the resident's feet and exited the room with the resident still seated in the wheelchair and feet flat on the footrest. The NA then took the resident to get weighed, returned the resident to the room and left the resident in the wheelchair in the room with both heels flat on the footrests. In an interview on 02/19/2026 at 9:23 AM, RN-N confirmed the resident had a pressure related intact blister to the left heel. Interventions were that the staff were to apply the Prevalon boot to the left heel while the resident was in bed. In an interview on 02/23/2026 at 10:38 AM, NA-C confirmed that NA-C recalled taking care of Resident 58 when the resident was on the 700 hall before the resident was transferred to a different hall. NA-C confirmed the resident did not have anything they were doing for the resident to prevent pressure on the left heel prior to the resident getting the left heel wound. In an interview on 02/23/2026 at 10:08 AM, RN-M confirmed Resident 58 did not have any pressure reducing interventions in place prior to finding the resident had a wound to the left heel. In an interview on 02/23/2026 at 1:57 PM, the facility's Assistant Director of Nursing (ADON)-A confirmed the pressure reducing mattress the resident had before 1/26/2026 was the facility's standard mattress, not an air mattress. The air mattress was not put on until 01/26/2026. ADON -A confirmed the facility should have put pressure reducing interventions in place to protect Resident 58 from developing a pressure ulcer after the Braden Scale For Predicting Pressure Sore Risk * - V 2 dated 01/22/2026 revealed Resident 58 was at risk for developing a pressure ulcer and there was not. The pressure reducing mattress the resident

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to ensure 2 (Resident 144 and 147) of 2 sampled resident's oxygen (o2) orders contained a dosage (settings) and ensure 1 (Resident 160) of 2 sampled residents had a Positive Airway Pressure (PAP) device order. The facility census was 122. Findings are:A.A record review of the National Library of Medicine's undated Nursing Skills, Chapter 11 Oxygen Therapy revealed that oxygen was considered a medication and required a prescription. www.ncbi.nlm.nih.gov/books/NBK593208/ A record review of the National Library of Medicine's undated Nursing Skills, Basic Concepts of Administering Medications revealed that according to the Centers for Medicare & Medicaid Services, all orders for the administration of drugs and biologicals must contain the following information: - Drug name - Dose, frequency, and route - Name/Signature of the prescriber - Specific instructions for use, when applicablehttps://www.ncbi.nlm.nih.gov/books/NBK593215/#:~:text=Components%20of%20a%20Medication%20Order,instructions%20for%20use%2C%20when%20applicable A record review of Resident 144's Order Summary Report dated 02/23/2026 revealed the only order the resident had for oxygen was: Titrate oxygen to maintain an oxygen level of 90 percent (%) two times a day for safe mobility. The order did not contain the dose and route of administration. A record review of Resident 144's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2026 revealed the order to titrate oxygen to maintain an oxygen level of 90% was marked two times a day except for 2 shifts. An observation on 02/18/2026 at 10:21 AM revealed Resident 144 was sitting in the resident's room, and the resident had an oxygen nasal cannula (tubing that goes in the nose to administer oxygen) on and the oxygen concentrator (a machine used to purify oxygen) was on and set at 2 liters per minute (l/m). An observation on 02/23/2026 at 6:27 AM revealed Resident 144 was lying in bed with a nasal cannula on and the resident's oxygen concentrator was on and set at 2 l/m. An observation on 02/23/2026 at 10:17 AM revealed Resident 144 was on an exercise bike with Therapy, and the resident did not have oxygen on. The resident's oxygen saturation (percentage of oxygen in the blood) was 82%. The Therapy staff went and got the resident's oxygen tank and placed the resident on oxygen at 2 l/m per nasal cannula and the resident's oxygen saturation increased to 95%. In an interview on 02/18/2026 at 12:33 PM, Resident 144 confirmed the resident had been on oxygen at 2 l/m since the resident was admitted to the facility from the hospital. In an interview on 02/23/2026 at 1:57 PM, the Assistant Director of Nursing (ADON)-A confirmed the only order the facility had for Resident 144's oxygen was the titrate oxygen to maintain an o2 level at or above 90% and the resident's oxygen order did not contain a setting. B.A record review of the National Library of Medicine's undated Nursing Skills, Chapter 11 Oxygen Therapy revealed that oxygen was considered a medication and required a prescription. www.ncbi.nlm.nih.gov/books/NBK593208/ A record review of the National Library of Medicine's undated Nursing Skills, Basic Concepts of Administering Medications revealed that according to the Centers for Medicare & Medicaid Services, all orders for the administration of drugs and biologicals must contain the following information: - Drug name - Dose, frequency, and route - Name/Signature of the prescriber - Specific instructions for use, when applicablehttps://www.ncbi.nlm.nih.gov/books/NBK593215/#:~:text=Components%20of%20a%20Medication%20Order,instructions%20for%20use%2C%20when%20applicable A record review of Resident 147's Order Summary Report dated 02/23/2026 revealed the order the resident had for oxygen was: Oxygen via nasal cannula two times a day. The order did not contain the dose. A record review of Resident 147's MAR & TAR dated February 2026 revealed the oxygen via nasal cannula was marked administered two times a day except for 2 shifts (02/09/2026 and 02/15/2026). An observation on 02/18/2026 at 9:55 AM revealed Resident 147 was lying comfortably in bed, and the resident had an oxygen nasal cannula on, and the oxygen concentrator was on and set at 2 l/m. An observation on 02/19/2026 at 1:13 PM revealed Resident 147 was lying in bed with a nasal cannula on and the resident's oxygen concentrator was on and set at 2 l/m while the staff performed wound vac dressing change. In an interview on 02/23/2026 at 1:57 PM, ADON-A confirmed the only order the facility had for Resident 144's oxygen was the Oxygen via nasal cannula two times a day and the resident's oxygen order did not contain a setting. C.A record review of the National Library of Medicine's undated Nursing Skills, Chapter 11 Oxygen Therapy revealed that a prescription was required for a PAP device. www.ncbi.nlm.nih.gov/books/NBK593208/ A record review of Resident 160's Clinical Physician Orders dated 02/19/2026 did not reveal an order for the resident's PAP device. A record review of Resident 160's Baseline Care Plan - V 2 dated 02/10/2026 revealed the resident was admitted to the facility 02/07/2026 but did not reveal the resident was on a PAP device. A record review of Resident 160's Care Plan Report with an admission date of 02/07/2026 revealed the resident had a focus area of at risk for altered respiratory function related to sleep apnea and asthma but did not reveal the resident was on a PAP device. A record review of Resident 160's Progress Notes dated 02/07/2026 - 02/22/2026 revealed Skilled Notes on 02/12/2026, 02/17/2026, 02/18/2026, and 02/19/2026 that staff documented the resident used a PAP machine. An observation on 02/18/2026 at 9:46 AM revealed Resident 160 had a PAP device on the bedside table. An observation on 02/18/2026 at 12:58 PM revealed Resident 160 had a PAP device on the bedside table. In an interview on 02/19/2026 at 1:57 PM, Resident 160 confirmed the resident brought the PAP machine when the resident was admitted to the facility and wore it every night. The facility changed the mask and tubing for the device when the resident brought the machine in. In an interview on 02/23/2026 at 1:57 PM, ADON-A confirmed the Resident 160 had a PAP device, did not have an order for the PAP device, and should have.

Based on observation, interview and record review, the facility failed to ensure 1 (Resident 129) of 1 Care Plan included a Risk for Elopement along with goals and interventions. The facility identified a census of 122 A record review of the Elopement (a patient or resident leaving a nursing home without authorization, supervision, or proper discharge) Risk Manual (the facility system to identify residents who are at risk for elopement) on the Lakeview unit revealed a resident sheet for Resident 129 containing an up-to-date picture and Resident 129's description details. A record review of the [NAME] Health Services Operating standards manual revealed the following: Elopement Prevention and Management Standard Resident Risk Review.All resident will be evaluated prior to admission for concerns related to elopement risk and resident safety. Appropriate placement of the resident is of utmost importance. Ongoing review will occur with all residents to ensure proper placement and a safe environment. Pre-admission/Admission. Upon admission, Social Services or Nursing will complete the elopement risk assessment, Med-pass form MP5472 as a component of admission paperwork.The facility has a system to identify resident who are at risk for elopement, and this is the Elopement Risk Manual. This manual is available to all staff and is maintained at the nurses' station.For those residents determined to be at risk, an admission photograph is taken by Nursing, and the Missing Resident Identification Form is completed, including resident photo, and placed in the Elopement Risk Manual at the nurses station for easy access during an emergency. Care Plan and Ongoing Review All residents at risk are care planned for elopement risk by Social Services or Nursing and approaches are implemented and maintained.Elopement Risk Assessment is a tool used to assist in determining and documenting Resident's elopement risk potential. The Elopement Risk Assessment is done on:Day of Admission, Quarterly, Change of Condition MDS (To assist in identifying when a change in resident status may now predispose a resident to elopement attempts). A. Record review of Resident 129's Clinical Resident Profile sheet, copied 2/19/2026 revealed Resident was admitted to the facility on [DATE].A record review of Resident 129's Comprehensive Minimum Data Set (MDS - a federally mandated clinical assessment tool used in Medicare/Medicaid certified nursing homes to evaluate the health, functional capabilities and needs of residents) submitted to and accepted by the Centers for Medicare and Medicaid Services (CMS - the federal agency that administers Medicare and Medicaid) on 01/12/2026 revealed Resident 129 had a Brief Interview for Mental Status (BIMS - a standardized cognitive screening tool mandated for all long-term care residents to measure memory, orientation and attention) of 10, indicating Resident 129 was moderately cognitively impaired.A record review of Residents 129's undated Care Plan (a comprehensive personalized document in healthcare that outlines an individual's specific health and social care needs, goals and the actions required to address them) revealed Resident 129 had the following diagnoses: Frontal lobe and executive function deficit following cerebral infarction (difficulty with planning, organization, impulse control, working memory and emotional regulation following a stroke), unspecified dementia, moderate with mood disturbance (a progressive decline in memory and cognitive function where the specific cause is not yet identified), Major Depressive Disorder (a serious mental health condition characterized by persistent, intense feelings of sadness and worthlessness) and generalized Anxiety disorder (a mental health condition defined by chronic, excessive and uncontrollable worry about everyday events, activities or potential disasters). A record review of the residents Risk Elopement assessments revealed Resident 129 was identified as a high Elopement Risk on 10/22/24, 12/12/24, 1/18/25, 2/17/25, 3/25/25, 6/25/25, 9/25/25, 12/25/25, 12/30/25 and 2/2/26.A record review of the residents undated care plan revealed it did not include a Risk of Elopement focus and did not contain any elopement interventions. An observation on 2/19/2026 at 11:35Am of the exterior of Resident 129's room revealed an electronic alarm was attached to the top of the residents door.An interview on 2/19/26 at 11:45 AM with Licensed Practical Nurse (LPN) I confirmed Resident 129 was on the elopement list. LPN I confirmed there was an alarm device on the top exterior of Resident 129's door which would alarm if Resident 129 exited their room.An interview on 2/19/2026 at 11:55 AM with Registered Nurse L (RN) confirmed a list of elopement risk residents was visible on every nurse station, an Elopement Risk Manual is on every station and the organization's home page had a list of elopement risk residents.An interview on 2/19/2026 at 12:10 PM with the Social Services Supervisor confirmed the Elopement management process is as follows: elopement assessments are to be completed by the floor nurse. If a resident is determined to have a high risk for elopement, the residents name is placed on a list, and the list is given to the front desk and also updated on the organizations internal internet page that all staff can access. An elopement sheet with details and a picture is placed in the elopement book on the unit the resident lives on. An interview on 2/19/2026 at 2:10 PM with LPN I confirmed nursing is responsible for completing the elopement risk assessment and the Assistant Director of Nursing (ADON) was responsible for updating the care plan.An interview on 2/19/2026 at 2:20 PM with ADON A confirmed Residents 129's care plan did not contain a risk for elopement and interventions to prevent it. ADON A confirmed the care plan update had not been completed.

Based on interview and record review, the facility failed to report and investigate an allegation of abuse for Resident 22 within the required timeframe. The facility claimed a census of 122. A record review of the facility's undated Abuse and Neglect Prevention Standard, revised 1/2023, revealed the following Required Elements:It is the responsibility of all team members to immediately report any act of witnessed, suspected, or reported abuse to the Administrator or their supervisor.InvestigationAll allegations of abuse and/or neglect will be investigated and reported in accordance with the state and federal laws.In the situation of an allegation of abuse, the following people will be notified immediately: Administrator, Director of Nursing (DON), and Social Services.The suspected team member(s) will be suspended immediately while an in-depth, documented investigation is conducted.ProtectionResidents will be protected from harm during an investigation.Team members suspected of abuse will be immediately suspended until the results of the investigation are complete.Reporting/ResponseReport all alleged violations involving abuse (physical, mental, verbal, or sexual) immediately, but no later than 2 hours after the allegation has been made.Report all alleged violations involving neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property if the resident property, if the allegation does not involve serious bodily injury immediately, but no later than 24 hours.A record review of Resident 22's Clinical Resident Profile revealed Resident 22 was admitted to the facility on [DATE] with a diagnosis of Rhabdomyolysis (a serious, potentially fatal syndrome involving the rapid breakdown of skeletal muscle, releasing toxic contents into the blood causing kidney damage).A record review of Resident 22's Minimum Data Set (MDS - a federally mandated clinical assessment tool used in Medicare/Medicaid certified nursing homes to evaluate the health, functional capabilities and needs of residents) submitted to and accepted by the Centers for Medicare and Medicaid Services (CMS - the federal agency that administers Medicare and Medicaid) revealed Resident 22 had a Brief Interview for Mental Status (BIMS - a standardized cognitive screening tool mandated for all long-term care residents to measure memory, orientation and attention) of 14 indicating Resident 22 is cognitively intact. MDS also revealed Resident 22 had a diagnosis of Anxiety Disorder (a functional abnormality in physical or mental health, causing distress or impaired functioning) and was dependent for assistance with footwear (a health status where an individual cannot independently manage their own shoes, socks, or foot care, necessitating help from a caregiver, nurse or professional). A record review of a physician orders dated 01/05/2026 revealed the following: Ace wraps (a stretchable wrap used to reduce swelling, support injured muscles, and stabilize joints like ankles, wrists, and knees) on in the AM and off at HS one time a day for edema (the buildup of fluid in body tissues, causing swelling) On in the AM and Off at HS remove per schedule. An interview on 2/18/26 at 2:40 PM with Resident 22 revealed on 2/17/2026 at 8:00 PM nurse assistant (NA) G came to Resident 22's room. Resident 22 revealed one of the ace wraps was off one and the other one partially off the other leg. Resident 22 reported NA G pulled the ace wrap roughly from their leg and hurt the resident. Resident 22 reported they told NA G that they did not want them to come back to their room. Resident 22 reported later that evening they told the evening Medication Assistant (MA) D what had happened and MA D told the resident to tell the night shift nurse. Resident 22 spoke to Licensed Practical Nurse (LPN) H about the incident on 2/17/2026. Resident 22 did not know if LPN H told anyone else, but a Nurse boss came to talk to the resident the next day. Resident22 reported they were afraid to have NA G provide their cares. An interview with an Assistant Director of Nursing B (ADON) on 2/18/26 at 3:20 PM confirmed they were instructed to talk to Resident 22 on 2/18/26 and Resident 22 informed ADON B that they did not want NA G to care for them again. ADON B confirmed they had asked Resident 22 if that would be enough to fix the problem and the resident agreed. ADON B confirmed the NA G was not suspended, the facility had not opened an abuse investigation and had not reported it as abuse to APS or DHHS. An interview on 2/18/26 at 3:25 PM with MA D confirmed Resident 22 had informed them on 2/17/2026 that NA G was rough when they removed their leg wraps and had hurt Residents 22's legs. MA D confirmed Resident 22 did not want NA G to take care of them again. MA D confirmed they told LPN H they needed to speak with Resident 22 about NA G. An interview on 2/18/2026 at 4:20 PM with ADON A revealed the facility had decided to treat the incident as an abuse investigation based on the surveyor informing ADON A Resident 22 had said the NA G was rough with the residents cares. An interview on 2/23/26 at 9:50 AM with the Director of Nursing ( DON) confirmed LPN H called the DON on 2/17/26 at midnight. LPN H reported Resident 22 had said NA G hurt them when they removed the residents ace wraps. DON confirmed they decided to open the issue as a grievance and instructed ADON A to address it in the morning. DON confirmed they did not open an abuse investigation until the afternoon of 2/18/2026.

Licensure Reference Number 175 12-006.09 (F)(III) Based on observation, interview and record review, the facility failed to update the Comprehensive Care Plans (CCP) related to wound care for Residents 7 and 88, anti-anxiety medication use for Resident 87 and targeted behaviors and interventions for Resident 69. The sample size was 5 and the facility census was 132. Findings are: A review of the facility's CCP policy dated [DATE] revealed it is the policy of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. It further confirmed that the comprehensive careplan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment and as needed. A review of the facility's Skin and Wound Management Standard policy reviewed 4/2019 revealed that an assessment should be completed on all skin tears/abrasions/bruises/scrapes/cuts, etc. It further revealed that all actions and interventions will be included in the careplan at the time of identification. A. A record review of Resident 88's facility Admission Record revealed Resident 88 had an admission to the facility on [DATE] with no diagnosis of wounds. A record review of Resident 88's quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 7, which indicates cognitive impairment. It also revealed, in Section M Resident 88 has no wounds but was at risk for developing wounds. A record review of Resident 88's progress notes dated 9/9/2024 revealed an open skin tear to the resident's lower left leg. A record review of the facility's non pressure skin condition record for Resident 88 dated 9/9/24 revealed a skin tear to left lower leg that measured 1.5 centimeters (cm) length, 1.5 cm width, and 0.2 cm depth. A record review of Res 88's Treatment Administration Record (TAR) for 9/2024 and 10/2024 revealed an order dated 9/25/24 for the left ankle wound to cleanse with wound cleanser, apply silver alginate (used in the treatment of at risk or infected wounds), apply adaptic dressing (used to help protect the wound while preventing the dressing from adhering to the wound), then cover with ABD pad (an highly absorbent sterile dressing). Change Monday, Wednesday, and Friday and as needed if soaked. A record review of Resident 88's physician orders dated 9/25/24 revealed an order for the Left ankle wound to cleanse with wound cleanser, apply adaptic dressing with silver alginate over it then cover with ABD pad. Change Monday, Wednesday, and Friday and as needed if soaked. An observation on 10/16/24 at 9:19 AM Registered Nurse (RN) - H provided wound care to Resident 88's left lower leg as ordered. A record review of Resident 88's CCP revealed: -problem for skin impairment due to fragile skin initiated on 2/28/2024 current skin issues: 1) Scabbed area to right temple 2) chin 3) unmeasurable area inside left ear 4) Labia/groin/buttocks redness 5) bruise to left outer aspect of eye 6) Skin tear to right thigh An interview on 10/16/24 at 9:41 AM with RN - H confirmed that all the resident careplans are supposed to be updated with all new orders and that careplans are periodically reviewed. An interview on 10/16/24 at 9:47 AM with ADON - B confirmed that the wound to Resident 88's left lower leg is not on the careplan and should have been. 47312 B. Observation on 10/16/24 at 10:37 AM of wound care to Resident 7's right second toe with RN-I revealed after removal of Resident 7's slipper, an approximately pea sized open area to the knuckle area, with soft yellow scabbed center, no drainage or odor. Resident 7's skin around the area was without redness. Review of Resident 7's MDS, dated [DATE], revealed the following: -One Stage 2 pressure injury (wound that affects the first two layers of skin) that was not present upon admission or reentry. Review of Resident 7's progress notes, dated 9/16/24 revealed the following: Weekly visual skin check complete. Noted new pressure area to right second toe. 1.1 cm x 1.1 cm in size. Area is non blanching with red and white center and purple skin at the outer edges of circle. No other areas of concern noted at this time. Review of Resident 7's CCP, dated 10/16/24, revealed a focus for potential for skin breakdown related to edema and impaired mobility. History of cellulitis to left lower extremity (LLE); Current skin issues: 1) Pressure injury to right second toe knuckle, revised 9/16/24. Further review of the care plan revealed no revisions were made and no new interventions were put into place after the area to Resident 7's toe was found. Review of the facility policy, Skin and Wound Management, dated 4/2019, revealed the following under Pressure Ulcer/Injury condition: -2. Care plan. All actions/interventions will be included in the care plan in PCC (point click care- electronic health record system) Interview on 10/16/24 at 10:55 AM with ADON-A confirmed that the care plan was not changed after the pressure area to Resident 7's right second toe was found, and Resident 7's care plan should have been updated. C. Review of Resident 87's orders, dated 10/15/24, revealed a new order received on 10/4/24 for Ativan (medication used to treat anxiety) oral tablet 0.5 milligrams (mg), give 0.5 tablet by mouth (PO) as needed (PRN) for anxiety for 30 days, give 0.25 mg PO twice daily PRN. Review of Resident 87's CCP, dated 10/15/24, revealed a focus of: uses psychoactive medications related to: depression, created 9/9/24. Further review of the CCP revealed no revisions or new interventions put into place after Resident 87 was started on an anti-anxiety medication. Interview on 10/16/24 at 7:51 AM with the MDS coordinator confirmed that there were no changes made to Resident 87's CCP after they were started on the anti-anxiety medication and that the CCP should have been updated. 45484 D. A record review of Resident 69's Admission Record printed 10/16/2024 revealed an admitted [DATE], and diagnoses of dementia, mood disorder, psychosis, and obsessive-compulsive disorder (OCD, a mental illness that causes people to have uncontrollable, recurring thoughts [obsessions] and repetitive behaviors [compulsions]). A record review of Resident 69's Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact. A record review of Resident 69's CCP revealed a focus for out-of-character responses due to dementia-related diagnosis. This focus had an initiation date of 06/27/2019 and had no revision dates or mention of specific responses the resident might exhibit. There was no mention in the CCP of the out-of-character responses or behaviors of coughing, looking for spouse, and frequent bathroom visits, or of the interventions of offering hard candy, going for walks, distraction, or offering food or snacks. A record review of Resident 69's Behavior/Intervention Monthly Flow Records for May 2024 to October 15, 2024, revealed the following: -May: Behaviors listed were OCD AEB [as evidenced by] face scratching, sleeplessness, agitation, and OCD AEB obsessed with toileting. A personalized intervention of encourage to come out of bathroom, was listed under OCD AEB obsessed with toileting. -June: Behaviors listed were OCD AEB face scratching, sleeplessness, and OCD AEB obsessed with toileting. There were no personalized interventions listed. -July: Behaviors listed were OCD AEB face scratching, sleeplessness, and OCD AEB obsessed with toileting. There were no personalized interventions listed. -August: Behaviors listed were OCD AEB face scratching and sleeplessness. There were no personalized interventions listed. -September: Behaviors listed were OCD AEB face scratching and sleeplessness. There were no personalized interventions listed. -October: Behaviors listed were OCD AEB face scratching, sleeplessness, and agitation. There were no personalized interventions listed. An interview on 10/16/2024 at 9:45 AM with Nurse Aide (NA) C revealed Resident 69 had behaviors of pacing the halls looking for their spouse, constantly going back and forth to the bathroom, and coughing frequently at meals. NA C stated the staff offered snacks and distraction to Resident 69 when they were pacing in the hall, and that was sometimes effective. NA C stated the coughing was a behavior, and to help with that, staff would take Resident 69 for a walk or offer hard candy. The NA reported there were no current effective interventions to distract Resident 69 from the bathroom. An interview on 10/16/2024 at 9:55 AM with NA D revealed Resident 69 had behaviors of going back and forth to the bathroom frequently. Reported that sometimes when the resident does that, they will forget they have eaten, so staff will save a tray for the resident. An interview on 10/16/2024 at 10:00 AM with NA E revealed that Resident 69 had behaviors of looking for their spouse, frequent bathroom trips, and coughing. NA E stated that staff attempted to redirect the resident or change the subject when Resident 69 was looking for their spouse and that going for walks and offering hard candy helped with the coughing. NA E further stated the resident's family member had suggested to have Resident 69 blow through a straw because that had helped in the past. NA E stated that there were no current effective interventions when the resident was going back and forth to the bathroom. NA E confirmed that the interventions of blowing in a straw, offering hard candy, and going for walks were not on the care plan. An interview on 10/16/2024 at 10:04 AM with Registered Nurse (RN) F revealed Resident 69 had behaviors of going to the bathroom frequently, coughing that the resident was unaware they were doing, and frequently looking for their spouse. When Resident 69 was coughing, staff offered candy or a walk, and would attempt to distract them when the resident was looking for their spouse. RN F revealed that the behaviors were documented on the Behavior/Intervention Monthly Flow Records kept at the nurse's station, and stated this was where staff would find what to do for each behavior. RN E confirmed the behaviors of coughing and looking for their spouse were not on the behavior flow sheet for Resident 69. An interview on 10/16/2024 at 12:39 PM with the Director of Nursing (DON) confirmed that Resident 69's behaviors of coughing and looking for their spouse was not on the Behavior/Intervention Monthly Flow Records. An interview on 10/16/2024 at 1:28 PM with the Assistant Director of Nursing (ADON) A confirmed that Resident 69's behaviors of coughing, frequent toileting, and looking for their spouse, and the interventions of offering hard candy, going for a walk, distraction, and offering food or snacks were not on the CCP and should be. ADON A further confirmed the care plan interventions were not personalized and had not been revised or updated since 06/28/2019, and should have been. A review of the facility's Comprehensive Care Plans policy dated 6.2017 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment, and that The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and as needed. A review of the facility's Psychoactive Medication and Medication Regiment Review Management Standard policy dated 9.2024 revealed on of the key elements was that the care plan was reflective of the out-of-character response/behavior and management. A review of the facility's Out of Character Response and Prevention Standard policy dated 6.2024 revealed: During the weekly Risk Meeting and at the care plan meetings, the care plan will be reviewed to ensure that it is current and up to date. Social Services and Nursing are responsible for working with the Interdisciplinary Team to develop a strengths-based care plan with a goal of addressing and preventing Out of Character Responses/Behaviors.

Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review, the facility failed to ensure food was stored in the facility's refrigerators and freezers in a sealed container that was labeled and dated. This had the potential to affect all 130 resident that consumed food from the kitchen. The total census was 130. Findings are: A record review of the facility's Dietary Storage Policy and Procedure dated 08/2023 revealed the facility staff should store food in covered containers or wrap securely and clearly label and date each item. An observation on 08/09/2023 at 07:35 AM revealed the following items were in the facility's reach-in freezer and were unsealed and not labeled or dated: 2 bags of onion rings 2 bags of French fries 1 bag of carrots 1 bag of waffle fries 1 bag of hamburger patties 1 bag of an unknown substance 1 bag of cookies An observation on 08/09/2023 at 07:35 AM revealed the following items were in the facility's walk-in refrigerator and were opened and did not have an open date: 1 container of pickles 1 container of relish 1 container of capers 1 bottle of enchilada sauce 1 bottle of French dressing 1 bottle of Sweet Baby Rays Bar-B-Que sauce 1 bottle of Sweet Baby Rays Wing sauce 1 bottle of mayonnaise In an interview on 08/16/2023, the Registered Dietician (RD) confirmed that 100 percent (%) of the residents in the facility consume food prepared in the kitchen. In an interview on 08/09/2023 at 07:35 AM, the Dining Specialist (DS)-D confirmed DS-D observed the opened, unsealed, unlabeled, and/or undated items and confirmed all opened items should have been in a sealed container and clearly labeled and dated.

Licensure Number 175 NAC 12-006.17D The facility failed to ensure that staff performed hand hygiene between Residents 9, 59, 77, 87, 91, 95, and 103 during dining and failed to ensure that staff performed hand hygiene when providing wound care to one (Resident 6) of two sampled residents. The total facility census was 130. Findings are: A. A record review of the facility's Hand Hygiene (washing) Policy dated 08/19/2022 revealed that according to the World Health Organization, 5 key moments in patient (resident) care during which hand hygiene should be performed is before touching a patient (resident), before a clean procedure, after touching a patient (resident), after body fluid exposure risk, and after touching a patient's (resident's) surroundings. A record review of the Dietary Handwashing Policy and Procedure dated 10/2017 revealed the staff should wash hands after handling soiled equipment or supplies, after touching bare body parts, and after engaging in other activities that contaminate hands. An observation of the 600-hall dining room on 08/15/2023 at 08:22 AM revealed Nursing Assistant (NA)-F assisted Resident 95 with bites of food using the resident's utensils, then went and a got clothing protector and placed around Resident 77 while touching Resident 77's clothing and hair. NA-F then went to dining room window and got plates for Resident 9 and Resident 87 and delivered plates to the residents. NA-F then went back and assisted Resident 95 with eating, all without having performed hand hygiene. An observation of the 600-hall dining room on 08/15/2023 at 08:28 AM revealed NA-F performed hand hygiene and went to the dining room window, placed NA-F's hands on the counter, and delivered a plate to Resident 91. NA-F sat the plate down in front of Resident 91 and opened the resident's yogurt container using both hands. NA-F then went to Resident 59 and assisted Resident 59 with drink by holding the cup and straw. NA-F then returned to Resident 95 and assisted 95 with eating oatmeal while NA-F touched surfaces in front of resident and the Resident 95's utensils without having performed hand hygiene throughout the observation. An observation on 08/15/2023 at 08:35 AM revealed NA-F scratched NA-F's own nose with the right hand, brushed hair to the side, and gave Resident 95 oatmeal bowl to another NA. NA-F was handed a plate of food and continued to assist Resident 95 with NA-F's right hand. NA-F got up, opened the blinds with NA-F's right hand and sat back down and continued to assist Resident 95 with eating eggs while NA-F used the right hand, all without having performed hand hygiene. An observation on 08/15/2023 08:46 AM revealed NA-F in the 600-hall dining room do hand hygiene, grab the coffee pot, went and served 3 residents coffee and touched the back of 2 of the resident's chairs, and 1 of the resident's wheelchair. NA-F then went and assisted Resident 59 with eating eggs and pancakes by using Resident 59's utensils, wiped food from the resident's lap and threw it away. NA-F got papers off the dining room counter and went to nurse's station and returned papers to dining room counter. At 08:55 AM, NA-F moved the chair by Resident 95 and assisted Resident 95 with a drink while NA-F touched the resident's cup and straw. NA-F then went and assisted Resident 64 with 2 bites of yogurt while Registered Nurse (RN)-E put medications in the spoon of yogurt. NA-F gave resident 1 more bite, got up by touching the chair and went and assisted Resident 103 with eating without having performed hand hygiene throughout the entire observation from before serving the coffee. In an interview on 08/15/2023 at 12:46 PM, Assistant Director of Nursing (ADON)-C confirmed NA-F should have performed hand hygiene before and after each resident contact. 45614 B. Record review on 08/15/23 at 1:19 PM Resident 6's electronic health record confirmed an Operative/Procedure Report signed by [NAME], MD (medical doctor) and dated 2/9/2023 which revealed Resident 6 had lower right extremity wounds. She previously hit her right foot back around Christmas time and since then the wound has been progressively getting worse. This wound was acquired prior to admission to the facility. Record review on 08/14/2023 at 9:00AM Resident 6's post surgical discharge instructions confirmed a wound care order to keep the dressing C/D/I. (Clean, dry, intact). Start vac (vacuum) therapy in conjunction with thigh wound starting 8/11/2023. Record review on 08/14/23 at 9:10 AM of Resident 6's Treatment Administration Record (TAR) revealed an active order, dated 8/11/2023 for the following: Foot Wound Vac Management: cleans wound with normal saline; use negative pressure black foam in wound place VAC at 125mmHg continuous. every day shift every Mon, Wed, Fri related to unspecified atherosclerosis of nonautologous biolgional bypass graft(s) of the extremities, right leg. An observation on 8/14/2023 at 11:45AM of the application of a wound vacuum system (provides vacuum assisted closure of a wound) and dressing change provided to Resident 6's right dorsal (related to the upper side) foot by ADON-A (Assistant Director of Nursing). ADON-A had the wound vacuum supplies laid out on a clean bedside table. These consisted of a sterile package containing black foam sponge, an adhesive pad attached to tubing and two separate wound care drapes (transparent sheets of adhesive film used to secure the dressing to the Resident). A second package containing a sterile scissors and two skin prep wipes was also on the bedside table. Resident 6 had their right leg propped up on a pillow with the foot extended beyond the pillow. A clean towel was beneath Resident 6's right leg. ADON-A donned basic exam gloves. ADON-A did not wash their hands or use hand sanitizer prior to donning gloves. ADON-A used a syringe and a bottle of normal saline to clean the surgical area and allow it to air dry. The ADON-A removed the exam gloves and did not perform hand hygiene prior to donning sterile gloves. ADON-A measured the surgical area. The wound is a large circular shape with a ring of staples securing the graft to the surrounding skin. The diameter measurements are 4.75cm x 4.0cm. ADON-A removed their gloves and had to leave the room to obtain another pair of sterile gloves. ADON-A did not wash their hands or use hand sanitizer before leaving the resident room or when ADON-A returned to the room or before donning the 2nd pair of surgical gloves. ADON-A opened the wound vac dressing package and the sterile scissors package. ADON-A cut a piece of black foam and trimmed it to fit the wound bed. ADON-A then trimmed two pieces of dressing drape to fit the wound. ADON-A peeled the backing from the first drape and placed the black sponge on the drape. ADON-A fit the sponge to the wound bed and pressed the adhesive drape to the resident's skin, creating a seal around the sponge. ADON-A cut an opening on the drape over the sponge. ADON-A attached the wound vaccum tubing to the sponge with the attached adhesive tab. ADON-A placed the second layer of adhesive drape over the tubing and created a seal with the original drape underneath. ADON-A attached the tubing to the wound vaccum and turned it on. The vaccum effectively created a seal. ADON-A cleared the debris from the end table and removed their gloves. ADON-A did not perform hand hygiene at that time. RN-B (Registered Nurse) was present in the room and observed the care provided by ADON-A to Resident 6. An interview on 8/15/2023 at 1:36 PM with RN-B confirmed ADON-A did not perform hand hygiene prior to putting their gloves on or after taking their gloves off. RN-B confirmed ADON-A did not perform hand hygiene when the wound care was complete or before they left the room. RN-B confirmed that hand hygiene should be completed before putting on gloves and after taking gloves off and hand hygiene should also be performed when the treatment is complete and when leaving the resident's room. Record review on 08/15/23 at 1:51 PM of the [NAME] Procedures - Hand Hygiene followed by the facility and reviewed August, 19, 2022 revealed the following: Using an alcohol-based rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment. Record review on 08/15/23 at 1:57 PM of the [NAME] Procedures - Negative Pressure Wound Therapy revised February 20, 2023 requires hand hygiene before donning (putting on) and doffing(removing) standard gloves, before donning and doffing sterile gloves, and when the wound vacuum dressing change is completed but before the wound vaccum is turned on.

Based on record review and interview, the facility failed to provide written notification for reason of transfer for Resident 23. The facility census was 121 and the sample size was 24. Findings are: A record review of Resident 23's Electronic Health Record revealed a transfer/discharge summary was not present for Resident 23's discharge to the Emergency Department on 3/28/2022. An interview with Licensed Practical Nurse-B (LPN-B) on 05/11/2022 at 12:11 PM confirmed a discharge transfer summary was to be completed every time a resident was sent to the hospital for evaluation. An interview on 05/11/2022 at 12:58 PM with Registered Nurse - C (RN-C) confirmed that a transfer/discharge summary was not done when Resident 23 was transferred to the Emergency Department on 3/28/22. RN-C confirmed that the expectation is that whenever a resident is discharged to another facility, a transfer/discharge summary is to be completed. An interview on 05/11/2022 at 01:02 PM with RN-C confirmed that a signed transfer/discharge summary was not given to the resident's family when Resident 23 was transferred to the hospital.

LICENSURE REFERENCE NUMBER 175NAC 12-006.09D3 Based on record review and interview; the facility staff failed to implement ordered interventions for bowel care for 1 (Resident 230) of 2 sampled residents. The facility staff identified a census of 121. Findings are: Record review of Resident 230's Office/Progress Notes dated 5-09-2022 revealed Resident 230 was admitted to the facility on [DATE] . According to Resident 230's Office/Progress Notes dated 5-09-2022, Resident 230 was seen by the practitioner on 5-04-2022 for a constipation issue. Record review of a Physician/Prescriber sheet dated 5-04-2022 revealed Resident 230's practitioner order a treatment plan for the constipation that included obtaining laboratory testing, Magnesium [MEDICATION(S)] (liquid [MEDICATION(S)] ) 1/2 bottle now and a fleets enema now. Record Review of Resident 230's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 230's Progress note dated 5-05-2022 revealed the Magnesium [MEDICATION(S)] was given on the 5th of May. On 5-11-2022 at 9:45 AM an interview was conducted with the Advanced Practice Registered Nurse (APRN) D. During the interview review of Resident 230's order for the Magnesium [MEDICATION(S)] was reviewed. APRP D reported the Magnesium [MEDICATION(S)] should have been given on 5-04-2022 and not on 5-05-2022. On 5-11-2022 at 11:25 an interview was conducted with Registered Nurse (RN) C. During the interview RN C confirmed the Magnesium [MEDICATION(S)] was not given as ordered.

Based on record review and interview, the facility failed to ensure an as needed antianxiety medication was administered only with an indication for use and after non-pharmacological interventions had been attempted for 1 (Resident 1) of 5 sampled residents reviewed for unnecessary medications. The facility identified 23 residents were receiving antianxiety medications. The census was 120. Findings are: The facility, Medication Management policy and procedure, undated, documented: The indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological interventions, are determined by assessing the resident's underlying condition, current signs and symptoms, and preferences and goals for treatment .The following considerations will be included in the management of [MEDICAL CONDITION]/psychoactive medication (with initiation of a medication and also for continued use of a medication) .Were non-pharmacological interventions considered? .Residents do not receive [MEDICAL CONDITION]/psychoactive drugs pursuant to a PRN (as needed) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record . Resident 1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 08/28/20, documented Resident 1's Brief Interview for Mental Status score was 99, which indicated severe cognitive impairment. The assessment documented the resident had exhibited no behaviors during the seven days prior to the assessment date and had received an antidepressant medication on seven of seven days prior to the assessment date. The care plan revised 09/14/20, documented Resident 1's problems included the use of psychoactive medications related to depression, and behavioral and psychotic symptoms due to dementia. The care plan did not address Resident 1's behaviors of crying/tearful, yelling at others, agitation/anxiousness, and/or paranoia/delusions. Non-pharmacological interventions for the behaviors were a not addressed in the care plan. A physician's orders [REDACTED]. (The order was discontinued on 09/14/20.) A physician's orders [REDACTED]. The Medication Administration Record, [REDACTED]. The clinical record (nursing progress notes and/or the behavior monitoring flow sheet) contained no documentation non-pharmacological interventions had been attempted prior to the administration of [MEDICATION NAME] for Resident 1' on the following dates/times: 09/10/20 at 7:46 PM, 09/11/20 at 5:47 PM, 09/12/20 at 4:12 PM, and 09/15/20 at 8:01 PM. On 09/16/20 at 12:24 PM, Registered Nurse (RN)-D was asked where in the clinical record a resident's behaviors would be documented. RN-D stated behaviors would either be documented in a progress note or on the behavior monitoring sheet. On 09/16/20 at 12:59 PM, the Director of Nursing (DON) was asked if non-pharmacological interventions should be attempted prior to the administration of a PRN anxiolytic medication. The DON stated, Yes. When asked if a behavior, which required the administration of a PRN anxiolytic medication, should be documented in the clinical record, the DON stated, Either in a progress note or on the behavior sheet. When asked if a behavior which required the administration of a PRN anxiolytic medication should be care planned, the DON stated, If there are multiple occurrences, it should be care planned. The above listed dates/times of the administration of [MEDICATION NAME] for Resident 1' were provided to the DON. The DON was asked to find documentation of non-pharmacological interventions attempted prior to the administration of [MEDICATION NAME] and/or indications for the administration of the [MEDICATION NAME] on the four dates/times. On 09/16/20 at 1:40 PM, the DON returned with Registered Nurse (RN)-B, who provided documentation of behaviors documented in the clinical record for the administration of [MEDICATION NAME] for Resident 1 on 09/12/20 at 4:12 PM. RN-B stated there was no documentation of non-pharmacological interventions having been attempted on any of the four dates/times and no indication for use of [MEDICATION NAME] documented on 09/10/20 at 7:46 PM, 09/11/20 at 5:47 PM, or 09/15/20 at 8:01 PM.

LICENSURE REFERENCE NUMBER 175NAC 12-006.09D1c Based on observation, record review, and interview, the facility failed to provide nail care for 1 (Resident 98) of 1 sampled resident reviewed that required assistance with activities of daily living (ADLs). This had the potential to affect all 120 residents currently in the facility that required assistance or were dependent on staff with activities of daily living. The facility census was 120. Findings are: Resident 98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status of 11, which indicated moderate cognitive impairment. The MDS documented the resident required limited assistance with ADLs, and extensive assistance with bathing. The care plan, dated 08/12/20, documented the resident's problems included ADL self-care deficit related to activity intolerance. The care plan documented the resident was dependent upon staff for bathing, and hair care/nail care was to be provided with bathing. It documented a licensed professional was to provide nail care because of Resident 98's [DIAGNOSES REDACTED]. The resident's clinical record contained no documentation Resident 98's toenails had been assessed and/or trimmed since admission. A summary of a pressure ulcer record, dated 09/02/20, documented: Resident asked nurse to trim toe nail. upon inspection of toe noted to have toe nail growing over tip of toe. area is dark purple intact skin. toe nail trimmed and filed as resident tolerated. On 09/16/20 at 9:00 AM, an observation, with the assistance of Registered Nurse (RN)-C, an area, approximately 1 centimeters (cm) x 1 cm was observed on the tip of the Resident 98's left great toe. RN-C confirmed the area was a ruptured blood blister which was the result of the toenail curving into the Resident 98's skin and was facility acquired. On 09/17/20 at 9:25 AM, RN-A was interviewed. When asked how long Resident 98's left great toenail was when the wound to the left great toe was discovered, RN=A stated the nail curled over the tip of Resident 98's s toe and was putting pressure on the end of the toe. RN-A used fingernail clippers to trim the nail and filed it. When asked if a licensed nurse was responsible to trim the nails because the resident was a diabetic, RN-A stated, Yes. When asked if the long, curled toenail should have been discovered prior to 21 days after admission and prior to the development of a wound, RN- A stated, Yes.

LICENSURE REFERENCE NUMBER 175NAC 12-006.10A1 Based on record review, observation and interview, the facility failed to assess the cognitive and physical ability of one resident (Resident 76) prior to allowing the self-administration of medication. The sample size was 24. The facility census was 120. Findings are: 09/14/20 10:32 AM An observation revealed Resident 76 had [MEDICATION NAME] mouth spray (a medication used to relieve dry mouth) at bedside. 09/15/20 11:20 AM An interview with Resident 76 revealed Resident 76 used the [MEDICATION NAME] twice daily. A record review for Resident 76 completed on 09/15/20 revealed no self-administration of medication assessment in the resident's record. The record review of the physician's orders [REDACTED]. 09/15/20 03:30 PM An interview with ADON-B (Assistant Director of Nursing) revealed it was a facility expectation to complete an assessment prior to allowing a resident to self-administer medications. A record review of the Medication Self-Administration Screen for Resident 76 had been completed on 09/16/20. 09/16/20 03:20 PM An interview with ADON-B confirmed the Medication Self-Administration Screen for Resident 76 did not exist prior to today.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and interview; the facility staff failed to evaluate and implement a toileting program for 1 (Resident 30) of 3 sampled residents. The facility staff identified a census of 132. Findings are: Record review of the facility Bowel and Bladder Management Standard sheet dated 4-18-17 revealed the following information: -Key Elements: - A resident who has a catheter or is incontinent of bladder will be identified and assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible. -Residents with fecal incontinence must receive the appropriate treatment and services to restore as much normal bowel function as possible. -Assessments tools: - Hourly Elimination diary, started 3 days after admission and to be completed by day 7. -Incontinence Summary Guide- A tool to assist in formulating comprehensive summary to assist in formulation of a Bowel and Bladder program. -Identify the nature of residents incontinence to apply appropriate interventions to restore resident continence. Review of the facility Bowel and Bladder Management Standards sheet dated 4-18-17 revealed the following information: -Introduction: -The purpose of the bowel and bladder Management Program is to maintain and interdisciplinary team approach to continence care and bowel management , to facilitate improvement in bladder and bowel function in those who can improve, and to prevent deterioration of bladder/bowel function. Identification and Assessment: -A. Hourly Elimination Diary. -The diary should be started 3 days after admission and completed no later than day 7 of the residents stay. The hourly elimination diary is completed for 3 days to establish the residents voiding and elimination pattern on residents who are incontinent. This document should be closely monitored so that hourly information is collected and record by staff. The document should be closely monitored so that hourly information is collected and recorded by staff. Gaps in collected information would warrant extending the tracking diary an additional day for a clearer picture of the residents voiding pattern. Treatment, Services and Care Planning: -Based upon resident assessment , determine if additional testing/medical intervention would be beneficial. Discuss any assessment findings with residents physician as appropriate to determine if further additions to plan of care are appropriate. -Identify the nature of the incontinence and identify appropriate program or interventions to address the incontinence. Record review of Resident 30's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) on 2-4-19 revealed Resident 30 was frequently incontinent of bowel and bladder and did not have a toileting program. Further review of Resident 30s MDS dated [DATE] revealed Resident 30 was assessed as having a 11 on the Brief interview of Mental status (BIMS). According to the MDS Manuel, a BIMS of 7 to 12 indicate some cognitive impairment. Record review of Resident 30's medical record revealed there was no evidence the facility staff had evaluated Resident 30 for a toileting program. On 4-17-19 at 3:51 PM an interview was conducted with ADON A. During the interview, ADON A confirmed Resident 30 was not evaluated for a toileting program.

Licensure Reference Number 175 NAC 12-006.18A Based on observation and interview, the facility staff failed to maintain the cleanliness of ventilation covers in 9 (rooms 410, 411, 412, 413, 706, 707, 709, 710, 713) of 106 occupied resident bathrooms as evidenced by the ventilation covers had a coating of dust on the interior and exterior of the ventilation cover. The facility census was 125. Findings are: Observation on 01/10/18 at 08:15 AM with the facility Administrator and the Maintenance Supervisor revealed ventilation covers that were coated with dust in resident bathrooms 410, 411, 412, 413, 706, 707, 709, 710 and 713. Interview on 01/10/18 at 08:31 AM with the Maintenance Supervisor confirmed that the ventilation covers had a coating of dust on the interior and exterior of the units in resident bathrooms 410, 411, 412, 413, 706, 707, 709, 710 and 713. Interview on 01/10/18 at 08:40 AM with the Housekeeping Supervisor revealed that the housekeeping cleaning schedules did not include dusting of the interior or the exterior of ventilation covers in resident restrooms.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview, the facility staff failed to perform hand hygeine when changing gloves during wound care procedure for 1 resident (Resident 69) and failed to perform hand hygeine for the recommended length of time during Gastrostomy tube feeding administration for 1 resident (Resident 189) of a total of 8 residents sampled. The facility census was 125. FIndings are: A. Record review of the facility Clean Dressing Competency revised 1/2010 revealed the following: 10. Wash hands 11. Apply clean gloves. 12. Remove old dressing and discard in the plastic bag previously established. 13. Remove gloves. Wash hands/use hand sanitizer. 14. Apply Clean gloves. 15. Cleanse wound with ordered solution. 16. Observe wound for size, color, and drainage. 17. Remove gloves. Wash hands/use sanitizer. 18. Apply clean gloves. 19. Apply any medications as ordered 20. Remove gloves. Wash hands/use sanitizer. 21. Position pt. 22. Wash hands prior to leaving the resident's room. Observation, on 1/10/18 at 9:23 AM , revealed Registered Nurse (RN) D performing wound care on Resident 69. Present in the room was also Assistant Director of Nursing (ADON) C. RN D was observed to remove the saturated dressing from Resident 69's wound. RN D was observed to remove the gloves. RN D was observed to apply new gloves. RN D did not perform hand hygiene before placing new pair of gloves. RN D was observed to assess the wound, remove those gloves and apply other gloves, without performing hand hygiene. RN D then applied the prescribed medications to the wound, removed the gloves, and placed on new pair of gloves, no hand hygiene was performed between gloves. Interview with ADON C on 1/10/18 at 9:42 AM confirmed that hand hygiene was to be performed between gloves use. ADON C confirmed that during the dressing change for Resident 69, RN D had failed to perform hand hygiene when changing gloves. Interview with ADON B and ADON C on 1/10/18 at 9:48 AM confirmed that the facility policy during a clean dressing change was to perform hand hygiene when changing gloves. B. Record review of Resident 189's Comprehensive Care Plan ( a document that identifies individualized care needs) dated 1/4/18 revealed that Resident 189 received supplemental nutrition via a Gastrostomy (stomach) tube five times per day between meals. Observation of a tube feeding administration for Resident 189 on 01/10/18 at 02:00 PM revealed that RN A cleaned a bedside table with a sanitary wipe, went into Resident 189's room and performed hand hygiene for a total of 10 seconds. RN A left the room, returned to the medication cart, checked the order and returned to Resident 189's room. RN A performed hand hygiene for a total of 10 seconds. RN A gathered the necessary supplies, placed them on a clean barrier on the bedside table and performed hand hygiene for 10 seconds. RN A donned gloves, pulled Resident 189's shirt up and accessed the feeding tube. RN A removed the gloves, performed hand hygiene for 8 seconds and donned new gloves. RN A checked for tube placement and then administered the tube feeding. After RN A completed the tube feeding administration, RN A removed the soiled supplies, entered the bathroom and performed hand hygiene for a total of 15 seconds. Interview on 01/10/18 at 02:20 PM with Assistant Director of Nursing (ADON) B confirmed that RN A did not perform hand hygiene for the expected 20 second timeframe. ADON B confirmed that RN A should have performed hand hygiene for 20 seconds each time. Record review of the facility Hand Hygiene Competency procedures date [DATE] included the directive to lather and rub hands together for a full 20 seconds.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interviews, the facility failed to evaluate and provide treatment to the post surgical site for Resident 84. This affected one of one sampled residents. The facility census was 134. Findings are: Record review of Resident 84's face sheet revealed admission to the facility was 08/31/16. Resident 84's admitting [DIAGNOSES REDACTED]. Record review of Physician Consult Progress note dated 9/22/16 revealed that Resident 84 had a Thoracotomy (surgical intervention of the lung) on 8/18/16 revealed that Resident had a abscess in the lung, pneumonia, [MEDICAL CONDITION] ( infection thru body). Interview on 10/05/2016 at 9:11:20 AM with Resident 84 revealed that upon admission to the facility, had surgical wounds on the right and left side of back and trunk area. Resident 84 revealed that a dressing had been applied and changed upon admission, and for several days following admission, to the facility. Resident 84 confirmed that the incision sites have healed. Record review of Resident 84's medical record Nursing Assessment, dated 8/31/16 revealed that Resident 84 had an surgical incision to the right side of chest of 12 cm . It revealed that the edges were well approximated. Resident had incision to Lower right chest, with a 1 cm X ,5 cm scab the incision was noted to have a scant amount of bloody drainage. Record confirmed that the area had been covered with a clean gauze. Resident 84 had a surgical incision to the Right side chest and puncture wound from having had a chest tube in. Record review of Nurse Practitioner's (NP) admission assessment dated [DATE], revealed that Resident 84's surgical incision on the right lower flank had a small amount bloody drainage, and the incision to the right middle flank was healed. Record review of Resident 84's medical record failed to provide the following: Documentation of assessment of the surgical sites A practitioner's order for a dressing change to the surgical incision sites Documentation of the dressings of the surgical sites A comprehensive plan of care for the surgical incisions. Interview on 10/05/2016 at 11:08:11 AM with the facility NP confirmed that there was a dressing present on Resident 84's surgical incisions sites on initial assessment. The facility NP confirmed that there was continued drainage from the surgical incision. The facility NP revealed that a verbal order, for the facility staff to continue dressing changes to the surgical incision area until no drainage present. The facility NP confirmed that the order did not get placed into Resident 84's medical record. Interview on 10/06/2016 at 7:29:36 AM with the facility Director of Nursing(DON) and the facility Administrator confirmed that Resident 84 did not have assessments documented by nursing staff after the initial nursing assessment. The facility DON and Administrator confirmed that a verbal order for dressing changes had not been documented in Resident 84's medical record and was not performed. The facility DON and Administrator confirmed that a comprehensive care plan had not been initiated for Resident 84's care and assessment of surgical sites.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7 Based on observation and interview, the facility failed to ensure that the gas fire place, on the Viewpoint Crossing area, was maintained at a temperature to prevent the potential for burn. This had the potential to affect 2 of 74 residents that reside on the Viewpoint Crossing Area of the building (Resident 133 and 137 whom were cognitively impaired and self mobile). The facility census was 134. Observation on 10/04/2016 at 2:00:39 PM of sitting area on the Viewpoint Crossing area, was a gas fire place, the area felt hot, there was no barrier present between fire place metal and resident area. Observation on 10/04/2016 at 2:23:32 PM revealed the temperature of the grate area of the gas fireplace was 294 degrees Fahrenheit. Interview on 10/04/201 at 2:23:32 PM with Registered Nurse (RN) A, confirmed that the temperature of the metal was 294 degrees and that the metal was easily accessed by the residents without a safety barrier between metal of fire place and resident area. Confirmed that if one was to touch this area would result in burns. Interview 10/04/2016 2:39:41 PM with the facility Administrator, confirmed that residents did use the fire place area. The facility Administrator confirmed that the temperature was at a degree that would cause significant burns. The facility Administrator confirmed that there were two residents that were cognitively impaired and self mobile, in the Viewpoint Crossing area. The facility Administrator confirmed that Residents 133 and 137 were cognitively impaired and the fire place temperature was a safety risk to Residents 133 and 137.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1) Based on record review, observations and interviews, the facility failed to provide catheter care in a manner to prevent potential cross contamination for Resident 103. The facility census was 131. Findings are: Review of Resident 103's care plan last revised 8-17-15 revealed Resident 103 was at increased risk for infection related to having an Indwelling catheter for a [DIAGNOSES REDACTED]. Review of Resident 103's medication administration records for July, August, September and October revealed: -In July Resident 103 received [MEDICATION NAME] and Keflex (antibiotics) for UTI ' s -In August Resident 103 received [MEDICATION NAME] (antibiotic) for a UTI -In September Resident 103 received [MEDICATION NAME] for a UTI. An observation was made on 10-8-15 at 7 am Nurse Aide (NA) C providing catheter care to Resident 103. NA C washed hands, donned gloves and took an alcohol wipe and made one wipe down the catheter tube from the resident to the bag then continued to get Resident 103 dressed and out of bed. An interview was conducted with the staff development/ Registered nurse (RN) D on 10/08/2015 at 7:44 AM that witnessed the catheter cares to Resident 103 by NA C. When RN D was asked if NA C should have washed around the labia and urinary meatus and provided peri-care? RN D stated yes that should have been done. When asked if Resident 103's catheter care was done correctly RN D stated no. Review of Mosby's textbook for nursing assitants-6th edition with copyright date of 2004 by Sheila Sorrentino, Urinary Elimination, Chapter 18, page 386 stated: Giving Catheter care: 9. Put on gloves 10. Drape the person for perineal care 14. Give perineal care 15. Apply soap to a clean, wet washcloth 16. Separate the labia (female) 17. Hold the catheter near the meatus 18. Clean the catheter from the meatus down the catheter about 4 inches. Rinse downward away from the meatus with one stroke. Repeat as needed with a clean area of the washcloth.