Every finding on record at CHI Health St. Francis

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(a) The facility failed to verify that the Central Registry (Maintains all reports of child abuse and neglect opened for investigation, classified as either Court Substantiated or Agency Substantiated) check was completed for 1 out of 10 Nursing Assistant (NA-A) sampled staff employees files. This had the potential to affect all 15 residents in the facility. Findings are: A record review of NA-A employee file revealed that the Nebraska Central Registry (Maintains all reports of child abuse and neglect opened for investigation, classified as either Court Substantiated or Agency Substantiated) with the following reason: -Notary needed A record review of NA-A work schedule revealed that NA-A worked the floor on: 3/13/25 3/14/25 3/15/25 3/17/25 3/18/25 3/19/25 An interview on 3/20/25 at 10:13 AM with the Administrator confirmed that NA-A did not have the Nebraska Central Registry check completed. The Administrator confirmed that NA-A should not have been working the floor prior the Nebraska Central Registry being completed and verified

Based on record review and interview, the facility failed to notify/provide the resident/resident's legal representative of the bed hold policy at the time of the transfer to the hospital and failed to provide written documentation of the bed hold policy to the legal representative for one (Resident 16) of 8 sampled residents. The facility's census was 15. Findings are: A closed record review revealed that Resident 16 was admitted to the facility on [DATE]. Resident 16 was admitted to the hospital on [DATE]. A review of the care notes revealed no documentation of a bed-hold policy being given to Resident 16 or Resident 16 family representative at time of transfer. Findings are: A record review of the undated facility's Transfer Process Policy revealed: -Put patient on LOA (Leave of Absence) in electronic health record. -If admitted to hospital, discharge from system unless they are Medicaid, then leave on LOA for bedhold. An interview on 3/18/25 at 2:30 PM with Social Service worker (SW) confirmed that the facility does not offer bed holds. SW confirmed that Resident 16 was not offered a bed hold when sent to the hospital. SW confirmed that a bed hold or written documentation of the bed hold was not given to Resident 16 and or family representatives.

Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review the facility failed to ensure items stored in the facility's refrigerators and freezers were sealed, labeled, and dated, ensure expired items were discarded, ensure kitchen staff performed handwashing for at least 20 seconds, and failed to ensure the temperature of the food was taken after being reheated in the microwave to prevent the potential for foodborne illness, and failed to ensure the thermometer probe was sanitized before use and between food items when the temperature was taken of the prepared food to prevent cross contamination. This had the potential to affect 15 of the 16 residents that consumed food from the kitchen. The total facility census was 16. Findings are: A. A record review of the facility's Food Supply and Storage policy with an origination date of ,d+[DATE] revealed the staff should use approved storage containers for food, cover tightly, and label and date the containers in the refrigerator. Staff should date and rotate food items in the refrigerator, discard by the use by date, and discard unused items within 48 hours. In the freezers, the staff should store food in approved containers with tight fitting lids. label both the bin and the lid, and date and rotate the items. Remove any items from dry storage for which the expiration date had expired. An observation on [DATE] at 8:25 AM of the facility's walk-in refrigerator revealed 1 package labeled Parmesan Cheese in a sealed zip lock style bag was not dated. The walk-in freezer contained 1 clear container with a blue lid with what appeared to be mixed veggies not labeled or dated, several clear cups of oval dark purple items not labeled or dated, and 2 white containers of an unknown substance not covered, labeled, or dated. An observation on [DATE] at 8:25 AM of the facility's reach-in refrigerator revealed the following was not labeled or dated: -1 container with a green lid containing sliced black items was not labeled or dated. -1 container with a green lid containing sliced green items was not labeled or dated. -1 container with a green lid containing white shredded cheeses was not labeled or dated. -1 container with a green lid containing green beans was not labeled or dated. -1 container with a green lid containing broccoli, not labeled or dated. -9 clear plastic containers of lettuce not labeled or dated. -3 croissant sandwiches not labeled or dated. -2 bags opened lettuce not labeled or dated. An observation on [DATE] at 8:25 AM of the facility's dry storage revealed 1 - Nepro Carb Steady Nutrition shake expired [DATE]. In an interview on [DATE] at 8:56 AM, the facility's Food Service Associate (FSA)-B confirmed FSA-B observed all the above concerns in the walk-in refrigerator, walk-in freezer, reach-in refrigerator, and dry storage listed above and confirmed the items were not covered, labeled, dated, or were expired. FSA-A confirmed the items should be covered, labeled, and dated and were not, and the expired Nepro Carb Steady Nutrition shake should have been discarded. FSA-B confirmed that 15 of the 16 facility residents consumed food from the kitchen. In an interview on [DATE] at 1:58 PM, the facility's Nutritional Services Manager (NSM) confirmed all opened items in the facility kitchen's refrigerators and freezers should have been sealed, labeled, and dated, and all expired items should have been discarded. B. A record review of the facility's Food Handling Guidelines with an effective date of ,d+[DATE] revealed staff should minimize hand contact with food using utensils or disposable gloves to prevent food infection. A record review of the facility's Hand Hygiene policy with an effective date of ,d+[DATE] revealed the staff's hands were to be washed before handling food, clean utensils, dishes, equipment, and before putting on gloves. The staff's hands were to be washed after handling shipping containers and removing gloves. Handwashing was to be completed by wetting hands with warm water, apply disinfecting soap lathering up to mid-arm and work lather into hands for 20 seconds before rinsing. In an observation on [DATE] at 7:15 AM revealed FSA-B completed handwashing for 8 seconds, then applied gloves,and then plated food, next removed gloves, and put items on the tray, covered the plate, and placed the tray in the cart. FSA-B then placed food items on a new tray including a plate, went to the walk-in freezer and got a box of frozen hamburger patties, removed gloves, and then got a pair of tongs, and put a hamburger patty on the plate and put the tray in cart without doing handwashing. FSA-B then went and got items from the walk-in refrigerator, and completed handwashing for 12 seconds, then applied gloves, then got a package of ground chicken from the reach-in refrigerator, and got a ladle, with gloved hands, put the chicken in a paper cup, ladled the gravy and mixed with a fork, scooped a portion on the plate, scooped mashed potatoes, added gravy and broccoli, placed plate on tray, got green beans from reach-in refrigerator, re-gloved, then put a scoop of green beans on the plate, and placed the plate on the tray, placed condiments and drinks on tray, and gloved with no handwashing. FSA-B got a scoop of broccoli, a chicken breast, a scoop of rice, a cup of pineapple, covered the plate and put the tray on cart. FSA-B went and got the food cart and took into another room for a different department, and completed handwashing for 10 seconds and then applied gloves. FSA-B then plated food and drink, got pineapple out of the reach-in refrigerator, covered, the plate and put the tray on the cart. FSA-B then put the cold food tray, went to the walk-in refrigerator and got a box, completed handwashing for 12 seconds, then opened the box, grabbed a can of non-stick spray and sprayed a bowl used for hot items, dumped the ground hamburger in, put a lid on the bowl, put the bowl on tray, and put the tray on the cart. FSA-B went to the walk-in refrigerator and got more ground chicken, placed into a paper bowl and mixed with a ladle of gravy, plated, and put the tray in the cart, without performing handwashing. FSA-B then went to walk-in and got something for another department, completed handwashing for 7 seconds, got gloves and placed the gloves on a plate, got a hot item bowl, sprayed the bowl with non-stick spray, dumped a can of soup in, put the hot item bowl on the plate that had gloves on it, covered the plate, and put the tray in the cart. FSA-B then went to the walk-in refrigerator, returned, got a tray off the cart and the food temp log clipboard, took a thermometer, wiped with dry paper towel, temped the omelet, wiped probe with dry paper towel and temped hash brown, wiped the probe with the same dry paper towel, temped the muffin, wiped the probe with a dry paper towel and temped the mandarin oranges, wiped with new dry paper towel and poked into orange juice container, wiped with a dry paper towel, and poked the probe in the container and temped milk all with no handwashing. FSA-B then competed handwashing for 9 seconds, and next grabbed 2 zip lock style bags 1 containing 6 pancakes and 1 containing 3 French toast slices from the top of the food cart, with gloved hand, then reached in the bag and grabbed 1 slice of French toast, opened the bag and grabbed 1 piece of French toast, put on a plate and placed in microwaved for 30 seconds. FSA-B then went to the drawer and grabbed a plastic knife and cut crust off while holding the slice of French toast. FSA-B then went and uncovered a plate in the cart and dumped the French toast onto the plate, covered, and shut the door, then returned to the microwave. FSA-B re-gloved and grabbed another piece of French toast out of the bag with a gloved hand, put on a foam plate, microwaved 30 seconds, took out cut the crust off, open the cart and removed the cover of a plate and dumped slice on the plate, covered, closed door, re-gloved. FSA-B dumped the final piece of French toast on a foam plate, put in microwave for 30 seconds, removed, cut crust off, opened cart door, removed the plate cover and dumped on a plate in the cart, and then covered, and closed the cart door. FSA-B then re-gloved, competed the microwave process and plating with the pancakes 5 times and did not temp after microwaving all without having performed handwashing again. In an interview on [DATE] at 8:19 AM, FSA-B confirmed that handwashing should have been completed for at least 20 seconds and was not. FSA-B confirmed that 15 of the 16 facility residents consumed food from the kitchen. In an interview on [DATE] at 1:58 PM, the facility's NSM confirmed FSA-B Should have performed handwashing for at least 20 seconds. C. A record review of the facility's Food Handling Guidelines with an effective date of ,d+[DATE] revealed foods heated in a microwave must reach an internal temperature of 165 degrees at all parts. The staff should rotate food or stir halfway between the process and let stand covered for 2 minutes after cooking to assure appropriate temperature throughout product. In an interview on [DATE] at 12:22 PM, FSA-B confirmed the temperature of the food that was reheated in the microwave had not been taken and should have been. FSA-B confirmed that 15 of the 16 facility residents consumed food from the kitchen. In an interview on [DATE] at 1:58 PM, the facility's NSM confirmed that any food that was heated in the microwave should have been temped after the microwave process was completed. D. A record review of the facility's Sanitization and Infection Control Program Overview with an effective date of ,d+[DATE] revealed proper sanitization and infection control practices were to be observed in all phases of the food production and service. In an interview on [DATE] at 12:22 PM, FSA-B confirmed FSA-B started the process of temping the food and went from food item to food item without sanitizing the thermometer probe, and the probe should have been sanitized before starting and between each food item the probe was inserted into. FSA-B confirmed that 15 of the 16 facility residents consumed food from the kitchen. In an interview on [DATE] at 9:11 AM, the Director of Nursing confirmed the facility did not have a policy, procedure, or guideline for the food temping process. In an interview on [DATE] at 1:58 PM, the facility's NSM confirmed that the thermometer probe should have been sanitized before it was inserted into any food product and between food items.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to notify the provider of a significant weight loss for 1 (Resident 70) of 2 sampled residents. The facility identified a census of 16. Findings Are: A record review of Resident 70's demographic information printed on 1/30/24 revealed Resident 70 admitted into the facility on [DATE]. The demographic information revealed Resident 70 had diagnoses of: Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus), Congestive Heart Failure (CHF- a serious condition in which the heart doesn't pump blood as efficiently as it should) exacerbation, and Acute on Chronic heart failure and Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels). A record review of Resident 70's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/25/24, revealed the resident's cognitive status was answered as not assessed/no information. The MDS revealed Resident 70 was independent with eating and oral hygiene. The MDS revealed Resident 70 was dependent for toileting, bathing and mobility. A record review of Resident 70's History & Physical dated 1/7/24 revealed the resident is lethargic, does not follow verbal commands, and is not able to give any interaction or follow commands. An observation on 1/29/24 at 9:52 AM revealed Resident 70 had 7 unopened bottles of Glucerna (a nutritional supplement specifically for patients with Diabetes Mellitus) sitting on the bedside table. A record review of Resident 70's Active Orders List printed 1/30/2024 revealed the resident had an order for daily weights due to CHF. A record review of Resident 70's daily weights dated 1/21/24 through 2/1/24 revealed: - 1/21/24 289 pounds (lbs) - 1/22/24 286 lbs - 1/23/24 287 lbs - 1/24/24 284 lbs - 1/25/24 285 lbs - 1/26/24 285 lbs - 1/27/24 285 lbs - 1/28/24 287 lbs - 1/29/24 247 lbs - 1/30/24 250 lbs - 1/31/24 no weight documented - 2/1/24 242 lbs On 1/28/2024, Resident 70 weighed 287 lbs. On 1/29/2024, Resident 70 weighed 247 pounds which is a 40 lb weight loss and -13.94 % loss in 24 hours. On 1/30/2024, Residnet 70 weighed 250 lbs. On 02/01/2024, Resident 70 weighed 242 pounds which is a 8 lb weight loss and -3.20 % loss in 24 hours. An observation on 1/30/24 at 9:30 AM revealed 9 unopened bottles of Glucerna sitting on the treatment cart in Resident 70's room. An interview on 1/30/24 at 2:32 PM with RN (Registered Nurse)-C after review of the daily weights for Resident 70 confirmed that no documentation of a re-weight existed, and no documentation of physician notification of the weight change existed and should have. An interview on 1/30/24 at 2:47 PM with the facility DON (Director of Nursing), after review of the daily weights for Resident 70 confirmed that the weight should have been rechecked to ensure accuracy and the physician should have been notified of the 40 lb weight loss documented between 1/28/24 and 1/30/24. An interview on 1/31/24 at 11:33 AM with UM (Unit Manager)-D revealed Resident 70 had a weight today (1/31/24) which was down another 12 lbs for a total of a 34 lb weight loss in 3 days. An interview on 2/1/24 at 10:15 AM with NA (Nurse Aide)-E revealed the night shift obtained daily weights at 5:00 AM or after every morning except on bath days when the weight would be obtained by the bath aide. The interview revealed that when entering the weight value into the electronic medical record, if the weight results turned red, that indicated that the weight was outside of normal limits for the resident and was to be reported to the nurse. NA-E was unable to confirm if the weights obtained in the last 3 days had been reported to the nurse. A record review of the undated facility policy titled Skills: Weight Measurement contained the following instructions and guidance: Completing the Procedure 6. Investigate significant fluctuations in weight for accuracy and clinical correlation. 8. Report significant changes in weight to the practitioner. 10. Document the procedure in the patient's record.

Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to perform hand hygiene and gloves changes between completing J-tube site cares, medication administration and oral suctioning for Resident 4, and the facility failed to clean or change Resident 3's nebulizer kit and mask to prevent the potential for cross contamination. The facility identified a census of 16. Findings Are: A. A record review of the demographic information revealed Resident 4 had been accepted into the facility on [DATE] with a primary diagnosis of a gunshot wound to the head with complications. A record review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 1/25/24, revealed the resident was in a persistent vegetative state/no discernible consciousness. The MDS revealed Resident 4 was dependent for all cares including toileting, bathing, repositioning, and enteral feedings. An observation on 1/29/24 at 10:17 AM of Resident 4's room revealed a sign posted outside the door indicating Resident 4 was in droplet (for patients known or suspected to be infected with pathogens transmitted by respiratory droplets)/contact isolation (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment). An observation on 1/29/24 at 10:17 AM revealed Resident 4 was connected to an enteral (allowing liquid food to enter your stomach or intestine through a tube) feeding currently, running Jevity (calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition) 1.5 @ 50 milliliter mL per hour (mL/hour). An observation on 1/30/24 at 10:15 AM revealed RN (Registered Nurse)-C had donned (to put on) full PPE (Personal Protective Equipment to include gloves, a gown, a mask, and goggles) and performed Resident 4's J-tube (jejunostomy tube -a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) site cares. RN-C then completed medication administration via J-tube. RN-C did not perform hand hygiene or change gloves between the J-tube site care and medication administration. During the observation RN-C left the room in full PPE at 10:37 AM to obtain a new wrist band without removing or changing PPE prior to re-entering Resident 4's room. RN-C revealed the resident was on isolation due to inactive tuberculosis (a contagious infection that usually attacks the lungs) but also brought something back from [NAME]. During the observation on 1/30/24 at 10:15 AM, RN-C was observed suctioning sputum which had been running down Resident 4's chest and then suctioned Resident 4's mouth without changing the yankaur (a tool is used to suction secretions from the part of the throat at the back of the mouth behind the oral cavity). RN-C did not perform hand hygiene and/or glove changes throughout the observation. Interview on 1/30/2024 at 11:15 AM RN-C revealed infection control training was provided to the facility four times a year. An interview on 1/30/24 at 2:30 PM with the facility DON (Director of Nursing) confirmed that the facility expectation was to perform hand hygiene and glove changes between completing J-tube site cares, medication administration and suctioning procedures. During the interview on 01/30/24 at 2:30 PM, the DON revealed that Resident 4 was currently being treated for an URI (Upper Respiratory Infection) and sputum culture which presented as Acinetobacter (a type of bacteria (germ) commonly found in the environment such as in soil and water and on hospital surfaces). A record review of the undated facility policy titled Skills: Feeding Tube: Medication Administration contained the following: 1. Perform hand hygiene before patient contact. Don appropriate PPE based on the patient's need for isolation precautions or the risk of exposure to bodily fluids. 45641 B. A record review of the facility's Infection Control of Respiratory Care Equipment policy with an origination date 06/2010 revealed all disposable equipment would be changed out weekly or per manufacturer's recommendations. All reusable equipment would be cleaned and sanitized between each individual patient use per the manufacturer's recommendations or current best practice. A record review of facility's My Unit sheet dated 01/30/2024 revealed Resident 3 had an admitted [DATE]. A record review of Resident 3's dated 12/06/2023 revealed Resident 3 had diagnoses of Stroke, Coronary Artery Disease, and Multidrug-Resistant Organism (a bacteria resistant to antibiotics). The resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 12 of 15 which indicates the resident was moderately cognitively impaired. The resident required partial/moderate assistance with oral and personal hygiene (cleaning), dependent on staff for toileting, and needed substantial/maximal assistance with shower/bathing, upper body dressing, and lower body dressing. An observation on 01/29/2024 at 12:19 PM revealed Resident 3 had a nebulizer (a device used to deliver liquid medications to the lungs) kit and mask on the oxygen flowmeter (a device used to adjust the flow of oxygen) with a residual amount of medication in the kit and oily substance and brown debris on the mask. An observation on 01/30/2024 at 12:26 PM revealed Resident 3 had a nebulizer kit and mask on the oxygen flowmeter with a residual amount of medication in the kit and oily substance and brown debris on the mask. An observation on 01/30/2024 at 12:26 PM revealed Resident 3 had a nebulizer kit and mask on the oxygen flowmeter with a residual amount of medication in the kit and oily substance and brown debris on the mask. An observation on 01/30/2024 at 2:40 PM with the Director of Nursing (DON) revealed Resident 3 had a nebulizer kit and mask on the oxygen flowmeter with a residual amount of medication in the kit and oily substance and brown debris on the mask. An observation on 01/31/2024 at 12:25 PM revealed Resident 3 had a nebulizer kit and mask on the oxygen flowmeter with a residual amount of medication in the kit and oily substance and brown debris on the mask. In an interview on 01/30/2024 at 3:44 PM, Licensed Practical Nurse (LPN)-A confirmed the staff was supposed to rinse the nebulizer kit and mask after each treatment with water and that LPN-A does it if LPN-A did the treatment. In an interview on 01/30/2024 at 02:40 PM, the DON confirmed the neb kit and mask had not been cleaned or changed since the last treatment and should have been cleaned after each treatment and changed weekly.

Licensure Reference Number 175NAC 12-007.04D Based on observations, record review, and interview the facility failed to ensure that bathroom exhaust vent fans were operational in 16 of 16 occupied rooms. This affected all facility residents. The facility census was 16. Findings are: Record review of the facility Admission Agreement Resident Rights dated 2016 revealed that the nursing facility must provide a safe, clean, comfortable, and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 3/7/23 at 9:36 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper (indicating that the vent was not operating). A strong odor of bowel movement (BM) was present. Observation on 3/7/23 at 9:38 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 9:40 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 9:42 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. A strong odor of BM was present. Observation on 3/7/23 at 9:44 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 9:48 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 9:52 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 11:15 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 11:25 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 between 9:30 AM and 9:50 AM in rooms 325, 327, 335, 337, 339, 341, and 345 revealed that the bathroom vent fans would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 4:41 PM on the south hall between the Director of Nursing (DON) office and the facility dining room revealed a strong odor of BM throughout the area. Observation on 3/8/23 at 2:11 PM on the south hall between room [ROOM NUMBER] and the facility dining room revealed a strong BM odor throughout that area. Observation on 3/8/23 at 2:45 PM on the south hall between room [ROOM NUMBER] and the facility dining room revealed a strong BM odor throughout the area. Interview on 3/13/23 at 9:43 AM with the facility Plant Operations Maintenance (POM) revealed that a vendor checks the bathroom exhaust fan ventilation system and checks that the belts are operational. The POM revealed that the ventilation system sometimes trips a breaker that needs reset. The POM revealed that a form documenting the checks of the ventilation system and work completed by the vendor is kept on the computer. This surveyor requested that the POM provide the documentation of the ventilation system checks for the past year. Record review of the Facility ONE Work order Management System report (a form documenting the checks and work completed on the ventilation system) dated 3/13/23 revealed that the exhaust fans preventive maintenance was performed on 10/19/22. Interview on 3/13/23 at 10:09 AM with the POM confirmed that the bathroom ventilation in the unit (facility) was not working. The POM revealed that the POM tested the vents in 1 room on each side of the unit and they were not working. The POM revealed that the vendor is to check the ventilation system every 6 months and the facility Preventative Maintenance (PM) person is to check the ventilation system in between so that a check is completed quarterly.

Licensure Reference Number 175NAC 12-006.09C1a Based on record review and interview the facility failed to ensure that the resident /resident representative received a written summary of the preliminary care plan (either the baseline or the comprehensive care plan) (a written initial plan of care required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) as required for 5 residents (Residents 66, 11, 69, 5, and 13) of 5 residents reviewed. This prevented the resident/resident representative from identifying additional areas of care required. The facility census was 16. Findings are: A. Record review of the facility policy titled Comprehensive Care Planning dated 2/2018 revealed that the purpose is to fulfill state and federal regulations for long term care and to focus on the resident's ability to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Record review of the facility Admission Packet Resident Rights dated 2016 revealed that the resident has the right to participate in the development and implementation of his or her person-centered care plan. The resident has the right to participate in the planning process and the right to request revisions to the person-centered plan of care. The resident has the right to see the care plan. Record review of the Admission Order Report dated 3/8/23 for Resident 66 revealed that the resident admitted into the facility on [DATE]. Record review of the nursing notes dated from 8/26/22 through 9/2/22 for Resident 66 revealed that it contained no documentation that a preliminary care plan was reviewed with Resident 66 or the resident representative. The nursing notes contained no documentation that a copy of a preliminary care plan was provided to Resident 66 or the resident representative. Interview on 3/8/23 at 11:48 AM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) revealed that the MDSC initiates a comprehensive care plan as the preliminary care plan for each resident. The MDSC confirmed that a review of the comprehensive care plan with the resident/resident representative within 48 hours of admission is not documented. The MDSC confirmed that there is no documentation that a copy of the comprehensive care plan is provided to the resident/resident representative. B. Record review of the undated Patient Information for Resident 11 revealed that Resident 11 admitted into the facility on [DATE]. Interview on 3/8/23 at 10:55 AM with Resident 11 revealed that the resident could not remember the facility reviewing or providing a preliminary care plan after admission to the facility. Record review of the nursing notes dated from 1/9/23 through 1/13/23 for Resident 11 revealed that it contained no documentation that a preliminary care plan was reviewed with Resident 11 or the resident representative. The nursing notes contained no documentation that a copy of a preliminary care plan was provided to Resident 11 or the resident representative. C. Record review of the undated Patient Information for Resident 69 revealed that Resident 69 admitted into the facility on [DATE]. Interview on 3/7/23 at 11:25 AM with Resident 69 revealed that the resident did not recall the facility providing or reviewing a preliminary care plan with them. Record review of the nursing notes dated from 2/24/23 through 3/4/23 for Resident 69 revealed that it contained no documentation that a preliminary care plan was reviewed with Resident 69 or the resident representative. The nursing notes contained no documentation that a copy of a preliminary care plan was provided to Resident 69 or the resident representative. 46438 D. Review of Resident 13's MDS (Minimum Data Set) dated 2/14/23 revealed that Resident 13 was admitted on [DATE]. Record review of Resident 13's medical record revealed no documentation that a copy of the baseline care plan was provided to the resident or resident representative. E. Review of Resident 5's undated admission information revealed that Resident 5 was admitted on [DATE]. Interview with MDSC (Minimum Data Set Coordinator) revealed Resident 5 has not been in the facility long enough to have had an MDS assessment. Record review of Resident 5's medical record revealed no documentation that a copy of the baseline care plan was provided to the resident or resident representative.

Licensure Reference Number 175NAC 12-006.12B Based on record review and interview, the facility failed to ensure that Gradual Dose Reductions (GDRs) (the periodic physician review of the amount of a [CONDITION(S)] medication that a resident is receiving to consider a decrease in the amount of the medication) were attempted for [CONDITION(S)] medications (any medication that affects behavior, mood, thoughts, or perception) as required for 2 residents (Residents 9 and 6) of 5 residents reviewed. This had the potential to prevent residents from being free from the use of unnecessary medications. The facility census was 17. Findings are: A. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 9 dated 1/29/21 revealed that the resident admitted to the facility on [DATE]. The MDS revealed that Resident 9 had diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities), and [CONDITION(S)] disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function). The MDS revealed that Resident 9 received antipsychotic (a [CONDITION(S)] medication used to manage psychotic disorders) and antidepressant medications all 7 days during the 7 day assessment period. The MDS revealed that no GDR had been attempted. Record review of the undated document titled Prior to Admission Medications for Resident 9 provided by the facility Clinical Coordinator (CC) revealed that the resident had been taking [MEDICATION(S)] 15 milligrams (mg) daily (an antipsychotic medication that works by changing the actions of chemicals in the brain used to treat [CONDITION(S)] disorder), [MEDICATION(S)] 30 mg daily (a [CONDITION(S)] antidepressant medication used to treat depression and anxiety), and [MEDICATION(S)] 100 mg daily at HS (bedtime) (a [CONDITION(S)] medication used to treat depression) since prior to admission into the facility. Record review of the MDS for Resident 9 dated 4/10/21 revealed that Resident 9 did not feel down or depressed and that the resident exhibited no behaviors. The MDS revealed that Resident 9 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 9 received antipsychotic medications on a routine basis and that no GDR had been attempted. Record review of the MDS for Resident 9 dated 6/2/21 revealed that Resident 9 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 9 received antipsychotic medications on a routine basis and that no GDR had been attempted. Record review of the MDS for Resident 9 dated 6/14/21 revealed that Resident 9 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 9 received antipsychotic medications on a routine basis and that no GDR had been attempted. Record review of the MDS for Resident 9 dated 7/27/21 revealed that Resident 9 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 9 received antipsychotic medications on a routine basis and that no GDR had been attempted. Record review of the MDS for Resident 9 dated 10/21/21 revealed that Resident 9 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 9 received antipsychotic medications on a routine basis. The MDS revealed that a GDR had been attempted on 10/13/21. Record review of the monthly medication reviews (a required review of each resident's medications by a licensed pharmacist at least once per month to identify any irregularities. Any irregularities must be reported to the physician or the Director of Nursing to be acted upon) for facility residents from November 2020 through October 2021 revealed no documentation of any GDR attempts for Resident 9's [MEDICATION(S)], [MEDICATION(S)], or Trazadone. Record review of the facility provided Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 9 revealed the section titled Problem: [CONDITION(S)] Drug Use. The documented goal for Resident 9 was that the resident will require the minimum dose of medications. The description revealed that Resident 9 has diagnoses of anxiety, depression, and [CONDITION(S)] disorder. Provide medications as ordered: [MEDICATION(S)] 15 mg daily, [MEDICATION(S)] 30 mg daily, and [MEDICATION(S)] 100 mg at HS. The Resident will require the minimum dose of medications to adequately perform activities of daily living with minimal side effects. Record review of the progress note dated 10/12/21 at 1:34 PM by Registered Nurse-B (RN-B) revealed that Resident 9 voiced concerns about tremors increasing especially in the resident's hands. RN-B discussed medication reduction with the resident and sent a fax to the physician about the resident's concerns. Record review of the fax to the physician of Resident 9 dated 10/12/21 revealed that Resident 9 has complained of increased tremors which could be a side effect of her medication [MEDICATION(S)] 15 mg. The fax asked the physician if the physician felt that the resident would benefit from a dose reduction. The response documented by the physician was that any dose reduction is up to the resident's psychiatrist. The fax did not request consideration of any dose reduction for Resident 9's [MEDICATION(S)] or [MEDICATION(S)]. Record review of the progress note dated 10/21/21 at 9:50 AM by RN-B revealed that Resident 9's physician responded to the fax in regards to a dosage reduction (for [MEDICATION(S)]) and wants it to go through the resident's psychiatrist. A note will be sent to the psychiatrist. The facility will continue with the current plan of treatment. Record review of the progress note dated 11/5/21 at 9:19 AM by RN-B revealed that a call was placed to the psychiatrist office to set up an appointment for Resident 9 regarding the resident's medication and shaking. The office was closed today and a call will be made again on Monday 11/8/21. Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 9 for the dates of 11/6/21 through 11/15/21 revealed that Resident 9 received [MEDICATION(S)] 15 mg daily on all 7 days recorded on the 7 day MAR. The MAR revealed that Resident 9 received [MEDICATION(S)] 30 mg daily on all 7 days recorded on the 7 day MAR. The MAR revealed that Resident 9 received [MEDICATION(S)] 100mg daily at bedtime on all 7 days recorded on the 7 day MAR. Interview on 11/15/21 at 12:14 PM with the Clinical Coordinator (CC) confirmed that the facility does not have a policy for gradual dose reduction (GDR). The CC confirmed that the facility had no documentation of any completed GDR attempts for Resident 9's [CONDITION(S)] medications in the past year. Interview on 11/15/21 at 3:21 PM with the Clinical Coordinator (CC) confirmed that the expectation is for a GDR to be attempted for [CONDITION(S)] medications in 2 separate quarters during the first year a resident is on a [CONDITION(S)] medication. The CC confirmed that a GDR is to be attempted annually after the first year. B. Record review of the MDS for Resident 6 dated 2/10/21 revealed that the resident admitted to the facility on [DATE]. The MDS revealed that Resident 6 had a diagnosis of depression. The MDS revealed that Resident 6 received an antidepressant medication all 7 days during the 7 day assessment period. The MDS revealed that no GDR had been attempted. Record review of the Orders and Progress Record provided by the CC revealed that Resident 9's physician started the resident on the [CONDITION(S)] antidepressant medication [MEDICATION(S)] 10 mg daily for depression on 7/22/20. Record review of the MDS for Resident 6 dated 5/5/21 revealed that Resident 6 felt down or depressed for 2-6 days of the 7 day assessment period. The MDS revealed that Resident 6 exhibited no behaviors. The MDS revealed that Resident 6 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 6 received antipsychotic medication on a routine basis only and that no GDR had been attempted. Record review of the MDS for Resident 6 dated 6/2/21 revealed that Resident 6 did not feel down or depressed. The MDS revealed that Resident 6 exhibited no behaviors. The MDS revealed that Resident 6 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 6 received antipsychotic medication on a routine basis only and that no GDR had been attempted. Record review of the MDS for Resident 6 dated 7/5/21 revealed that Resident 6 did not feel down or depressed. The MDS revealed that Resident 6 exhibited no behaviors. The MDS revealed that Resident 6 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 6 received antipsychotic medication on a routine basis only and that no GDR had been attempted. Record review of the MDS for Resident 6 dated 7/17/21 revealed that Resident 6 did not feel down or depressed. The MDS revealed that Resident 6 exhibited no behaviors. The MDS revealed that Resident 6 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 6 received antipsychotic medication on a routine basis only and that no GDR had been attempted. Record review of the MDS for Resident 6 dated 10/13/21 revealed that Resident 6 did not feel down or depressed. The MDS revealed that Resident 6 exhibited no behaviors. The MDS revealed that Resident 6 received an antidepressant medication all 7 days of the 7 day assessment period. The MDS revealed that Resident 6 received antipsychotic medication on a routine basis only and that no GDR had been attempted. Record review of the monthly medication reviews (a required review of each resident's medications by a licensed pharmacist at least once per month to identify any irregularities. Any irregularities must be reported to the physician or the Director of Nursing to be acted upon) for facility residents from November 2020 through October 2021 revealed no documentation of any GDR attempts for Resident 6's [MEDICATION(S)]. Record review of the facility provided Care Plan for Resident 6 revealed the section titled Problem: [CONDITION(S)] Drug Use. The documented goal for Resident 6 was that the resident will require the minimum dose of medications. The description revealed that Resident 6 has a diagnosis of depression. Resident 6 takes routine [MEDICATION(S)] 10 mg daily. The Resident will require the minimum dose of medications to adequately perform activities of daily living with minimal side effects. Record review of the MAR for Resident 6 for the dates of 11/6/21 through 11/9/21 revealed that Resident 6 received [MEDICATION(S)] 10 mg daily on all 4 days recorded on the 4 day MAR. Record review of the MAR for Resident 6 for the dates of 11/12/21 through 11/15/21 revealed that Resident 6 received [MEDICATION(S)] 10 mg all 4 days recorded on the 4 day MAR. Interview on 11/10/21 at 1:33 PM with RN-B confirmed that Resident 6 had one leg amputated and later had the second leg amputated. RN-B revealed that therapy felt the resident was unmotivated to do therapy because of depression. RN-B confirmed that a gradual dose reduction had not been attempted for Resident 6. Interview on 11/15/21 at 12:14 PM with the Clinical Coordinator (CC) confirmed that the facility does not have a policy for gradual dose reduction (GDR). The CC confirmed that the facility had no documentation of completed GDR attempts for Resident 6's [CONDITION(S)] medication in the past year. Interview on 11/15/21 at 3:21 PM with the Clinical Coordinator (CC) confirmed that the expectation is for a GDR to be attempted for [CONDITION(S)] medications in 2 separate quarters during the first year a resident is on a [CONDITION(S)] medication. The CC confirmed that a GDR is to be attempted annually after the first year.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to maintain a urinary catheter drainage system to prevent the potential for cross contamination by storing a catheter bag on the garbage can and the floor which affected 1 of 1 residents with urinary catheters, Resident 117; and the facility failed to ensure that staff performed hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) during wound care to prevent the potential for cross contamination for 1 resident (Resident 6) of 2 residents observed for wound care. The facility identified a census of 17 at the time of survey. Findings are: A. Review of Resident 117's Admission Record dated 11/9/2021 revealed an admitted [DATE]. Review of Resident 117's Admission MDS revealed it was in progress. Review of Resident 117's Active Orders dated 11/9/2021 revealed the following: continue indwelling urinary catheter (a tube inserted into and left in the bladder to drain urine); catheter change every month on the 19th. Urinary catheter care 2 times daily. Interview with Resident 117 on 11/08/21 at 10:41 AM revealed they had an indwelling urinary catheter. Observation of Resident 117 at this time revealed the urinary catheter drainage collection bag was connected to the drainage tube that was connected to the indwelling catheter inserted into Resident 117's bladder. The urinary catheter drainage bag was uncovered and was hanging on the trash can; the drainage bag was touching the trash can and there was garbage visible in the trash can. Observation of Resident 117 on 11/09/21 at 4:44 PM revealed Resident 117 was resting in their recliner in their room. Resident 117's urinary catheter drainage bag was hanging on the garbage can that had visible garbage in it. The bottom part of the bag was touching the trash can. Observation of Resident 117 on 11/09/21 at 6:33 PM revealed Resident 117 was resting in their recliner in their room. Resident 117's urinary catheter drainage bag was hanging on the garbage can with garbage visible in the can. The drainage bag was touching the trash can. Observation of Resident 117 on 11/10/21 at 8:03 AM revealed Resident 117 was sitting in their recliner in their room. Resident 117's urinary catheter drainage bag was hanging on the trash can and was touching the trash can and the floor. There was garbage visible in the garbage can. Interview with the Clinical Coordinator (CC) on 11/15/21 at 12:29 PM revealed the urinary catheter drainage bags were to be stored below the level of the bladder either on the bed frame or on the back of the recliner; there was a place to hang them. The CC revealed the staff should not hang the catheter bags on the garbage can and they were to be kept off the floor. Review of the facility policy Urinary Catheter: Indwelling (Foley) Catheter Care dated 11/15/2021 revealed the following: Secure the catheter bag and tubing below the level of the bladder. There was no documentation of the procedure for the storage of catheter bags. B. Record review of the History and Physical (H&P) for Resident 6 from the resident's physician dated 7/6/21 revealed that Resident 6 had a below the knee amputation of the right leg on 7/15/20. The H&P revealed that Resident 6 has a large wound with necrotic (dead or dying) tissue that is not improving in wound care. Record review of the Wound Specialist Consultation note for Resident 6 dated 11/2/21 revealed that Resident 6 did have the right lower extremity (leg) amputated below the knee. The wound specialist has been seeing the resident for the nonhealing surgical incision. Both wounds continue to be full-thickness (extending through all layers of the skin) down to and past the subcutaneous tissue. Record review of the undated facility procedure titled Skills Dressing: Dry and Moist to Dry (wound dressing change) revealed the steps for changing a dressing on a wound: Step 1. Perform hand hygiene before patient contact. Step 11. Prepare the supplies on a clean or sterile field. Step 16. Perform hand hygiene and don (put on) gloves. Step 21. Remove the primary dressing that is contact with the wound bed. Step 22. Fold the dressing with the drainage contained inside, discard it in a waterproof bag, and remove the gloves inside out. Step 23. Perform hand hygiene and don clean gloves. Step 26. Cleanse the wound. Step 28. Remove gloves and perform hand hygiene. Don clean gloves. Step 29. Apply the dressing Step 31. Label the dressing per the organization's practice. Step 35. Discard supplies, remove PPE, and perform hand hygiene. Step 36. Document the procedure in the patient's record. Record review of the undated facility procedure titled Skills Hand Hygiene revealed the steps to perform hand washing with soap and water: Step 1. Stand in front of a sink. Step 2. Turn on the water. Step 3. Avoid splashing water on the uniform. Step 4. Regulate the temperature to ensure that the water is warm. Step 5. Wet the hands and wrists thoroughly under the running water. Step 6. Apply the soap to the hands. Step 7. Lather thoroughly. Step 8. Apply friction and perform hand washing for at least 20 seconds. Step 10. Rinse the hands and wrists thoroughly. Step 11. Dry the hands thoroughly. Observation on 11/10/21 at 11:44 AM in the room of Resident 6 revealed that Licensed Practical Nurse-A (LPN-A) performed hand hygiene with ABHR and then entered Resident 6's room. Resident 6 was seated in the chair in the room with a laptop computer on the over bed table in front of the resident. LPN-A put on disposable gloves and arranged supplies on the top of the cart in the room. LPN-A removed the soiled dressing from the resident's right leg stump revealing 2 separate wounds. LPN-A removed the gloves and disposed of them. LPN-A did not perform hand hygiene. LPN-A put on a new pair of gloves. LPN-A placed a soaker pad underneath the resident's right leg stump. LPN-A opened a container of normal saline water and sprayed the water into the open wounds to rinse the wounds. LPN-A removed a swab from a package and placed the swab into the wound closest to the middle of the stump to measure the depth of the wound. LPN-A placed the swab tip into the wound furthest from the middle of the stump to measure the depth. LPN-A removed the gloves and discarded them. LPN-A went to the sink in the resident's room and wet the hands and applied soap. LPN-A scrubbed the hands underneath running water for 8 seconds and then dried the hands. LPN-A put on new gloves. LPN-A removed a strip of Aqua Cell Ag (antimicrobial dressing material) and placed it into the wound closest to the middle of the stump. LPN-A removed another strip of Aqua Cell Ag and placed it into the wound furthest from the middle of the stump. LPN-A removed a swab stick from the package and used the swab stick to push the Aqua Cell Ag into the depth of the wound furthest from the middle of the stump. LPN-A opened a dressing and used a sharpie marker to document the date and the LPN's initials on the dressing. LPN-A applied the dressing to cover the two open wounds on the resident's right leg stump. LPN-A removed the gloves and discarded them. LPN-A went to the sink in the resident's room and applied soap to the dry left hand and then placed both hands under running water and scrubbed the hands for 5 seconds. LPN-A applied additional soap to the left hand and scrubbed the hands for 3 seconds. LPN-A rinsed and dried the hands. LPN-A exited the resident's room. Interview on 11/15/21 at 12:14 PM with the facility Clinical Coordinator (CC) confirmed that staff are expected to perform hand hygiene before putting on gloves and after taking gloves off. The CC confirmed that during hand washing with soap and water the staff are expected to scrub the hands with soap for 20 seconds before rinsing and drying the hands.

Based on observation, interview and record review, the facility failed to protect all residents in the facility by not following acceptable infection control practice recommendations for COVID-19 from the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid (CMS) Services. The facility failed to have a screening system in place to ensure all staff and visitors were screened for signs and symptoms of COVID-19 prior to having contact and providing care to the residents. The facility failed to initiate a COVID-19 screening on a federal surveyor, allowing the federal surveyor access to resident care areas, allowed staff to enter the facility and pass multiple resident rooms prior to being screening for signs and symptoms of COVID-19 and obtaining a mask at the nurses station. The facility failed to follow up on employee documented signs and symptoms of COVID-19 and allowed them to work and provide care to the residents. The facility failed to ensure an employee was screened for signs and symptoms of COVI-19 on 4/13 and 4/14/20, and allowed the employee to work and provide care to the residents. This employee exhibited signs and symptoms of COVID-19 on 4/18/20, which included fever and cough, and tested positive for COVID-19 on 4/21/20. This deficient practice placed all 18 residents at risk for contracting COVID-19 and resulted in Immediate Jeopardy. As a result of the identified non-compliance, the Administrator was notified on 6/18/20 at 5:20pm of the Immediate Jeopardy (IJ). Findings include: During an interview on 6/18/20 at 11:40am, the Director of Nursing (DON) stated the facility began screening all staff for signs and symptoms of COVID-19 on 4/6/20. Review of CMS, Center for Clinical Standards and Quality, Safety and Oversight (QSO) Memo 20-14-NH, dated 3/13/20, provided guidance to long term care facilities which included screening all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough and sore throat. If ill, have them self-isolate at home. Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 3/13/20, showed the following: -Screen all healthcare professionals (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. If they are ill, have them keep their facemask on and leave the workplace. -Fever is either measured temperature >100.0 degrees Fahrenheit or subjective fever. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath and sore throat. Review of the COVID-19 screening log book provided by the DON on 6/18/20, showed the facility failed to actively screen staff and visitors for signs and symptoms of COVID-19 from March 13 through April 5, 2020. On 6/18/20 at 8:30am, a federal surveyor entered the building on the first floor and approached a person sitting behind a table. The person identified that the skilled nursing facility was located on the third floor. The surveyor was then directed to the elevator. Once off the elevator, a stand up sign was observed, which stated Stop No Visitation. The federal surveyor observed a hallway to the left and to the right. An employee asked if the surveyor had been helped and the surveyor who she was and why she was there. Approximately two minutes later, Practical Nurse (PN)2 approached the surveyor. PN2 proceeded to allow the surveyor to ambulate down the hall past resident rooms but the surveyor stopped and let the PN2 know a screening for signs and symptoms of COVID-19 screened had not been conducted and requested a screening prior to entering any resident care areas. PN2 asked the surveyor if there was anyone at the table downstairs and surveyor stated yes, but no screening was offered. PN2 proceeded to assess the surveyor's temperature and asked about a sore throat and any travel outside of the country. During an interview on 6/18/20 at 9:30am, the DON stated the screening person at the table on the first floor should have called up to the skilled nursing unit on the 3rd floor and let someone know that someone was coming to the unit. She stated someone would have been standing by the elevator to conduct a screening for signs and symptoms of COVID-19. During an interview on 6/18/20 at 9:30 am, DON stated that staff had been instructed to conduct screenings for COVID-19 on themselves at the nurse's station prior to providing care to the residents. She stated staff entered the unit from the front stairs and elevator and the back stairs and elevator. She stated the front elevator and stairs were only used at certain times by staff due to it being used as a public elevator for people from the community going to the fourth floor to see physicians. During a tour of the facility on 6/18/20 at 9:45am, the DON identified the back elevator at the end of a hallway. She stated that once staff exited the back stairwell or elevator onto the third floor, they would continue down the hallway passing by resident rooms 335, 337, 339, 341, 343, 345 and 347 prior to entering the nurse's station to screen themselves for signs and symptoms of COVID-19 and obtain a mask. During an interview on 6/18/20 at 10:24am, housekeeper (HK)1 stated she typically worked in the Intensive Care Unit (ICU) at the hospital but sometimes worked at the skilled nursing facility. She stated when she came to work at the skilled nursing unit she had stopped at the screening table on the first floor but was told they only screened people who were going to the family practice offices located on the fourth floor of the building. She stated she came up the back elevator and went to the nurse's station and took her temperature and completed the screening form. During an interview on 6/18/20 at 10:34am, Physical Therapist (PT)1 stated she comes up the back stairs and goes to the nurse's station and checks her temperature. She stated that she did not complete the screening form to assess for signs and symptoms of COVID-19 but would only take her temperature. Review of the employee screening log dated 6/18/20 showed no documentation of PT1 being screened for signs and symptoms of COVID-19 prior to providing care to the residents. During an interview on 6/18/20 at 10:39am, Nurse Aide (NA)1 stated that she goes to the nurse's station and takes her temperature and completes the COVID-19 screening form when she comes to work. Review of the employee screening log dated 6/18/20 showed no documentation of NA1 being screening for signs and symptoms of COVID-19 prior to providing care to the residents. During an interview on 6/18/20 at 10:44am, NA7 stated she normally worked on the Medical Surgical floor of the hospital but did work in the skilled nursing facility a few times a month. She stated she did care for COVID-19 positive patients at the hospital about a month ago. She stated when she came to work on 6/18/20 she was screened by the screener on the first floor and given a mask to wear. During an interview on 6/18/20 at 2:01pm, the screener on the first floor identified she screens individuals who are going to see physicians on the fourth floor and had not screened any employees working in the skilled nursing unit on this day. During an interview on 6/18/20 at 10:55am, NA2 stated she screens herself at the nurse's station. She stated she checks her temperature and completes the screening form. During an interview on 6/18/20 at 11:03am, NA3 stated when she comes to work she goes to the nurses station and screens herself by taking her temperature and completing the screening form. She stated she also works at the hospital. She stated she had provided care to COVID-19 positive patients on the Medical Surgical floor at the hospital on [DATE]. Review of the employee screening log dated 6/18/20 showed no documentation of NA3 being screened for signs and symptoms of COVID-19 prior to providing care to the residents. During an interview on 6/18/20 at 11:40am, the DON stated some of the employees were part of a resource pool and worked at the hospital and the skilled nursing facility. She stated these employees were not supposed to care for COVID-19 positive patients at the hospital and then care for residents in the skilled nursing facility. She was not aware of any staff who have provided care to COVID-19 positive patients at the hospital and then provided care to residents of the skilled nursing facility. Review of the employee COVID-19 screening form on 6/18/20 showed staff were to write their name, circle yes or no if they had shortness of breath, new onset of cough or change in cough, or sore throat and if they had a temperature greater than 99.9 degrees Fahrenheit. Review of an employee screening form dated 4/11 and 4/13/20, showed LPN1 documented having a sore throat. Review of LPN1's time clock records revealed she worked 13 hours and 30 minutes on 4/11/20 and 12 hours on 4/13/20. Review of an employee screening form dated 4/12 and 4/26/20, showed NA5, and documented having a sore throat. Review of NA5's employee time clock records revealed she worked 6 hours and 45 minutes on 4/12/20 and 7 hours and 45 minutes on 4/26/20. Review of an employee screening form dated 4/14/20, showed RN1, documented having occasional cough. Review of RN1's employee time clock records revealed she worked 12 hours and 15 minutes on 4/14/20. Review of NA3's employee screening form dated 4/6-4/7/20 revealed no documentation of a temperature being assessed. Review of employee screening forms dated 5/24, 5/26, 6/1, 6/2, and 6/3/20, showed Activity Director (AD)1 circled yes on the forms indicating she had shortness of breath, new onset of cough or change in cough, or sore throat. Review of AD1's employee time clock records showed she worked 8 hours and 45 minutes on 5/24, 8 hours on 5/26, 8 hours on 6/1, 8 hours on 6/2 and 8 hours and 15 minutes on 6/3/20. During an interview on 6/18/20 at 11:40am, the DON stated it was the employee's responsibility to conduct screenings on themselves at the nurse's station for signs and symptoms of COVID-19 prior to providing care to the residents. When staff identified symptoms of COVID-19 on their screening form, they had been instructed not to work and to contact the employee health nurse. The employee health nurse would then make a decision on how to proceed. She stated that she and the employee health nurse were responsible to ensure all screenings for signs and symptoms of COVID-19 were completed on all staff prior to providing care to the residents. During an interview on 6/18/20 at 1:18pm, the Employee Health Nurse stated employees were supposed to call her if they documented any signs or symptoms of COVID-19 on the employee screening form. She said occasionally she would find out through a manager that an employee was ill so she would get their number and call them. She stated employees were told not to work if they documented any signs or symptoms of COVID-19 on the screening form. During an interview on 6/18/20 at 1:18pm, the Employee Health Nurse provided a tracking document that she utilized when she was notified of employees with signs and symptoms of COVID-19. The document identified the date the illness started, symptoms, tested for COVID-19, results of test, self-monitoring, self-isolating and a return to work date for employee's who reported signs and symptoms of COVID-19 when completing their screening form. Review of the tracking document provided by the Employee Health Nurse showed no documentation of LPN1, NA5, RN1, NA3, and AD1 signs and symptoms of COVID-19 being reported to the employee Health Nurse. Review of the tracking document provided by the employee health nurse showed NA6 reported symptoms of cough and fever on 4/18/20, and tested positive for COVID-19 on 4/21/20. Review of NA6 time clock records showed she worked in the skilled nursing facility for 12 hours on 4/13/20 and 12 hours on 4/14/20 and provided care to the residents. Review of the employee screening form dated 4/13 and 4/14/20 showed no documentation of NA6 being screened for signs and symptoms of COVID-19 prior to providing care to the residents. During an interview on 6/18/20 at 1:48pm, the DON stated she was not aware that NA6 had reported signs and symptoms of COVID-19 on 4/18/20 and tested positive for COVID-19 on 4/21/20. During an interview on 6/18/20 at 12:47pm, the Infection Control Nurse stated staff were supposed to be monitoring themselves for signs and symptoms of COVID-19 prior to coming to work and she felt that they were [MEDICATION NAME] social distancing when ambulating to the nurses station and passing multiple resident rooms prior to screening themselves for signs and symptoms of COVID-19. She stated it would not be appropriate for staff who were exhibiting signs and symptoms of COVID-19 to be in close contact of resident rooms. She stated if any staff had any signs or symptoms of COVID-19, they should not be coming to work. The facility submitted an acceptable plan and the IJ was removed and deficient practice corrected on 6/19/20 after verification of implementation of the removal plan.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.07 Based on record review and interview, the facility's Quality Assurance Committee (QA) failed to develop and implement plans of actions to correct issues of deficient practice relevant to resident care and services and the facility failed to implement effective plans of action to maintain correction for 4 previously cited areas of deficient practice identified (F638, F655, F812, and F8[AGE]). This had the potential to affect all residents that reside in the facility. The facility census was 16 at the time of the survey. Findings are: Record review of the Statement of Deficiencies for the annual survey completed on 9/27/2018 revealed repeat citations at F638 Quarterly Assessments, F655 Baseline Care Plan, F812 Food Procurement/store/prepare/serve-Sanitary, and F8[AGE] Infection prevention & Control. The facility was found to be deficient in the area of Federal regulatory compliance after the tasks of the annual standard survey were completed 01/06/2020. The facility failed to maintain corrections for the regulation identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings. -F550 Resident Rights/Exercise of Rights-Dignity -F5[AGE] Safe/Clean/Comfortable/Homelike Environment -F636 Comprehensive Assessments & Timing -F640 Encoding/Transmitting Resident Assessment -F641 Accuracy of Assessments -F657 Care Plan Timing and Revision -F658 Services Provided Meet Professional Standards -F[AGE]6 Drug Regimen Review -F[AGE]8 Free from Unnecessary [MEDICAL CONDITION] Meds/PRN use -F[AGE]7 QA Interview on 1/06/2020 at 4:11 PM with RN-B ( Clinical Manager/QA Coordinator) revealed the QA committee meets at least quarterly and more often if needed. Also currently working on falls, Urinary Tract Infections's, Pressure ulcers, [MEDICAL CONDITION] ([MEDICAL CONDITIONS] results from disruption of normal healthy bacteria in the colon, often from antibiotics) infections and CAUTI's (Catheter Associate Urinary Tract Infections). There was a unit based council that will monitor and identify issues and report back to the committee.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.17A Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during resident dining, failed to wear a mask per facility policy to prevent the potential spread of infection to the facility residents, and failed to perform hand hygiene, change gloves, and perform wound care to prevent potential cross contamination for Resident 14 and Resident 9. This had the potential to affect all of the facility residents. The facility identified a census of 16 at the time of survey. Findings are: A. Observation of the facility dining room on 12/31/19 at 12:13 PM revealed NA-C (Nurse Aide) did a 2 second hand scrub with hand sanitizer and got a tray out of the food cart and gave it to Resident 7. NA-C then then put on gloves and set up Resident 7's tray of food by handling the plate, glasses, and silverware. NA-C had the same gloves on and took Resident 12 a tray of food. NA-C then took a phone from another staff member and put it into their pocket. NA-C then continued to set up Resident 12's tray of food without changing gloves. NA-C then took the gloves off, performed a 3 second hand scrub with hand sanitizer then took food to Resident 216 and set up their tray of food. NA-C then did a 2 second hand scrub with hand sanitizer, put gloves on and set up Resident 216's tray of food. Resident 7, Resident 12, and Resident 216 were all observed feeding themselves and handling the items NA-C had handled. Observation of the facility dining room on 12/31/19 at 12:18 PM revealed NA-E did a 1 1/2 second hand scrub with hand sanitizer and opened the thermal cart and took a tray out and took it to Resident 217. NA-E removed the cover from Resident 217's food, drinks and touched the glass, the containers of food and a cookie that was wrapped in plastic wrap. Resident 217 then proceeded to touch the items with their hands that NA-E had handled. Observation of NA-E passing room trays on 12/31/19 at 12:21 PM revealed the following: NA-E performed a 3 second hand scrub with hand sanitizer then took Resident 9 a tray of food and handled the items on the tray by removing the food cover, plate, and glasses to remove the plastic wrap covering them. NA-E then did a 3 second hand scrub and took a tray to Resident 218 who was in contact isolation. NA-E donned gown, gloves, and mask and took the tray in to Resident 218. NA-E then washed their hands for 5 seconds after removing the gown and gloves. NA-E then left the room and went to the dining room galley and got 2 cans of soda out of the cupboard and then opened the refrigerator in the galley. On 12/31/19 at 12:28 PM NA-E then took a Styrofoam cup and a can of soda to Resident 9. NA-E then went and got an ice bag out of the staff room and took it to resident 9, opened the can of soda and poured ice into a glass out of the bag it was in and poured the soda into the Styrofoam cup. Resident 9 then drank out of the cup. Interview with RN-B (Registered Nurse) on 12/31/19 at 12:48 PM revealed Resident 218 was in contact isolation as a precaution as they were waiting for a report to determine if Resident 218 had [DIAGNOSES REDACTED]icile ([MEDICAL CONDITION] (klos-TRID-e-um dif-uh-SEEL), also known as Clostridioides difficile and often referred to as [DIAGNOSES REDACTED]icile or [DIAGNOSES REDACTED], is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from [DIAGNOSES REDACTED]icile most commonly affects older adults in hospitals or in long-term care facilities and typically occurs after use of antibiotic medications). At 1:02 PM, RN-B reported they were able to lift the contact isolation for Resident 218. Review of the undated Mandatory Education Log revealed the following: Infection control policy outlined and reviewed. This is to include types of isolation and PPE related to each type. Proper signage directions related to isolation. Accurate donning and doffing of PPE (Personal Protective Equipment) including sequencing of procedure, use of hand sanitizer prior to gloving, and hand washing guidelines. Clinical skills video in Mosby education module to be viewed regarding proper PPE and application. Hand hygiene audit forms are introduced and explained for compliance and monitoring process. Outline disciplinary action for failure to follow proper infection control guidelines. Review of the facility policy Hand Hygiene dated 11/2012 revealed the following: In the Food and Nutrition Department, all employees associated with the handling of food will wash hands. Hands are to be washed with soap and water at the following times: before handling food or clean utensils/dishes/equipment, putting on gloves; between handling raw and cooked foods; after touching hair, skin, beard, or clothing; handling soiled silverware; removing gloves; any other activity that may contaminate the hands. While on the nursing units, alcohol-based hand sanitizer/gel is used to decontaminate hands when there is no visible soiling of the hands (food or other materials). Procedure: Wet hands with warm water, and apply disinfectant soap, lathering up to mid-arm. Work lather into hands for 20 seconds, including areas under fingernails, between fingers, and on the inside and outside of hands. Rinse thoroughly under warm running water, allowing the water to flow from the arm, down to the fingertips. Review of the undated facility policy Hand Hygiene revealed the following: Hand hygiene is not optional. Hand Antisepsis Using and Instant Alcohol Waterless Antiseptic Rub: Dispense the recommended amount of product per the manufacturer's instructions for use into the palm of one hand. Rub the hands together, covering all surfaces of the hands and fingers with antiseptic rub. Rube the hands together until the alcohol is dray. Allow the hands to completely dry before donning gloves. Perform hand hygiene with an instant alcohol waterless antiseptic rub, from start to dry, for 20 to 30 seconds. Do not use an alcohol waterless antiseptic rub for hand hygiene when spore-producing pathogens are suspected or confirmed. Interview with RN-B on 01/06/20 at 12:54 PM revealed if staff were going between residents or handling food or touched that food it would be considered contaminated gloves before they go to the next resident so hand hygiene was expected. The expectation for hand sanitizer is to scrub for 20-30 seconds. We always tell the staff to say the pledge of [MEDICATION NAME] when they wash their hands; The whole process should take at least 1 or 2 minutes by the time they go through the washing, scrubbing nails, rinsing and drying. B. Interview with Resident 14 on 12/31/19 at 11:25 AM revealed they had a sore on their bottom the facility staff were treating. Observation of RN-F on 01/02/20 at 2:09 PM revealed RN-F assisted Resident 14 to stand and get into bed. Resident 14 was wearing a non-skid sock on the right foot and an orthotic boot on the left foot. RN-F removed the boot from Resident 14's left foot. RN-F then donned gloves and lifted up Resident 14's left leg. There was a dark black area on the back of Resident 14's left heel about the size of a quarter. RN-F then put a pillow under Resident 14's left leg to prop up their foot. RN-F then opened the room door with the same gloved hands and went out of the room and brought back in some washcloths and [MEDICATION NAME] swabs. RN-F laid the washcloths on the arm of Resident 14's wheelchair which was parked in front of the sink and put the [MEDICATION NAME] swabs on the bedding at the foot of the bed. RN-F turned the faucet on and wet some washcloths and put soap on one of the wash cloths from the soap dispenser by the sink. RN-F then turned the faucet off by the handle with the same gloved hands. RN-F then handled Resident 14's heel and washed the heel with one of the washcloths. RN-F then put the washcloth into the sink. RN-F then dried the area on the heel with another washcloth; opened one of the [MEDICATION NAME] swabs and washed the area from the outside to the inside toward the center of the wound. RN-F then removed the right glove and put another one on and did not change the left glove or perform any hand hygiene before putting their hand into the box of gloves and using the left gloved hand to put the new right glove on. RN-F then picked up an [MEDICAL CONDITION] wear and put it on Resident 14's left leg handling and touching their foot and leg. RN-F then put the boot back on to Resident 14's left lower leg and foot; RN-F touched the boot which Resident 14 had stood on to transfer into bed with the gloved hands. RN-F then put an [MEDICAL CONDITION] wear and the same non-skid sock onto Resident 14's right leg/foot which was soiled from standing on it to transfer. At 2:21 PM RN-F said they were now going to do wound care on Resident 14's bottom as they had an open area on their bottom. RN-F was still wearing the same gloves. RN-F picked up a stethoscope that was laying on Resident 14's love seat and put it around RN-F's neck. RN-F then helped Resident 14 roll to their right side in bed. RN-F lowered Resident 14's pants then covered Resident 14 with a blanket as there was a knock at the door. RN-F had asked them to wait while they covered Resident 14 with a blanket. RN-F then said come in and no one came in so RN-F went to the door and opened it with the same gloved hands. No one was there so RN-F closed the door and went to the sink. RN-F took the dirty washcloth out of the sink and laid it on the edge of the sink. RN-F touched the faucet with the same gloved hands and turned the water on. RN-F then touched the open area on Resident 14's left buttock while RN-F examined it. The area was open on the left buttock. RN-F then went to the sink and wet a washcloth by handling the faucet and put soap on it from the dispenser by the sink. RN-F washed the wound with the washcloth from outside to inside toward the wound and up and down over the wound. RN-F then washed an area on Resident 14's tailbone with the same washcloth. RN-F then put that washcloth onto the edge of the sink; RN-F then grabbed the last washcloth from the arm of Resident 14's wheelchair and dried the wound areas with it. RN-F was still wearing the same pair of gloves. RN-F then picked up a tube of ointment from Resident 14's bed and put ointment on the open area on Resident 14's buttock using the same gloved hands then put ointment on Resident 14's tailbone. At 2:30 PM RN-F pulled up Resident 14's brief and pants; RN-F still had the gloves on. RN-F touched Resident 14's belly and shirt then grabbed Resident 14's right hand with the same gloved hands. RN-F then put the gloved hands on Resident 14's back and helped them sit up. RN- F picked up a gait belt and put it around Resident 14's waist and helped them stand and get into the wheelchair. RN-F put the foot pedal for Resident 14's left leg on the wheelchair. At 2:36 PM RN-F removed the gloves and handled Resident 14's water pitcher and gave Resident 14 a Styrofoam cup which Resident 14 started to drink from. RN-F picked up the other [MEDICATION NAME] swab off the bed they had not used and put it in their pocket. RN-F then went to the computer in Resident 14's room and touched the mouse and the keyboard and charted. RN-F did not do any hand hygiene after they had removed the gloves. Interview with the DON (Director of Nursing) on 1/02/20 at 3:00 PM revealed gloves were to be changed when they are soiled and hand hygiene should be done after gloves are removed. Wound care was to be completed from the center of the wound moving outward. Review of the undated facility policy Skills Pressure Injury: Treatment revealed the following: Gather the necessary equipment and supplies. Perform hand hygiene and don gloves. Cleanse the pressure injury and surrounding skin with a 0.9% [MED] chloride solution or wound cleanser. Apply skin barrier/protectant to peri-wound skin, as needed, or apply prescribed medication ointment to the wound using cotton-tipped applicators or gauze. Measure the pressure injury dimensions. Discard supplies, remove PPE, and perform hand hygiene. Document the procedure in the patient's record. C. Observation on 12/31/19 at 11:57 AM revealed NA-C (Nurse Aide) washing NA-C's hands for 45 seconds using soap and water. NA-C then took a glass of water to Resident 14 and touched the middle of the glass . NA-C then used hand sanitizer for 2 seconds quickly touching the bottom and top of both hands. NA-C then applied a pair of blue gloves and entered the kitchenette to make a root beer float for Resident 14. NA-C touched the door handle of the refrigerator with the gloved hands which contaminated them. NA-C then took a can of root beer from the refrigerator and touching the handle of the freezer (further contaminating NA-C's hands) removed the ice cream. On the way from the kitchenette NA-C grabbed a Styrofoam cup. NA-C obtained a plastic spoon and began placing the ice cream into the Styrofoam cup. There was ice cream dripping down the outside of the ice cream container and NA-C used NA-C's contaminated gloved finger to wipe off the ice cream and placed the ice cream covered finger inside the Styrofoam cup. NA-C then scrapped the ice cream from the finger by drawing it along the inside of the cup. NA-C also used the spoon for stirring the ice cream mixture to scrape ice cream off the side of the container. NA-C removed the gloves and reapplied new gloves without doing hand hygiene. NA-C then added root beer to the ice cream in the cup. NA-C then opened a straw and used the outside of the glove, which had touched the can of root beer, into the cup. NA-C touched the drinking end of the straw and handed the cup to Resident 14. NA-C had washed NA-C's hand one time during the meal service and used hand sanitizer the rest of the meal time. Interview on 12/31/19 at 1:09 PM with RN-B (Clinical Manager) revealed NA-C was the Activity Coordinator and a NA and had received all of the competency checks from hand hygiene to peri care. Also staff are to wash hands between changing gloves or use hand sanitizer. The hand sanitizer was to cover all areas of the hands, between the fingers and under the nails. The hand sanitizer was too dry before touching anything. D. Observation on 1/02/20 at 3:19 PM of NA-D (Nurse Aide) revealed NA-D sitting in dining room documenting on the computer with the isolation mask NA-D had on under her nose and not over the nose. There were residents seated slight to the right and behind NA-D. Interview on 1/02/20 at 3:41 PM with NA-D revealed NA-D was wearing the mask was because NA-D opted to not receive the influenza vaccine and NA-D was wearing the mask due to it being the peak flu season and it protects the residents. Interview on 1/02/20 at 3:30 PM with the DON (Director of Nursing) revealed that staff who do not receive influenza vaccine were to wear a mask until the flu season was over. This was per facility policy. Review of the infection control and prevention policy revealed a comprehensive Influenza and Pneumococcal Vaccine Policy that states the purpose was to protect the health and well-being of all employees, physicians, volunteers, students, faculty, patients, families, and the community at large. Scope and definitions were defined. Also included is the vaccination of health care workers. It states on page 3 of the policy #2 Employee Requirement: B. If an employee does not receive the vaccination, they must sign a declination form and a mask must be worn until it is announced flu season has officially ended. E. When the prevalence of influenza disease rises to the threshold designated by the local CHI Health ministry, masking will be instituted for all non-vaccinated employees and non-employed health care providers working in a CHI Health facility. 1. Masks must cover the mouth and nose. 2. Masking occurs in all areas of the facility, unless the employee is eating/drinking in approved areas, i.e., break room, cafeteria, etc. 3. Masks are provided by the employer. E. Record review of the facility skills titled Hand Hygiene (hand washing) dated June 2019 revealed the section titled Hand Antisepsis (using an antiseptic to eliminate germs that cause disease) using an Instant Alcohol Waterless Antiseptic Rub (the same as ABHR) Step 1. Dispense the recommended amount of product per the manufacturer's instructions for use into the palm of one hand. Step 2. Rub the hands together, covering all surfaces of the hands and fingers with antiseptic rub. Step 3. Rub the hands together until the alcohol is dry. Allow the hands to completely dry before donning gloves. Perform hand hygiene with an instant alcohol waterless antiseptic rub, from start to dry, for 20 to 30 seconds. Record review of the facility skills titled Hand Hygiene dated June 2019 revealed the section titled Hand Washing Using Plain or Antimicrobial Soap and Water Step 2. Turn on the water. Step 5. Wet the hands and wrists thoroughly under the running water. Keep the hands and forearms lower than the elbows during washing. Step 6. Apply the recommended amount of plain or antimicrobial soap to the hands according to the manufacturer's instructions for use. Step 7. Lather thoroughly. Step 8. Apply friction and perform washing for at least 15 seconds or for the length of time stated in the manufacturer's instructions for use for the product used. Interlace the fingers and rub the palms and back of the hands together using a circular motion for at least five cycles. Keep the fingertips down to facilitate the removal of microorganisms. Observations of wound care on 1/6/20 at 2:13 PM for Resident 9 in the resident's room revealed that Licensed Practical Nurse A (LPN-A) applied alcohol based hand rub (ABHR) to the hands and rubbed the hands for 14 seconds and then put on disposable gloves. Registered Nurse B (RN-B) entered the room and turned on the water at the sink with the right hand and wet the right hand. RN-B then applied soap to the dry left hand and performed scrubbing with soap for 12 seconds before rinsing the hands. RN-B put on a pair of disposable gloves. LPN-A removed the disposable gloves and performed hand washing with ABHR rubbing the hands for 5 seconds and then put on disposable gloves and set a clean linen on the foot of the resident's bed. LPN-A placed the wound care supplies on top of the clean linen. LPN-A removed the gloves and performed 7 seconds of rubbing with ABHR and then put on new gloves. RN-B removed the dressing from the resident's right knee wound. The wound on top of the right knee contained meaty reddish pink tissue with a hole on the top edge of the wound. RN-B removed the gloves and applied ABHR and rubbed the hands for 16 seconds and then put on disposable gloves. LPN-A removed the gloves and rubbed the hands for 4 seconds with ABHR and then put on disposable gloves. RN-B obtained a 4X4 gauze and went to the sink and wet the gauze with tap water. RN-B scrubbed the wound with the 4X4 gauze and discarded the gauze into the trash. RN-B used a new dry gauze to pat the wound dry. RN-B removed the gloves and performed 20 seconds of rubbing with ABHR and then put on new disposable gloves. LPN-A removed the gloves and performed 4 seconds of rubbing with ABHR and then put on new disposable gloves. RN-B inserted a swab stick into the hole at the top of the wound and measured the depth of the hole at 4.2 centimeters. RN-B measured the width across the wound at 4.4 centimeters and the length up and down of the wound at 5.0 centimeters. LPN-A wrote the measurements on the whiteboard on the wall in the resident's room. LPN-A removed the gloves and rubbed the hands with ABHR for 5 seconds and then put on new disposable gloves. RN-B inserted a piece of white foam into the hole at the top of the wound using a swab stick. RN-B then opened some clear adhesive dressings and adhered the clear dressings around the edges of the wound. LPN-A then trimmed a piece of black foam for the wound. RN-B applied the piece of black foam on top of the wound. LPN-A cut a piece of clear adhesive cover to place over the black foam on the wound and RN-B placed the adhesive cover over the black foam on the wound. LPN-A cut a small hole in the cover on top of the black foam. RN-B applied the suction tubing on the top of the hole over the black foam. LPN-A connected the wound vac (a type of therapy machine that provides vacuum assisted closure of a wound to help a wound heal) to the suction tubing from the wound. LPN-A turned on the wound vac. The dressing on Resident 9's right knee drew tight to the resident's skin. RN-B then removed the disposable gloves and rubbed the hands for 17 seconds with ABHR and then put on new disposable gloves. RN-B assisted the resident in putting a shoe on the right foot. LPN-A gathered the trash into the trash bag and then removed the gloves. LPN-A performed hand rubbing for 3 seconds with ABHR and then put on new disposable gloves. RN-B and LPN-A placed a soft brace on the right leg of the resident. RN-B removed the disposable gloves and then went to the sink and turned on the water with the right hand and wet the right hand. RN-B applied soap to the dry left hand and then performed soap hand scrubbing for 26 seconds and then rinsed the hands. Interview on 1/6/20 at 4:23 PM with the Director of Nursing (DON) confirmed that the procedure for hand washing with the alcohol based hand rub (ABHR) requires that the rubbing be performed for 20-30 seconds until dry and that rubbing with the ABHR for less than 20 seconds does not meet the procedure requirements. The DON confirmed that the policy for soap hand washing steps includes wetting both of the hands prior to applying soap. The DON confirmed that applying soap to a dry hand does not follow the policy.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to knock and request permission to enter Resident 66's room and exposed Resident 68 and left their door open during a medical procedure. This affected 2 of 2 sampled residents. The facility identified a census of 16 at the time of survey. Findings are: A. Review of Resident 66's Care Plan revealed an admission date of [DATE]. Observation of Resident 66 on 12/31/19 at 1:45 PM revealed they were sitting in their recliner in their room talking with visitors. NA-H (Nurse Aide) walked into 66's room and did not knock or request permission to enter. NA-H walked in and said I have to chart and went to the computer in the corner of the room and started working with it. B. Review of Resident 68's initial MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/20/2019 revealed an admission date of [DATE]. Observation of Resident 68 on 1/02/20 at 10:32 AM revealed RN-F (Registered Nurse) administered an injection into Resident 68's belly after pulling up their shirt and exposing their belly. Resident 68's door was open. Resident 68 was lying in the bed and was visible to the hall and potential passersby. Review of the facility policy Patient Rights and Responsibilities dated 2/2019 revealed the following: It is the policy (facility) to honor patient rights and support patients in meeting their responsibility. Patient rights and responsibilities are defined according to the following goals: Dignity and respect; privacy and confidentiality. Interview with RN-B on 1/06/20 at 12:54 PM revealed the privacy curtain should have been pulled or the door closed while RN-F was administering the injection to Resident 68. Staff were to take residents to a private place when doing medical procedures and that would apply in the room as well. It was RN-B's expectation that staff knock and request permission to enter a resident's room and wait for a response before entering.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.18 Based on observation, interview, and record review; the facility staff failed to maintain a clean environment by failing to clean the light fixtures, exhaust fan covers and a feeding tube pole. This affected 3 of 3 sampled residents (Residents 67, 14 and 11). The facility identified a census of 16 at the time of survey. Findings are: A. Observation of Resident 67's room on 12/31/19 at 3:09 PM revealed there were dead insects in the light fixture in the bathroom. Observation of Resident 67's room on 1/06/20 at 12:16 PM with the HS (Housekeeping Supervisor) confirmed there were dead insects in the light fixture in the bathroom. B. Observation of Resident 14's room on 12/31/19 at 3:07 PM revealed there were dead insects in the light fixture in the bathroom and the bathroom exhaust cover was soiled with gray debris. Observation of Resident 14's room on 1/06/20 at 12:18 PM with the HS confirmed there were dead insects in the light fixture covers and the bathroom exhaust cover had gray debris on it. Interview with the HS on 1/06/20 at 12:18 PM revealed housekeeping staff was supposed to be cleaning the bathroom exhaust fan covers. The HS revealed it was their expectation that the exhaust fan covers were cleaned. Interview with the HS on 01/06/20 at 2:10 PM revealed the facility staff were supposed to notify maintenance when the lights needed to be cleaned. Review of the facility policy How to Clean a discharged Patient Room revealed the following: High dust with microfiber sleeve high duster in room and rest room: vents Review of the undated facility policy Daily Patient Room Cleaning revealed the following: no direction for cleaning vents. C. Observation of Resident 11's room on 12/31/19 at 10:32 AM revealed there was cream colored spillage on the base of the pole that held a feeding tube pump. Observation of Resident 11's feeding tube pump pole with the DON (Director of Nursing) on 01/06/20 at 02:43 PM revealed it had cream colored spillage on it. Interview with the DON at this time revealed it was their expectation that it would be cleaned. The DON revealed the facility staff were supposed to clean the poles on Sundays and when they were soiled. Review of the facility policy Cleaning and Disinfection of Environment and Equipment dated 3/2019 revealed the following: To ensure appropriate techniques, products, and cleaning schedules are used to reduce the potential for disease transmission and provide the most effective means of maintaining a clean, healing, and professional environment. Patient rooms are cleaned daily, at discharge, and as needed in between.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09B Based on observation, interview and record review; the facility staff failed to code MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) assessments to reflect the resident condition at the time of the assessment. This affected 3 of 16 residents whose MDS assessments were reviewed during the survey process (Resident 14, Resident 68, and Resident 217). The facility identified a census of 16 at the time of survey. Findings are: A. Observation of Resident 14 on 01/02/20 at 2:09 PM revealed they had a black area on the back of the left heel. Review of Resident 14's SCSA (Significant Change in Status) MDS dated [DATE] revealed no documentation of the area on Resident 14's left heel. Review of the MDS manual revealed the following: Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined. Review of Resident 14's Wound Care Clinic visit dated 12/6/2019 revealed documentation Resident 14 had a deep tissue injury to the left heel. Review of Resident 14's Orders and Progress Record dated 12/20/2019 revealed Resident 14 had a DTI (Deep Tissue Injury) to the left heel. Review of Resident 14's Orders and Progress Record Wound Care Note dated [DATE] revealed the following: Area to left heel has an approx. 5x5 cm (centimeter) DTI. Review of Resident 14's Wound Assessments and Treatments dated 1/5/20 revealed the area to the left heel was marked as 1.5 cm x 1.5 cm. Interview with LPN-A (Licensed Practical Nurse) on 1/06/20 at 10:12 AM confirmed they did not mark the DTI on Resident 14's heel on the SCSA MDS and they should have as it was present at the time of the assessment. B. Interview with Resident 68 on 12/31/19 at 2:43 PM revealed they had an infection in their leg that had occurred sometime after surgery and they had been receiving antibiotics. Review of Resident 68's Admission MDS dated [DATE] revealed an admission date of [DATE]. Antibiotics were received 7 days of the 7 day look back period. There was no active [DIAGNOSES REDACTED]. Interview with LPN-A on 1/02/20 at 3:35 PM confirmed they did not mark an infection on the MDS. Review of Resident 68's Orders and Progress Record dated 1[DATE]19 revealed an order for [REDACTED]. C. Review of Resident 217's Admission MDS dated [DATE] revealed an admission date of [DATE]. Antipsychotic medication was received 7 days of the 7 day look back period. Fractures and other multiple trauma was marked as the primary medical condition. No other active [DIAGNOSES REDACTED]. Review of Resident 217's Medication Reconciliation Tool dated 1/2/20 revealed the following medications: [REDACTED]. Interview with LPN-A on 1/02/20 at 3:28 PM confirmed there was not an active [DIAGNOSES REDACTED]. Interview with LPN-A on 1/02/20 at 3:54 PM confirmed they had omitted Resident 14's pressure ulcer and Resident 16's infection from the MDS assessments. Interview with RN-B on 1/06/20 at 12:54 PM revealed if the conditions were present at the time of the assessments, they should have been coded on the MDS assessments. Review of the facility policy Resident Assessment Instrument Minimum Data Set (MDS) Policy and Procedure revealed the following: This facility will conduct initially and periodically an accurate, standardized reproducible assessment of each resident's current functional, psychosocial, clinical and mental status. The interdisciplinary team members, completing any items on the MDS, will access the RAI 3.0 User's Manual, Chapter 3, for guidance to ensure coding accuracy.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09C1a Based on interview and record review, the facility failed to put interventions for bleeding risk on the baseline care plan for Resident 6 and failed to provide a written summary of the baseline care plan to the resident or resident representative prior to the initial care plan meeting for Residents 14, 67, and 8. This affected 4 of 14 sampled residents whose baseline care plans were reviewed during the survey process. The facility identified a census of 16 at the time of survey. Findings are: A. Interview with Resident 6 on 01/02/20 at 10:22 AM revealed they received a blood thinner. Review of Resident 6's baseline care plan dated 12/30/2019 revealed an admission date of [DATE]. There was no documentation of interventions to monitor for bleeding risk due to the use of a blood thinner. Review of Resident 6's Medication Reconciliation Report dated 1/2/20 revealed the following: [MED] (a blood thinner) 20 mg (milligram) administered every day. Review of the Nursing2018 Drug Handbook revealed the following nursing considerations for [MED]: Monitor patient carefully for bleeding which can occur at any site during therapy. Watch for signs and symptoms of blood loss. Search for a bleeding site if an unexplained fall in hematocrit (the ratio of the volume of red blood cells to the total volume of blood) or BP (blood pressure) occurs. Life-threatening adverse reactions listed: GI (gastrointestinal) hemorrhage, bleeding events (including hemorrhage). Interview with RN-B (Registered Nurse) on 1/06/20 at 12:54 PM confirmed there were no interventions regarding bleeding risk on Resident 6's baseline care plan. Interview with NA-E (Nurse Aide) on 1/06/20 at 1:41 PM revealed they got the information they needed to care for the residents from the care plan. B. Interview with Resident 14 on 12/31/19 at 11:21 AM revealed they did not recall receiving a written summary of their baseline care plan prior to their initial care plan meeting. Review of Resident 14's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/10/2019 revealed an admission date of [DATE]. Resident 14 had a BI[CONDITION] (Brief Interview for Mental Status) score of 14 which indicated Resident 14 was cognitively intact. Review of Resident 14's Care Plan dated 12/3/2019 revealed no documentation a written summary of the baseline care plan was given to Resident 14 or their resident representative. Review of Resident 14's Interdisciplinary Care Plan sheet dated 12/16/2019 revealed the resident signed attendance at the initial care plan conference. There was no documentation that Resident 14 received a written summary of their baseline care plan or that it was reviewed with them prior to the initial care plan conference date. C. Interview with Resident 67 on 12/31/19 at 10:52 AM revealed they didn't recall receiving a written summary of their baseline care plan. Review of Resident 67's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 67 had a BI[CONDITION] score of 14, which indicated Resident 67 was cognitively intact. Review of Resident 67's baseline care plan dated 12/5/2019 revealed no documentation a written summary was given to the resident or resident representative or that it was reviewed with them prior to the initial care plan conference. Review of Resident 67's Interdisciplinary Care Plan sheet dated 1[DATE]19 revealed the resident and family signed attendance at the initial care conference. There was no documentation a written summary of the baseline care plan had been given the Resident 67 or their personal representative prior to the initial care conference on 1[DATE]19. Interview with RN-B on 01/02/20 at 2:01 PM confirmed the facility staff were not giving the resident and/or resident representative a written summary of the baseline care plan. Review of the undated untitled facility policy regarding care planning revealed no documentation the resident/personal representative would be given a written summary of the baseline care plan and that it would be reviewed with them. D. Review of the Care Plan for Resident 8 with an initiation date 4/29/19 revealed no signatures of the resident representative and the other signatures were of the nursing staff. Review of the [DIAGNOSES REDACTED]. Review of the Progress Notes for Resident 8 revealed no documentation that the resident or the resident representative was given a summary of the baseline care plan. Interview on 1/06/20 at 8:40 AM with RN-B (Clinical Manager) revealed there was no written summary of the baseline care plan given to the residents or resident representatives.

Licensure Reference Number 1[AGE]NAC 12-006.09C1c Based on record review, observation, and interview the facility failed to ensure that the resident care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) was updated to include care for anticoagulant (a blood thinner medication used to prevent the formation of blood clots) use for 2 residents (Residents 1 and 9) of 2 residents reviewed, and the facility failed to ensure that the resident care plan was updated to include care for resident Continuous Positive Airway Pressure ([MEDICAL CONDITION]) (a machine pump that forces air through a face mask into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing for patients with obstructive sleep apnea) use for 1 resident (Resident 9) of 1 resident reviewed. The facility census was 16. Findings are: A. Record review of the Registration/Admission Form for Resident 9 revealed that the resident admitted to the facility on [DATE]. Record review of the scheduled MEDICATION ORDERS FOR [REDACTED]. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment dated [DATE] for Resident 9 revealed in section N0410 that Resident 9 had received an anticoagulant each day. Record review of the care plan for Resident 9 revealed that it contained no care plan interventions for the resident use of an anticoagulant. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 9 had a physician's orders [REDACTED]. LPN-A confirmed that the care plan for Resident 9 did not contain a care plan for the resident use of an anticoagulant. LPN-A confirmed that care plan interventions for anticoagulant use should have been on the resident's care plan. B. Record review of the Registration/Admission Form for Resident 1 revealed that the resident admitted to the facility on [DATE]. Record review of the Transfer Order for Resident 1 dated 1[DATE] revealed that Resident 1 had a physician's orders [REDACTED]. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment dated [DATE] for Resident 1 revealed in section N0410 that Resident 1 had received an anticoagulant. Record review of the care plan for Resident 1 revealed that it contained no care plan interventions for the resident use of an anticoagulant. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 1 had a physician's orders [REDACTED]. LPN-A confirmed that the care plan for Resident 1 did not contain a care plan for the resident use of an anticoagulant. LPN-A confirmed that care plan interventions for anticoagulant use should have been on the resident's care plan. C. Record review of the Registration/Admission Form for Resident 9 revealed that the resident admitted to the facility on [DATE]. Record review of the Transfer Order for Resident 9 dated 10/25/19 revealed that Resident 9 had a physician's orders [REDACTED]. Record review of the After Visit Summary (patient information and instructions provided to a patient by a health care provider) dated [DATE] for Resident 9 revealed a [DIAGNOSES REDACTED]. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway). Observation on 1/2/20 at 2:02 PM revealed that Resident 9 was in the bed in the resident's room with the resident's eyes closed. Resident 9 had a [MEDICAL CONDITION] mask on with the [MEDICAL CONDITION] pump running. Record review of the care plan for Resident 9 revealed that it contained no care plan for the resident use of the [MEDICAL CONDITION]. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 9 had a physician's orders [REDACTED]. LPN-A confirmed that the care plan should have contained a care plan for the resident's [MEDICAL CONDITION] use.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to store food off of the floor. This affected 2 of 2 residents who received nutritional supplements (Residents 14 and 217) and 2 of 2 residents who received tube feeding formula (Residents 8 and 17). The facility identified a census of 16 at the time of survey. Findings are: Observation of the facility kitchen on 12/31/19 at 9:20 AM revealed there were 4 boxes of [MEDICATION NAME] 1.5 cal (a formula used for residents requiring tube feeding) and 5 boxes of Ensure [MEDICATION NAME] (an oral liquid dietary supplement) sitting on the floor. Interview with DA-I (Dietary Aide) at this time confirmed the supplements were for the facility residents. Interview with the DON (Director of Nursing) on 01/06/20 at 10:53 AM revealed the supplements were not supposed to be stored on the floor. Review of the facility policy Food Supply and Storage dated 3/2018 revealed the following: Store dry and staple items at least 18 inches above the floor. Received a list from RN-B on 1/06/20 at 5:00 PM of the residents receiving [MEDICATION NAME]: Resident 8 and Resident 11. Resident 14 and Resident 217 received the Ensure.

Licensure Reference Number 1[AGE]NAC 12-006.09B(7) Based on observation, interview, and record review the facility failed to ensure that the required Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) documented the resident use of Continuous Positive Airway Pressure ([MEDICAL CONDITION]) (a machine pump that forces air through a face mask into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing for patients with obstructive sleep apnea) for 1 resident (Resident 9) of 1 resident reviewed. The facility census was 16. Findings are: Record review of the Registration/Admission Form for Resident 9 revealed that the resident admitted to the facility on [DATE]. Record review of the Transfer Order for Resident 9 dated 10/25/19 revealed that Resident 9 had a physician's order for [MEDICAL CONDITION] use during sleep. Record review of the After Visit Summary (patient information and instructions provided to a patient by a health care provider) dated [DATE] for Resident 9 revealed a [DIAGNOSES REDACTED]. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway). Observation on 1/2/20 at 2:02 PM revealed that Resident 9 was in the bed in the resident's room with the resident's eyes closed. Resident 9 had a [MEDICAL CONDITION] mask on with the [MEDICAL CONDITION] pump running. Record review of the MDS assessment dated [DATE] for Resident 9 revealed that documentation of the resident [MEDICAL CONDITION] use was omitted from section O0100G ([MEDICAL CONDITION] use) of the MDS. Record review of the facility policy titled Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Policy and Procedure dated 4/2019 revealed Procedure Step 1. The facility must make a comprehensive assessment of the resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by C[CONDITION] (Centers for Medicare and Medicaid Services). Step 5. The interdisciplinary team members, completing any items on the MDS, will access the RAI User's Manual for guidance to ensure coding accuracy. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 9 had a physician's order for [MEDICAL CONDITION] use and that the [MEDICAL CONDITION] use was not identified and documented on the resident MDS assessment. LPN-A confirmed that the resident [MEDICAL CONDITION] use should have been identified and documented in section O0100G of the MDS.

LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09B2 Based on record review and interview, the facility failed to ensure the completion an MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) every 3 months on one resident (Resident 3) out of one resident sampled. The facility census was 16 at the time of the survey. Findings are: Record review of Resident 3's quarterly MDS dated [DATE] for the ARD (Assessment Reference Date). There was no assessment in progress at the time of survey entrance. The required time frame between ARDs was to be 92 days or less. Interview on 1/02/20 at 3:10 PM with LPN-A (Licensed Practical Nurse) revealed that the last MDS Quarterly assessment had a dated of 9/20/19 for Resident 3 and the next MDS should have been completed before 12/31/19. The MDS was not scheduled to be completed until [DATE] which is outside the required ARD of 92 days or less. Review of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Policy and Procedure policy revealed in accordance with Federal Regulation, Title 42 4[AGE].20-Resident assessment. This facility will conduct initially and periodically an accurate, standardized reproducible assessment of each resident's current functional, psychosocial, clinical and mental status. Procedure: for #3 states: A facility must assess a resident using the quarterly review instrument specified by the State and approved by C[CONDITION] not less frequently then every 92 days.