Every finding on record at Eastmont

Licensure Reference Number: 175 NAC 12-006.09(H)(vi)(3) Based on record review and interview, the facility failed to ensure 3 (Residents 2, 6, and 8) of 6 sampled residents were provided with oxygen in accordance with physician orders. The facility had a total census of 19 residents. Findings are:Record review of Weights and Vitals Summary dated 03/28/2026 at 7:02 AM revealed that Resident 2 had an oxygen (O2) saturation (the percentage measurement of oxygen circulating in the blood) of 89% on room air (RA). Record review of Mayo Clinic definition of hypoxemia (low levels of oxygen in the blood) considers oxygen saturation values under 90% to be low (https://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym-20050930). Record review of Resident 2's The Administration Record revealed Resident 2 had an order to apply oxygen to keep oxygen saturations greater than 90% as needed for decreased O2 saturations. Record review of Progress Notes dated 03/28/2026 charted by Registered Nurse (RN) revealed that 911 was called at 7:15 AM and Resident 2 left the facility at 7:41 AM. An interview on 04/14/2026 at 9:46 AM with Medication Aide (MA) revealed that they (MA) reported that Resident 2 had an O2 saturation of 89% to RN by phone call. MA reported that they remained with Resident 2 until RN arrived at the bedside. An interview on 04/15/2026 at 10:01 AM with RN confirmed that if a resident had an O2 saturation below 90% they would look oxygen order, call the doctor and request an order if there was not one, and administer oxygen. RN confirmed the location of oxygen and that it was readily available in the event it was needed. RN reported that MA called the nurse cell phone the morning of 03/28/2026 to report that Resident 2 had low blood pressure and an O2 saturation of 89%. RN confirmed that it took approximately three minutes to get to the Resident 2's room. RN confirmed that they assessed the resident, then went back to the office to make the phone call to 911 and print the paperwork. RN reported that they took the crash cart (a portable wheeled cart that contains necessary equipment used during critical care situations, including oxygen) to the outside of Resident 2's room, but 911 had arrived at that time. RN confirmed that they did not administer oxygen to Resident 2 per the physician's order and did not recheck the O2 saturation. Record review of Weights and Vitals Summary dated 02/18/2026 at 9:39 AM revealed that Resident 6 had an O2 saturation of 82% on RA. The admission Order dated 11/03/2025 revealed that Resident 6 had an order to apply oxygen as needed to keep O2 saturations above 90%. Record review of the Care Plan (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) that was initiated 06/14/2022, revised 09/02/2025, with a target date of 02/14/2026 revealed that resident 6 was at risk for respiratory distress. The goal was that O2 saturations were to remain above 88% daily. Record review of Progress Notes dated 02/18/2026 charted by RN revealed that Resident 6 vomited and looked tired at 7:00 AM and O2 saturation was 90% on RA. At 9:30 AM, Resident 6 was noted to be lethargic (a general state of sluggishness, being tired) and their O2 saturation was 83% on RA. Record revealed that RN called the Power of Attorney (a person to look after one's affairs when they cannot manage due to mental incapacity or physical disability) and 911. Resident 6 left the facility at 9:58 AM. An interview on 04/14/2026 at 2:30 PM with Resident 6 and a family member confirmed that resident had influenza A (inflammation of the mucous membranes of the respiratory tract) and was sent out via 911. Resident 6 revealed that they were lethargic so they cannot remember if oxygen was put on them. Resident 6's family member stated that Resident 6's O2 saturation was 70%. An interview on 04/15/2026 at 10:01 AM with RN confirmed that they could not recall if oxygen was administered for Resident 6 and that it was unclear if any staff remained with the resident while waiting for 911 arrival. RN confirmed that they left the room for an unknown amount of time to obtain paperwork needed for transfer. RN confirmed that they should have put oxygen on first, make sure the resident were comfortable, then make phone calls. RN confirmed that the nurse's cell phone was always carried with them and that they had access to a portable computer if needed in emergency situations. Record review of Progress Notes dated 02/18/2026 at 12:30 PM charted by RN revealed that Resident 8 had an O2 saturation of 88% on RA. A phone call was placed to the provider at that time. The Weights and Vitals Summary dated 02/18/2026 at 5:11 PM revealed that the O2 saturation was 89% on RA. Record review of Progress Notes dated 02/18/2026 at 6:07 PM revealed that Resident 8 was transferred via ambulance to the emergency department at 5:58 PM. An interview on 04/15/2026 at 9:44 AM with Resident 8 revealed that they were unable to recall if oxygen was administered prior to transferring to the hospital. Resident 8 confirmed that they were very sick and cannot remember what happened during that time. An interview on 04/15/2026 at 10:01 AM with RN confirmed that they called Resident 8's primary care provider to report their condition. During that phone call, RN confirmed they asked for an oxygen order. RN stated, I think I put oxygen on them that day, but I do not remember. RN confirmed that there was no documentation of oxygen being administered to Resident 8. An interview on 04/14/2026 at 1:05 PM with the Director of Nursing (DON) confirmed that the oxygen supply was on the fourth floor and an oxygen tank was on the crash cart at the nurses' station on the fifth floor. The oxygen tank at the nurses' station was checked monthly by the DON. The DON confirmed that oxygen is readily available for patient needs. An interview on 04/14/2026 at 5:13 PM with the DON revealed that it is their expectation that all orders are followed as written and that if a resident has an O2 saturation below 90%, they are to try deep breathing and rest. If it is still below 90%, then apply oxygen. An interview on 04/15/2026 at 8:46 AM with the DON confirmed with a record review that Residents 2, 6, and 8 all had O2 saturations documented below 90% and the facility nursing staff did not have oxygen applied prior to hospital transfer. The DON confirmed that the care plan goal to keep O2 saturations above 88% for Resident 6 was not met. DON further confirmed that the only training completed on oxygen is during new hire orientation, which included the facility's standing orders. Record review of RN revealed that they completed new employee orientation on 04/28/2022. Part of the orientation included education on the oxygen room, crash cart education and location, processes binder, processes for the charge nurse phone, orders and faxing, and the transfer out process.

Licensure Reference Number 175 NAC 12-006.09Based on record reviews and interviews, the facility failed to ensure all orders that were prescribed by a medical practitioner for the use of oxygen when needed, were entered into the resident's Order Summary for 2 (Resident 5 and Resident 6) of the 6 residents sampled . The facility census was 19. Findings are: Record review of Resident 5's admission Record dated 04/14/2026 revealed that the resident was originally admitted to the facility on [DATE] with a diagnosis of a pulmonary embolism (a sudden and dangerous blockage of one of the lungs arteries caused by a blood clot). Record review of Resident 5's admission Orders dated 12/18/2025 revealed an order, signed by the resident's Primary Care Provider (PCP) for oxygen as needed to keep sats (blood oxygen saturation) 90%.Record review of Resident 5's Order Summary dated 12/30/2025 revealed no order for oxygen to be administered as needed to keep blood oxygen saturation at 90%. Record review of Resident 6's admission Record dated 04/14/2026 revealed that Resident 6 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD, a long-term lung disease that makes it hard to breathe due to lung damage). Record review of Resident 6's Compressive Care Plan (CCP, a document that includes measurable objectives and timelines to meet resident's medical, mental and psychosocial needs) revealed that the resident is at risk for respiratory distress and the goal is that the resident's oxygen saturation would remain above 88%. Record review of Resident 6's admission Orders dated 11/04/2025 revealed an order, signed by the resident's PCP for oxygen as needed to keep sats at 90%.Record review of Resident 6's Order Summary dated 11/25/2025 revealed no order for oxygen to be administered as needed to keep blood oxygen saturation at 90%. Record review of Resident 6's Weight and Vitals Summary revealed that on 02/18/2026 the resident's oxygen level was 82%. Record review of Resident 6's Progress Notes for 02/18/2026 revealed that at 7AM the resident's oxygen was 90%. The nurse reassessed the resident's oxygen at 9:30AM and it was 82%. No documentation that any supplemental oxygen was provided to the resident. Record review of the facility's policy titled Medication Administration with a reviewed date of 11/10/2025 revealed that the facility ensures that all medications are documented in accordance with the physicians' order. Interview with the Director of Nursing (DON) on 04/14/2025 at 5:13 PM revealed that all residents should have standing orders (pre-approved written instructions from a doctor that allows nurses to provide specific medications that are not regularly administered to the resident). The standing orders are obtained upon admission for each resident and if a resident transferred from a skilled (higher level of care) floor to a long-term care floor, the standing orders would transfer with them. The DON revealed that charts are not consistently reviewed to ensure that all orders are placed and available for the residents. The DON confirmed that it is the facility's expectation that every resident has standing orders available for administration in the resident's EMAR. Interview with the DON on 04/15/2026 at 8:46 AM confirmed that Resident 5 and Resident 6 had admission orders (standing orders) to administer oxygen as needed to keep oxygen at 90% but were not entered into Resident 5 and Resident 6's Order Summary and should have.

Licensure reference number 175 NAC 12-006.11C Based on interviews, record review, and observations, the facility failed to ensure kitchen staff wore hairnets and beard nets, performed hand hygiene for 20 seconds and hand hygiene between glove changes, and failed to ensure the food is labeled and dated, and inside of ice machine was clean to prevent food-borne illness. This had the potential to affect all 17 residents who ate out of the kitchen. The facility census was 17. Findings are:Record review of Eastmont Towers Community Handwashing policy and procedure dated 2/1/2017 revealed: Dietary staff will hand wash hands before starting work, when returning to work, after smoking, eating, drinking and visiting restrooms, using phones and handling money, after handling garbage or chemicals and at other times when hands have been soiled. -Procedure: Turn on faucet with warm running water. Wet hands and apply soap. Rub your hands together to make a lather. Scrub well for at least 20 seconds. Pay attention to your wrist, back of hands, between fingers and under fingernails. Rinse your hands well under running water. Use a clean wipe to dry hands and use a paper towel to turn off water. Record review of Eastmont Hair restraints dated 12/8/2016 revealed: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles.Record review of Eastmont's Cleaning Instructions: Ice machine and Equipment Policy dated 8/12/25 revealed:-Ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. Record review of Eastmont's General Food Preparation and Handling Policy dated 8/15/19 revealed: -Food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep free of harmful organisms and substances.-Bare hands should never touch ready to eat raw foods directly. Disposable gloves are a single use item and should be discarded after each use.-Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour after cooking or service) in a refrigerator. Record review of Eastmont's Food Storage policy dated 8/12/25 revealed: -Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination.-Food should be dated as it is placed on the shelves if required by state regulation.-Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (Time/temperature control for safety) foods should be consumed, sold, or discarded.-Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.-Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 20217 Federal Food Code.- All foods should be covered, labeled, and dated, and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Observation on 8/6/25 at 7:25 AM Floater-C went into the walk-in refrigerator and walked out with a bag of lettuce, went to the prep table and applied gloves without hand hygiene. Observation on 8/6/25 at 7:34 AM revealed:-Macaroni package had been opened but not date. -Graham cracker crumbs had been opened but not date. Observation on 8/6/25 at 7:39 AM revealed the ice machine had some white debris on the inside of the lid, also on the inside towards the top of the ice bin. The upper portion of the inside of bin in front of the ice shoot has rust-looking debris. An interview on 8/6/25 at 7:45 AM with the (CDM) Certified Dietary Manager revealed that a service technician maintains the ice machines yearly for the facility. CDM said the facility kitchen staff removes the ice every month and clean it out, although the light on the machine tells when it's time to clean but usually once a month. The CDM was unsure when the last time it was cleaned. Observation on 8/11/25 at 7:15 AM of salad/baker-B did not have a hair net or beard net on while frosting a cake. Salad/baker-B did not have hair on top of head although has approximately 1 inch hair around the sides and back of head. The salad/baker-B has a beard with a short (shadow beard) on the chin and the sides of face the beard hair was approximately 1 1/2 inch long. An interview on 8/11/25 at 7:15 AM with salad/baker-B revealed [gender] wasn't sure if [gender] needed the hair net and beard net. An interview on 8/11/25 at 8:09 AM with the CDM confirmed the staff should wear beard nets and hair nets, wash hands before gloving, the food items should be dated after opening, and the ice machine needs cleaned out due to white debris and rust-like debris on the inside. Observation on 8/11/25 at 11:49 AM with Dietary Technician (DT)-E prior to serving food in the kitchenette, washed hands with soap and water for 15 seconds, then used [gender] hand to shut off the water faucet, and applied gloves. Observation on 8/11/25 at 12:00 PM where DT-E finished obtaining food temperatures and changed gloves without hand hygiene. Observation on 8/11/25 at 12:02 pm DT-E served food plates onto trays for the staff to give to the residents. Observation on 8/11/25 at 12:03 PM DT-E picked up their cell phone with gloves on and called the kitchen, and did not change gloves or perform hand hygiene when off phone. DT-E then began serving food trays again. Observation on 8/11/25 at 12:15 PM DT-E stopped serving food and changed gloves without hand hygiene. An interview on 8/11/25 at 12:16 PM with DT-E confirmed that [gender] should have washed hands for 20 seconds and in between glove changes. Observation on 8/11/25 at 12:20 PM of the refrigerator in the kitchenette with tomato juice in a pitcher 1/4 full that was covered with saran wrap and undated, and the sides of the pitcher had hardened red substance on it where the tomato juice raised to. An interview on 8/12/25 at 1:10 AM with CDM revealed the facility did not have a policy on monthly cleaning of the ice machine but was unsure when the last time it was cleaned, the tomato juice should be dated and discarded if expired, and the staff should wash hands between glove changes.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)Based on record review and interview, the facility failed to ensure 2 (Medication Aide (MA) L and M) of 5 employees sampled Adult/Child background check was completed. This has the potential to affect all residents that reside in the facility. The facility census was 17. Findings are:Record review of Staff names, seniority dates, and department list dated 8/6/25 revealed MA-L's start of employment was 9/5/23. Further record review of MA-L's personal records revealed no documentation of an Adult/child central registry. Record review of Staff names, seniority dates, and department list dated 8/6/25 revealed MA-M's start of employment was 12/20/23. Further record review of MA-M's personal records revealed no documentation of an Adult/child central registry. An interview on 8/7/25 at 1:10 PM with HR confirmed there was not any Adult/child central registry form in MA-L and MA-M personal records. Record review of Eastmont Hiring Process policy dated 6/28/2019 revealed: Purpose: Eastmont is committed to hiring the best person to provide the highest quality standard of care to our residents. We complete various checks on potential employees to verify that there is no evidence of abuse, neglect, or other civil activities that would be inappropriate to work with the senior adult.-Background checks: A thorough background check including, but not limited to, criminal history, sex offenders registries, adult and child registry checks, Office of the Inspector General (OIG), verification of previous employment, Social Security number verification, and driving record check, (if required), is performed for all new employees to verify persons hired do not have evidence of abuse, neglect, or other criminal activities that would be an inappropriate to work with senior adults.

Licensure Reference Number 175 NAC 12-006.18(B)Based on observations, record review, and interviews, the facility failed to ensure infection control practice with hand hygiene during resident care, medication administration, and housekeeping to prevent cross contamination with 2 (Residents 6 and 22) of 3 sampled residents . The facility census was 17. Findings are:A record review of the facility policy titled Handwashing/Hand Hygiene. Revision date of 8/30/2024 revealed the following: Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. All personnel shall follow the handwashing or the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Wash with soap and water when hands are visibly soiled. Wash with soap and water or use an alcohol-based hand rub containing at least 62% alcohol for the following situations: before and after the direct contact with the residents; before preparing or handling medications; after contact with a resident's intact skin; after contact with blood or bodily fluids; after contact with objects (medical equipment) in the immediate vicinity of the resident; after removing gloves. The use of gloves does not replace hand washing or hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.The procedure for washing hands involves wetting the hands first with water and then apply soap. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use a towel to turn off the faucet. When using alcohol-based hand rubs apply a generous amount of the product to the palm of the hand and rub the hands together. Cover all surfaces of the hands and the fingers until the hands are dry. A. An observation on 8/11/2025 at 9:10 AM revealed Medication Aide (MA-K) did not use hand sanitizer prior to putting medication into the medication cup for Resident 22. MA-K then carried the medication in the cup and walked to Resident 22's room. Medication was handed to Resident 22 without MA-K using hand sanitizer or washing hands and then left the room. When MA-K returned to the medication cart hand sanitizer was not used. An interview on 8/11/2025 at 09:25 AM with MA-K confirmed that hand sanitizer was not used prior to setting up meds or after giving the medication to Resident 22.An interview on 8/12/2025 at 10:30 AM with Infection Control Nurse (IP)-J confirmed that hand sanitizer or washing hands are to be done prior and after giving medication to the residents. An observation on 8/11/2025 at 11:30 AM revealed Housekeeper (H-H) was in a Resident 22's bathroom and flushed toilet and then walked out of the bathroom and into the hallway holding the cleaning supplies against genders uniform. H-H then put the supplies on the cleaning cart and did not wash or sanitize H-H's hands and remained at the housekeeping cart.An interview on 8/11/2025 at 11:32 AM with H-H confirmed that [gender] did have gloves on when flushed the toilet in the Resident 22's bathroom and took them off in the bathroom prior to coming out into the hallway. H-H confirmed that {gender} did not wash or sanitize hands after leaving Resident 22's room.An observation on 8/11/2025 at 11:40 AM revealed H-H going back into Resident 22's room and washed hands with soap and water for 15 seconds and then used bare hand to shut the faucet off at the sink.An observation on 8/11/2025 at 11:42 AM of H-H revealed H-H in Resident 22's room removing the trash without gloves out of the garbage cans from the Resident 22's bathroom and beside the recliner chair. H-H removed the garbage sacks from the room and placed them in the housekeeping garbage container. H-H went back into Resident 22's room and washed {genders} hands for 10 seconds and used bare hand to shut the faucet off.An interview on 08/11/2025 at 11:47 AM with H-H confirmed that the staff are to wash their hands for at least one minute after handling garbage sacks from the resident rooms. B. An observation on 8/11/2025 at 3:10 PM with Licensed Practical Nurse (LPN-I) revealed [gender] went into Resident 22's room without sanitizing hands. LPN-I performed a blood pressure check and touched Resident 22's arms. LPN-I did not wash hands or use hand sanitizer and exited Resident 22's room. An interview on 8/11/25 at 3:15 PM with LPN-I confirmed hand sanitizer or washing hands should have been performed before and after leaving Resident 22's room.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, record review, and interviews, the facility failed to maintain the exhaust hood over the cooking area in clean and sanitary conditions to prevent the potential for food-borne illnesses. This had the potential to affect all residents who ate food served from the kitchen. The facility census was 17. Findings are: An observation on 07/29/2024 at 9:10 AM during the initial brief tour of the kitchen revealed the exhaust hoods over the cooking areas were coated with a dark brown substance. In an interview on 07/29/2024 at 9:10 AM, the Dietary Manager (DM) confirmed the exhaust hoods over the cooking area were not clean. The DM revealed that twice a year, an external company comes out to clean them. A review of the 2017 Nebraska Food Code 4-601.11 Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces, and Utensils, revealed: (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. A review of the 2017 Nebraska Food Code 4-602.13 Nonfood-Contact Surfaces, revealed: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. A record review of the Sample Daily Cleaning Schedule Form dated 7/24 to 7/30 revealed that cleaning the exhaust hoods was not an assigned task. A record review of the Cleaning Schedule dated July 29-[DATE] revealed that cleaning the exhaust hoods was not an assigned task. A review of an invoice from a cleaning company revealed that Hood Exhaust Cleaning Production Kitchen was performed on 03/27/2024. An observation on 07/31/2024 at 8:07 AM revealed the exhaust hoods over the cooking area remained coated with a dark brown substance. In an interview on 07/31/2024 at 9:05 AM, the DM confirmed the exhaust hood cleaning task was not on the cleaning lists provided. The DM further confirmed that they had not been cleaning the exhaust hoods.

Licensure Reference Number 175 NAC 12-006.18 (C) Based on observation, record review, and interviews, the facility failed to ensure hand hygiene was performed in a manner to prevent the potential for cross contamination during peri-cares (washing the genitals and anal area) for Resident 16. This affected 1 resident sampled for urinary tract infections (UTIs). The facility census was 17. Findings are: A review of Resident 16's Admission Record printed 07/30/2024 revealed the resident was admitted on [DATE] with diagnoses of heart attack, heart failure, Alzheimer's disease, rhabdomyolysis (a condition in which damaged muscle breaks down quickly and releases potential toxins into the blood), high blood pressure, and anxiety. A review of an SBAR [Situation-Background-Assessment-Recommendation, a tool used for communicating with a medical provider] Tool for Suspected Urinary Tract Infection) dated 097/19/2024 revealed the nurse reported symptoms of increased urinary incontinence, urgency, and frequency, and received an order to check a Urine culture (if indicated) (check a urine sample for infection.) A review of a urine culture report reported 07/24/2024 revealed an order dated 07/29/2024 for amoxicillin (an antibiotic) 500 milligrams (mg) give 1 by mouth twice a day for five days. An observation of peri-cares performed by Nurse Aide (NA) A on 07/31/2024 at 11:22 AM revealed the NA sanitized their hands, entered the room, moved the resident's wheelchair, then washed their hands with soap and water for 8 seconds and put on gloves. NA A then assisted Resident 16 to sit up in their recliner, put a gait belt (a device put on a patient who has mobility issues by a caregiver to aid with transfers) on the resident, and assisted the resident to walk into the bathroom with their walker. NA A assisted Resident 16 by pulling down the resident's pants and incontinence wear and stepped outside the bathroom door. When the resident indicated they were finished in the bathroom, NA A, still wearing the same gloves, assisted Resident 16 to stand and performed peri-care. The NA removed their gloves, did not perform hand hygiene, and pulled up the resident's incontinence wear and pants, then assisted the resident to walk back to their recliner. NA A then emptied the trash, washed their hands with soap and water for 5 seconds, and gave the resident their call light and a blanket before leaving the room. A review of the facility's Handwashing/Hand Hygiene Policy with Revision/Reviewed date of 08/30/2023 revealed: -Policy Interpretation and Implementation -7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; -Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off faucet. 5. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. An interview on 07/31/2024 at 11:35 AM with NA A confirmed that handwashing with soap and water should be done for 20 seconds and should be done after touching other objects and before touching the resident. In an interview on 07/31/2024 at 4:13 PM the Director of Nursing (DON) confirmed that handwashing should be done for 20 seconds, and that five and eight second durations were not long enough.

Based on record review and interview: the facility failed to submit their Payroll Based Journal (PBJ) data for quarter 2 of 2024 as required. This had the potential to affect all resident residing within the facility. The facility identified a census of 17. Findings are: A record review of the PBJ report from Centers for Medicare and Medicaid services (CMS) revealed the facility had failed to submit data for the second quarter (January 1, to March 31) in 2024. The PBJ report is a collection of staffing information and is a requirement of all long-term facilities to promote accountability and consistency. An interview on July 31, 2024, at 3:45 PM, the Staffing Coordinator (SC) revealed the facility did not get the PBJ report turned in within the allotted time frame placed by CMS. The SC stated the facility was one week late. The SC confirmed the PBJ report was not turned in on time. An interview on July 31, 2024, at 3:55 PM, the Administrator (ADM) revealed the facility had recently switched to a new payroll vendor. The new payroll vendor was placing all facility hours into the PBJ system (Paid time off, sick leave, education hours) as worked hours on the floor. Due to this discrepancy with the new payroll system the facility was not able to correct and turn in the report within the allotted time.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications related to medication being given outside of the physician ordered parameters for 1 (Resident 5) of 2 sampled residents. The facility identified a census of 16. Findings Are: A record review of Resident 5's MAR (Medication Administration Record) dated July 2023 revealed Resident 5 was taking the following medication; Midodrine (a medication which causes the blood vessels to tighten, which increases blood pressures) 10 milligrams (MG) 1 tablet three times daily for hypotension and medication should be held for systolic blood pressure (SBP (systolic blood pressure which indicates the pressure caused by your heart contracting and pushing out blood)) greater than 140. A record review of the MAR's dated July 2023, June 2023 and May 2023 revealed the Midodrine which had parameters to hold if SBP was greater than 140, had been given outside of ordered parameters on the following days; 6/4/23 at 12:00 PM with a documented B/P (blood pressure) of 145/79 6/4/23 at 8:00 AM with a documented B/P (blood pressure) of 152/79 6/3/23 at 12:00 PM with a documented B/P (blood pressure) of 153/78 6/1/23 at 8:00 AM with a documented B/P (blood pressure) of 150/90 5/25/23 at 8:00 AM with a documented B/P (blood pressure) of 205/68 5/24/23 at 6:00 PM with a documented B/P (blood pressure) of 166/88 5/23/23 at 12:00 PM with a documented B/P (blood pressure) of 145/81 A record review of the facility policy titled Administering Medications, with a revision date of April 2019, revealed the policy did not address or provide guidance related to having blood pressure parameters. A record review of the facility policy titled Blood Pressure, Measuring with a revised of September 2010, revealed the policy did not address or provide guidance related to having blood pressure parameters. An interview on 7/13/23 at 10:02 AM with the DON (Director of Nursing), after review of the blood pressures found given outside the ordered parameters for Resident 5, confirmed that on the listed 7 days, the Midodrine should have been held and not given.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A2 Based on interview, observation, and record review, the facility failed to provide fluids to meet the ordered restrictions for 1 (Resident 5) of 1 sampled resident. The facility identified a census of 19. Findings Are: A record review on 7/10/23 of Resident 5's demographic information revealed Resident 5 admitted to the facility on [DATE]. A record review on 7/10/23 of the diagnoses list revealed Resident 5 had diagnoses of ESRD (End Stage Renal Disease) dated 10/26/20 and Chronic Kidney Disease and Resident 5 was receiving dialysis treatments. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/5/23 revealed Resident 5 had a BIMS score ( Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 14 which indicated Resident 5 was cognitivley intact. The MDS revealed Resident 5 was dependent for transfers and did not ambulate in the room. During an interview on 07/10/23 at 12:21 PM, Resident 5 revealed [gender] was on a fluid restriction but was unaware of the restricted amount. Observation on 7/10/23 at 09:45 AM of Resident 5's room revealed no signage posted related to being on a fluid restriction. The observation revealed Resident 5 had a full 240cc (cubic centerimeter which is a measure of volume in the metric system) glass of water, and an empty 120cc glass also setting at Resident 5's bedside table, no meal tray was present. A record review of the active Order Summary ran on 7/11/23 revealed Resident 5 had the following order; -1500cc fluid restriction per day per Dialysis Center of Lincoln with an initial order date of 8/31/21. An observation on 07/11/23 at 9:56 AM of Residnt 5's breakfast tray revealed a 240cc glass of juice, 240cc cup of coffee, and 240cc glass of water. The observation revealed that the diet card which was on the breakfast tray that had been sent to Resident 5's room did indicate Resident 5 was on a fluid restriction but did not indicate an amount. The observation revealed all fluids that were requested by Resident 5 were sent for breakfast. A record review of Resident 5's electronic medical record conducted on 7/12/23 at 10:00 AM revealed Resident 5's fluid restriction was being documented in 3 different locations, 2 different areas on the MAR (Medication Administration Record) and Task charting. A record review of the Medication Administration Records dated June 2023 and July 2023 revealed 2 entries related to Resident 5's fluid restriction; -1500cc fluid restriction per day per Dialysis Center of Lincoln every evening shift with a start date of 8/31/2021, -1500cc fluid restriction per day per Dialysis Center of Lincoln every shift with a start date of 8/31/2021which indiciated the amount was to be charted for days, evenings, and nights. A record review of Resident 5's Task section within Point of Care revealed a task of: Fluid Intake (1500cc fluid restriction, do not count boost). A record review of the fluid restriction entries over the last 30 days revealed the follow intakes; 7/8/23 MAR entry #1 160 cc MAR entry #2 770 cc TASK 1200 cc with a 24 hour total of 2130 cc 7/6/23 MAR entry #1 360 cc MAR entry #2 60 cc TASK 1255 cc with a 24 hour total of 1675 cc 7/4/23 MAR entry #1 480 cc MAR entry #2 600 cc TASK 1200 cc with a 24 hour total of 2280 cc 7/1/23 MAR entry #1 340 cc MAR entry #2 1255 cc TASK 920 cc with a 24 hour total of 2515 cc 6/30/23 MAR entry #1 480 cc MAR entry #2 560 cc TASK 1080 cc with a 24 hour total of 2120 cc 6/29/23 MAR entry #1 240 cc MAR entry #2 800 cc TASK 1040 cc with a 24 hour total of 2080 cc 6/28/23 MAR entry #1 0 cc MAR entry #2 960 cc TASK 640 cc with a 24 hour total of 1600 cc 6/27/23 MAR entry #1 480 cc MAR entry #2 1000 cc TASK 1440 cc with a 24 hour total of 2920 cc 6/26/23 MAR entry #1 720 cc MAR entry #2 360 cc TASK 650 cc with a 24 hour total of 1730 cc 6/25/23 MAR entry #1 0 cc MAR entry #2 1130 cc TASK 1115 cc with a 24 hour total of 2245 cc 6/24/23 MAR entry #1 480 cc MAR entry #2 1135 cc TASK 1340 cc with a 24 hour total of 2955 cc 6/22/23 MAR entry #1 600 cc MAR entry #2 650 cc TASK 1320 cc with a 24 hour total of 2570 cc 6/21/23 MAR entry #1 0 cc MAR entry #2 1080 cc TASK 960 cc with a 24 hour total of 2040 cc 6/20/23 MAR entry #1 600 cc MAR entry #2 700 cc TASK 1420 cc with a 24 hour total of 2720 cc 6/19/23 MAR entry #1 360 cc MAR entry #2 840 cc TASK 960 cc with a 24 hour total of 2160 cc 6/15/23 MAR entry #1 480 cc MAR entry #2 580 cc TASK 1080 cc with a 24 hour total of 2140 cc 6/14/23 MAR entry #1 897 cc MAR entry #2 537 cc TASK 720 cc with a 24 hour total of 2154 cc 6/13/23 MAR entry #1 480 cc MAR entry #2 840 cc TASK 1320 cc with a 24 hour total of 2640 cc A record review of the undated facility policy titled Encouraging and Restricting Fluids revealed the following steps; Restricting Fluids: 8. Wash and dry your hands thoroughly before serving the resident fluids. 9. Take the fluid container to the resident's room. 10. Inform the resident you have brought him or her a drink. Tell the resident what type of drink it is. 11. Encourage the resident to drink the fluid if it is within their restricted limit. Should the resident refuse, report such information to your supervisor. 12. Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid intake in ml's (milliliters) 13. Provide mouth care as necessary. 14. Wash and dry your hands thoroughly. An interview on 7/13/23 at 10:02 AM with the DON (Director of Nursing), after review of the 24-hour fluid totals over the last 30 days for Resident 5, confirmed that the fluid intakes exceeded the ordered fluid restrictions on 18 of the 30 days and should not have.

Licensure Reference Number 175 NAC 12-006.09C Based on observation, interview, and record review, the facility failed to ensure straight catheterization (cath)(a soft, thin tube used to pass urine from the body) on Resident 8, and the Continuous Positive Airway Pressure ([CONDITION(S)])(a machine used to deliver positive airway to a resident's airway to prevent it from closing during sleep) device for Resident 11 was included in the Comprehensive Person-Centered Care Plan (a plan that provides direction on the type of nursing care the resident may need). This affected 2 of 9 sampled residents. Total facility census was 16. Findings are: A. In an interview with Resident 8 on 04/25/2022 at 10:44 AM, the resident stated the nurses straight cath the resident to drain the bladder (a sac in which urine is held). Record review of Resident 8's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 8's Clinical physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 8's Minimum Data Set (MDS)(a comprehensive assessment of each residents functional capabilities), section H0100, dated 03/23/2022 revealed Resident 8 needed intermittent (recurring) catheterization. Record review of Resident 8's Comprehensive Person-Centered Care Plan did not reveal interventions (action taken to improve) for straight catheterization. In an interview on 04/27/2022 at 11:25 AM, the Director of Nursing confirmed the order for straight catheterization should have been on the Comprehensive Person-Centered Care Plan. B. An observation of Resident 11's room on 04/25/2022 at 12:36 PM revealed a ResMed S9 Continuous Positive Airway Pressure ([CONDITION(S)])(a machine used to deliver positive airway to a resident's airway to prevent it from closing during sleep) device with a heated humidifier located on the resident's nightstand along with uncovered [CONDITION(S)] Mask and supplies. Record review of Resident 11's Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 04/26/2022 at 12:36 PM revealed a [CONDITION(S)] machine and supplies located on the Resident 11's nightstand. An observation on 04/27/2022 at 06:45 AM revealed Resident 11's [CONDITION(S)] machine and uncleaned supplies was located on the resident's nightstand. The [CONDITION(S)] tubing was off the mask and 1 side of the forehead cushion was not on the mask. In an interview with Resident 11 on 04/27/2022 at 06:45 AM, Resident 11 confirmed Resident 11 used the [CONDITION(S)] at night. In an interview with Medication Aide (MA)-C on 04/27/2022 at 09:04 AM, MA-C confirmed Resident 11 has a [CONDITION(S)] and the nurses helped the resident put the mask on at night. MA-C was not sure who cleaned the mask or supplies, but assumed nursing did it if the resident had not. MA-C confirmed that MA-C had never cleaned the [CONDITION(S)] mask or supplies. Record review of Resident 11's Admission Minimum Data Set (MDS)(a comprehensive assessment of each residents functional capabilities), section O0100 dated 10/20/2021 revealed Resident 11 used a [CONDITION(S)]. Record review of Resident 11's Comprehensive Person-Centered Care Plan (a plan that provides direction on the type of nursing care the resident may need) dated 10/15/2021 did not reveal any interventions for Resident 11's [CONDITION(S)]. In an interview with the Director of Nursing (DON) on 04/27/2022 at 09:04 AM, the DON confirmed the [CONDITION(S)] and supplies were not on the Comprehensive Person-Centered Care Plan.

Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, interview, and record review; the facility failed to ensure oral care was completed for 1 (Resident 11) of 2 sampled residents. Total facility census was 16. Findings are: An observation on 04/25/2022 at 11:09 AM revealed Resident 11 was still in bed and personal care had not been done. In an interview on 04/25/2022 at 11:09 AM Resident 11 confirmed the staff did not help with ADLs and Resident 11 uses fingernail to take care of Resident 11's teeth. In an interview with Resident 11 on 04/27/2022 at 06:45 AM, Resident 11 confirmed ADLs had not been done and the resident again stated the resident uses fingernail to brush teeth. Record review of Resident 11's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 11's Significant Change Minimum Data Set (MDS)(a comprehensive assessment of each residents functional capabilities), Section G0110, dated 04/07/2022 revealed Resident 1 was assessed as an Extensive Assistance for Self-Performance and a 1 person physical assist on Support for Personal hygiene. Record review of Resident 11's Comprehensive Person-Centered Care Plan (a plan that provides direction on the type of nursing care the resident may need) dated 10/15/2021 revealed Resident 11 is not independent with ADLs and an intervention (action to improve a situation) was: Staff to assist with ADLs as needed and provide cares according to facility guidelines. Record review of the facility's Morning and Afternoon Care Guideline dated 09/2021 revealed the staff should have performed oral care (before or after breakfast) and again in the afternoon. In an interview on 04/27/2022 at 06:50 AM Nursing Assistant (NA)-D confirmed that Resident 11 did not usually get out of bed until right before lunch. NA-D confirmed the staff assisted the resident to the wheelchair, and the resident performed own ADLs. In an interview on 04/27/2022 at 11:25 AM, the Director of Nursing confirmed the facility staff would attempt to allow the resident to do own oral care, but if unable to, the staff should have assisted in completing the task.

Based on record review and interviews, the facility failed to identify and monitor target behaviors when a [CONDITION(S)] medication is used for Resident 2. Findings are: Review of Resident 2's Electronic Medical Record (EMR) revealed Resident 2 was ordered [MEDICATION(S)](used for seizures and [CONDITION(S)]) and [MEDICATION(S)] (antidepressant) for Major Depressive Disorder. Review of Resident 2's EMR revealed no list of target behaviors to be monitored to ensure the effectiveness of the medication. Review of Resident 2's Care plan revealed no care plan related to the monitoring of target behaviors with the use of a [CONDITION(S)] medication. Interview on 04/27/22 at 08:09 AM with Registered Nurse (RN)-F revealed behavior notes are completed in the progress notes however no target behaviors are identified in Resident 2's EMR. Interview on 4/27/22 at 1:00 PM with the Director of Nursing (DON) revealed no documentation of target behaviors being identified or any occurence of behaviors charted.

Licensure Reference Number 175 NAC 12-006.09D7 Based on interview and record review, the facility failed to transfer 1 (Resident 8) of 2 sampled residents in a manner to prevent a fall. Total facility census was 16. Findings are: Record review of Resident 8's History and Physical dated 03/16/2022 revealed the physician documented the resident had continued to become increasingly weak and fatigued to the point that the resident required 2 people to assist with all transfers and change in position. Record review of Resident 8's Medical Diagnosis list dated 04/26/2022 revealed the resident had a diagnosis of [CONDITION(S)] (a progressive disease of the nervous system marked by shaking, stiff muscles, and slow, imprecise movements), Weakness, and Dementia (a group of thinking and social symptoms that interferes with daily function). Record review of Resident 8's Progress Notes on 04/18/2022 revealed the resident continued to be an extensive 1 assist with EZ Stand (a mechanical lift to raise a person to a standing position, or lower a person to a sitting position) for transfers. Record review of Resident 8's Admission Minimum Data Set (MDS)(a comprehensive assessment of each residents functional capabilities) dated 03/23/2022 revealed the resident had been assessed as extensive assistance needed for transfers on Self-Performance and 2 plus person assist for Transfer Support. Record review of Resident 8's Comprehensive Person-Centered Care Plan (a plan that provides direction on the type of nursing care the resident may need) dated 03/18/2022 revealed Resident 8 is ask risk for falls and no transfer interventions (action to improve a situation) until after the fall on 04/21/2022. Record review if Medicare/Care Plan/Discharge Plan team note dated 04/12/2022 revealed the Physical Therapist (PT)-E documented Resident 8 was a Transfer Assist of 1 assist when working with a PT, but EZ Stand with nursing. In an interview on 04/26/2022 at 11:06 AM, Resident 8 confirmed the resident fell on [DATE] while being transferred to a shower chair. Resident 8 stated it was due to the shower chair was the wrong size. Resident 8 confirmed the resident's back was pretty bruised up, but no major injuries. Record review of the 04/22/2022 Progress Notes by the Director of Nursing (DON) revealed on 04/21/2022 a Medication Aide (MA) transferred Resident 8 into the shower chair and the resident did not bend legs when the resident sat down on the shower chair. Resident 8's back applied pressure to the back of the shower chair and it tipped Resident 8 backwards. The DON documented Resident 8 did complain of back pain which was relieved with heat, and no apparent injuries reported. EZ Stand was to be utilized when staff transferred Resident 8 to the shower chair for the resident's safety. The time of the fall was not documented by the DON. Record review of the Progress Notes on 4/21/2022 at 09:17 PM revealed Resident 8 did complain to the staff of lower back and stomach pain. Resident did moan and grimace when repositioned in the chair/bed. Heat pack applied by nursing. Record review of the Progress notes dated 04/22/2022 at 08:50AM revealed nursing staff documented: no bruising or swelling to mid upper back. Resident stated the resident felt better. Record review of Resident 8's Resident dashboard dated 04/26/2022 revealed the resident was 6 foot 6 inches tall on 03/18/2022 and weighed 199 pounds on 04/18/2022. In an interview on 04/27/2022 at 12:02 PM with PT-E confirmed PT recommended Resident 8 be transferred with an EZ Stand by nursing since admission. In an interview on 04/27/2022 at 03:00 PM the Administrator confirmed it is the facility's expectation that the Comprehensive Person-Centered Care Plan would incorporate the information on the MDS and recommendations from PT for transfer interventions, and the nursing staff would follow those recommendations.

Licensure Reference Number 175 NAC 12-006.09D6 Based on observation, interview, and record review, the facility failed to ensure a valid order was in the medical record for the Continuous Positive Airway Pressure ([CONDITION(S)])(a machine used to deliver positive airway to a resident's airway to prevent it from closing during sleep) and that supplies were cleaned and changed according to manufacturer's recommendations for 1 (Resident 8) of 1 sampled residents. Total facility census is 16. Findings are: An observation of Resident 11's room on 04/25/2022 at 12:36 PM revealed a ResMed S9 [CONDITION(S)] machine with a heated humidifier located on the resident's nightstand along with an uncovered, uncleaned ResMed Mirage [NAME] [CONDITION(S)] mask, headgear, and heated tubing. Record review of Resident 11's Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 04/26/2022 at 12:36 PM revealed a [CONDITION(S)] machine and uncleaned supplies located on Resident 11's nightstand. An observation on 04/27/2022 at 06:45 AM revealed Resident 11's [CONDITION(S)] machine and uncleaned supplies was located on the resident's nightstand. The [CONDITION(S)] tubing was off the mask and 1 side of the forehead cushion was not on the mask. In an interview with Resident 11 on 04/27/2022 at 06:45 AM, Resident 11 confirmed Resident 11 used the [CONDITION(S)] at night, and the facility did not clean the [CONDITION(S)] or the [CONDITION(S)] supplies. In an interview with Medication Aide (MA)-C on 04/27/2022 at 09:04 AM, MA-C confirmed Resident 11 has a [CONDITION(S)] and the nurses help the resident put the mask on at night. MA-C was not sure who cleaned the mask or supplies, but assumed nursing did it if the resident had not. MA-C confirmed that MA-C had never cleaned the [CONDITION(S)] mask or supplies. Record review of the facility's [CONDITION(S)] Guidelines dated 06/2011 revealed: See manufacturer's instructions. Record review of the undated Resmed S9 [CONDITION(S)] Welcome Guide revealed ResMed recommended tube cleaning weekly, machine cleaning monthly, and replace the filter every 6 months. Record review of the undated ResMed Mirage [NAME] [CONDITION(S)] mask Users Guide revealed ResMed recommended cleaning the mask daily and the headgear weekly. Record review of the undated ResMed Heated Humidifier Welcome Guide revealed ResMed recommended cleaning the humidifier daily. Record review of Resident 11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 11's Admission Minimum Data Set (MDS)(a comprehensive assessment of each residents functional capabilities), section O0100 dated 10/20/2021 revealed Resident 11 used a [CONDITION(S)]. Record review of Resident 11's Comprehensive Person-Centered Care Plan (a plan that provides direction on the type of nursing care the resident may need) dated 10/15/2021 did not reveal interventions for Resident 11's [CONDITION(S)]. In an interview with the Director of Nursing (DON) on 04/27/2022 at 09:04 AM, the DON confirmed there was not a valid order for a [CONDITION(S)], the [CONDITION(S)] and supplies were not on the Comprehensive Person-Centered Care Plan, there was not a schedule for the [CONDITION(S)] or supplies to be cleaned, there was not a record of the [CONDITION(S)] or supplies being cleaned, and there was not documentation of when the [CONDITION(S)] was put on or taken off Resident 11, and all of the above should have been completed and documented in the medical record.

Based on record review and interview, the facility failed to monitor a [CONDITION(S)] access site for Resident 3. The facility census was 16. Findings are: Review of Resident 3 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 3's Care plan revealed the following interventions related to the [CONDITION(S)] access site: - Do not draw blood or take blood pressure readings in my left arm where my I have my fistula(an access site) for [CONDITION(S)]. - Monitor, document, and report as needed any signs or symptoms of infection to access site: Redness, Swelling, warmth or drainage. - Monitor,document, and report as needed for signs or symptoms of the following: excessive bleeding, blood infection or septic shock(a life threatening infection). Review of progress notes revealed no documentation of monitoring bruit and thrill, removal or assessment of pressure dressing, or any care of the [CONDITION(S)] site. Review of Resident 3's Medication administration record(MAR) and Treatment Record (TAR) revealed no documentation of monitoring of the fistula. Rreview of the facility policy dated 12-2020 titled Eastmont Guidelines for Residents Receiving Hemodialysis revealed : - Eastmont will routinely observe the vascular access site for changes, assess for bruit and thrill and report changes to the [CONDITION(S)] facility - Eastmont will coordinate with the [CONDITION(S)] facility regarding diet orders and sending a sack lunch with the resident to [CONDITION(S)]. -If the vascular access site is noted to have active bleeding, Eastmont staff will reinforce the dressing, apply pressure and notify the [CONDITION(S)] center. Review of the April 2022 MAR and TAR for Resident # 3 revealed no documentation of follow up assessment of bruit and thrill (an assessment to determine if access is working) between [CONDITION(S)] appointments and no assessment for bleeding on the day of [CONDITION(S)] after the resident returns. Review of Resident 3's Progress notes revealed no documentation of assessment of [CONDITION(S)] access site between or after [CONDITION(S)] appointments. Interview on 04/27/22 at 8:05 AM with Registered Nurse (RN) F revealed that the staff should be checking for Bruit and Thrill and monitor bleeding after [CONDITION(S)] and documenting in Resident 3's medical record.

Based on record review and interviews, the facility failed to ensure the Ombudsman was informed in writing of unplanned transfers/discharges for 2 residents (Resident 6 and 7). The facility census was 9. The sample included 9 current residents. Findings are: A. Record review of Resident 7's Interdisciplinary Progress Note (IPN) revealed the resident had been transferred to the hospital on [DATE]. Record review of Resident 7's electronic medical records revealed no documentation the Ombudsman was notified in writing of the resident's hospital discharge. Interview with the DON (Director of Nursing) on 02/11/21 at 11:11 AM revealed the facility did not notify the Ombudsman of Resident 7's discharge to the hospital. B. An interview on 02/10/21 at 10:59 AM with Resident 6 revealed the resident fell and broke thier leg and had to be transferred to the hospital for blood in the stool. Record reivew of Resident 6's PN (Progress Note) dated 1/29/21 at 11:54 AM revealed; COMMUNICATION - with Physician: Noted patient had two maroon colored stools with visible clots, [MEDICATION NAME] positive, Blood Pressure was 129/100 as patient kept moving, no SOB (Shortness of Breath), skin is pale per normal, pulse 106, O2 is 93% on RA (Room Air), temp 97.0, called PCP (Primary Care Physician) and updated on condition and asked for call back, will update family as soon as orders received from PCP and will call back within one hour if no return call. Record review of Resident 6's PN dated 1/29/2021 at 1:59 PM COMMUNICATION with Physician revealed; Received orders to send patient to ER (emergency room ) for evaluation of GI (Gastrointestinal) bleed. Record review of Resident 6's PN dated 1/29/21 at 2:01 PM revealed; Patient alert, skin was pale per normal. Patient states (gender) felt cold. Blood pressure was 94/42, SaO2 is 92% on RA(Room Air), patient was able to answer questions, updated patient on PCP order to send to ER for evaluation of possible gi s/s (signs/symptoms, also that we had updated family, patient agreed hospital would be best. Patient left the facility going to the hospital. An interview on 02/16/21 with the Administrator confirmed the facility failed to notify the ombudsman of Resident 6's unplanned discharge.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E3 & 12-006.12E1 Based on observation, interviews, and record review; the facility failed to ensure all medications were stored and labeled in accordance with standards of practice. This had the potential to affect 2 residents (Resident 108 and Resident 110) out of 9 sampled residents. The facility census was 9. Findings are: Observation on 2/10/21 at 2:45 PM of the medication server closet in room [ROOM NUMBER] revealed a medication cup full of an unidentified/unlabeled orange medication and a medication cup with 2 pills of an unidentified white medication. RN (Registered Nurse) A and MA (Medication Assistant) B were present for the observation and could not identify the medications. Interviews of RN A and MA B on 2/10/21 at 2:50 PM revealed the staff could not identify either medication left in the unlabeled and undated medication cups in the storage closet of room [ROOM NUMBER]. Further interview identified this was not the protocol of the facility. Interview of the Director of Nursing on 02/10/21 at 03:50 PM revealed the expectation of staff would be to ensure that medications remained in a container provided by pharmacy so staff could identify the medication. Review of document titled Policy and Procedure Manual for Medication Storage In Facility revised 2020 revealed medications and biologicals were to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. B. Record review of Resident 110's PN (Progress Note) dated 2/4/2021 at 9:11 PM revealed; Resident 110 stated (gender) took medications that (gender) brought with them from the hospital. These medications were Pantoprazole, Ropinirole, Tylenol and restless leg medication. An interview on 02/11/21 at 10:39 AM with the DON (Director of Nurses) confirmed Resident 110 had access to medications brought from hospital and took them without having a self-administration assessment completed. The DON reported the medications had been faxed but the pharmacy had not received the medication list which caused a delay in delivery of Resident 110's medication. The DON confirmed they had not seen Resident 110 take the medications. A record review of the Medication Storage Policy not dated revealed; Purpose: Safely store various medications Equipment: Refrigerator, med carts, narcotic drawer Policy: 1. All medications will be stored in a locked area unless a may keep at bedside order is present. 2. All narcotic will be stored in a double locked area 3. Medications labeled Refrigerate will be stored in the refrigerator under the narcotic drawer. 4. Internal and external medications will be stored on separate drawers in the medication cart 5. Pharmacy will complete Medication Room Inspection from periodically. 6. Medications and treatments will be properly labeled. 7. House medications will be stored in a locked cupboard in the medication room.

Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observations, record reviews and interviews; the facility failed to ensure the oxygen tubing and nasal cannula were not left on the floor, and failed to ensure oxygen tubing was changed per facility policy. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation on 07/02/19 at 09:46 AM revealed Resident 9 sitting up in recliner chair, oxygen off and oxygen tubing including the nasal cannula lying on the floor. Observation on 07/02/19 at 01:00 PM revealed Resident 9 sitting up in recliner chair finishing eating lunch. Oxygen off and oxygen tubing including the nasal cannula lying on the floor. Review of Oxygen Therapy Protocol dated 9/26/12 revealed that if using PRN oxygen, change nasal cannula and tubing every other week. Record review of (MONTH) and (MONTH) Treatment Administration Record (TAR) 2019 revealed no documentation of oxygen tubing being changed. Interview with Director of Nursing (DON) on 07/02/19 at 03:35 PM confirmed that nasal cannula tubing should not be on the floor and that tubing information should be documented on the TAR. Interview with DON on 07/03/19 at 12:57 PM confirmed that no documentation was present to reflect that the oxygen tubing had been changed on Resident 9.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to ensure staff followed facility policy to wash hands and change gloves after handling used dressings. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation of wound care on 07/02/19 at 09:46 AM- 09:46 AM by RN (Registered Nurse) A revealed RN A washed hands and set up supplies on towel placed on chair, applied gloves, took Resident 9's shoe and sock off right foot, cleansed scissors with alcohol pad and cut off outer Kerlix dressing, then removed [MEDICATION NAME] pad and with same gloves on, went to sink and wet wash cloth, applied soap and washed wound. Then RN A removed gloves, washed hands and applied clean gloves, applied gauze drsg to wound and then wrapped area with Kerlix, applied tape, dated dressing, applied Resident 9's sock and shoe and then removed gloves and washed hands. Review of hand washing guidelines dated 12/14 revealed hand washing should be done after handling used dressings. Interview on 7/2/19 at 3:35 PM with DON (Director of Nursing) confirmed that after removing dirty dressings, gloves should be removed, hand hygiene completed and clean gloves applied before continuing with wound treatment.