Every finding on record at Eventide Crete

Licensure Reference Number 175 NAC 12-006.09(G)(ii).Based on record review and interview, the facility failed to document a recapitulation (a complete summary of the resident stay in the nursing home from admittance to discharge) for one (Resident 38) of 5 sampled residents. The facility census was 32. A record review of admission record reveals that Resident 38 was admitted to the facility on 7/25 with the diagnosis of Heart failure, pericardial effusion (where excessive fluid accumulates in the pericardial sac, the thin membrane surrounding the heart), Coronary artery disease (where the arteries that supply blood to the heart become narrowed or blocked), Acute-on-chronic kidney disease (where an acute decline in kidney function that occurs in individual with chronic kidney disease), and Hypertension (high blood pressure). A record review of Resident 38 progress notes revealed that on 8/15/25 Resident 38 was discharged to the hospital due to critically high potassium levels. Resident 38 representative was present and a bed hold policy was given to the representative and the representative declined the bed hold policy. Resident 38 was discharged from the facility.A record review of the Facility's undated policy for Discharge residents revealed:Team leaders will complete discharge checklist, notify necessary departments and documents in medical recordsRN/LPN will complete a discharge progress note.An interview on 9/17/25 at 1:30 PM with the MDS coordinator confirmed that a discharge summary for Resident 38 had not been completed. The MDS coordinator confirmed that (gender) didn't think a discharge summary was to be done because Resident 38 was sent to the hospital.MDS coordinator confirmed that (gender) was aware that the representative for Resident 38 declined the Bed hold and that Resident 38 was discharged from the facility.

Based on interview and record review, the facility staff failed to complete a PASARR (Pre-admission Screening and Resident Review) assessment for one resident (Resident 28) of 5 sampled residents after a new diagnosis of a mental disorder, after admission to the facility, to determine if Resident 28 was receiving the necessary services indicated for the disorder. The facility census was 32. A record review of Resident 28 admission record dated 9/17/25 reveals that Resident 28 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease (a progressive neurological disorder that affects movement), Dementia with mood/psychotic disturbance (includes depression, anxiety while psychotic symptoms include hallucinations, and delusions), Adjustment disorder with mixed anxiety and depressed mood (persistent feelings of sadness, hopelessness), Hallucinations (something that seems real to the person but has no actual external stimulus or physical source), Delusional disorders (false beliefs that persist for at least a month).A record review of Resident 28 PASARR dated 3/23/23 reveal SMI (Significant Mental Illness) and mental disorder was marked as Major Depression. No other PASARR was noted to be completed after 3/23.A record review of Resident 28 diagnosis revealed that on:12/5/24 received a new diagnosis of Delusional Disorder.1/13/25 received a new diagnosis of Hallucinations.3/6/25 received a new diagnosis of Adjustment Disorder with mixed anxiety and Depressed Mood.A record review of the Care Plan with a initiated date of 10/19/23 and Revision date of 5/2/25 revealed that Resident 28 had a history of hallucinations and delusions and adjustment disorder with mixed anxiety and depression.A record review of the facility Policy and Procedures for readmission Assessment and Annual Resident Review Screening (PASRR) with no date revealed:Procedure:The facility will complete a new PASARR screen upon a significant change in mental health or with newly diagnosed mental illness/disorder, intellectual disability, or related condition for a Level 2 review. The resident care plan will be updated to reflect the changes in the assessment or identified in the PASRR screen.An interview on 9/17/25 at 10:13 AM with Social Services confirmed that the last PASARR for Resident 28 was done on 3/23 and a new PASARR for Resident 28 should have been done with each of the new mental illness/disorder diagnosis and it wasn't done.

Licensure Reference Number 175 NAC 12-006.11(E) Based on record reviews, observations, and interviews, the facility failed to ensure the facility's dishwashing machine for House 2 reached the required water temperature to prevent the potential for food borne illnesses, failed to clean range hoods and ice machines in Houses 1 and 2, and ovens in House 1 in a manner to prevent the potential for food borne illnesses, failed to ensure food was covered to prevent cross-contamination while transported through the hallway for Resident 2 and Resident 13, and failed to implement hand hygiene practices in House 2 to prevent cross contamination and the potential for food borne illnesses. These practices had the potential to affect all residents who ate food that was prepared in one of the kitchens. The facility census was 34, and there was one resident who received nutrition through a feeding tube, and did not eat. Findings are: A. A review of the 2017 Nebraska Food Code 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature revealed: (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (2) For a stationary rack, dual temperature machine, 66 C [degrees Celsius] (150 F). An observation made on 08/07/2024 at 7:30 AM of the House 2 kitchen revealed the kitchen had two dishwashing machines. The machine on the left was a [NAME] brand. The machine on the right was a [NAME] brand, and had a panel on the bottom of the front that had gauges on it. Two of the gauges were labeled Wash High Temp 150 F [degrees Fahrenheit] and Rinse High Temp 180 F. An interview on 08/07/2024 at 7:40 AM with [NAME] B revealed that the facility used heat, not chemicals for dish sanitation. An observation on 08/07/2024 at 7:41 AM of the [NAME] dishwashing machine running through a cycle revealed the wash temperature reached 130 F and the rinse temperature reached 190 F. An interview on 08/07/2024 at 7:41 AM with Medication Aide (MA) A confirmed that the [NAME] dishwashing machine wash temperature had been 130 F. An observation on 08/08/2024 at 8:44 AM of the [NAME] dishwashing machine running through a cycle revealed the wash temperature got to 120 F, and the rinse temperature got to 190 F. An interview on 08/08/2024 at 8:44 AM with the Dietary Manager (DM) confirmed that the wash temperature had been 120 F. An observation on 08/12/2024 at 10:11 AM of the [NAME] dishwashing machine running through a cycle revealed the wash temperature reached 134 F and the rinse temperature reached 200 F. An interview on 08/12/2024 at 10:11 AM with the DM confirmed the wash temperature had been 134. A review of the facility's undated Dishwasher Temperature Logs/Reporting policy revealed the following: -Each dish machine will be monitored for established proper temperature for dish washers -A temperature log will be maintained for recording wash and final rinse temperatures. The cook will record the temperature on the temperature log daily. The dishwasher will be drained and cleaned at the completion of each meal service. Temperatures that do not meet standards will be reported to the Dietary Manager or Maintenance Department. In addition, all dishes that have been washed while at substandard temperatures will be rewashed once the machine is at acceptable temperatures. If acceptable temperatures cannot be maintained, the 3 sink method of dishwashing will be employed, with a sink for washing, one for rinsing and one for sanitizing being used. A review of the Dishwashing/Warewashing Machine Temperature Log marked [DATE] provided for House 2 revealed no temperatures were documented for 08/03/2024 or 08/04/2024. On 08/01/2024, the wash temperature was documented as 140 F, and the rinse temperature as 116 F. On 08/02/2024, the wash temperature was documented as 167 F, and the rinse temperature was not documented. On 08/05/2024, the wash temperature was documented as 140 F, and the rinse temperature was not documented. On 08/06/2024, the wash temperature was documented as 168 F, and the rinse temperature was not documented. There was no indication on the log of which machine had been checked. The top section of the log had spaces to list the type of machine and the temperature requirements for high and low temperature machines, and the chemical concentration [measured in parts per million (ppm)], requirement for low temperature machines. It also had instructions to Use a separate Temperature Log sheet for each machine, and Record temperatures, flow pressure (** and ppm, where applicable) once during each meal period. None of the temperature or ppm requirements were filled out. An interview on 08/07/2024 at 8:02 AM with [NAME] B confirmed that the cooks checked the dishwashing machine temperatures daily and kept a log. [NAME] B further confirmed that they only checked the temperature of one dishwashing machine per House during the day. An interview on 08/08/2024 at 8:46 AM with the DM confirmed that the cooks checked the water temperatures on whichever dishwashing machine they were using, and that they used one machine during the day. The DM confirmed that the cooks should have marked which machine they checked on the Dishwashing/Warewashing Machine Temperature Log, and should notify the DM or maintenance right away if the temperatures were low. The DM further confirmed that the dishwashing machine water temperatures did not get checked until the cook arrived, and that the staff member serving breakfast did not check the dishwashing machine water temperatures. An interview on 08/08/2024 at 8:56 AM with the DM confirmed that the aides were not likely to watch the water temperatures and rerun the machine if they were low. An interview on 08/08/2024 at 8:56 AM with Housekeeper (Hsk) D confirmed they did not watch the temperatures while the dishwashing machine was running. An interview on 08/08/2024 at 2:09 PM with the DM confirmed that the cooks did not come in until 10:00 AM. Prior to 10:00 AM, another person who worked in the House prepared and served breakfast and cleaned up after the meal. The DM confirmed that from Monday through Friday that person was Nurse Aide (NA) C in House 2 and Hsk D in House 1. The DM revealed that each person who worked in the kitchen completed a basic education packet on preventing food borne illnesses. A review of the undated Care Partner Training Preventing Food Borne Illness packet provided by the DM revealed no information regarding required dishwashing machine temperatures. B. 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. An observation on 08/07/2024 at 7:44 AM revealed the exhaust hoods above the stove in House 2 had a dark brown substance on them. An interview on 08/07/2024 at 7:44 AM with MA A confirmed there was a dark brown substance on the exhaust hoods in House 2. An observation on 08/07/2024 at 7:55 AM revealed the exhaust hoods above the stove in House 1 had a dark brown substance on them. An interview on 08/07/2024 at 7:55 AM with [NAME] B confirmed there was a dark brown substance on the exhaust hoods in House 1. An observation on 08/08/2024 at 8:46 AM revealed the exhaust hoods above the stove in House 2 had a dark brown substance on them. An interview on 08/08/2024 at 8:46 AM with the DM confirmed there was a dark brown substance on the exhaust hoods in House 2. The DM further confirmed that the exhaust hoods had not been cleaned for about 3 months since they changed maintenance personnel. The DM stated the task had been on the previous maintenance person's calendar, and when the new maintenance person started, they forgot to add cleaning the exhaust hoods to the new person's calendar. An observation on 08/08/2024 at 9:00 AM revealed the exhaust hoods above the stove in House 1 had a dark brown substance on them. An interview on 08/08/2024 at 09:00 AM with the DM confirmed there was a dark brown substance on the exhaust hoods in House 1. C. An observation on 08/12/2024 11:57 AM revealed a room tray was carried in the hall to Resident 2 by Nurse Aide (NA) C. A container of peaches was not covered to be carried through the halls. An observation on 08/12/2024 12:00 PM revealed a room tray was carried in the hall to Resident 13 by NA G. A container of peaches was not covered to be carried through the halls. An interview on 08/12/2024 12:15 PM with NA C confirmed that the peaches had not been covered and that foods and drinks should be covered to carry them through the halls. An interview on 08/12/2024 12:16 PM with NA G confirmed that the peaches had not been covered and that foods and drinks should be covered to carry them through the halls. 47406 D. An observation on 08/12/2024 at 9:56 AM with Cook-B for meal preparation in House 1 revealed Cook-B with gloved hands placed frozen chicken in a mixture of flour, salt, and pepper, then placed in pan to fry. An observation of on 8/12/24 at 10:25 AM with Cook-B revealed [gender] washed [gender] hands with soap and water for 10 seconds then dried [gender] with a paper towel. Cook-B then shut the faucet off with [gender] bare hand. Next Cook-B opened a can of green beans and placed then in a pan on top of the stove. An observation on 8/12/24 at 10:36 AM of Cook-B revealed [gender] washed [gender] hands with soap and water for 12 seconds then donned (put on) gloves. Cook-B then cut up onions, and added minced garlic, thyme, mushrooms, and cooking [NAME] into bowl per recipe, then stirred and sat to the side for later. An observation on 8/12/24 at 10:51 AM of Cook-B revealed [gender] washed [gender] hands for 10 seconds and then dried [gender] hands. Cook-B then used the same paper towel that was used to dry [gender] hands to shut off the water faucet. Cook-B placed lemon juice, diced up tomatoes, dill weed dried, parsley, pepper, and diced onion in bowl for later after stirring. Cook-B placed Rotini noodles in a pan of water and placed on the stove. All of this was done using a recipe. In an interview with Cook-B on 8/12/24 at 11:07 AM revealed Cook-B should have washed [gender] hands longer and used a clean towel to shut off the faucet, and stated, I was in a hurry I guess. In an interview with the DM on 8/13/24 at 7:20 AM revealed the expectation of the kitchen staff is to wash hands for 20 seconds and to use a paper towel when shutting off the faucet. A record review of Hand Hygiene- Infection Prevention policy dated 9/25/2019 revealed: A. Indications for Handwashing 3. Handwashing shall also be used for routinely decontaminating hands in the following clinical situations: -After removing gloves -Before any food preparation or serving Non-Surgical Hand Hygiene Technique Handwashing with soap and water: Vigorously rub hands together for at least 15-20 seconds, covering all surfaces of hands and fingers. Dry hands thoroughly with a disposable towel(s). Use disposable towel to turn off the water. E. An observation on 8/12/24 at 10:59 AM revealed the ice machine in House 1 had a greenish substance on the deflector of the machine. The Registered Dietician (RD) wiped off some of the substance onto a paper towel and revealed a dark greenish moist substance. In an interview on 8/12/24 at 11:00 AM with the RD confirmed that the ice machine needed to be cleaned. An observation on 8/12/24 at 11:03 AM of House 2 kitchen's ice machine deflector had a blackish substance on it. The RD wiped the deflector with a paper towel and revealed a black moist substance. In an interview on 8/12/24 at 11:04 AM with the RD confirmed that the ice machine needed to be cleaned also. RD said both ice machines would be cleaned today, and the facility would use the ice machine in the garage. An observationoOn 8/12/24 at 11:20 AM of the ice machine in garage revealed the machine was clean. Record review of kitchen weekly cleaning schedule revealed the ice machine is to be cleaned every Wednesday. Record review revealed these were not marked as being completed. F. An observation in House 1 on 8/12/24 at 10:56 AM revealed both ovens with black and brown charred substance. In an interview on 8/12/24 at 10:57 AM with the RD revealed the ovens were dirty and needed cleaned. Record review of kitchen weekly cleaning schedule revealed the left and right ovens are to be cleaned on Friday. Record review revealed these were not marked as being completed.

Licensure Reference Number 175 NAC 12-006.09 (C)(ii) Based on record reviews and interviews, the facility failed to complete a Significant Change in Stats Assessment (SCSA) Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities. An SCSA is required when a resident has a major improvement or decline in condition that will not resolve itself.) was completed within 14 days of a significant change for 1 (Resident 17) of 12 residents sampled. The facility census was 34. Findings are: A record review of Resident 17's Admission Record dated 08/08/2024 revealed an admitted [DATE], and diagnoses of heart failure, chronic kidney disease, poor circulation in the legs, dementia, and a history of a heart attack. The resident had a diagnosis of pneumonia with an onset date of 05/19/2024. A record review of the Minimum Data Set 3.0 Resident Assessment Instrument User's Manual v1.18.11 effective October 2023: Some Guidelines to Assist in Deciding If a Change Is Significant or Not: A condition is defined as self-limiting when the condition will normally resolve itself without further intervention or by staff implementing standard disease-related clinical interventions. If the condition has not resolved within 2 weeks, staff should begin an SCSA. An SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. An SCSA is also appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL [Activities of Daily Living-activities related to personal care, such as eating, dressing, and hygiene] decline or improvement). Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; A record review of Resident 17's Quarterly MDS dated [DATE], Section O Special Treatments, Procedures, and Programs revealed that the resident was not using oxygen at that time. Section GG Functional Abilities and Goals revealed the resident's assistance needs were as follows: Coding for the amount of assistance needed is as follows: 06. Independent - Resident completes the activity by themselves with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) Self-Care Eating-5 Oral hygiene-5 Toileting hygiene-2 Shower/bathe-2 Dressing upper body-5 Dressing lower body-5 Putting on footwear-2 Personal hygiene-4 Mobility Rolling side to side in bed-6 Going from sitting to lying-6 Going from lying to sitting-6 Going from sitting to standing-6 Transferring to and from bed to chair or wheelchair-6 Toilet transfer-6 Tub/shower transfer-4 Walking 10 feet-6 Walking 50 feet with two turns-6 Walking 150 feet-6 A record review of Resident 17's Quarterly MDS dated [DATE], Section O Special Treatments, Procedures, and Programs revealed that the resident was using oxygen at that time. Section GG Functional Abilities and Goals revealed the resident's assistance needs were as follows: Self-Care Eating-5 Oral hygiene-4 Toileting hygiene-2 Shower/bathe-2 Dressing upper body-3 Dressing lower body-3 Putting on footwear-2 Personal hygiene-4 Mobility Rolling side to side in bed-5 Going from sitting to lying-4 Going from lying to sitting-4 Going from sitting to standing-3 Transferring to and from bed to chair or wheelchair-3 Toilet transfer-3 Tub/shower transfer-1 Walking 10 feet-4 Walking 50 feet with two turns-Not attempted due to medical condition or safety concerns. Walking 150 feet-Not attempted due to medical condition or safety concerns. Compared to the 05/07/2024 MDS, Resident 17 was requiring more assistance to move in bed, go from sitting to lying or lying to sitting, walk 10 feet, and perform oral hygiene. Resident 17 had also begun to need oxygen. The resident was newly coded as 3-partial/moderate assistance for dressing their upper and lower body, going from sitting to standing, transferring to or from bed to chair or wheelchair, and toilet transfer, as a 1-dependent for tub/shower transfer, and as not attempted for walking 50 feet with two turns or 150 feet. A review of Resident 17's Progress Notes revealed a note from 05/19/2024 that indicated when the resident became ill. An observation on 08/08/2024 at 9:01 AM revealed Resident 17 in their room, seated in the recliner with their feet up. Resident 17 was wearing oxygen set at 1 liter per minute (L/min) on the oxygen concentrator. An observation on 08/12/2024 at 7:39 AM revealed Resident 17 seated in the dining room for breakfast wearing oxygen connected to the portable tank. An observation on 08/13/2024 at 7:40 AM revealed Resident 17 seated in the dining room for breakfast wearing oxygen connected to the portable tank. An interview on 08/13/2024 at 7:50 AM with the Director of Nursing (DON) confirmed that Resident 17 had a decline in abilities in May of 2024, due to having pneumonia, and was not back to their baseline at this time. An interview on 08/13/2024 at 12:35 PM with the Registered Nurse/MDS Coordinator (RN-MDS) revealed that Resident 17 had improved since the 05/25/2024 MDS was completed, but was still not back at their baseline. An interview on 08/13/2024 at 2:35 PM with the RN-MDS confirmed that an SCSA should have been done within 14 days when Resident 17 had a significant decline in status and did not return to her baseline.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record reviews and interviews, the facility failed to revise the comprehensive care plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) after a change for Resident 22 regarding code status (the type of treatment a person would or would not receive if their heart or breathing were to stop) and for Resident 33 regarding a urinary catheter (tube to drain the bladder). This affected 2 of 12 residents reviewed for care plan revision. The facility census was 34. Findings are: A. A record review of Resident 22's Clinical Census dated 08/08/2024 revealed the resident was admitted to the facility on [DATE] and was admitted to hospice services on 06/06/2024. A record review of Resident 22's Medical Diagnosis List dated 08/13/2024 revealed the resident had diagnoses of chronic kidney disease, atrial fibrillation (an irregular heartbeat), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anxiety, exocrine pancreatic insufficiency (a condition in which your small intestine can't digest food completely because of problems with digestive enzymes from your pancreas), a history of blood clots in the legs, and pain. A record review of Resident 22's Electronic Health Record (EHR) revealed a Do Not Resuscitate (DNR-if heartbeat and respirations stop, the individual does not want medical personnel to attempt to restart the heart) document signed by the resident's POA (Power of Attorney- a legal document that allows one person to make decisions for another person) on 06/06/2024 and by the medical provider on 06/17/2024. A record review of Resident 22's CCP revealed a care plan focus initiated 12/29/2021 and revised on 10/04/2022 that stated: Advance Directive [a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury]: Full Code [if heartbeat and breathing stop, the individual does want medical personnel to start interventions needed to get the heart restarted, including chest compressions, a breathing tube, and shocking the heart to correct a life-threatening rhythm]. The goal, initiated 12/29/2021 and revised 08/07/2024, for this care plan was: [Resident 22's] wishes will be followed through next review. The intervention, initiated 12/29/2021 and revised 06/01/2022, listed for this care plan was: Advance Directive completed full code, POA Healthcare: [family members listed]. An interview on 08/13/2024 at 12:11 PM with Registered Nurse (RN) E confirmed Resident 22's care plan was not revised to reflect the change in Resident 22's code status. B. A record review of Resident 33's Admission Record dated 08/08/2024 revealed the resident was admitted to the facility on [DATE] and had diagnoses of a right femur (thigh bone) fracture, chronic kidney disease, heart disease, urinary retention (a condition where you can't empty your bladder), and a history of prostate (a gland located just below the bladder in men that surrounds the top portion of the urethra [the tube that drains urine from the bladder]) cancer. A record review of Resident 33's Progress Notes revealed a N Adv Clinical Admission note from 06/19/2024 at 11:48 AM that stated Elder has history of Prostate Cancer. Had severe urinary retention requiring catheterization in the hospital. Urology placed foley [a type of urinary catheter] prior to discharge on 6/18 with orders for follow up in two weeks. A record review of Resident 33's Progress Note dated 08/01/2024 at 2:57 PM revaled that Resident 33 returned from their cystoscopy (a procedure healthcare providers use to view the inside of the bladder and urethra) appointment with the catheter removed. A record review of Resident 33's Order Summary dated 08/08/2024 revealed: -an order dated 08/07/2024 that stated if the resident was unable to urinate, the facility should do a bladder scan (a portable ultrasound that measures the volume of urine in the bladder) and if it was over 400 milliliters (ml) insert a temporary tube to drain the bladder and update the urologist and primary care during business hours, and -an order dated 08/04/2024 to track the resident's intake and output twice a day to monitor for urinary retention. A record review of Resident 33's CCP revealed a care plan focus initiated 07/04/2024 and revised on 07/04/2024 that stated: Urinary: [Resident 33] has an indwelling Foley Catheter Following with [provider office] -Unsuccessful removal in-house 6/24/24 -7/3 Voiding trial at [provider office] failed -Scheduled Cystoscopy The goals, initiated 07/04/2024 and revised 08/07/2024, for this care plan was: -The resident will show no s/sx [signs or symptoms] of urinary infection through review date; and -The resident will be/remain free from catheter-related trauma through review date. The interventions, all initiated and/or revised on 07/04/2024, listed for this care plan were: -Catheter: [Resident 33] needs 18fr Foley Cath. Position catheter bag and tubing below the level of the bladder and away from entrance room door. -Flush with NS [normal saline-a solution used to rinse out debris or mucus] as ordered by [provider office]. -Monitor for s/sx of discomfort on urination and frequency. -Monitor/document for pain/discomfort due to catheter. -Monitor/record/report to MD for s/sx UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, -Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. -Notify [provider office] pf s/s of bleeding (as per orders). An interview on 08/07/2024 at 1:36 PM with Resident 33 revealed that the resident had previously had a urinary catheter, but it was removed due to bladder irritation and blood in the urine. The resident stated the staff were trying to train me to have more function. An interview on 08/13/2024 at 12:10 PM with RN E confirmed that Resident 33's care plan had not been revised after the catheter was removed to reflect the resident's change in urinary status.

Licensure reference number 175 NAC 1-005.06 (D) Based on observation, interviews and record review, the facility failed to ensure that staff performed hand hygiene between glove changes prevent cross contamination during catheter care for 1 (Resident 19) of 1 sampled resident. The facility census was 34. Findings are: Record review of Resident 19's medical record of clinical census revealed Resident 19 admitted to the facility on [DATE]. Record review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/4/24 revealed Section H: scored 9 indicating resident had a catheter. Observation of catheter cares for Resident 19 on 8/12/24 at 8:33 AM with MA-F, revealed MA-F donned (put on) surgical mask, gloves, and gown. Observation did not revealed that MA-F performed hand hygiene prior to donning gloves. MA-F pulled resident's sweatpants down to ankles and opened the brief on the resident. MA-F then changed [gender] gloves and did not complete hand hygiene. Next MA-F completed peri care and catheter for Resident 19. MA-F then assisted Resident 19 to [gender] left side and removed the dirty brief and applied a clean brief and pulled up the sweatpants. The observation did not reveal that MA-F changed gloves and did not perform hand hygiene prior to applying a clean brief. MA-F then changed [gender] gloves then used a graduate container and emptied the catheter drainage bag. MA-F then cleaned the catheter drainage bag opening with an alcohol wipe and washed [gender] hands with soap and water for 20 seconds. Interview on 8/12/24 at 8:48 AM with MA-F confirmed [gender] should have performed hand hygiene prior to donning gloves, mask, and gown, and when changing gloves each time. Interview on 8/12/24 at 2:35 PM with DON revealed the facilities expectations for hand washing is 15-20 seconds and to perform hand hygiene between changing gloves. Hand hygiene- infection prevention policy dated 9/25/19 revealed: Procedure: A. Indications for Handwashing 3. Handwashing shall also be used for routinely decontaminating hands in the following clinical situations: -when moving from a contaminated body site to a clean body site during client care, and after removing gloves. If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminated hands in the following clinical situations: When moving from a contaminated body site to a clean body site during client care, and after removing gloves.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to ensure that food was held at 135 degrees Fahrenheit or above during meal service to prevent the potential for foodborne illness. This had the potential to affect 37 residents that ate food prepared in the facility kitchen. Facility census was 38. Findings are: An observation on 10/4/22 at 11:19 AM revealed in House 1, the Cook removed food items from the oven. Temperatures were as follows: roast turkey 195.4 degrees F (Fahrenheit), pork 196.2 degrees F, squash 180 degrees F, green beans 194.8 degrees F. Twenty-two minutes after the food was removed from the oven, the Cook began to serve without rechecking temperatures. At 11:55 AM, meal service ended. The temperature of the turkey was 116.5 F. Interview with the Cook on 10/4/22 at 11:55AM revealed 116.5 F temperature of the turkey was not high enough of a temperature. An observation on 10/4/22 AM at 11:35 AM revealed in House 2, the Cook removed food items from the oven. Temperatures were as follows: green beans 180 degrees F, stuffing 190 degrees F, pork 180 degrees F, squash 190 degrees F, turkey 190 degrees F. The food was immediately served. At 12:07 PM, all residents had been served and the Dietary Manager (DM) stated, we're finished. In an interview on 10/4/22 at 12:07 PM with the DM revealed that the facility does not check temperatures at the end of meals. A record review of daily temperature logs from September 3rd and 4th revealed no temperatures had been taken after meals on those dates. An observation on 10/4/22 at 3:34 PM of the DM looking through a pile of September temperature logs, revealed no temperatures recorded on other dates as well. A record review of the undated [NAME] Health Care Services Policy & Procedure Manual, [NAME] in [NAME] Food and Nutrition: Safe Food Temperatures for Meal Services, revealed #5: Food should be removed from the oven/refrigerator/freezer just prior to service. Temperatures are then taken of all potentially hazardous items. These temperatures are to be recorded into the food temperature log found in the HACCP book. There is no mention of holding temperatures at the end of meal service. A record review of Nebraska Food Code Section 81-2, 272.01: Time/Temperature Control for Safety Food, Hot and Cold Holding revealed: food to be held at 135 F or above. In an interview on 10/4/22 at 3:34 PM with DM confirmed that no temperatures had been taken throughout September after meal service.

Based on record review and interview, the facility failed to provide a surety bond to cover the amount in the Resident Trust Accounts (RTA). This had the potential to affect 21 residents. The facility census was 33. Findings are: A review of an email dated 10/5/22 provided by the facility gave the balance of the facility's trust account as $4864.06. In an interview conducted on 10/6/22 at 10:44 AM, the Administrator (ADM) confirmed the facility did not currently have a surety bond for the trust account. In an interview conducted 10/6/22 at 11:13 AM, the ADM confirmed that 21 residents had RTAs.

Licensure Reference Number 175 NAC 12-006.05 (1) Based on record review and interview, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) within the required time frame for 2 Residents (7 and 27) of 3 sampled residents. The facility census was 33. Findings are: A. A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review worksheet for Resident 7 revealed a last covered day of Medicare Part A service of 7-14-22. No SNF ABN was completed, and the reason given was No reason to believe payment would be denied. B. A review of the SNF Beneficiary Protection Notification Review worksheet for Resident 27 revealed a last covered day of Medicare Part A service of 8-12-22. No SNF ABN was completed, and the reason given was No reason to believe payment would be denied. An interview with the Administrator (ADM) conducted 10/5/22 at 3:24 PM confirmed that the facility had not provided SNF ABNs to Resident 7 or Resident 27.

LICENSURE REFERENCE NUMBER 12-006.09D Based on interview and record review, the facility failed to ensure residents received medication monitoring in accordance with professional standards of practice and per facility policy related to blood pressure, pulse and weight monitoring for Residents 8, 16, 22, 28, 31 and 32. The sample size was 12. The facility identified a census of 36. FINDINGS ARE: A. A record review completed on 06/08/21 at 09:13 AM of the active orders for Resident 8 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review for Resident 8 revealed daily weights were scheduled every morning at 04:00 AM. A record review completed on 06/08/21 at 09:13 AM of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review completed on 06/08/21 at 09:13 AM of the Progress Notes dated 5/18/21 through 5/24/21 for Resident 8, revealed on 5/21/21 and 5/24/21 daily weights had not been completed due to Resident 8 being unsteady on feet or requiring 2 asst. The record review of the MAR/TAR dated May 2021 for Resident 8 revealed that the [MEDICATION(S)] 20mg extra dose had been given despite no weights being completed. An interview with the DON (Director of Nursing) conducted on 06/08/21 at 09:05 AM confirmed [MEDICATION(S)] had been given to Resident 8 despite no weights being obtained and documented. During the interview, it was confirmed that the facility did have other means of obtaining a weight such as wheelchair scales and Hoyer lift (a mechanical lift used to transfer residents from one surface to another) scales. B. A record review of the active orders list for Resident 16 conducted on 06/02/21 at 02:01 PM revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MAR/TAR dated June 2021 for Resident 16 conducted on 06/02/21 at 02:01 PM revealed no blood pressure monitoring had occurred. C. A record review of the active orders list for Resident 22 conducted on 06/07/21 at 09:51 AM revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It is also used to treat certain types of irregular heartbeat (such as chronic [CONDITION(S)] fibrillation) without parameters and [MEDICATION(S)] (a medication used to treat high blood pressure and It is also used to lower the risk of strokes in patients with high blood pressure and an enlarged heart) and [MEDICATION(S)] (a medication used to treat hypertension and angina) without parameters. A record review of the MAR/TAR dated June 2021 and May 2021 for Resident 22 conducted on 06/07/21 at 09:51 AM revealed no blood pressure or pulse monitoring had been documented. An interview with the facility DON on 06/07/21 at 03:30 PM confirmed the facility policy titled Medication Monitoring Guidelines, undated, was to check pulses prior to giving [MEDICATION(S)]. After review of the June 2021 MAR for Resident 22, the DON confirmed pulses for [MEDICATION(S)] and blood pressures for [MEDICATION(S)] should have been done prior to med administration and was not. A record review conducted on 06/08/21 at 09:34 AM of the facility policy, undated and titled Medication Monitoring Guidelines revealed procedure guideline 1a to read [MEDICATION(S)] 1) obtain [MEDICATION(S)] level, electrolyte and creatinine q 6 to 12 months and 2) check radial/apical pulse immediately before administering. If pulse is less than 50 or irregular, hold dose and contact physician. An interview with the facility DON on 6/8/21 at 09:30 AM revealed that a fax had been sent to the physician of Resident 22 questioning the need for parameters for the [MEDICATION(S)] and [MEDICATION(S)], to which the physician stated parameters were not needed due to such low doses. D. A record review conducted on 06/08/21 at 02:03 PM of the active orders list for Resident 28 revealed a current order for [MEDICATION(S)] 80 mg by mouth in the morning for pulmonary hypertension, notify MD if weight gain of >5 lbs and will return dose to 40 mg twice daily. A record review of the MAR/TAR dated June 2021 for Resident 28 revealed no blood pressure monitoring had been documented. E. A record review of the active orders list for Resident 31 conducted on 06/08/21 at 02:05 PM revealed Resident 31 had currently been taking [MEDICATION(S)] and [MEDICATION(S)] with no blood pressure monitoring or parameters. A record review of the active orders list for Resident 32 conducted on 06/08/21 at 03:02 PM revealed Resident 32 had currently been taking [MEDICATION(S)] 12.5mg by mouth two times daily with no blood pressure monitoring or parameters. An interview with Resident 32 conducted on 6/2/21 during the initial screening process revealed Resident 32 had fallen on two occasions since being admitted two weeks ago. Resident 32 voiced the falls had been due to dizziness. A record review of the MAR/TAR dated June 2021 for Resident 32 revealed no blood pressure monitoring or parameters related to the [MEDICATION(S)] administration.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on record review and interview, the facility failed to ensure NAs (Nurse Aides) implemented care planned interventions related to level of assistance required for mobility and transfers to prevent falls for 1 resident (Resident 1) of 7 residents reviewed. The facility census was 36. Findings are: Review of Resident 1's Order Summary Report dated 6/3/21 revealed diagnoses including [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting the left side (a mild or partial to severe or complete loss of strength or paralysis that affected the left side of the body following a stroke), age related [CONDITION(S)] (a condition where bones become weak and brittle), history of falling, weakness, unsteadiness on feet, and repeated falls. Review of Resident 1's quarterly MDS (Minimum Data Set - a health status screening and assessment tool) dated 5/18/21 revealed Resident 1 required extensive assistance (the resident was involved in the activity and staff provided weight-bearing support) with the physical assistance of two or more people for transfers. Resident 1 also utilized mobility devices including a walker and wheelchair. Review of Resident 1's ADL (Activities of Daily Living) Care Plan dated 12/2/20 revealed Resident 1 had a self care deficit related to CVA (Cerebrovascular accident, or stroke) and left sided weakness with flaccid left arm. Care planned interventions revealed Resident 1 required the assistance of 1 person with the use of a gait belt for ambulation and transfers. 1) Review of a Progress Note dated 3/12/21 at 1:38 PM revealed NA-A (Nurse Aide) was assisting Resident 1 with transferring to the wheelchair when Resident 1 became weak and fell to the ground. Resident 1 did not want to use the walker to transfer. NA-A was educated in the moment on the importance of using gait belts and the walker for all transfers with Resident 1. Review of the Post Fall Huddle dated 3/12/21 revealed the root cause of Resident 1's fall was no gait belt and no walker. The documented intervention was that education in writing was given to the staff. Review of the TIC Nursing Department Orientation Checklist dated 1/20/21 revealed NA-A had completed transfer training as evaluated by the ADON (Assistant Director of Nursing). Review of the [NAME] Disciplinary Action form dated 3/16/21 revealed NA-A had received a written warning related to safety due to NA-A not using a gait belt or walker when transferring a resident when the resident became weak and fell to the floor. The form was signed by NA-A and the DON (Director of Nursing). 2) Review of a Progress Note dated 5/17/21 at 1:36 AM revealed at 9:55 PM Resident 1 was being assisted from the bathroom to the bed by NA-B. NA-B went to turn down the bedding when Resident 1 lost (genders) balance and fell backwards to the bathroom floor. Resident 1 was sent to the emergency room , then returned later that night with no injury noted. Review of the Post Fall Huddle dated 5/17/21 revealed no root cause was identified for Resident 1's fall, but documentation included in the 5 Whys tool (a technique used to determine the root cause of a problem by repeating the question Why?) revealed: 1. No one was holding the gait belt to guide (gender) 2. CNA (Certified Nurse Aide) was turning down bed covers Documentation revealed if the root cause had been removed, the fall could have been prevented. The intervention identified was to always assist Resident 1 with ambulation using a gait belt, and Resident 1 needed to wearing shoes instead of gripper socks. Review of the TIC Nursing Department Orientation Checklist dated 1/11/21 revealed NA-B had completed transfer training as evaluated by the ADON. Review of the [NAME] Disciplinary Action form dated 3/16/21 revealed NA-B had received a written warning related to safety due to NA-B not staying with the resident who requires the assist of 1 person with ambulation. The form was signed by NA-B and the DON (Director of Nursing). Review of Resident 1's Fall Care Plan initiated on 12/2/20 and revised on 5/17/21 revealed Resident 1 was at risk for falls related to CVA and weakness with falls noted on 3/12/21 and 5/16/21. Care planned interventions included written education that was given to staff addressing the need to assist Resident 1 with transfers by using a gait belt (a device put on a resident prior to movement to aide in safe transfers) in case of a fall (initiated on 3/12/21 in response to the fall on 3/12/21). Causal factors were identified on the Care Plan as weakness and impaired mobility for the fall on 3/12/21 and history of falls, impaired mobility, and weakness for the fall on 5/16/21. Review of the Client and Staff Safety: Moving and Lifting policy dated 10/31/13 revealed: Procedure 2b. stated to use mechanical lifting devices and other approved lifting or moving aides for high-risk tasks except when absolutely necessary, such as in a medical emergency. Interview on 6/8/21 at 10:08 AM with NA-C revealed interventions in place to prevent Resident 1 from falling include the use of a gait belt and the assistance of 1-2 people, depending on how Resident 1 is standing. NA-C also revealed the expectation is to always have a hand on the gait belt when assisting with transfers. NA-C revealed if a task needed to be done while assisting a resident, one hand should stay on the gait belt and to use the other hand to perform the task. Interview on 6/8/21 at 10:28 AM with RN-D (Registered Nurse) revealed factors that put Resident 1 at risk for falls include stroke deficits to the left side of the body and if Resident 1's blood sugars are off due to being diabetic (a group of diseases that affect how your body uses blood sugar). RN-D revealed staff are monitored for implementation of care planned interventions by watching cares throughout the day and staying on the staff. Interview on 6/8/21 at 11:42 AM with the ADON confirmed staff should use a gait belt when transferring a resident, and staff should be next to the resident when transferring.

Licensure Reference Number 175 NAC 12-006.17A Based on observations, interviews and record reviews, the facility failed to implement infection control practices and Centers for Medicare and Medicaid Services (CMS) guidelines to prevent the potential spread of COVID by failing to ensure staff wore available N95 masks to provide care for residents admitted within the prior 2 weeks. The census was 35 and sample size was 6. A. Record review of direction from the Centers for Disease Control titled Preparing for Covid-19 in Nursing Homes dated June 25, 2020 revealed the following. Facilities should create a plan for managing new admissions and readmissions whose Covid-19 status is unknown. Health care personnel should wear an N95 or higher-level respirator if available, eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Review of a document titled Tabitha Health Care Services Personal Protective Equipment (PPE) Status dated July 7, 2020 revealed the following. The Tabitha Corporation had 10,565 N95 masks in stock for use in Green/Yellow/and Gray zones. The Tabitha Corporation had 1800 N95 masks in stock for Red zone use. Bulleted at the bottom of the form was the following Green/Yellow/Transitional Zones are very close to 100%, and Supply Chain will order 3000 N95 masks and 3000 disposable gowns to reach full capacity. The form also directed that N95 masks need to be used for red, yellow and gray zone activity. Review of an untitled document provided by the facility on 7/8/2020 concluded the facility would require 200 N95 masks per week. Review of N95 mask requests made from Tabitha of Crete to Corporate revealed requests of 20 masks were made on 5/8, 5/14, 6/11, 6/18 and 6/25. Requests of PPE were made on 5/21 but there were no requests of N95 masks made at this time. The total of all N95 requests made to Tabitha Corporate based upon information provided was a total of 100 N95 masks or the equivalent of a half week of the facility's reported need of N95 masks. Observation of therapy staff member A exiting transitional/gray room # 11 of house #2 at 10:27 AM on 7/8/2020 revealed the staff member had been wearing a surgical mask rather than an available N95 mask to provide care to Resident 2 who had admitted within the prior 2 weeks. Observation of facility Personal Protective Equipment storage on 7/8/2020 at 11:00 AM with Administrator and Director of Nursing (DON) revealed the facility had approximately 8 boxes of unused N95 or KN95 masks with 20 masks per box. Interview with LPN B on 7/8/2020 at 9:00 AM revealed the resident #2 was newly admitted as of last Thursday and remained in 2 weeks of isolation in a transition room. N95 masks were available but were not used in transitional rooms unless the resident would have tested positive. There was plenty of PPE. Staff were to wear a surgical mask, gown, goggles, and gloves when in a transitional room. Interview with RN C on 7/8/2020 at 10:20 AM revealed the difference between gray zones and transitional zones was that gray zones required N95 masks and transitional zones only required the use of surgical masks. Interview with the Infection Control Preventionist on 7/8/2020 at 10:40 AM revealed the facility wanted to use CDC guidance to not use N95 masks for new admissions as the facility has not been able to secure enough N95 masks required for transitional zones. The staff person didn't know the current number of N95 masks available at the facility. Supplies were ordered weekly from Corporate by the DON and Infection Control Preventionist. B. Observation on 7/8/20 at 10:21 AM revealed that NA D and NA E where wearing surgical masks and goggles and went into nurses' station and washed hands and then came out and put on gowns, gloves and went into Resident 1's room. Upon exiting Resident 1's room, both NA D and NA E removed gown and gloves and discarded them into trash container sitting by doorway inside of room. NA D and NA E then used hand sanitizer and then removed goggles and mask, then exited room and immediately outside room put on new surgical mask and pair of goggles and then went to nurses' station and washed hands.

Based on record review and interview; the facility failed to provide competencies for the nursing staff to care for residents with wounds. This affected 1 resident (Resident 17) of 2 reviewed. The facility census was 35. FACILITY Sufficient and Competent Nurse Staffing Findings are: Record review of Competencies of RN (Registered Nurse) D dated 1/24/19 revealed; RN F had not received training for wound care or wound identification. An interview on 10/30/19 11:06 AM with the DON (Director of Nurses) revealed; that the facility felt that the RN who originally assessed the wound was incorrect and QA nurse had correctly identified the wound as an Abrasion, The DON reported that the facility needed to educate the RN who completed the wound documentation. An 10/30/19 04:05 PM with the DON confirmed RN F , that the the 01/2019 competencies had not included wound management or staging for Pressure Ulcer. Orientation check list dated 09/24/18 revealed; staff member RN F was oriented on wound charting/staging, putting new wounds in PCC Nurses notes, how to update changes after assessment and how to order supplies. Record review of the Facility assessment dated 9 revealed that the Assessment did not address competency required by staff for wound care and catheter care. The Assessment revealed; Annual Nursing competency and Audits and Testing or on an as needed basis. Record review of the Facility Assessment Action Plan dated 2019-2020 revealed; the following actions to be completed during the year. The competencies would be: Hand-washing, [MEDICAL CONDITION], ADL, Elopement, Sanitation, and Review of Lifts.

Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to monitor and ensure bathroom vents were in working order. This had the potential to affect all the residents in the facility. The facility census was 35. Findings are: An observation on 10/28/19 of the Environment the following room vents were not functioning in Rooms 5, 6, 11, 12, 14, and 16. An environmental tour on 10/31/19 at 08:38 AM with the Administrator and the Maintenance Director revealed; that the vent in room [ROOM NUMBER] was not working. An interview with the MD (Maintenance Director) on 10/31/19 at 08:43 AM confirmed; that the ventilation system was on a cycle and would cycle on and off and if one vent was not working all the vents in the building would not be working due to they were all on the same cycle. The MD reported that they know the system was functioning related to not having an odor in the building and that there is none. The MD confirmed; no documentation had been completed, of the maintenance checks to ensure that the ventilation was monitored and working on a monthly basis. An interview on 10/31/19 at 12:47 PM with the Administrator revealed; that the facility had called the company about the vents- the administrator confirmed that the company would send out a technician to adjust the ventilation so that they would continually be working. An interview on 10/31/19 at 12:50 PM with ST (Service Tech) [NAME] confirmed; that both buildings had been recalibrated so that they run like they should when the building was in operation. Record review of Monthly documentation of ventilation checks revealed; the facility was unable to provide the monthly documentation to ensure the ventilation system was functioning.

Licensure Reference Number 175 NAC 12-006.09B Based on interview and record review, the facility staff failed to accurately code the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool) for PASARR (Preadmission Screening and Resident Review, an assessment that determines whether or not an individual has an active [DIAGNOSES REDACTED]. Sample size was 12. Facility census was 35. Findings are: Record review of Resident 15's [DIAGNOSES REDACTED]. Record review of PASARR completed on 10/02/15 revealed [DIAGNOSES REDACTED]. The medications used were [MEDICATION NAME] and [MEDICATION NAME]. An interview on 10/29/19 at 12:09 PM with the Administrator confirmed; that the MDS dated [DATE] was marked no for Dementia [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed; Section A for 1500 PASARR revealed; the answer no for PASARR level II. Section I Active [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed; Section A for 1500 PASARR revealed; the answer no for PASARR level II. Section I Active [DIAGNOSES REDACTED]. Record review of MDS dated 9 revealed; the assessment had been modified to reflect PASARR level II. Section A1500 PASARR Level II, was answered yes. Section 1510 [NAME] revealed: 1 [NAME] serious mental illness. Section x 0900 Data entry error.

Licensure Reference Number 175 NAC 12-006.09D Based on observation, interview and record review the facility staff failed to ensure an identified pressure injury (a local injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and or friction) had continued documentation as pressure and was measure weekly. The facility also failed to ensure the wound documentation reflected the correct extremity. This had the potential to affect 1 resident (Resident 17). The facility census was 35. Findings are: An observation on 10/28/19 at 08:34 AM of Resident 17 in bed with a pillow place to resident back. Resident 17 had a walking boot on the left leg/foot. Record review of Progress Note dated 9/18/2019 Post op cast had rubbed scab open on right lower leg (WRONG EXTREMITY). A Band-Aid was applied to the right leg. Ace wrap over post op cast were bunched up and loose, ace wraps reapplied and posterior splint edge reinforced with cast padding. Record review of Orthopedic note dated 9 revealed; the surgical wound had little serous drainage on 4x4 next to ORIF (Open Reduction and Internal Fixation- a surgical repair of a broken ankle) of ankle fracture, pressure ulcer to the heel with blister formation, but no full thickness break down to the skin. Cast applied, staples removed, Xeroform over the heel and incision. Recommend support leg around calf area and not let rest on heel. Record review of Progress Note dated 9/24/2019 Elder was very restless in wheelchair, and was non-compliant with keeping left leg elevated. (Gender) moves both legs about while seated in wheelchair. Scheduled medication had been given previously. Elder was assisted to bed with 2 assist and Hoyer lift. A 1.0 cm x 1.0 cm abrasion on posterior left leg below knee, where cast had rubbed on skin. Small amount of bleeding noted. The area was cleansed and applied a 4x4 gauze dressing applied to the area for protection and to prevent further skin damage. Record review of Physician Communication form dated 10/13/19 for Resident 17 A Pressure injury stage 2 of the left foot 5th digit 0.53cmx 0.6cm this was due to prolonged pressure from the cast rubbing up against (gender) toe, No signs or symptoms of infection noted, did react with signs and symptoms of pain at times but usually denied at rest, area was dry. Folded 4x4 in between the toe and cast for comfort. An order received for: Apply piece of Duoderm to rough area on cast. Record review of Wound letter to the Provider dated 10/13/19- A full thickness loss, presented as a shallow, open ulcer with a red-pink wound bed: left foot 5th toe measured 0.53x0.5. Superficial wound treatment of [REDACTED]. Use 4 in 1 lotion cleanser to remove leaving a thin layer. Record Review of [DIAGNOSES REDACTED]. Record review of Orthopedic note dated 10/16/19 revealed; Post status open reduction internal fixation of ankle fracture, but was though that (gender) sits with legs down that caused swelling and pressure wound to the heel. Resident 17 had a full thickness rub on the small toe where the edge of the cast was, that was cleansed and dressed with Xeroform, the area were the pressure sore was 50% down, about the size of a dime, had some tenuous skin. Record review of PO sheet and PN dated 10/16/19 revealed; orders for change dressing to right heel with Xeroform every 3 days. Pad heel to protect. (Wrong extremity) Record review of PO dated 10/17/19 revealed; an order to apply Xeroform to areas on right foot (heel, toe, and outer ankle then wrap ankle heel area to protect from pressure. (Wrong extremity) Record review of the resident MAR (Medication Administration Record)/TAR (Treatment Administration Record) dated 10/17/19 revealed; Apply Xeroform dressing to the right foot (heel, little toe, outer ankle wrap ankle/heel area to pad and protect from pressure, change 3 times weekly. Record review of Care Plan revealed; Resident 17 had o Skin - Resident 17 is at risk for impaired skin integrity related to incontinence of urine, impaired mobility, and potential shearing. A Pressure area to left Heal from cast 10/19/19 and a Pressure are to left little toe 10/19/19. o Resident 17 would maintain or develop clean and intact skin by the review date. o Follow the MD orders for wound care (SEE MAR (Medication Administration records) FOR ORDERS). o Identify/document the potential causative factors and eliminate/resolve where possible. o Monitor Resident 17 for side effects of the antibiotics and over-the-counter pain medications: [REDACTED]. o Monitor/document the location, size and treatment of [REDACTED]. to Provider. o Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. An interview with QA (Quality Assurance) Nurse on 10/29/19 at 04:53 PM revealed that (gender) felt the toe injury was due to rubbing on the cast, shearing/friction that caused an abraded area. Record review of Wound Assessment for Resident 17 left foot 5th digit was 16 days old in house acquired documents the toe as an Abrasion measurement dated; 10/13/19 [MEDICAL CONDITION] 0.6cm soap and water no dressing applied 10/17/19 0.44x0.75x0.78 soap and water, no dressing applied. Documented as improving (LARGER) 10/27/19 wound was not measured. Documented as improving (NO MEASUREMENTS) 10/28/19 [MEDICAL CONDITIONS] Documented of Pressure to the left heel caused by a Medical device that was 1 month old- in house acquired date measured: 09/20/19 NO MEASUREMENTS, soap and water, antimicrobial NO Measurements for 3 weeks (casted covered heel). 10/17/19 Measured Stage III 1.45cmx1.43cmx1.42cm 10/24/19 measured Stage III 1.5cmx1.3cmx1.3cm An interview on 10/30/19 at 11:06 AM with the DON (Director of Nurses) revealed; that the facility felt that the RN who originally assessed the wound was incorrect and the QA nurse had identified the wound as an Abrasion, that the facility needed to educate the registered nurse that did the wound documentation. An interview on 10/30/19 at 3:49 PM with QA nurse confirmed; that the physician had a transcription error, the physician had ordered the treatment to the right heel. The nurse transcribed the order to the computer. QA nurse confirmed; that doing a part of the medication/treatment administration was to check to make sure that the order was correct prior to administration. An interview on 10/30/19 at 4:05 PM with the DON confirmed; the wound order for the right foot was incorrect for the extremity, the facility had been treating the correct extremity and the order had been transcribed wrong and the QA nurse had filled out the paperwork for a transcription error. Record review of transcription error dated 10/30/19 at 4:16 PM revealed; an order discovered on 10/30/19 to be transcribed incorrectly by physician. This was noticed to be written as a right ankle instead of the correct left ankle on treatment administration. This was corrected upon discovery. Upon investigation the cares were completed to appropriate ankle but not documented correctly due to order indicating right extremity. Resident description: Resident unaware of any issue due to cares still being performed correctly. Other: Discrepancy from Right Ankle to Left ankle originally transcribed by physician however facility did not notice discrepancy Record review of PO sheet and PN dated 10/30/19 at 1:05PM revealed; follow up for ankle fracture with pressure sore on the heel and abrasion left small toe. Record review of new order dated 10/30/19 at 2:18 PM for Apply Xeroform to left heel change 3 times weekly. Pad heel and wrap with ace wrap

Licensure Reference Number 175 NAC 12-006.12E7 Based on observation, record review and interview; the facility failed to ensure the medication label for eye drops contained the dosage for 1 resident (Resident 84) receiving eye drop medication. The facility census was 34. Findings are: Observation on 10/30/19 at 09:25 AM of Resident 84's [MEDICATION NAME] (a solution specially formulated to moisten the eyes) eye drop solution bottle label revealed to give TID (three times a day). Review of the physician orders [REDACTED]. Interview on 10/30/19 at 09:26 AM with LPN-C (Licensed Practical Nurse-Certified) A confirmed the medication label for Resident 84's [MEDICATION NAME] eye drops did not match the physician's orders [REDACTED].

Based on observation, record review and interview; the facility failed to prepare pureed foods in a manner to preserve the nutritive value of food. This had the potential to affect 1 resident, (Resident 18) that ate pureed foods. The facility census was 35. Findings are: An observation on 10/29/19 at 11:09 AM of pureed beans for Resident 18, Cook F added 3 teaspoons of water to the green beans prior to puree. An interview with Cook F on 10/29/19 at11:41 AM confirmed; 1/4 cup of water was added to the creamed turkey prior to puree. Cook F confirmed; that the tray was for Resident 18 Cook F used a scoop to remove the pureed creamed turkey from the blender and was unable to completely fill the scoop. A record review of the Creamed turkey recipe revealed; 1. Add prepared product to blender or food processer. 2. Then blend turkey until smooth. 3. Scrape down the sides and bottom of bowl. 4. Continue blending until pudding like consistency is reached. 5. Adjust liquid as needed to obtain desired consistency. 6. Reheat to 165/74 held for 15sec. An interview on 10/29/19 at 02:13 PM with the DM (Dietary Manager) confirmed; the scoop used to remove the creamed turkey from the blender would have prevented Cook F from removing the entire amount of food out of the blender. The DM confirmed; added water to the creamed turkey would have decreased the nutritional value had the size portion not been increased. The DM confirmed; the amount of product that had been in the blender was 1 scoop prior to the water being added. The DM was unable to confirm that Resident 18 had been given a complete portion of creamed turkey. Record review of Resident 18's intake dated 10/28/19 revealed; the resident ate 76-100% of noon meal.

Licensure Reference Number 175 NAC 12.006.17B Based on observation, record review and interview; the facility failed to ensure that staff performed gloving and hand hygiene in a manner to prevent potential cross contamination while performing catheter care and wound care for 1 resident (Resident 14) of 1. The facility census was 34. Findings are: Observation on 10/30/19 at 10:05 AM of NA (Nursing Assistant) B and NA C assisting Resident 14 with catheter (a flexible tube inserted into the bladder to drain urine) care. NA B and NA C both washed their hands and donned gloves, raised bed to working height. NA B then took wet wipes from package and began to wipe in each groin area, then with clean wipe, wiped area around catheter with downward stroke and repeated with clean wipe and then wiped a few inches outward on the catheter tubing. Then with same gloves on, NA B rolled Resident 14 on their right side and with clean wipe, wiped reddened area on coccyx (tailbone area) and then with another clean wipe, cleaned rectal area. NA B then removed gloves and without performing any hand hygiene, touched bed controls and bedside table. NA B then went into the bathroom and washed hands with soap and water. Observation on 10/30/19 at 10:32 AM of LPN-C (Licensed Practical Nurse-Certified) A and NA B entered Resident 14's room, both washed hands and donned gloves, and assisted Resident 14 to roll on their right side. LPN-C A then applied ointment and protective ointment to reddened area with small open areas to coccyx (tailbone area) with gloved hand. LPN-C A then removed one glove (the glove used to apply the ointments) without performing hand hygiene and NA B removed both gloves without performing hand hygiene. Both LPN-C A and NA B continued to assist Resident 14 with repositioning and NA B touched Resident 14's catheter tubing and placed tubing into leg strap and then touched lift sling and placed under Resident 14. LPN C A assisted NA B, touching resident and lift sling. After both LPN-C and NA B assisted Resident 14 out of bed and into wheelchair, both staff then washed their hands. Record review of facilities Indwelling Catheter Care policy dated (YEAR) revealed the following steps after wiping of the area where the catheter is inserted; secure the drainage bad and tubing below the level of the bladder, discard supplies and remove gloves and perform hand hygiene. Record review of facilities Hand Hygiene-Infection Prevention Policy dated 9/25/19 revealed under Indications for Handwashing and Hand rubbing include after removing gloves. Under Gloves and Hand Hygiene, includes wash hands following the removal of gloves. Interview on 10/31/19 at 3:15PM with QA (Quality Assurance) Coordinator/Infection Preventionist confirmed that staff should be performing hand hygiene after removal of gloves.

Licensure Reference Number: 175 NAC 12-006.09D7b Based on observation, interview and record review; the facility failed to assess and address the causal factors for falls, in an effort to prevent injuries from occurring, for two residents (Residents 1 and 3). The facility's census was 41. Findings are: A. Review of Resident 3's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 1/18/16 revealed Resident 3 had moderately impaired cognition, required extensive assistance with transfers and ambulation and was unable to stabilize without assistance when going from a seated to standing position. Review of Resident 3's Care Plan dated 12/14/15 revealed Resident 3 had a history of [REDACTED]. Approaches staff were to implement in an effort to prevent falls included adding lighting to the resident's room/bathroom, assisting Resident 3 with ambulation and with toileting as needed and using alarms to the chair at all times to alert staff when Resident 3 was getting up unattended. Review of Resident 3's Departmental Notes revealed on 3/4/16 Resident 3 had been confused throughout the shift. At 2:57 PM Resident 3 was found on the floor in front of the recliner which was in the highest position and the alarm had not activated as it had pulled free of Resident 3's clothing. Resident 3 complained of head pain and was transferred to the hospital for further evaluation. Review of the facility's internal investigation dated 3/8/16 revealed Resident 3 was attempting to ambulate to the restroom without asking for assistance. Care plan interventions to prevent further falls were to 1) Place call light within reach and instruct on call light usage. 2) Pain medications as needed for comfort. 3) Participate in therapies as recommended by physician. 4) Continued use of Alarms. 5) Assess for toileting need and schedule if appropriate. Injuries that resulted from the fall included , Right Tibia Fracture (lower leg), C-Spine Fracture (Cervical Spine or neck fracture) and laceration to the left side of the forehead. Interview with Nursing Assistant (NA) A and Licensed Practical Nurse (LPN) B on 3/22/16 at 3:35 PM revealed Resident 3's recliner had electronic controls and Resident 3 often used those controls to raise to a standing position. NA A went on to state that the facility initiated the use of the alarms to alert staff when Resident 3 was raising self to a standing position so they could intervene before Resident 3 began to attempt independent ambulation. NA A stated Resident 3 would raise self to a standing position all the time. Interview with the Director of Nursing (DON) on 3/22/16 at 3:51 PM revealed that Resident 3 had not been assessed to determine if Resident 3 was safe to operate the electric controls of the lift chair. The DON further confirmed the change in interventions after Resident 3's fall did not address the use of the lift chair. Review of the facility's Policy and Procedure for Fall Risk and Post Fall Assessments dated 1/6/14 revealed if a client (resident) falls the plan of care should be updated to include any causal factors and what changes need to be made to prevent a similar occurrence in the future. B. Review of Resident 1's Minimum (MDS) data set [DATE] revealed Resident 1 had severely impaired cognition, required extensive assistance with transfer, had poor balance and had one fall since admission to the facility. Review of Resident 1's Departmental Notes revealed on 1/8/16 Resident 1 was found on the floor in front of the lift chair. The lift chair was noted to be raised about half way to the standing position. The remote for the chair was noted to be between the recliner and Resident 1's right thigh. Review of Resident 1's Department Notes dated 1/16/16 revealed Resident 1 was found on the floor in front of the recliner and appeared to have slid from the chair as it was in the elevated position. Resident 1 voices that this is what occurred. Review of Resident 1's Care Plan, updated 2/1/16, revealed Resident 1 was at risk of further falls and interventions included using a slip cushion with the lift chair and pinning the electric recliner remote on the outside of the chair for safety. Observation of Resident 1 on 3/23/16 at 11:45 AM revealed Resident 1 reclined in the lift chair with the controls to the lift chair hanging freely to the right side of Resident 1. Resident 1 was moving Resident 1's legs back and forth in the chair. Resident 1 was sitting on an incontinent pad and an alarm sensor. No slip cushion was noted. Observation of Resident 1 on 3/23/16 at 12:50 PM revealed Resident 1 now lying in the bed. Observation of the lift chair revealed the electric controls were still hanging freely and not pinned on the outside as care planned. Further observation confirmed the only items in the lift chair were an incontinent pad and an alarm sensor. Interview with LPN B on 3/23/16 at 3:36 PM revealed a non slip pad would be a piece of dycem (a pad made of polymer material that has non slipping properties.) LPN B was unsure why the dycem was not in place on Resident 1's chair. LPN B was further unaware that the controls for the lift chair were to be pinned onto the chair for safety.