Every finding on record at Good Samaritan Society - Beatrice

The facility failed to follow the meatloaf recipe during meal preparation, this had the potential to affect all residents that eat food served from the kitchen. The facility census was 60 at the time of the survey. An observation on 01/22/2026 at 11:16 AM revealed Lead [NAME] (LC) beginning to prepare meatloaf to be served the following day. LC removed 20 lbs. (pounds) of ground beef from the walk in refrigerator, applied gloves, removed the ground beef from the outer wrap, removed gloves and washed hands with soap and water. LC then referred to recipe.A record review of the meatloaf recipe with a copyright date of 2025 revealed the ingredients needed to make 70 servings:Liquid eggs: 2 3/4 cups Milk: 1 QT (quart) 3 TBS (tablespoon) Ground beef: 17.5 lbs.Tomato paste 1 lbs. 1 ozGarlic minced 8.5 oz (ounce)Salt 1 Tbs. 1 tsp. (teaspoon)Onion 1 lbs. 1ozBreadcrumbs 2 lbs.Pepper: 3/4 tsp Directions:1. In mixer bowl, combine eggs and milk with paddle at medium speed 1-2 minutes or until combined.2. Add beef, tomato paste, garlic, salt, pepper, onions and breadcrumbs to egg mixture. Mix for 2-3 minutes at low speed or until blended. DO NOT over mix.3. Press mixture into 12x20x2 inch pans sprayed with nonstick vegetable spray.LC proceeded to place the 20 lbs. of ground beef into a pan. LC then measured the liquid eggs, pouring them directly over the ground beef, and not in a separate mixing bowl as the recipe states. LC said that since the recipe calls for 17.5 lbs of ground beef and there is 20 lbs in the pan (gender) will just add a little more of each ingredient. LC stated that (gender) will just eyeball the amount needed of each ingredient. LC proceeded to measure each ingredient and then add a little more.LC then used gloved hands to mix the ingredients together and not with the mixer as the recipe instructs. LC covered the meatloaf mixture with foil and placed it in the walk-in refrigerator. LC said the meatloaf will sit overnight and if looks too dry tomorrow, (gender) will add extra eggs or milk. When asked if LC has had to adjust recipes often, LC replied sometimes but it's much easier to do when it's made on the stove because they can taste test it along the way and add more seasoning or broth if it's too bland. LC also said that sometimes (gender) will add less of a spice if (gender) feels it's too spicy. When asked why the extra 2.5 lbs were not removed before starting the recipe, LC replied that it would go to waste unless it could be browned and used for another meal. LC confirmed that the recipe should be followed as written and that it was not.An interview on 01/22/2026 at 1:14 PM with the Food Service Director revealed that it an expectation that the cooks follow the recipes provided.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, interviews and record reviews, the facility failed to maintain and serve foods at a safe and appetizing temperature to prevent the potential for food borne illnesses on unit 1. This had the potential to affect all 16 residents on unit 1 who eat from the kitchen.Findings:An observation on 01/26/2026 at 11:25 AM revealed a [NAME] (C-B) transferring an insulated food cart from the main kitchen to the 100's dining room. The cart was filled with stainless steel pans of the different hot food items to be served for lunch. C-B placed each pan on the stream table, covering the pans with a lid.C-B then took the temperature of each hot food item using the facility's thermometer which revealed:The Breaded Chicken was 150 degrees FahrenheitThe Pureed Chicken was 115 degrees FahrenheitThe Potato Casserole was 160 degrees FahrenheitThe Un-breaded chicken was 140 degrees FahrenheitThe Peas were 140 degrees FahrenheitThe Cauliflower was 140 degrees FahrenheitC-B then went to the small unit kitchen to obtain the drinks for each resident and proceeded to pass the drinks to the residents in the dining room.C-B then performed hand hygiene with soap and water and applied gloves. At 11:45 AM C-B began to place food on the plates. During this process the lids were off the pans and were not replaced at any time. Residents in the dining room were served first and then those residents who chose to eat in their rooms were served next.C-B began to set up the room trays and pass them out. C-B was unable to locate insulated covers for the room trays, so C-B placed a Styrofoam plate over the food. The dessert, a room temperature mixed fruit cobbler with ice cream, was delivered to the rooms, uncovered. At 12:25 PM C-B was asked to obtain another set of temperatures for a test tray. The available items and their temperatures were:The Breaded Chicken was 120-130 degrees FahrenheitThe Potato Casserole was 138-140 degrees FahrenheitThe Peas were 120 degrees FahrenheitOn 01/26/2026 at 12:30 PM a taste test of the lunch items was conducted by the survey team.The temperatures at the time of the tasting were: The Breaded Chicken was 110 degrees FahrenheitThe Potato Casserole was 106 degrees FahrenheitThe Peas were 105 degrees FahrenheitThe survey team reported that the chicken was tough and all items were barely warm.C-B reported that the food was OK, not the best but not the worst. C-B confirmed that the serving temperatures should be over 135 degrees Fahrenheit and confirmed that none of the foods on the test tray were above 135 degrees Fahrenheit.Record review of the facility's policy titled Food Temperature Monitoring-Food and Nutrition Services dated 12/19/2025 revealed the proper holding temperature for hot foods should be greater than 135 degrees Fahrenheit and the proper serving temperature should be appetizing for the residents.An interview on 01/27/2026 at 9:30 AM with the Food Service Supervisor (FSS) revealed that it is an expectation that food is served between 135-145 degrees Fahrenheit.

Licensure Reference Number 175 NAC 12.007.04(D) Based on observation, interview, and record review the facility failed to ensure the ventilation (the provision of fresh air to a room, building, etc.) systems were operational in seven resident bathrooms (rooms 120, 301, 303, 305, 308, 309, and 313) out of 24 resident rooms sampled. The facility census was 60. Findings are: Observations on the initial tour on 1.21.2026 at 9:30 AM revealed the bathroom ventilation was not functioning in seven resident rooms (rooms 120, 301, 303, 305, 308, 309, and 313). Observations during a facility tour on 1.26.2026 at 10:40 AM with Water Management (WM) revealed the bathroom ventilation was not functioning in seven resident rooms (room [ROOM NUMBER], 301, 303, 305, 308, 309, and 313). In an interview on 1.26.2026 at 10:40 AM with the WM, it was confirmed the bathroom ventilation was not functioning in seven resident rooms (room [ROOM NUMBER], 301, 303, 305, 308, 309, and 313) and it should be. WM confirmed the company that services the HVAC system was notified and they provided a report that showed the reason the bathroom vents are not working was because of the cold temperatures and the coils were frozen. Also confirmed that the bathroom vents are not checked when the temperature drops below freezing, and the issue would have been identified when the vents are checked this month, and the vents are checked quarterly. A record review of the facility Vents Resident Rooms and Hallways log dated October 2025 revealed the most recent bathroom vent check was completed in October 2025.

175 NAC 12-006.09(G)(i)Based on record review and interviews, the facility failed to complete a discharge summary for Resident 67(A) after a medical appointment with a direct admission to the hospital. Resident 69 (B) was transferred to hospital and did not return to facility. This affected 2 out of 2 residents with a closed record review. The facility reported a census of 60.Findings are: A Record review of Resident 67's hospital Discharge summary dated [DATE] revealed a primary diagnoses of sepsis (an extreme, life-threatening response to an infection), severe thrombocytopenia (a condition where the blood has very few platelets, causing prolonged bleeding), cirrhosis of the liver with ascites (permanent scaring of the liver causing a buildup of fluid in the abdomen). Record review of Resident 67's admission Record revealed an admission date to the facility of 10/16/2025. Record reviews of Resident 67's Electronic Medical Record (EMAR) revealed no documentation of a transfer notice or a discharge summary that included: resident's medical information, resident's emergency contact information, special instructions for ongoing care, etc. An interview with the Social Service Director on 01/22/2026 3:36 PM revealed that facility had transported Resident 67 to an appointment in [NAME] and the clinic then sent Resident 67 to the hospital due to kidney failure. An interview with the Director of Nursing on 01/26/2026 12:15 PM confirmed that the facility did not notify Resident 67's representative in writing, of the transfer to the hospital or the subsequent discharge from the facility. B. A record review of Resident 69's admission Record revealed that resident was admitted on [DATE]. A record review of the electronic health record (EHR) revealed that Resident 69 was discharged on 12/19/2025. Further investigation of EHR revealed that no Discharge Summary (a comprehensive document that summarizes a patient's stay including diagnosis, treatment and condition upon leaving) was completed by the facility for Resident 69. In an interview on 01/27/2026 at 10:04 AM with Director of Nursing (DON) confirmed the facility did not complete a Discharge Summary for Resident 69.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g)Based on record reviews, observations, and interviews, the facility failed to obtain a doctor's order for a continuous positive airway pressure machine (CPAP, a bedside device that uses mild air pressure to keep airways open during sleep) for one (Resident 2) of one sampled resident. The facility census at the time of the survey was 60. Findings are:Observations of Resident 2's room on 01/21/2026 at 12:42 PM revealed a CPAP machine on the bedside table with a CPAP mask in the drawer and the water chamber 1/4 full of water. Record review of Resident 2's admission Record revealed an admission date to the facility on [DATE] with a diagnosis of obstructive sleep apnea (a sleep disorder where the airway becomes blocked or narrowed resulting in a brief loss of breathing). Record review of Resident 2's order summary revealed no order for pressure settings for the CPAP machine. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/30/2025 in section O Special Treatments, Procedures, and Programs revealed that Resident 2 uses a noninvasive ventilator or CPAP. Record review of Resident 2's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revised on 07/10/2025 revealed that Resident 2 is at risk for altered respiratory status related to sleep apnea. Interview on 01/22/2026 at 2:07 PM with Licensed Practical Nurse (LPN-B) reports that Resident 2 does wear a CPAP every night and that LPN-B removes the CPAP in the morning. LPN-B confirmed that there was no order for the CPAP in Resident 2's Electronic Medical Record. Interview with the Director of Nursing (DON) on 01/22/2026 at 2:21 PM confirmed that there is no physician's order for the CPAP settings for Resident 2. Follow up interview with the DON on 01/27/2026 at 12:39 PM confirmed that the facility was unable to locate an order for the CPAP settings because Resident 2 was admitted from home with the CPAP. Interview with Clinical Care Leader on 01/27/2026 at 12:53 PM CCL revealed that the facility does not have a system in place to ensure that residents admitted with a personal CPAP have an order and they should have.

Licensure Reference Number 175 NAC 12-006.18Based on record reviews, observations, and interviews, the facility failed to follow infection control practices during catheter care for 2 Residents (Resident 4 and Resident 12) out of 2 observed for catheters, and during wound care for 2 Residents (Resident 12 and Resident 19) out of 5 observed for wound care. The facility census was 60.Findings are: A record review of the facility's Hand Hygiene policy last reviewed 11/13/2025 revealed that when using alcohol-based hand rub (ABHR) for hand hygiene (HH- a general term that applies to either handwashing or applying hand sanitizer to prevent the spread of disease causing organisms) the staff member should apply enough ABHR to one palm, then rub hands together, covering all surfaces of the hands and fingers until hands are dry, which should take 15 to 20 seconds. When washing the hands with soap and water, the staff member should wet their hands and apply soap, then rub hands together briskly, covering all surfaces of the hands, fingers, and wrists for at least 15 to 20 seconds. The policy also stated that HH should be performed between changing gloves.A record review of the facility's Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen policy last reviewed 04/06/2025 revealed that catheter (a tube placed into the bladder to drain urine) tubing should never touch the floor, and that performing catheter care for an indwelling catheter included to remove gloves, perform hand hygiene and don gloves prior to touching the catheter. A record review of the facility's Wound Dressing Change policy last reviewed 10/31/2025 revealed the procedure was that after staff removed and discarded the old dressing, they should remove their gloves and perform hand hygiene before putting on clean gloves. A.A record review of Resident 4's admission Record printed 01/22/2026 revealed the resident was admitted to the facility 08/27/2024 and had diagnoses of skin cancer, obstructive uropathy (a blockage that makes it difficult or impossible to urinate), and urinary retention (the inability to fully empty the bladder).A review of an undated list of residents on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. EBP involves wearing a gown and gloves during high-contact resident care activities, such as wound care, for residents known to be colonized or infected with a MDRO as well as residents at increased risk of MDRO acquisition [for example, residents with wounds or indwelling medical devices]) provided by the facility revealed that Resident 4 was on EBP due to having an indwelling medical device.An observation on 01/26/2026 at 2:57 PM of Licensed Practical Nurse (LPN) A performing wound and catheter care for Resident 4 revealed that after completing the wound care, the LPN removed their gloves performed HH, then took new gloves out of the box. The LPN dropped one of the gloves on the floor, then picked it back up and put it on. The LPN then threw away some trash, removed and discarded used gloves, and washed her hands with soap and water for six seconds. The LPN then put on new gloves and performed catheter care.An interview on 01/26/2026 at 3:39 PM with LPN A confirmed that the glove that fell on the floor should have been discarded and not used. The LPN further confirmed that handwashing should have been done for 20 seconds.An interview on 01/27/2026 at 11:01 AM with the Infection Preventionist (IP-a healthcare professional who makes sure healthcare workers and facilities are doing everything necessary to prevent the spread of infections) confirmed that Personal Protective Equipment (PPE-special equipment, including gloves, gown, masks, and eye protection, worn to prevent exposure to hazards such as infectious materials) that touches the floor should be thrown away and not used, and that HH should have been performed when gloves were changed.B.A record review of Resident 12's admission Record printed 01/22/2026 revealed the resident was admitted to the facility 06/30/2025 and had diagnoses of urinary retention and a stage 2 pressure ulcer (wound caused by prolonged pressure in one area, stage 2 is an open area that does not go all the way through the skin) on the right buttock.A record review of an undated list of residents on EBP provided by the facility revealed that Resident 12 was on EBP due to having an indwelling medical device.A record review of a wound clinic note for Resident 12 dated 01/19/2026 revealed the resident had open areas on both buttocks. The note further revealed that the wound clinic had diagnosed those areas as Moisture Associated Skin Damage (MASD-damage to the skin caused by prolonged exposure to moisture, such as urine, feces, or sweat), not pressure ulcers.An observation on 01/26/2026 at 1:55 PM of LPN A performing wound and catheter care for Resident 12 revealed the LPN put on a gown outside the room and took supplies into the room, then performed HH and put on gloves. LPN A took the stand-aide (specialized mobility equipment designed to help partially weight-bearing individuals transition from sitting to standing) to the resident, hung the catheter drainage bag on the lift, then assisted the resident to stand up. The LPN washed Resident 12's left buttock with soap and water, changed gloves without performing HH, used a wet 4 x 4 gauze sponge to rinse the area, changed gloves without performing HH, then patted the area dry, applied cream using gloved fingers and put on a clean dressing. LPN A changed gloves without performing HH, then washed Resident 12's right buttock with soap and water, changed gloves without performing HH, used a wet 4 x 4 gauze sponge to rinse the area, changed gloves without performing HH, then patted the area dry, applied cream using gloved fingers and put on a clean dressing. The LPN then changed gloves without performing HH, assisted the resident back into the recliner, and put the catheter drainage bag on the floor. LPN A removed their gloves, washed their hands with soap and water for seven seconds, then put on clean gloves. They then got some 4 x 4 gauze sponges wet, removed the right glove, got towels and more gloves, then put the right glove back on. Wearing the same gloves, LPN A washed the resident's suprapubic (SP-the area just above the pubic bone. A SP catheter is inserted into the bladder through the lower abdomen) catheter insertion site with soap and water, changed gloves without performing HH, used a wet 4 x 4 to rinse the area, changed gloves without performing HH, patted the area dry with a towel and covered the area with a dressing. LPN A removed their gloves, washed their hands with soap and water for four seconds, and put on clean gloves. The LPN then removed Resident 12's shoes, socks, and edema wear (a mesh compression garment to reduce swelling) from both legs, applied a medicated gel, then replaced shoes, socks and edema wear. LPN A changed gloves without performing HH, the put leg wraps on Resident 12's legs. Without changing gloves, LPN A moved the trash can, emptied it, then put a new bag in it, and hung the catheter drainage bag inside the trash can. The LPN bagged the trash and linens used during the wound and catheter cares, removed and discarded their gown and gloves, then left the room without performing HH. Discarded the bagged trash and linens, then used ABHR.An interview on 01/26/2026 at 3:39 PM with LPN A confirmed that they did not perform HH when changing gloves and should have, and that the catheter bag should not have been placed on the floor.An interview on 01/27/2026 at 11:01 AM with the IP confirmed that the catheter bag should not have been placed on the floor, and that HH should have been performed when gloves were changed.C.A record review of Resident 19's admission Record printed 01/22/2026 revealed the resident was admitted to the facility 05/16/2017 and had a diagnosis of multiple sclerosis (MS-a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control).A record review of an undated list of residents on EBP provided by the facility revealed that Resident 19 was on EBP due to having a chronic wound.A record review of a wound clinic note for Resident 19 dated 01/19/2026 revealed the resident had a deep tissue injury (DTI- damage to soft tissues beneath intact skin, appearing as a localized purple or maroon area, sometimes with a blood-filled blister, caused by pressure, often over bony areas like heels) on their left heel.An observation on 01/26/2026 at 2:25 PM of LPN A preparing to perform wound care for Resident 19 revealed that as the LPN was putting on a gown outside the room, the LPN dropped the gown, and it touched the floor. The LPN picked the gown up and put it on and continued to wear it during wound care.An interview on 01/26/2026 at 3:39 PM with LPN A confirmed that the LPN should not have used the gown that touched the floor but should have disposed of it and gotten a clean one for performing cares.An interview on 01/27/2026 at 11:01 AM with the IP confirmed that PPE that touches the floor should be thrown away and not used.

Licensure Reference Number 12-006.11E Based on observations, record review and interviews; the facility failed to change gloves and perform hand hygiene for 20 seconds to prevent potential food born illness. This had the potential to affect all 60 residents who served food from the kitchen. The facility identified a census of 60. Findings are: A record review of the policy: Hand Hygiene, dated 03/29/2022, revealed the following: Policy: Hand hygiene should be performed after glove removal. Procedure: HCW will use waterless alcohol-based sanitizer or soap and water to clean their hands: After removing gloves regardless of task completed. Washing with soap and water: -Wet hands first with tepid water, apply amount of soap to hands as recommended by the manufacturer. -Rub hands together briskly for at least 15-20 seconds covering all the surfaces of the ands, fingers and wrists (CDC). -Rinse hands with water and dry thoroughly with a disposable towel or warm-air hand dryer if disposable towel not available. An observation on 9/19/24 at 10:49 AM while in the kitchen with Lead [NAME] (LC-B.) LC-B places gloves on both of their hands and began preparing the noon meal. LC-B removes 3- 5-pound (lbs.) bags of chicken breast from a pushcart they have removed from the walk-in refrigerator. LC-B cuts opens a bag of chicken and places the chicken into a bowl of milk that was previously prepared. LC-B then walks to the hand washing station, removes the gloves and turns the water on. LC-B places soap on [gender] hands and began to rub them together for a total of 10 seconds then rinses [gender] hands and dries them with a paper towel. LC-B returns to the food preparation area, places new gloves on their hands and began to remove the raw chicken from the milk mixture with tongs. LC-B places the raw chicken into a pan of premixed cornflakes breading. LC-B then uses their gloved hands to pat the cornflake breading into the raw chicken. LC-B removes the raw chicken from the cornflake breading with their gloved hands and places the raw chicken on to a baking sheet that was covered with parchment paper and non-stick cooking spray. LC-B then with the same gloves removed the baking sheet filled with the raw chicken, grabbed, and opened the standing oven doors, and placed the baking sheets of raw chicken into the oven. LC-B then grabbed the standing oven doors, again to close them. As LC-B attempts to proceed by grabbing the tongs used to remove the raw chicken from the milk mixture, LC-B stopped and removed [gender] gloves, and proceeded to the hand washing station. LB-C turns on the water, places soap onto [gender] hands and began to rub [gender] hands together for 10 seconds. An interview on 9/19/24 at 11:02 AM with LC-B. LC-B stated hand washing is to be preformed for 20 seconds. When asked if they felt they had created friction for 20 seconds between their hands while washing LC-B stated [gender] had not rub [gender] hands with soap for 20 seconds. LC-B confirms they should have removed their gloves and preformed hand hygiene for 20 seconds after handling raw chicken and prior to touching oven. An interview with the Dietary Manager (DM-C) confirmed the friction action of hand washing is preformed for 20 seconds, DM-C Confirmed LB-C did not perform hand hygiene as it is indicated.

Licensure Reference Number 175 NAC 1-005.06(D) Based on record review, observations, and interviews; the facility failed to change gloves and complete hand hygiene during wound care and catheter care for 2 (Resident 8 and 208) out of 5 sampled residents. The facility census was 60. Findings are: A. Record review of Resident 208's Admission Record revealed admitted on [DATE]. Record review of Resident 208's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 9/2/24 revealed in Section C: BIMS (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) scored 15. In Section H: indwelling catheter. In Section M: at risk for pressure ulcer, uses pressure reducing devices used in bed and w/c, 3 total number of venous and arterial ulcers present, application of nonsurgical dressings (with or without topical medications) other than to feet, and applications of ointments/medications other than to feet. Record review of Resident 208's Diagnosis dated 9/19/24 revealed: Type 2 Diabetes Mellitus without complications, Peripheral Vascular Disease, and Non-Pressure Chronic Ulcer of Right Ankle with Fat Layer Exposed. Record review of Resident 208's Physician orders revealed: -Wound care to right medial ankle/calf, remove old dressings. Wash area with dial soap and water, rinse and pat dry. May shower on dressing change days, otherwise keep dressing clean and dry. Do not scrub off old Calmoseptine layer, just gently cleanse. Apply calmoseptine to good skin surrounding areas. Apply Aquacel AG to open areas. Cover with superabsorber. Secure with Tubigrip. Complete dressing change 3 times weekly (change outer superabsorber every day which is put in as a separate order). Observation of right lower leg wound cares on 9/19/24 at 9:00 AM by Licensed Practical Nurse (LPN)-D. LPN-D donned gown outside the room. LPN-D washed hands x 20 seconds and donned gloves. LPN-D then removed stretch net bandage and the superabsorber dressing from right lower leg. LPN-D did not change gloves and then dated the new dressing and applied it over the wound. LPN-D then reapplied the stretch net bandage as resident refuses to wear Tubigrip. LPN-D with the same gloves on opened the front of the resident's brief and took 2 moist wipes out of the cleansing wipes container and cleansed the groin area. Nest LPN-D took a clean wipe from the wipe container and cleansed the urethral meatus (the opening at the end of the urethra that allows urine to leave the body) and with same wipe moved down the catheter tubing. LPN-D assisted Resident 208 to turn to the right side and removed the brief. LPN-D with the same gloves on and took 2 wipes from the wipes container and cleansed resident's perianal area. LPN-D removed gloves, did not perform hand hygiene prior to donned new gloves and applied a new brief. Interview with LPN-D on 9/19/24 at 9:20 AM confirmed LPN-D should have changed gloves more often, performed hand hygiene between glove change, not use dirty gloves when getting into the clean wipe container, and should have used a clean wipe to cleanse the tubing. Interview with Director of Nursing on 9/19/24 at 11:35 AM revealed the facilities expectation is to change gloves often per policy when performing procedures such as wound and catheter cares, perform hand hygiene between glove changes, not to use dirty gloves when getting into the clean wipe container, and to use a clean wipe to cleanse the tubing. Record review of Hand Hygiene Policy dated 3/29/22 revealed Purpose: To establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. Policy: All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 moments of hand hygiene and 2 Zones of Hand Hygiene. 1. Entering Room 2. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting Room Record review of Catheter Care-Indwelling Catheter Policy undated revealed: Procedure: -raise the bed to an appropriate working height. Facing the resident if right-handed stand on the left side of the bed, if left-handed stand on the right side of the bed. -Remove gloves, perform hand hygiene, and don gloves. -Expose the urethral meatus with the non-dominant hand. -Gently retract and fully expose the catheter insertion site. -Provide perineal care with soap and water, peri-wash as directed or disposable wipes. -Use a clean washcloth or disposable wipe to clean the perineal area and the portion of the catheter in contact with the perineum or meatus. Use a clean section of the washcloth or wipe for each stroke. -Cleanse away from the meatus to remove secretions or encrustation to avoid contaminating the urinary tract. -If using soap and water, rinse thoroughly and pat dry with a clean towel. Record review of Wound Dressing Change Policy dated 7/9/24 revealed: Remove soiled dressing and discard in plastic bag, avoid contact and thus contamination of other surfaces. Remove gloves and discard in the same plastic bag. Perform hand hygiene. 48271 B. A record review of Resident 8's Admission Record revealed that Resident 8 was admitted to the facility on [DATE] with diagnosis of Contusion of left lower leg(an injury to the skin and tissue of the lower leg that occurs when soft tissue is crushed), Open wound, Left Lower Leg (an injury that breaks the skin and exposes the underlying tissue to the outside environment), uspecified open wound, right lower leg,sequela (a long-term effect or complication of an injury or condition, such as an open wound), and non-pressure chronic ulcer of right ankle(is a raw wound on the legs, ankles, or feet that takes a long time to heal due to underlying tissue damage or trauma). A record review of the MDS(Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 06/25/24 revealed a BIMS (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) score of 15 indicating cognitively intact. A record review of the Care Plan (a written plan that directs the care of the resident) dated 7/26/22 with revision date of 4/15/24 revealed that the care plan addressed the acute and chronic wounds on the left and the right leg. A record review of Resident 8's Physician orders dated [DATE] revealed orders to Remove old dressing, wash areas with dial soap and water, rinse and pat dry. May shower on dressing days otherwise keep area clean and dry. Apply a super absorbent dressing over any open areas. Between the 2 layers using the co-flex with calamine. Apply multilayer compression. An observation on 09/23/24 at 10:24 AM for Resident 8's dressing change to left lower leg wound revealed the following: LPN-A and the Regional Educator (RE) entered the room with gloves, and gown's on. LPN-A gathered up all the supplies for the dressing change and then assisted Resident 8's legs on to the bed. LPN-A without changing gloves, removed the tablet, and water cup from the tray table and then went into the bathroom without changing gloves and turned on the faucets filling up two plastic cups of water, one with soap and the other with water. LPN-A with the same gloves shut off the faucets and placed the cups of water and several 4x4 gauze on the tray table without sanitizing or without placing barriers down on the tray table. RE helped lift Resident 8's left leg and LPN-A put a disposable pad under Resident 8's left leg. LPN-A without changing gloves moved the tray table to the bed besides [gender] and started to removed the old dressing that had drainage spots (red/pink and brown)on them from Resident 8's left leg. LPN-A had not changed [genders] gloves or performed hand hygiene after touching Residents 8's leg, gathering supplies, and moving items from tray table or moving tray table before the start of the dressing change. LPN-A without changing gloves or performing hand hygiene started cleaning the wound on the Resident 8 left leg with the dial soap in the cup and 4x4 gauze that was on the tray table. LPN-A after cleaning with a 4x4 gauze threw the gauze in the trash can. LPN-A with the same gloves gathered another 4x4 and started to rinse off the wound on Resident 8 left lower leg. RE then intervened and reminded LPN-A [gender] that [gender] needed to change gloves. LPN-A then changed gloves at that time. LPN-A continued to clean Resident 8's wounds and replace dressing on left lower leg. Dressing wraps continued to hit the pad that had been placed under Resident 8's leg due to possible drainage as LPN-A was wrapping it around Resident 8's left lower leg that RE was holding up. LPN-A finished wrapping Resident 8's left lower leg. LPN-A then cleaned up the empty dressing wrappers and tray table and put Resident 8's tablet and water mug on the tray table wearing the same gloves that LPN-A had on during dressing change. LPN-A then gathered that plastic bag out of the garage can and took it out of room removing [genders] gown and gloves. A record review of the facility Policy entitled Wound Dressing Changes-R/S, TLC,Therapy & Rehab dated 7/0/24 included the following information: Purpose: -To promote wound healing -To help wound remain free of infection Procedure: -Follow EBP(Enhanced Barrier Precautions) wash hands before entering and exiting room, wear gloves and gown. -Remove soiled dressing and discard in plastic bag, avoiding contact and thus contamination of other surfaces. Remove gloves and discard in same plastic bag. Perform hand hygiene. -Open all supplies and pour solutions if ordered. -Put on gloves. -Cleanse the skin and wound thoroughly with normal saline, using gauze wipes, wound cleanser or ordered antiseptic solution. Remove gloves and perform hand hygiene. An interview on 9/23/24 at 11:00 AM with LPN-A confirmed that [gender] should have changed [genders] gloves after getting things ready and touching resident leg and faucets and [gender] didn't. LPN-A confirmed that [gender] should of put a barrier down on the tray table or wiped it down with a disinfected wipe and didn't use a barrier or wipe. An interview on 9/23/24 at 11:00 AM with RE confirmed that LPN-A should have changed [gender] gloves from dirty to clean and that a barrier should of been put down on the tray table and no barrier had been put down.

Licensure Reference Number 175 NAC 12 006.09(H)(vi)(3)a-i) Based on observation, record reviews and interviews; the facility failed to keep Oxygen tubing nasal cannula (piece of the oxygen tubing which is inserted into the nose to deliver oxygen) off the floor and to date the tubing for 1 (Resident 39) of 1 sampled residents. The facility census was 60. Finds are: Record review of Resident 39's Admission Record revealed admitted was 12/4/23. Record review of Resident 39's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/21/24 revealed BIMS (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 15. Observation on 9/18/24 at 10:40 AM Resident 39's O2 (oxygen) tubing was undated and hanging over the oxygen concentrator with the nasal cannula touching the floor. Interview on 9/18/24 at 10:40 AM with Resident 39 revealed Resident 39 wears O2 at night and as needed. Observation on 9/19/24 at 2:00 PM O2 tubing was hanging over the concentrator and nasal cannula was touching the floor and tubing was undated. Observation on 9/19/24 at 8:17 AM revealed O2 tubing was undated and the nasal cannula was touchging the floor. Record review of Resident 39's Physician's Orders revealed Oxygen via nasal cannula 1-5 liters per minute as needed for dyspnea, hypoxia (O2 saturation less than 90%) as needed for dyspnea, hypoxia related to Encounter For Prophylactic Measures, Unspecified. Record review of Resident 39's Diagnosis is Chronic Systolic (Congestive) Heart Failure, and Chronic Obstructive Pulmonary Disease. Interview with the Director of Nursing on 9/19/24 at 11:47 AM revealed the nurses are to date the O2 tubing weekly, not let the O2 tubing cannula touch the floor O2 and place the tubing in the protective bag that is hanging on the concentrator. Oxygen Administration Policy dated 7/8/24 revealed: Purpose - To keep oxygen equipment clean and maintained in good condition. 14. When oxygen is not in use, store cannula, face mask or face tent and tubing in zip-lock bag/plastic bag secured to oxygen cylinder or concentrator. Cleaning the concentrator/Filters and inspections -Disposable equipment should be changed weekly or according to manufacturer's instruction and marked with date and initials.

Licensure Reference Number 175 NAC 12-006.12(A)(i-vi) Based on record review and interviews, the facility failed to provide a stop date for the use of as needed antianxiety medication and failed to monitor specific target behaviors for antipsychotic medications and implement non-pharmacological interventions( is a healthcare intervention that doesn't primarily rely on medications) for 4 (Resident 29, 19, 212, and 32) with the sampled size of 5. The facility census was 60. Findings are: A. A record review of a facility policy entitled: Psychotropic Medications-Rehab/Skilled dated 12/06/23 included the following information: Purpose: -To evaluate behavior interventions and alternative before using psychotropic medications. -To eliminate unnecessary psychotropic medications. - Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate monitoring. -While the use of PRN (as needed) psychotropic medications is not encouraged, if a PRN physician's order is received, ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to the use of PRN psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that its is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. -Throughout the administration of psychotropic medications, the following must be completed: Mood and behavior documentation must continue in order to monitor the effect the medication has on behavior. B. A record review of Resident 29's Admission Record with a printed date of 09/19/24 revealed that Resident 29 was admitted to the facility on [DATE] with diagnoses that of: unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety( a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), generalized anxiety (mental disorder that causes people to experience excessive, persistent, and uncontrollable worry for months or years) and depressive disorder (a serious mental health condition that involves a persistent low mood or loss of interest in activities). A record review of Resident 29's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 09/10/24 with a BIMS (a brief interview for Mental status, a test used to get a quick snapshot of a residents' cognitive function, scored from 0-15, the higher the score, the higher the cognitive function), score of 15 which indicates Resident 29 is cognitively intact. A record review of Resident 29's Physician Orders dated 11/06/23 revealed the following orders: -Abilify (is an antipsychotic that helps treat several kinds of mental health conditions) 2 mg daily for anxiety related to major depressive disorder, -donepezil HCL(to treat dementia (memory loss and mental changes) associated with mild, moderate, or severe Alzheimer's disease) 5 mg give 2 tablets daily for memory related to unspecified dementia, -duloxetine HCL( used to treat a variety of conditions, including depression, anxiety) 60 mg daily for depression related to depressive episodes, -and trazodone HCL ( A drug used to treat depression. It may also be used to help relieve anxiety) 100 mg daily for depression related to specified depressive episodes. A record review of Resident 29's 'Physician orders dated 9/11/24 revealed the following orders: -Lorazepam 2 mg/ml give 0.25 ml po every 2 hours as needed for restlessness/anxiety/and agitation with no stop date. Record review of Resident 29's most recent Medication Administration Record (MAR) dated [DATE] revealed the continued use of Abilify, donepezil, Dulozetine, and trazodone. The MAR did not identify specific target behaviors and or non-pharmacological interventions to monitor for Resident 29. Record review of Resident's Electronic Medical Record (EMR) for the past 6 months, including behavior monitoring sheets, nurse aide task lists and behavioral progress notes, revealed that no resident specific target behaviors had been identified or monitored for the continued use of the antipsychotic medication. Record review of Resident 29's Comprehensive Care Plan (CCP, a written plan that directs the care of the resident) dated 11/10/23 revealed that Resident 29 did use antipsychotic medications. The CCP did not identify any specific target behaviors and or non-pharmacological interventions to observe for or identify how the staff were to monitor target behaviors for the continued use of the antipsychotic. CCP with revision date of 1/31/24 further revealed that Resident 29 also did not have non-pharmaceutical interventions in place. An interview on 9/23/24 at 2:29 PM with LPN-A confirmed that no specific target behaviors had been identified for Resident 29 in the EMR or on the care plan. LPN-A confirmed that there was no documentation of behavior monitoring for the continued use of the antipsychotic medication for Resident 29. C. A record review of Resident 19's Admission Orders with a printed date of 09/23/24 revealed Resident 19 was admitted to the facility on [DATE] with diagnoses of: frontal lobe and executive function deficit (part of the brain that controls executive function, which is a set of skills that help us get things done), cognitive communication ceficit (a difficulty with communication that's caused by a disruption in cognition. Cognitive processes include attention, memory, organization, problem solving, and more), attention and concentration deficit (an be symptoms of a number of conditions, including attention deficit hyperactivity disorder (ADHD) and concentration deficit disorder (CDD), generalized anxiety disorders(mental disorder that causes people to experience excessive, persistent, and uncontrollable worry for months or years), major depressive disorder (a serious mental health condition that involves a persistent low mood or loss of interest in activities), unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances). A record review of Resident 19's MDS dated [DATE] revealed a BIMS score of 7 which indicates Resident 9 is cognitively impaired. A record review of Resident 19 CCP dated 4/3/24 revealed that there were no non-pharmaceutical interventions in place. A record review of the MAR for [DATE] revealed that Resident 19 had a order for ABR Transdermal Cream (Ativan (0.5)-Benadryl (25 mg) and Reglan (5 mg)) as needed with a start date of 4/2/24 and has no stop date. A record review of Resident 19's EMR for the past 6 months reveals no documentation from a physican indicating rationale to extend the Ativan cream beyond the 14 days. An interview on 9/23/24 at 2:30 PM with the Director of Nursing (DON) confirmed that there was no stop date for the PRN Lorazepam for Residents 29 and 19 and there should have been. The DON also confirmed that there was no non-pharmaceutical interventions in place for Residents 29 and 19 and there should have been. The DON further confirmed there was no specific target behaviors that had been identified for Resisdent 29 in the EMR or CCP for continued monitoring of the medications, and there should have been 47406 D. Record review of Resident 212 Admission Record revealed admitted on [DATE]. Record review of Resident 212's diagnosis dated 9/19/24 revealed the following diagnoses: generalized anxiety disorder, delirium due to known physiological condition, restless and agitation, unspecified dementia unspecified severity with anxiety, and depression unspecified. Record review of Resident 212's MDS dated [DATE] revealed Section N: Reflects on Antianxiety, Antidepressant, Opioid, and Antiplatelets. Sections J revealed scheduled pain medication received, PRN pain medication received, and non-medication interventions not used. Record review of Resident 212's CCP dated 9/3/24 revealed that the resident did use antidepressants, antianxiety medications. The CCP did not identify any specific target behaviors and or non-pharmacological interventions to observe for or identify how the staff were to monitor target behaviors for the continued use of the antipsychotic. CCP further revealed there was no non-pharmaceutical interventions in place for Resident 212. Record review of Resident 212's EMR dated 9/23/24 including behavior monitoring sheets, nurse aide task lists and behavioral progress notes, revealed that no resident specific target behaviors had been identified or monitored for the continued use of the antipsychotic medication. Record review of Resident 212's MAR revealed the following orders dated 9/19/24: -Lorazepam Oral Tablet 0.5 mg (mg), give 1 tablet by mouth every 8 hours as needed for anxiety related to generalized anxiety disorder with a start date of 9/5/24. -Tramadol HCL oral tablet 25 mg-give 25 mg by mouth every 8 hours for pain related to encounter for prophylactic measures, unspecified. -Oxycodone HCL Oral Tablet 5 mg, give 2.5 mg by mouth every 8 hours as needed for pain related to encounter for prophylactic measures, unspecified. -Paroxetine HCl Oral Tablet 30 mg, give 1 tablet by mouth one time a day for depression. -Depakote Oral Tablet Delayed Release 125 mg, give 1 tablet by mouth two times a day for combativeness, psychomotor agitation, sundowning related to delirium due to unknown physiological condition, restlessness and agitation. -Tramadol HCl Oral Tablet 25 mg, Give 25 mg by mouth every 8 hours for pain related to encounter for prophylactic measures, Record review of Resident 212's EMAR dated 9/23/24 revealed targeted behavior was not being documented on. Interview on 9/24/24 at 10:15 AM with DON revealed the facility did not have behavior documentation or non-pharmacological interventions inplace for antianxiety and anditdepressant medications for Resident 212 and should have. The DON furhter confimed Resident 212 did not have a stop date for the as needed lorazepam. E. Record review of Resident 32 Admission Record revealed Admission was 12/20/23. Record review of Resident 32's diagnosis on Admission Record dated 9/19/24 revealed the following diagnoses: anxiety disorder, other specified depressive episodes, unspecified dementia unspecified severity with psychotic disturbance, delirium due to known physiological condition, and mood disturbance. Record review of Resident 32's MDS dated [DATE] revealed Section N: Reflects on Antipsychotic and Antidepressant. Record review of Resident 32's CCP dated 9/3/24 revealed that the resident did use antipsychotic and antidepressants medications. The CCP did not identify any specific target behaviors and or non-pharmacological interventions to observe for or identify how the staff were to monitor target behaviors for the continued use of the antipsychotic. Record review of Resident 32's EMR dated 9/19/24 including behavior monitoring sheets, nurse aide task lists and behavioral progress notes, revealed that no resident specific target behaviors had been identified or monitored for the continued use of the antipsychotic medication. Record review of Resident 32 Physicians Orders revealed the following orders: -Seroquel Oral Tablet 25 mg give 1 tablet by mouth one time a day for delirium related to delirium due to known physiological conditions, -and Sertraline HCl Oral Tablet give 100 mg by mouth one time a day related to other specified depressive episodes. Interview on 9/24/24 at 10:15 AM with the DON revealed the facility did not have behavioral documentation and non-pharmacological interventions for antipsychotic and antidepressant medications and they should have.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to follow physician's orders related to notification of blood sugar results for 1 (Resident 163) of 1 sampled resident. The facility identified a census of 62. Findings Are: A record review of the undated demographic information revealed the facility had admitted Resident 163 on 9/18/23 with a primary diagnoses of unspecified intracapsular fracture of the left femur (thigh bone) and unspecified Dementia. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 9/22/23 revealed Resident 163 had a BIMS (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) score of 01 which indicated resident was severely cognitlvey impaired. A record review of the Order Summary list ran on 10/12/23 revealed Resident 163 had the following orders related to Diabetes Mellitus (DM-a diseases that affect how the body uses blood sugar): - Check blood glucose levels before meals and at bedtime. Notify the provider if the blood surgar is less than 60mg/dL (Milligrams per deciliter; a unit of measure that shows the concentration of a substance in a specific amount of fluid) or greater than 400 mg/dL ordered on 9/19/23. - Tresiba Subcutaneous Solution (a long-acting insulin used to control high blood sugar )100 U/ML (units per milliliter). Inject 18 units subcutaneously (in the fatty tissue, just under the skin) in the morning for diabetic related to DM. - Glucagon Subcutaneous Solution (an injectable medication used to increase blood sugar levels) 1 MG (milligram)/0.2ML (milliliter). Inject 1 mg subcutaneously as needed for low blood sugar related to DM. - Humalog Injection Solution (a fast-acting insulins used to control high blood sugar) 100 U/ML Inject subcutaneously before meals and at bedtime related to DM. A record review of the blood glucose results dated 9/28/23 through 10/11/23 for Resident 163 revealed the following blood sugars which were outside of ordered parameters; -09/29/23 at 11:32 AM blood sugar was 57 --no physician notification had been documented -09/28/23 at 08:28 AM blood sugar was 47 --no physician notification had been documente A record review of the Progress Notes dated 9/28/23 through 10/11/23 for Resident 163 revealed no documentation of notifying the physician when the blood sugars were outside of ordered parameters. An interview on 10/16/23 at 10:52 AM with the DON (Director of Nursing) after review of Resident 163's blood sugars the DON revealed the physician should have been notified per the order. An interview on 10/17/23 at 9:38 AM with LPN-I revealed that if a resident's blood sugar is below parameters of 60 mg/dL then [gender] would provide juice or snacks with high protein to increase the resident's blood sugar until the blood sugar was above 60mg/dL. If the provided juice and snacks were unsuccessful then [gender] would give ordered glucagon to increase the resident's blood sugar. Further, LPN-I revealed once the resident's blood sugar was stable then [gender] would notify the physcian. If the blood sugar was greater than 400 mg/dL then [gender] would call the physican to notify. An interview on 10/17/23 at 9:58 AM with the DON revealed that the facility expectation was to recheck the blood sugar when results received were below the ordered parameters and then notifiy the physician by call or fax or by informing the APRN (Advanced Practice Registered Nurse) upon arrival to the facility when making daily rounds. A record review of the facility policy titled Blood Glucose Monitoring, Disinfection and Cleaning with a reviewed date of 9/22/23 revealed that it did not contain any directions or guidance related to the timeliness of physician notification of blood sugars outside of ordered parameters.

Licensure Reference Number 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to provide bathing weekly for 1 (Resident 4) of 2 sampled residents. The facility identified a census of 62. Findings are: A record review of form [NAME] Policy for Rehab/Skilled and Long Term Care Activities of Daily Living-R/S, LTC reviewed and revised 11/29/22; revealed the purpose was to provide resident with appropriate treatment and services to maintain or improve ability in activities of daily living for the well-being of mind, body and soul. The policy identifiied residents were to recieve a bath at least weekly. Record review of Resident 4's undated facesheet revealed Resident 4 was admitted [DATE]. The facesheet revealed Resident 4 had the following diagnoses: Chronic Obstructive Pulmonary Disease, Diabetes Mellitus with Diabetic Polyneuropathy, and Morbid (severe) obesity. A record review of Resident 4's MDS (Minimum Data Set is a standardized assessment tool that measures health status in nursing home residents), dated June 16, 2023, revealed in Section G that Resident 4 required one person extensive physical assist for bathing. A record review of Resident 4's active Care Plan revealed, Resident 4 requires extensive assistance for bathing: shower or bath. The Care Plan identified if the resident refuses the staff are to ask the resident if they would agree to a bed bath. An interview with Resident 4 on 10/11/23 at 3:09 PM revealed [gender] may recieve a bath once a week. Resident 4 revealed they would enjoy a bath twice weekly but would be okay if [gender] just recieved at least one. A record review of the [NAME] Creek Bath Schedule revealed, Resident 4 to be on the schedule twice weekly on Wednesday and Saturday evenings. The Bath Schedule identiifed the residents must get at least one bath per week. If a resident refuses, they shall be offered an alternative and document what was completed in a progress note. A record review of Resident 4's Personal Hygiene and bathing record revealed, Resident 4 received bathing on the dates as documented below: - 9/17/2023, - 9/27/2023 (for a total of 9 days with no bathing documented), - 10/2/2023, - 10/16/2023 (for a total of 15 days with no bathing documented). An interview with Certified Medication Aide (CMA)-E on 10/17/23 at 10:34 AM revealed residents should have a bath of some type at least once a week. CMA-E confirmed Resident 4 did not have a bath for a total of 14 days. An interview on 10/17/23 at 10:28 AM with Licensed Practical Nurse (LPN)-F revealed residents should have some type of bathing once a week. An interview on 10/17/23 at 10:30 AM with LPN-G revealed a resident should have one bath weekly, most want two, but should have at least one. An interview with the Administrator on 10/17/23 at 11:30 AM revealed the expectation for bathing residents, is to have a bath every week.

Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to document consistent assessment of characteristics or wound measurements which affected 1 (Resident 40) of 1 sampled resident for pressure ulcer. The facility had a census of 62. Findings are: A record review of Resident 40's Admission Record dated 12/15/2022 revealed, Resident 40 was admitted on [DATE] with diagnoses of: pressure ulcer (PU) (injury to skin from prolonged pressure) of sacral region, stage 4, morbid (severe) obesity due to excess calories, nutritional deficiency, reduced mobility and venous insufficiency (poor blood flow). A record review of the MDS (Minimum Data Set) (a tool used to measure a residents health status) dated 9/8/2023 under Section C, Brief Interview for Mental Status (BIMS) (a tool used o identify the cognitive condition of a resident) had a score of 15 which indicated the resident is cognitively intact. A record review of Resident 40's Care Plan dated 9/16/2023 indicated a Problem of: The resident has actual impairment to skin integrity evidenced by sacral wound with twice weekly dressing changes. Goal was the resident will not have complications related to the wound of the sacrum through the review date. The care plan identified interventions of: Monitor the location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to health care provider. An observation of Resident 40's PU wound care on 10/17/2023 at 9:10 AM by Licensed Practical Nurse (LPN)-B and Registered Nurse (RN)-D revealed Resident 40's wound edges were pink and the treatment was completed. The observation revealed measurements were not completed by either LPN-B or RN-D. A record review of the Treatment Administration Record (TAR) (record used to document treatments for resident) shows an order to complete dressing as scheduled, sooner if needed due to drainage, wash the area with dial soap and water, rinse and pat dry, keep dressing clean and dry. If Calmoseptine was used prior, do not scrub old layer off, just gently cleanse, apply Calmoseptine (a cream to protect skin) to the good skin surrounding the open areas, prisma (a wound dressing) to the wound base, apply Aquacel rope (a wound dressing) to open area, cover with Mepilex (a wound dressing) every day shift, every Tue and Fri. The start date of the order was 6/2/2023. A record review of the facility policy Skin Assessment Pressure Ulcer Prevention and Documentation Requirements-Rehab/Skilled dated 4/26/2023 under Procedure revealed: If a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound Data Collection UDA (User-Defined Assessments). Observations of the ulcer's characteristics may be documented by a licensed nurse and should include at least the following: measurements-length, width, depth; characteristics of the ulcer-including wound bed, undermining and tunneling, exudate, surrounding skin, etc; presence of pain and current treatments. A record review of the Wound Data Collection UDA's (an assessment tool performed on pressure wounds to include identification, daily monitoring and wound characteristics) dated from 8/17/2023 to 10/17/23 revealed documentation of wound measurements on 8/26/2023, 8/29/2023, 9/16/2023 and 10/17/2023 however, there was no documentation on the characteristics of the wound. Wound Data Collection UDA's dated 8/17/2023, 8/18/2023, 8/21/2023,8/24/2023, 8/25/2023, 8/27/2023, 8/28/2023, 8/30/2023, 8/31/2023, 9/1/2023 through 9/12/2023, 9/14/2023, 9/15/2023, 9/17/2023 through 9/21/2023, 9/23/2023, 9/25/2023, 9/26/2023, 9/28/2023 through 9/30/2023 and 10/1/2023 through 10/6/2023 had no measurements or description of wound. The Wound Data Collection UDA notes that measurements are required at least once every 7 days under Identification subset. A record review of the Wound RN Assessments UDA's dated from 8/12/2023 through 10/14/2023 have no measurements or description of wound. A interview with LPN-B on 10/17/2023 at 9:07 AM revealed, wound measurements and assessment are documented on the Wound Data Collection UDA and should be done weekly. LPN-B stated any nurse can complete the assessment but is usually the floor nurse for that day. LPN-B stated they do not have a designated wound nurse. An interview with RN-D on 10/17/2023 at 12:25 PM revealed, that RN-D completed a Wound Data Collection UDA with wound measurements after observation of wound care was performed this morning on 10/17/2023 at 9:10 AM. Inquired how these measurements were obtained as no observation of either nurse was made measuring the wound. RN-D replied, I did it outside of the room. Inquired how this was done. RN-D replied, I measured it with a Q-tip and used the grid on the dressing paper. Inquired how this was done as Q-tips were observed being thrown away in room after use. RN-D replied, I know based on the Q-tip and where my finger hit on the Q-tip. RN-D confirmed this is not the correct or accurate way of measuring a wound. RN-D also confirmed wounds should be measured weekly. An interview with the MDS Coordinator on 10/17/2023 at 1:15 PM revealed, that all wounds/pressure ulcer should be documented weekly with measurements and characteristics of wound. MDS Coordinator further revealed that this has not been done on a weekly basis for Resident 40 . MDS Coordinator also revealed that measurement of wound by RN-D was incorrectly performed.

Licensure Reference Number 175 NAC 12-006.17d Based on observations, record review and interview; the facility staff failed to provide handwashing to prevent cross contamination before medication administration for 1 (Resident 6) of 1 sampled resident. The facility census was 62. Findings are: Record review of Resident 6's Admission Record dated 9/29/2023 revealed Resident 6 was admitted on [DATE] with diagnoses of: unspecified severe protein-calorie malnutrition, encounter for attention to gastrostomy (a surgical opening into the stomach), abnormal weight loss, nausea, and vomiting. An observation on 10/16/2023 at 11:00 AM of medication administration through gastrostomy tube (GT) for Resident 6 revealed LPN-A performed hand hygiene (HH) at the bathroom sink by first wetting their hands. Then applied soap and lathered their hands with soap for 7 seconds and then rinsed hands under the water. Record review of Hand Hygiene policy dated 3/29/2022 under section Procedure-Washing with soap and water/liquid antiseptic and water revealed the following process: Wet hands first with tepid water, apply amount of soap to hands as recommended by the manufacturer. Rub hands together briskly for at least 15-20 seconds covering all surfaces of the hands, fingers and wrists (CDC). Rinse hands with water and dry thoroughly with a disposable towel or warm-air hand dryer if disposable towel not available. Interview with LPN-A on 10/16/2023 at 11:20 AM confirmed that 7 seconds was not long enough to perform hand hygiene according to facility policy of 15-20 seconds to prevent cross-contamination. Interview with LPN-C on 10/16/2023 at 11:30 confirmed hand hygiene should be 20 seconds. Interview with DON on 10/16/23 at 1:20 PM confirmed LPN-A hand hygiene was not long enough.

Based on interview and record review, the facility failed to prevent the potential spread of Covid-19 related to not following up on screening questions for visitors prior to allowing entrance into the facility. This had the potential to affect all residents. The sample size was 6. The facility census was 63. FINDINGS ARE: An interview with the facility ICP (Infection Control Practicioner) on 6/8/22 at 2:05 PM revealed the facility was Green with no current positive Covid-19 cases amongst the residents and none in the last 4 weeks. The interview revealed one staff member having Covid-19 in the last 4 weeks. The interview revealed the facility has had 1 staff member with a positive Covid-19 test in the last four weeks. Continued interview with the facility ICP on 6/8/22 at 2:05 PM revealed the facility had 4 unvaccinated residents. An interview on 6/8/22 at 2:25 PM with NA-A (Nurse Aide) revealed all staff were being tested twice weekly for Covid-19. The interview with NA-A revealed NA-A had been vaccinated but had not received the boosters yet. Continued interview with NA-A on 6/8/22 at 2:25 PM confirmed that education related to the Covid-19 vaccine had been provided during orientation and NA-A had awareness of precautions to take until fully vaccinated. An interview on 6/8/22 at 2:30 PM with LPN-B (Licensed Practical Nurse) confirmed having had the Covid-19 vaccine but not the booster thus far. The interview confirmed that all staff had been provided education related to the vaccine. During the interview, LPN-B revealed that non-vaccinated staff were not re-assigned or treated differently but did have to wear an N95 face mask while working. An interview on 6/8/22 at 2:40 PM with NA-C revealed NA-C had received the Covid-19 vaccine but not yet the booster. During the interview, NA-C confirmed that NA-C had been provided education regarding the vaccine prior to receiving it. An interview on 6/8/22 at 02:44 PM with MA-D (Medication Aide) revealed being fully vaccinated for Covid-19. During the interview, it was confirmed that staff were aware of which residents were not fully vaccinated for Covid-19 at this time. The interview confirmed that staff were aware of precautions to take with the non-vaccinated residents such as the non-vaccinated staff sat 2 at a table in the dining room with plexi-glass partitions present. The interview confirmed that all residents were encouraged and reminded to wear a mask outside of the rooms. An interview on 6/8/22 at 2:43 PM with PTA-E revealed a non-vaccinated Covid-19 status. During the interview, PTA-E confirmed that the facility had provided education to staff related to the Covid-19 vaccine. The interview confirmed no change in assignments had occurred due to non-vaccination status. The interview revealed staff were being tested twice weekly at this time. An interview on 6/8/22 at 2:57 PM with LPN-F revealed a status of fully vaccinated for Covid-19. The interview revealed that non-vaccinated staff were currently being tested for Covid-19 twice weekly. During the interview, LPN-F revealed that the unit had 2 unvaccinated residents and 1 wishes to eat in the dining room for meals but does sit alone while the other unvaccinated resident has chosen to eat in their room. An interview on 6/8/22 at 4:39 PM with the facility Administration, after a review of the facility staff and visitor screening logs dated 5/1/22 through 6/8/22 revealed that the screening logs were reviewed periodically and not shiftly or daily. The interview revealed that if someone answered outside of the normal/acceptable limits, the charge nurse followed up with that person prior to allowing entrance into the facility anytime the Administrator or DON (Director of Nursing) were not available. An interview on 6/9/22 at 11:10 AM with the facility ICP revealed that the facility uses the same week schedule as NHSN (National Healthcare Safety Network) reporting does for better tracking, which is Wednesday through Tuesday. The interview confirmed that if staff members are scheduled PRN (as needed) and are not testing twice weekly, then they are required to test prior to reporting to the unit for assignments. A record review of a non-vaccinated staff member, LPN-G testing log dated 4/8/22 through 6/8/22 revealed testing only once during the week of 5/4/22 through 5/10/22 and no testing had been completed prior to work during the week of 5/25/2 - 5/31/22. A record review of a non-vaccinated staff member, RN-H, scheduled PRN (as needed) at the facility, testing log dated 4/8/22 through 6/8/22 revealed no test had been completed prior to working on 4/28/22. A record review of the facility policy titled Covid-19 Immunization, Employee dated 2/16/22, contained the following guidelines: Any person who is exempt from the Covid-19 vaccination for a medical or religious exemption (Exempt Person ) shall be required to wear source control covering the nose and mouth at all times, submit to mandatory surveillance testing, or other agreed upon reasonable accommodations (such a periodic testing) as determined on a case-by-case basis in accordance with the Reasonable Accommodations/ADAAA-Enterprise policy. An interview on 6/8/22 at 11:23 AM with the facility Administrator, after review of the testing logs for LPN G and RN-H, confirmed testing twice weekly or prior to a scheduled shift did not occur and should have.

LICENSURE REFERENCE NUMBER: 12-006.09D2b Based on observation, interview and record review, the facility failed to provide care and services to heal a pressure ulcer (localized damage to the skin and or underlying soft tissue usually over a bony prominence) for 1 of 2 (Resident 18) residents sampled. The facility had a total census of 63 residents. Findings are: Record review of the facility policy Pressure Ulcers-Rehab/Skilled, Therapy & Rehab. Reviewed/revised 02/10/2021 Purpose: To provide appropriate assessment and prevention of pressure ulcers, as well as treatment when necessary. Policy: Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to ensure that a resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Record review of a Nurse to Nurse admission communication dated 4/15/21 stated Resident 18 had no wounds or pressure ulcers. Record review of Resident 18's admission Minimum Data Sheet (MDS) dated [DATE] revealed no pressure ulcers present. Record review of Resident 18's MDS dated [DATE] revealed a Stage 2 pressure ulcer (an open wound extending into the deeper layers of skin) noted with application of non surgical dressing. Record review of Resident 18's Braden risk assessment (an assessment used to identify a resident's risk to develop wounds/pressure ulcers) revealed the following scores: · 4/15/2021: score of 15 which indicated mild risk · 7/21/2021: score of 13 which indicated moderate risk · 10/30/21: score of 13 which indicated moderate risk. Observation on 11/13/2021 at 2:00pm with RN A (Registered Nurse) and MA C (Medication Aide) revealed Resident 18 lying in bed. MA C assisted Resident 18 to turn onto their left side. RN A removed a [MEDICATION(S)] dressing from Resident 18's mid-back which showed an open wound present. No measurements were taken at the time of the observation. RN A performed hand hygiene and placed a [MEDICATION(S)] (a type of foam dressing) dressing over the wound. Review of Resident 18's Progress Note from the Primary Care Physician (PCM) dated 7/14/21 at 1:00pm revealed the following: · Review of Systems. Back: There is a small area noted on lower back where there is nonblanchable [CONDITION(S)] (skin redness that does not turn white when pressed) of which a very small portion where outer skin layer is removed - there is a bony prominence noted under it. · Assessment/Plan of Care: Pressure Injury of back, Stage 1. (skin redness that does not turn white when pressed). Nursing today just noted area on lower back where there is the start of a pressure injury. I discussed importance of repositioning often with nursing staff. They did start applying a barrier cream. Will have them apply [MEDICATION(S)] dressing to area and monitor this very closely each day for any worsening symptoms. · Patient Instructions: Monitor pressure injury on lower back closely each day. Make sure to REPOSITION patient every 2 hours so he is not always on his back. Apply [MEDICATION(S)] (or available foam) dressing to area. Please notify us if worsening or not healing. · Orders: Monitor pressure ulcer on lower back closely each day. Make sure to REPOSITION patient every 2 hours so he is not always on his back. Apply [MEDICATION(S)] (or available foam) dressing to area. Please notify us if worsening or not healing. Record review of APRN (Advanced Practice Registered Nurse) orders dated 8/12/2021 revealed a mid spine partial thickness pressure ulcer Stage 2 with a new order for Hydrogel sheet change every 3 days. Record review of Resident 18's Medication Administration Records (MARs) and Treatment Administration Record (TARs) for August 2021, September 2021 and October 2021 revealed no documentation that the order for Hydrogel dressing was ever implemented. Record review of Resident 18's Progress note dated 9/16/21 by the APRN revealed a pressure sore mid back that was unstageable due to having yellow tissue present. There were no signs or symptoms of infection and no new orders. The APRN recommended to continue the same treatment by covering the pressure with foam dressing; avoid pressure to spine and to place a cushion in back of the resident's chairs. Record review of Resident 18's wound data collection records revealed the following measurements and measurement changes of the pressure sore to the mid back. · 8/2/2021, 2x1.5cm (centimeter) · 9/1/2021, 2.7 x 2cm · 9/7/2021, 3 x 2cm · 9/15/2021, 2.0 x1.7x 0.5cm · 9/17/2021, 2.0 x 1.7cm · 9/20/2021, 2 x 1.7cm · 9/24/2021, 2 x 1cm · 9/29/2021, 2.8 x 1.8cm · 10/3/2021, 2.5 x 2.5cm · 10/9/2021, 3 x 2cm · 10/17/2021, 3 x 3cm · 10/20/2021, 3.5 x 3cm · 10/31/2021, 3.5 x 3.5cm Record review of a fax communication to the PCM dated 10/28/2021 revealed that the area to the resident's mid lower back does not seem to be improving. Currently covering the pressure sore with [MEDICATION(S)] and repositioning every 2 hours. The wound bed is white in color and has medium amount of serosanguineous drainage. The resident does complain of pain in the area occasionally. Record review of the response received from the APRN, dated 10/28/2021 revealed that the APRN wanted the facility to schedule an appointment with the [NAME] Community Hospital (BCH) wound specialist. Interview on 11/04/2021 at 10:29am with the Director of Nursing (DON) confirmed that Resident18's pressure ulcer declined in condition from 2 cm x 1.5cm on 8/5/2021 to 3.5cm x 3.5cm on 10/30/2021 and went from a Stage 2 pressure ulcer on 8/21/2021 to an unstageable pressure ulcer by 9/16/2021. Interview with Nurse Supervisor A on 11/8/2021 at 01:35pm confirmed that Resident 18's wound had declined, the treatment had not been changed and the physician had not been notified of the decline until 10/28/2021. Interview with Nursing Supervisor A on 11/08/2021 at 11:35am confirmed that NA on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility failed to implement, evaluate and/or revise nutritional interventions to prevent ongoing weight loss for 1 of 2 residents sampled (Resident 18). The facility census was 63. Findings are: Record review of Resident 18's Admission Record Face Sheet dated 4/15/2021 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident 18's Care Plan dated 4/27/2021 revealed a potential nutritional problem of weight loss related to recent admission, history of difficulty chewing and swallowing and the use of [MEDICATION(S)]. Goals included that Resident 18 would maintain weight and not have significant weight loss by the review date. Revision of the care plan on 07/08/2021 the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 18's Mini-Nutritional Assessment (MNA) dated 4/22/2021 and signed by the Dietary Manager (DM) revealed a score of 11 which indicated a risk of malnutrition. Record review of the MNA dated 07/29/2021 and signed by DM revealed a score of 9 which indicated a risk of malnutrition. Record review of the MNA dated 10/27/2021 and signed by the DM revealed a score of 12 which indicated a normal nutrition status. Record review of the weights summary revealed the following weights: · 4/15/2021; Admission weight: 185.7lbs. (pounds) · 9/16/2021; Weight: 168 lbs. · 10/31/21; Weight: 166 lbs. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Nursing Supervisor A on 11/08/2021, at 11:35am confirmed that the check mark in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/08/2021 at 10:25am with the DM confirmed that the supplement Mighty Shake had not been available for Resident 18's consumption between 4/15/2021 and 11/08/2021. Record review of Resident 18's Progress note dated 9/16/21 and signed by APRN (Advanced Practice Registered Nurse) indicated the following in the Assessment/Plan of Care. Weight loss worsening - increased weakness and now dependent on staff for eating; 5 lb weight loss past 2 months and 18 lbs past 4 months - is to be getting Mighty Shake BID - nursing staff not aware of this - will change to Ensure. D/C Mighty Shakes. Give Ensure supplement 240 ml twice a day (due to weight loss 5 lbs past 2 months and 18 lbs past 4 months. Record review of Resident 18's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident's MAR for September 2021 and October 2021 revealed that the House Supplement was checked as given except on the following dates when NA (not available) was marked on the MAR. · 9/19/2021 · 9/23/2021 · 9/24/2021 · 9/28/2021 · 10/2/2021 am · 10/14/2021 am · 10/15/2021 · 10/18/2021 am · 10/21/2021 · 10/22/2021 · 10/26/2021 am · 10/30/2021 · 10/31/2021 Interview with MA-B (Medication Aide) on 11/08/21 at 9:00am stated that the nutritional house supplements were documented depending on how the order was written. If the order asked for an amount given, MA-B charted how much was ingested, otherwise the item was checked off as given on the MAR. Interview with Nursing Supervisor A on 11/08/2021 at 11:35am confirmed that NA on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/08/21 at 09:05am Cook-A stated that the House Supplement was not charted separately from any other fluids as being provided. Record review of Resident 18's Nutritional Status Notes signed by the Contracted Dietician (CD) revealed the resident had increasing weight loss. · 6/16/21; Resident's current weight 176, decrease of 10% in 30 days and decrease of 5% from admission weight of 185. · 7/7/21; Resident's current weight 175, decrease of 4% in 30 days, decrease of 5% from admission weight of 185. (4/15/21)) · 8/17/21; Resident's current weight 160, decrease of 6% in 30 days, decrease of 13% from admission weight of 185. · 9/2/21; Resident's current weight 165, decrease of 4% in 30 days, decrease of 16% in 90 days. Admission weight 185. · 9/15/21; Resident's current weight 168, increase of 4% in 30 days, decrease of 16% in 90 days. Admission weight 185. · 10/20/21; Resident continues at risk for malnutrition due to significant weight loss. Resident's current weight 158. decrease of 5% in 30 days, decrease of 12% in 180 days · 11/3/21; Resident's current weight 166, decrease of 2% in 30 days, decrease of 11% in 180 days. Interview on 11/3/21 at 01:30pm with the (CD) CD confirmed Resident 18's significant weight loss. Record review of Resident 18's Dietician Notes dated 6/16/21, 7/7/21, 7/29/21, 8/17/21, 9/2/21, 9/15/21, 10/20/21, and 11/3/21 revealed weight loss was attributed to fluid shifts from [MEDICATION(S)] and use of [CONDITION(S)] glove. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on survey dates 11/1/2021, 11/2/2021, 11/3/2021, 11/4/2021 and 11/8/2021 revealed no use of [CONDITION(S)] glove on these dates.

812 LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review, and interview; the facility kitchen and dietary staff failed to outdate and discard food on the stainless steel tables inside the kitchen; failed to provide plastic wrap and foil to cover the food such as pudding, or salads, or other food items; from kitchen or dining room to residents rooms; the kitchen staff failed to clean items in the kitchen area to include but not limited to the fryer, steamer for vegetables, stove, oven, handles on the stove; and dining room staff failed to ensure that masks, and hair coverings; were covering nose and mouth , and hair, when working with food. The facility failed to ensure that staff performed hand hygiene between residents during meal service, and in the kitchen; to include wearing gloves and taking them off and doing hand hygiene, to prevent the potential for cross contamination when working with food items. The facility failed to clean appliance surfaces to prevent contamination with food for the food leaving the kitchen and the dining area. All residents of the facility could have been affected. The facility census was 63. Findings are: 11/1/21 at 9:19 AM Observation in kitchen and found bread and buns that were outdated from week of 1026/21 on stainless steel table in kitchen. 11/1/21 at 9:25 AM Observation in the walk in refrigerator found 2 large plastic bags full of cut up lettuce without a date, and the lettuce was wilted and the bags had green slimy liquid in them. 11/1/21 at 9:32 AM Observation of the washing hands for 8 seconds after taking gloves off that the cook used completing different job items in the kitchen. 11/1/21 at 9:30 AM Observation of the fryer, steamer for vegetables, stove-on top and burners food particles and rust, knobs to turn stove on covered with thick gray oily lint material, oven-covered with burned black raised crust and food particles to include the oven door. 11/1/21 at 11:23 AM Cook B observed dishing up pudding for the day, and carried tray of pudding from kitchenette to dining room by steam table totally uncovered and left uncovered whole meal time. 11/1/21 Observation between 11:24 AM and 12:30 PM and on 11/4/21 at 11:30 AM Cook B had hair coming out from under hair covering on front and sides. The face mask the cook is weaning is being worn under the nose. 11/1/21 at 11:32 PM Cook B Was wearing gloves in kitchenette and dining room, touching tables, food and drinks by steam table, taking cookies and coffee to residents, not using hand hygiene between touching several residents and items. 11/1/21 at 12:15 PM Cook B completing hand hygiene in 8 seconds, then put glove back on. Record review of The Nebraska Food Code dated 2017 Food Code 2-402.11 revealed the following related to hair restraints effectiveness: 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. Interview on 11/4/21 at 10:30 AM with the Dietary Manager (DM) revealed the expectation is to use proper hand hygiene, wearing gloves does not take over for hand hygiene, wear hair restraints to keep hair contained, wearing face masks appropriately, that food items that are are outdated or look uneatable should be discarded. The DM has cleaning lists for the dietary and dining staff to complete, and revealed the areas in the kitchen were not up to the expectation to prevent food borne illnesses.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to review and 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) related to 1) fall interventions for Resident 30 and 39, and 2) wishes to not take lunches to [CONDITION(S)] for Resident 8. The sample size was 16. The facility identified a census of 63. Findings are: A. An interview on 11/1/21 at 10:45 AM with Resident 30 revealed the abrasions on (gender's) knee had been the result of a fall. A record review conducted on 11/02/21 at 10:56 AM of the facility incident log titled Incidents by Incident Type and dated 11/1/20 - 11/1/21 revealed Resident 30 had had six falls in the last year. A record review on 11/07/21 at 02:23 PM of the post fall root cause analysis reports titled Fall Scene Huddle Worksheet dated 1/8/21 revealed an intervention that read re-educated staff to assist with footwear every am and then every shift to ensure (gender) has proper footwear on. A record review on 11/07/21 at 02:25 PM of an undated CCP for Resident 30, under the problem category of falls, revealed no intervention had been added related to footwear or dated 1/8/21. B. A record review conducted on 11/07/21 at 05:30 PM of the facility incident log titled Incidents by Incident Type and dated 11/1/20 - 11/1/21 revealed Resident 39 had had 12 falls since admission on 3/1/21. A record review on 11/07/21 at 05:41 PM of the undated CCP for Resident 39 related to fall interventions revealed the following; The fall intervention of 5/9/21 to offer resident chair while in dining room had not been added. An interview on 11/08/21 at 10:00 AM with Nursing Supervisor-A, after review of the Fall Huddle Worksheets and the CCP for Resident 39 confirmed that new interventions that had been listed on the Fall Scene Huddle Worksheets were not added to the CCP. C. A record review on 11/08/21 at 09:35 AM of the CCP for Resident 8 revealed an intervention that sack lunches will be sent to [CONDITION(S)] with resident and did not indicate resident's wishes to not take a lunch. During an interview on 11/01/21 at 02:10 PM, Resident 8 denied taking a sack lunch on [CONDITION(S)] days. An interview on 11/03/21 at 08:15 AM with MA-A (Medication Aide) confirmed that Resident 8 chose not to take a sack lunch to [CONDITION(S)]. The interview confirmed that Resident 8 will request a snack upon return when desired. An interview with the CDM (Certified Dietary Manager) conducted on 11/03/21 at 10:38 AM confirmed that the facility had snacks available on each unit. The interview confirmed Resident 8 did not take a sack lunch to [CONDITION(S)] per choice and (gender) would ask for a snack upon return if (gender) wishes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation and interview, the facility failed to ensure measures were in place related to the potential choking risk for Resident 57. The facility identified a census of 63. Findings are: An observation on 11/1/21 at 11:40 AM, revealed all nursing staff had left the dining room while Resident 57 remained at the table eating lunch. An interview on 11/01/21 at 11:45 AM with Cook-B confirmed that Resident 57 had swallow precautions in place to prevent choking and an order to have nectar thick fluids. An interview on 11/03/21 at 02:55 PM with the Director of Nursing (DON) revealed that the facility allowed dietary staff to monitor meals in the dining rooms, stating there is a call light in there to reach the nursing staff when needed, we've already had an incident happen and the call light system worked then. An observation on 11/04/21 at 10:40 AM revealed Resident 57 to be at a table in the 400 hall dining room eating eggs and noted to be coughing. During the observation, no staff, nursing or dietary, were present in the dining room. An interview on 11/04/21 at 10:43 AM with LPN-G (Licensed Practical Nurse) confirmed that staff should be in the dining room while Resident 57 was eating or drinking due being deemed a choking risk. The interview with LPN-G confirmed no nursing or dietary staff were present until LPN-G had returned to the lounge.

Licensure Reference Number 175 NAC 12XXX C3a(6) Based on record review and interview the facility failed to notify the resident's physician of a change in condition for 1 resident (Resident1) related to unrepsonsiveness and required emergency transport to the hospital with a [DIAGNOSES REDACTED]. The facility census was 67. Findings are: Record review of Survey Report ADL (Activities of Daily Living) for Resident 1 dated 02/12/20 revealed; on 2/7/20 Resident 1 required limited assistance of 1 person while eating at 8 AM at 5PM Resident 1 required total assistance while eating. On 2/8/20 Resident 1 had not eaten the breakfast and noon meal. Record review of Incident Report dated 2/7/20 revealed; Resident 1 had an unresponsive episode. Record review of Fax form dated 2/7/20 at 4:30 PM the form had not listed the Provider. allergies [REDACTED]. Concern: Resident 1 went unresponsive while in the sit to stand and was lowered to the floor by staff. Resident 1 was recently treated for [REDACTED]. BS (Blood sugar) was 98, no signs or symptoms of pain. Notified Provider and received a phone order for sterile catheter urinalysis with culture and sensitivity if indicated. No injuries noted. Orders to: Do not use sit to stand lift for transfers. Use Hoyer lift instead. Record review of a phone order dated 02/07/20 at 6:06 PM revealed; an order for [REDACTED]. DX: Mental status change. Record review of Clinical Monitoring dated 02/07/20 at 12:47 AM revealed Resident 1 weight was 229.2, temperature 98, Pulse 20, Respirations 20 Blood pressure 109/83, oxygen saturation 96% Room air, Pain none, blood glucose 269, alert, cap refill not assessed, infection was urinary/genital, incontinent, frequency and pain with urination. Interventions monitor and observe, Fluid Hydration. Record review of Clinical Monitoring dated 02/07/20 at 9:59 PM revealed; Resident 1 weight was 229.2, temp 96.7, Pulse 62, Respirations 18, Blood pressure 116/93, oxygen saturation 93% Room air, Pain none, blood glucose 98, lethargic and oriented, cap refill not assessed, infection was urinary/genital, incontinent, frequency residue. Interventions monitor and observe, Fluid Hydration, Antibiotic started and administered. Other Note: Resident 1 was lethargic and mumbling, oriented to self, became unresponsive while transferring in the sit to stand then was lowered to the floor, was incontinent, vs WNL, and used full total lift assist 2. Record review of PN (Progress Note) dated 2/7/20 at 3:15 PM revealed; Resident 1 had went unresponsive while being transferred in the STS (Sit to Stand) to the toilet, was lowered to the floor. VS (Vital Signs) and ROM (Range of Motion) WNL (Within Normal Limits), no apparent injuries. Notified POA (Power of Attorney), case manager, Physician, administrator, DON (Director of Nurses), and social services. Provider recommends resident to be transferred in a Full Lift 2 assist. Staff got PO (Phone Order) for UA (Urinalysis) with C&S (Culture and Sensitivity) with sterile catheter will be sent to the hospital tonight. Record review of PN dated 2/8/20 at 9:30 AM revealed; Resident 1 stayed in bed this am resident difficult to arouse refused to eat breakfast, Blood glucose check 91. VS BP 108/56 80 temp 98, Spo2 (Oxygen Saturation) 93% resident incontinent of urine and large BM 2 assist with repositioning and peri care awaiting UA results. Record review of PN dated 2/8/20 at 11:20 AM revealed; Resident stayed in be this am difficulty to arouse refused to eat breakfast Blood Glucose check 91. Resident had large loose incontinent. BM (Bowel Movement) 2 assist and peri care and repositioned. 108/56, P 81 18 temp 98, SPAO 93%. Record review of PN dated 2/8/19 at 11:23 PM revealed; Resident 1 in bed this evening. Non responsive to verbal and tactile stimuli. Color Pale. Repositioned and no response from resident. Refused supper when offered and also medications. At 7:00 PM resident's family member was in facility. Upset about Resident 1's condition. Family wanted Resident 1 taken to the hospital or I'll call 911 to come get Resident 1. Provider notified of resident status and family request. Order received and Family notified of order. At 7:20 EMS (Emergency Medical Services) in the facility and resident was discharged to hospital. At 2130 notified of Resident 1 being transferred to Lincoln with a dx [MEDICAL CONDITION] and kidney failure. Record review on 2/8/20 at 11:10 AM revealed; Note Text: [MEDICATION NAME] 70/30 held ate nothing this am. Blood Glucose was 91. An interview on 02/12/20 at 5:22 PM with LPN (Licensed Practical Nurse) A Resident 1 had some difficulty to wake up and was muttering something then went back to sleep. At 4:00 PM a family member was at the facility and Resident 1 had slept while the family was there. Resident 1 had not used the call light during the shift. LPN A reported that Resident 1 normally had not used the call light, so the staff had increased observations. Staff had taken Resident 1 pudding and the resident had not eaten the pudding. LPN A reported that they did not call the physician until the grandson had arrived. LPN A reported that the MA (Medication Aide) had to crush the medications related to the condition of the resident. LPN A reported the family member asked to speak with the Nurse, family had reported they had never seen Resident 1 in that condition. LPN A reported that the family was on the phone calling people and asked the Resident 1 be transferred to the hospital. An interview on 2/12/19 at 5:59PM with the Provider confirmed; they were in the building on Friday and spoke with the family DNR (Do Not Resuscitate) verses Cardiopulmonary Resuscitation. The Provider reported they were informed of the non-responsive episode on 2/7/20 of Resident 1 during the transfer in the sit to stand. UA orders were given, and collected, the results were negative. On Saturday 2/8/20 Resident 1 was kept in bed the staff called the provider at 5:21 PM to request transfer for non-response, the Provider confirmed the facility had not called them earlier in the day related to the decline in condition. An interview on 02/12/20 at 6:27 PM with the DON confirmed; staff should inform the physician related to decline in condition and should have contacted the physician on 2/8/20 when the resident had declined food, fluids and medication and had an increase in lethargy. An abaitement completed on 02/12/20 revealed; the facility will complete assessments on all residents 2/12/20 to identify any change of condition and report to physician if necessary. Starting 2/12/20, all licensed nursing staff will be educated prior to starting shift of policy and procedure and process for identifying change in condition and communicating to physician. Interview conducted with all nursing staff on 02/13/20 revealed; the facility had educated all nursing staff prior to the start of shift related to change in condition and notification of notification of change in condition.

Licensure Reference Number 175 NAC 12.006.09D7b Based on record reviews, interviews and observations the facility failed to ensure interventions were implemented to prevent repeated falls with injuries including lacerations, bruised and skin tears for one resident (Resident 2) from falls. The facility census was 72. Findings are: Record review of Resident 2's (EHR) Electronic Health Records revealed Resident 2 was admitted from home on 5/18/20 with recent history of multiple falls and dementia. Record review of Resident 2's incident reports revealed Resident 2 has had 7 falls from 6/6/20-7/14/20. Record review of Resident 2 Progress Notes dated 6/6/20 at 8:03 PM revealed Resident 2 was found on the floor in (gender) room in restroom. resident sustained [REDACTED]. Record review of Resident 2's Care Plan( a written document that details a residents care including problems, goals and interventions) dated 7/15/20 revealed on 6/9/20 an intervention was added- resident was reminded to use call light - staff to ensure it is within reach at all times. An interview/ observation on 7/21/20 at 11: 15 AM with Resident 2 revealed Resident 2 was unable to press call light or understand what call light was for. Record review of Resident 2 Progress Notes dated 6/20/20 at 11:30 AM revealed Resident 2 fell and had skin tears and small emesis at the time of fall. Resident on Blood thinner at the time of fall. Record review of Resident 2's Care Plan dated 7/15/20 revealed No new interventions were added on 6/20/20 for fall on 6/20/20. Record review of Resident 2 Progress Notes dated 6/23/20 at 1:36 AM revealed Resident 2 was found sitting on floor in (gender) room. No injuries sustained. Record Review of Resident 2's Care Plan dated 7/15/20 revealed an Audio monitor was placed in Resident 2's room and instructions to be on at all times to alert staff to any movement. An interview on 7/21/20 at 11:25 AM with LPN-B revealed Resident 2 has a baby monitor audio monitor in Resident's room and receiver at nurse's station. LPN-B stated that staff check on resident when (gender) hollers out family members names. Record review of Resident 2's Progress notes dated 6/6/20 revealed conversation with staff to Resident 2's family reporting Resident 2 would continuously holler out at home and this was Resident 2's normal baseline behavior. Record review of Resident 2's Incident Report dated 7/6/20 at 11:50 AM revealed Resident 2 was found on floor in (gender) room in front of recliner. Record review of Resident 2's Care Plan dated 7/15/20 revealed the following intervention was added to Care plan on 7/6/20- educate staff to have push pad call light to resident at all times. Record review of Resident 2's Progress notes dated 7/11/20 at 6:35 PM revealed Resident 2 was found on floor in (gender) room in front of recliner; foot rest of recliner was up. No injuries noted. Record review of Resident 2's Care Plan dated 7/15/20 revealed No new interventions were added on 7/11/20 for fall on 7/11/20. Record review of Resident 2's Progress notes dated 7/12/20 at 4:45 PM revealed Resident 2 was found on floor, injury to left eye and side of face, hematoma to left arm, no other injuries noted. Resident 2's Physician notified and Resident 2 sent to hospital for evaluation. An interview on 7/20/20 at 11:25 AM with LPN-B revealed that Resident 2 fell on [DATE] and Resident was found lying face down on floor and bleeding from forehead area. LPN-B contacted DON and Resident physician was called Resident 2 was sent to hospital. Record review of Resident 2's Progress notes dated 7/12/20 at 3:28 PM revealed Resident was sitting on foot of recliner while chair was in reclined position. Resident 2 was anxious for restroom, resident was assisted off chair and walked into bathroom. Resident 2 was reminded to use call light and not get up without staff assistance. Record review of Resident 2's Care Plan Dated 7/15/20 revealed on 7/11/20 an intervention was added monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. Note on 7/12/20 resident was sent to ER for evaluation and treatment. [DIAGNOSES REDACTED]. Record review of Resident 2's Care Plan Dated 7/15/20 revealed on 7/11/20 an intervention was added Review and modify environmental hazards that could cause or contribute to fall. Frequent Checks on Resident in room and make sure resident has recliner control. 7/12/20 education to staff not to leave resident unattended in restroom. An interview on 7/21/20 at 1:30 PM with DON (Director of Nursing) confirmed frequent checks would be a minimum of 1 time hour. Record review of Resident 2's task charting Titled Observed dated 7/15/20 - 7/21/20 revealed Staff are not checking on Resident 2 at least 1 time per hour. Record review of Resident 2's Progress Notes dated 7/14/20 at 1:40 AM revealed Resident 2 was found on in (gender) room with legs straight ahead of resident facing recliner. Resident 2 had been sitting in recliner and doesn't remember why (gender) fell . Open skin area measuring 2 x 1.5 cm to right knee with small amount of red drainage noted. Resident was receiving oxygen via nasal cannula at time of fall. An observation on 7/21/20 at 11:05 AM revealed Resident 2 was attempting to crawl over arms of recliner. Record review of Resident 2's Care Plan dated 7/15/20 revealed on 7/14/20 the following interventions were added - bed changed out from bariatric bed to regular bed as regular bed can going a lower position and at bedtime pin call light to residents shirt and implement use of a horse shoe pillow around resident or equivalent. An interview on 7/21/20 at 1:30 PM with DON confirmed Resident 2 was admitted to facility with history of falls at home and resident family was no longer able to care for resident 2. DON confirms interventions for Resident 2 were not specific to Resident 2's goal (Resident will resume usual activities without further incidents).

Licensure Reference Number: 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to identify the underlying cause of a fall with injury in order to implement pertinent interventions in an effort to prevent future falls from occurring for one resident (Resident 16). The facility census was 73. Findings are: Review of Resident 16's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7/7/15 revealed moderately impaired cognition, supervision to one assist required with transfer and ambulation and [DIAGNOSES REDACTED]. Review of Resident 16's Care Plan initiated on 7/16/14 revealed, The resident is at risk for falls .unsteady gait and poor safety awareness will not always use call light. Updated interventions were as follows: -7/29/14 remind to lock wheelchair and keep it next to (resident). -11/21/14 check on-while in room each hour and make sure to place the wheelchair next to bed or chair, make sure it is locked to promote safe transfers because (Resident 16) will not use the walker. Review of an electronic incident report dated 7/12/15 for Resident 16 revealed Resident 16 had turned the call light on and staff found (Resident 16) on the floor when answering it. Resident did not remember how the fall occurred. Predisposing environmental factors listed were poor lighting Review of Resident 16's Progress Notes dated 7/13/15 revealed Resident 16 was found on the floor by the bathroom at 11:10 PM. Resident 16 reported feeling funny with complaints of nausea and unsteadiness but denied hitting (resident's) head. Review of a faxed update to Resident 16's physician on 7/17/15 revealed Resident 16 had continued to decline since the fall. Resident 16 was difficult to arouse, more withdrawn and had several emesis. Orders were received and followed to send Resident 16 to the emergency department to rule out a cranial bleed. Review of the Emergency Department report dated 7/17/15 revealed probably [DIAGNOSES REDACTED]. During an interview with Medication Aide (MA) A on 8/18/15 at 10:41 AM, MA A was asked what new fall interventions were in place since Resident 16's latest fall. MA A responded that staff were to place Resident 16's wheelchair close by the resident and reinforce with Resident 16 to use the call light. Interview with Registered Nurse (RN) B on 08/18/2015 at 11:53 AM revealed the facility did not use alarms as fall interventions so staff were to check on Resident 16 frequently and remind Resident 16 to utilize the call light because Resident 16 was getting self off of the toilet and didn't call for help before getting up when the fall occurred. When asked if Resident 16 had dementia or forgetfulness RN B stated, yes, (Resident 16) is forgetful.