Every finding on record at Good Samaritan Society - Grand Island Village

Licensure Reference Number 175 NAC 12-006.05(D)Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview the facility failed to ensure that consent was obtained prior to the administration of psychoactive medications (any medication that affects behavior, mood, thoughts, or perception) for 2 of 3 sampled residents (Residents 3 and 4). The facility census was 57.Findings are:A.Record review of the facility policy titled Psychotropic Medications dated 12/9/25 revealed that a psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. The policy revealed that a psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include antipsychotics, antidepressants, antianxiety, and hypnotics. A consent form must be signed for the use of psychotropic medications. The Permission for Use of Psychotropic Medications form will be used to obtain consent. The Permission for Use of Psychotropic Medications consent form must be completed with a dose change of psychotropic medication. B.Record review of the admission Record dated 6/1/26 for Resident 3 revealed that Resident 3 admitted into the facility on 8/30/24. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/11/26 for Resident 3 revealed that Resident 3 did not take any psychotropic medications. Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a resident at a facility by a health care professional) for March 2026 for Resident 3 revealed that there was an order for Mirtazapine 7.5 milligrams (mg) (a psychotic medication used to treat depression) to be administered 1 time daily at bed time. The MAR revealed documentation that the Mirtazapine was administered to Resident 3 on 3/28/26, 3/29/26, 3/30/26, and 3/31/26. Record review of the medical record for Resident 3 revealed that it did not contain a consent for the psychotropic medication Mirtazapine.Record review of the progress note for Resident 3 dated 3/31/26 at 11:19 AM revealed that the Social Service Director (SSD) contacted the Power of Attorney (POA) for Resident 3 regarding a consent form needing to be signed for Resident 3's Mirtazapine. The POA stated that they would be at the facility today to sign the consent. (Resident 3 had already received 3 doses of the Mirtazapine prior to this communication to the POA).Interview on 6/1/26 at 2:15 PM with the Facility Administrator (FA) confirmed that the facility must obtain consent for psychoactive medications prior to the medication being administered.Interview on 6/1/26 at 2:39 PM with the FA confirmed that the facility failed to obtain consent for the psychoactive medication prior to administration as required for Resident 3.C. Record review of the admission Record dated 6/1/26 for Resident 4 revealed that Resident 4 admitted into the facility on 4/25/25.Record review of the Order Recap Report (a listing of all active and discontinued medications for a resident) dated 6/1/26 for Resident 4 revealed that Resident 4 had an order for Abilify 5 mg (an antipsychotic medication) one time a day for major depressive disorder. The order date for the medication was 6/13/25 and the order was discontinued on 4/13/26. Resident 4 had an active (current) order for Abilify 10 mg with an order date of 4/13/26 (this order increased the amount of the medication from 5 mg to 10 mg). Record review of the MAR for April 2026 for Resident 4 dated 6/1/26 revealed that Abilify 10 mg was administered to Resident 4 on 4/14/26 and 4/15/26.Record review of the untitled consent form dated 4/15/26 for Resident 4 revealed that it included the antipsychotic medication Abilify 10 mg. The section titled The symptoms that you are experiencing that the medication is intended to help are: was left blank. The section titled The non-pharmacological alternatives attempted are listed below: was left blank. The consent form was signed by the facility Social Services Director (SSD) dated 4/15/26. The consent form was signed by Resident 4 and dated 4/15/26. (Resident 4 had already received 1 dose of the Abilify 10 mg prior to the consent form being signed).Interview on 6/1/26 at 2:15 PM with the Facility Administrator (FA) confirmed that the facility must obtain consent for psychoactive medications and antipsychotic medications prior to the medication being administered.Interview on 6/1/26 at 2:39 PM with the FA confirmed that the facility failed to obtain consent for the increased dose of the antipsychotic medication prior to administration as required for Resident 4.

Licensure Reference Number 175 NAC 12-006.09 (F)(i)Based on record review and interview the facility failed to ensure that a baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed by staff to provide initial effective and person-centered quality care for a resident) was developed and reviewed with the resident/resident representative and ensure that a written summary was offered to the resident/resident representative for 3 of 3 residents reviewed (Residents 7, 2, and 9). The facility census was 46.Findings are:A.Record review of the facility policy titled Care Plan dated 12/1/25 revealed that the baseline care plan includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. A baseline care plan will be developed upon admission according to state and federal regulations. The facility must provide the resident and resident representative with a written summary of the baseline care plan. Use the Care Conference Note progress note to document that the meeting occurred with the resident and representative and any significant discussion that occurred. The resident /family or legal representative will have the opportunity to participate in the planning of his or her care to the extent possible. Record review of the admission Record for Resident 7 dated 12/22/25 revealed that Resident 7 admitted into the facility on 3/20/25. Diagnoses included Acquired Absence of the Right and Left Legs, Diabetes, and Anxiety.Record review of the medical record for Resident 7 revealed no baseline care plan for Resident 7.Record review of the progress notes for Resident 7 revealed no documentation of any baseline care plan discussion or summary of a baseline care plan with the resident or resident representative. Interview on 12/29/25 at 3:33 PM with the facility Director of Nursing (DON) confirmed that the facility did not complete a baseline care plan for Resident 7 due to a gap in the facility process. The DON confirmed that the facility had no documentation of a baseline care plan review with the resident or resident representative. The DON confirmed that the resident/resident representative were not offered a summary of a baseline care plan as required. B.Record review of the admission Record for Resident 2 dated 12/22/25 revealed that Resident 2 admitted into the facility on 3/26/25. Diagnoses included High Blood Pressure, Fracture of the Right Upper Leg, and Sleep Apnea.Record review of the medical record for Resident 2 revealed no baseline care plan for Resident 2.Record review of the progress notes for Resident 2 revealed no documentation of any baseline care plan discussion or summary of a baseline care plan with the resident or resident representative. Interview on 12/29/25 at 3:33 PM with the facility Director of Nursing (DON) confirmed that the facility did not complete a baseline care plan for Resident 2 due to a gap in the facility process. The DON confirmed that the facility had no documentation of a baseline care plan review with the resident or resident representative. The DON confirmed that the resident/resident representative were not offered a summary of a baseline care plan as required. C.Record review of the admission Record for Resident 9 dated 12/22/25 revealed that Resident 9 admitted into the facility on 6/24/25. Diagnoses included Chronic Kidney Disease, Obesity, and Peripheral Vascular Disease (A circulatory problem where narrowed blood vessels reduce blood flow to the limbs, most commonly the legs, requiring care, medications, or procedures to prevent severe complications like limb loss or stroke). Record review of the medical record for Resident 9 revealed no baseline care plan for Resident 9.Record review of the progress notes for Resident 9 revealed no documentation of any baseline care plan discussion or summary of a baseline care plan with the resident or resident representative. Interview on 12/29/25 at 3:33 PM with the facility Director of Nursing (DON) confirmed that the facility did not complete a baseline care plan for Resident 9 due to a gap in the facility process. The DON confirmed that the facility had no documentation of a baseline care plan review with the resident or resident representative. The DON confirmed that the resident/resident representative were not offered a summary of a baseline care plan as required.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review, observations and interviews, the facility failed to ensure that the medication error rate was not 5% or higher. This affected 4 of 8 residents (Residents 21, 26, 40, and 58). The facility census was 46. Findings were:Record review of the facility policy Medication: Administration Including Scheduling and Medication Aides dated 4/08/2025 revealed the policy purpose was to administer medications correctly and in a timely manner and to provide direction regarding medications aides among other purposes. This policy also stated the medications are administered to the resident according tot he Six Rights; right medication, right dose, right time, right resident, right route, and right documentation. All employees passing medications are familiar with action and adverse reactions of medications. Record review of the Certified Medication Aide; Trained Medication Aide competency training for Medication Aide (MA) A which was completed on 11/4/2025 at the time of new hire orientation. The skills testing revealed that MA-A had completed the self assessment (which were then signed off by a preceptor) indicating that MA-A was able to perform without supervision the following skills, among others: 1. Verbalizes and demonstrates that medications must be administered in a timely manner within 60 minutes on each side of ordered time, except for state medications which must be given immediately or other time sensitive medications. 2.Demonstrates providing the Six Rights of Medication right medication to the right person at the right time in the right dose and by the right route , right documentation ensuring all changes in medications are responded to in a timely manner. 3. Demonstrates appropriate delivery of medications. 4. Demonstrates appropriate action per location policy for missed medications 5. Follows location procedure including timelines for documenting medication immediately after being provided. A. Record review of the medication orders revealed that during the AM medication pass, Resident 58 was to receive the following medications: 1. Amiodarone 200 milligrams (mg) oral daily for Paroxysmal Atrial fibrillation (intermittent irregularly-irregular heart beat) 2. Cholecalciferol 50 mg oral daily for osteoporosis of the bones 3. Choline Fenofibrate 135 mg oral daily for elevated lipids 4. Cyanocobalamin 1000 mg oral daily for end stage renal disease 5. Folic Acid 1 mg oral daily for end stage renal disease 6. Isosorbide mononitrate 30 mg oral daily for high blood pressure 7. Pantoprazole 40 mg oral daily for gastroesophageal reflux disease (heartburn) 8. Torsemide 100 mg oral daily for congestive heart failure 9. Doxycycline 100 mg oral daily (last dose) for a urinary tract infection 10. Gabapentin 100 mg oral for diabetic neuropathy (pain caused by diabetes) 11. Metoprolol 25 mg oral daily for elevated blood pressure 12. Midodrine 5 mg to be taken with meals at 8:00 AM for anemia 13. Sevelamer 800 mg oral daily for end stage renal disease Observation on 12/29/2025 at 10:23 AM of Medication Aide (MA) A who prepared medications for administration to Resident 58. MA-A pulled all of the medications from the drawer, checked off each medication one at a time with the bubble pack holding the medication to the electronic medical record to assure accuracy. MA-A then put each pill ordered into a small medication cup. MA-A then marked all of the medications as given in the electronic medical record. MA-A then went to Resident 58's room only to find Resident 58 was gone. In an interview on 12/29/2025 at 10:38 AM, MA stated that Resident 58 had left the facility and gone to dialysis because this was Monday. MA stated Usually the van driver tells me they are leaving and asks if Resident 58 has had ordered medications yet. But Resident 58 is already gone. I usually give the medications to Resident 58 between 9 and 10 because breakfast has already been served and I know this resident will not get sick taking medications on an empty stomach. I cannot give any of these medications now because there is a risk that I would duplicate some medications when Resident 58 returns from dialysis. Observation on 12/29/2025 at 10:40 AM as MA-A worked with the Clinical admission Specialist (CNE) to mark the medications in the electronic medical record (EMAR) as not given. The CNE assisted MA-A with the policies and protocols needed to destroy the medications in the medication room, to inform the charge nurse, to contact the dialysis center, and to fill out a medication error form. B. Record review of the EMR for Resident 21 revealed an order for Gabapentin 400 mg oral 3 times daily for osteoarthritis. The medication was due to be given at 11:30 AM. Observation on 12/29/2025 at 12:38 PM of MA-A as the medication was double checked on the bubble pack and the EMR. The medication was highlighted in a red box on the EMR. MA-A gave the medication to the resident and then MA-A charted the medication as given. In an interview with MA-A on 12/29/2025 at 12:42. MA-A revealed that the medication was highlighted on the EMR by a red box and was due to be given at 11:30 AM. Because MA-A was helping with other resident cares prior to the medication pass, MA-A was a little bit behind on giving all of the medications. MA-A confirmed that the Gabapentin was administered late as the staff only have 1 hour before or one hour after the designated time to administer medications. C. Record review of the EMR for Resident 26 revealed an order for Torsemide 20 mg oral twice a day for edema. The medication was due to be given at 11:30 AM. The medication was highlighted in a red box on the EMR. Observation on 12/29/2025 at 12:47 PM of MA-A as the medication was double checked on the bubble pack and the EMR. The medication was highlighted in a red box on the EMR. MA-A gave the medication to the resident and then MA-A charted the medication as given. In an interview with MA-A on 12/29/2025 at 12:53 PM confirmed that the medication was late and given a the wrong time. D. Record review of the EMR for Resident 40 revealed that there were orders for Sinemet 25/100 mg 1 1/2 tabs to be given for Parkinson's disease at 11:30 AM and another medication midodrine 5 mg to be given at 11:30 AM for hypotension (low blood pressure). Observation on 12/29/2025 at 12:55 PM of MA-A as the medications were double checked against the EMR. Both medications were highlighted by a red box on the EMR. MA-A gave the medications to the resident and then MA-A charted the medications as given. In an interview with MA-A 12/29/2025 at 1:00 PM MA-A confirmed that both medications given to Resident 40 were given late and at the wrong time. Medications listed in red are actually late. We have one hour to give the medications.

Licensure Reference Number 175 NAC 12-006.05 (D)Licensure Reference Number 175 NAC 12-006.05 (E)Based on record review and interview the facility failed to be inform the resident/resident representative of the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to choose the alternative or option they prefer prior to administering psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) for 2 (Resident 3 and Resident 4) of 5 residents. The facility census was 46.Findings are:A. Record review of the facility policy titled Psychotropic Medications dated 12/9/25 revealed that before the administration of non-emergency psychotropic medications a consent form must be signed for the use of psychotropic medications. The Permission for Use of Psychotropic Medications will be used to obtain consent. Record review of the admission Record for Resident 3 dated 12/22/25 revealed that Resident 3 admitted into the facility on 5/16/23. Diagnoses included Paranoid Personality Disorder, Dementia, and Anxiety. Record review of the current care plan for Resident 3 revealed that Resident 3 takes psychotropic medications and staff are to monitor and document side effects and effectiveness of the medications initiated 9/18/24. Record review of the November 2025 medication administration record (MAR) (a legal record of the prescriber ordered medications administered to a patient at a facility by a health care professional) for Resident 3 dated 12/30/25 revealed that the prescriber ordered medication Rexulti (a psychotropic medication used to manage psychotic disorders- possible side effects of Rexulti include sleepiness, dizziness, and increased risk of death in certain elderly patients) 3 milligrams once a day had an order start date of 7/22/25. The MAR revealed documentation that the ordered medication Rexulti was administered daily to Resident 3. Record review of the December 2025 MAR for Resident 3 dated 12/30/25 revealed documentation that the ordered medication Rexulti was administered daily to Resident 3 from 12/1/25-12/30/25. Record review of the medical record for Resident 3 revealed no documented consent for use of psychotropic medications for the prescriber ordered Rexulti 3 milligrams once a day that started on 7/22/25, or documentation informing the resident/resident representative of the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to choose the alternative or option they prefer. Interview on 12/30/25 at 10:24 AM with the facility Director of Nursing (DON) confirmed that the facility did not have a consent for use of the psychotropic medication Rexulti for Resident 3. B. Record review of the New Prescription Summary for Resident 3 dated 12/15/25 revealed a prescription order for Trintellix (a psychotropic medication used to treat Major Depressive Disorder-possible side effects of Trintellix include nausea, vomiting, and thoughts of suicide) 10 milligrams take 1 tablet in the morning. Record review of the December 2025 MAR for Resident 3 dated 12/30/25 revealed documentation that the ordered medication Trintellix was started on 12/16/25. The MAR revealed documentation that the Trintellix was administered daily to Resident 3 from 12/16/25-12/30/25. Record review of the medical record for Resident 3 revealed no documented consent for use of psychotropic medications for the prescriber ordered Trintellix 10 milligrams take 1 tablet in the morning that started on 12/16/25. Interview on 12/30/25 at 10:24 AM with the facility Director of Nursing (DON) confirmed that the facility did not have a consent for use of the psychotropic medication Trintellix for Resident 3 as required. C. A review of a admission Record indicated the facility admitted Resident 4 on 05/23/2025 with diagnoses of major depressive disorder (a mood disorder causing persistent sadness and loss of interest, affecting how one feels, thinks, and acts), and generalized anxiety disorder (a condition characterized by excessive anxiety and worry about a variety of events or activities (e.g., work or school performance) that occurs more days than not, for at least 6 months). A review of Resident 4 Physician Orders on 12/29/2025 revealed that Resident 4 was prescribed Zoloft (a psychotropic antidepressant medication) and Alprazolam (a psychotropic anti-anxiety medication) when admitted to the facility on [DATE]. The comprehensive 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 05/29/2025 revealed Resident 4 had received routine antianxiety and antidepressant medication during the assessment period. A review of a facility supplied document titled Permission for Use of Psychotropic Medications and dated 08/04/2025 revealed in the section titled Antidepressant Medication the Zoloft and the Alprazolam medications to be listed under this section. In the area of the form titled the symptoms that you are experiencing that the medication is intended to help there are no symptoms listed the area of the form is left blank. In the area of the form titled nonpharmacological alternatives attempted are listed below there is no documentation or no alternatives attempted listed in this area of the form. In an interview completed on 12/30/2025 at 02:55 PM with the facility Social Services Director (SSD), the SSD confirmed that there were no symptoms listed that the medications were being used to treat on the form and should have been, that there were no nonpharmacological alternatives listed to attempt for Resident 4. The SSD confirmed that the resident was admitted to the facility on [DATE] receiving these medications. The SSD confirmed that the form was not completed and signed until 08/04/2025 and not at the time of admission. The SSD confirmed that no education was provided in regard to the symptoms or alternatives to the medications to be provided.

Licensure Reference Number 175 NAC 12-006.02 (H)State Statute 28-372Based on record review and interview, the facility failed to report all allegations of mistreatment and abuse within the regulatory reporting parameters. This affected 1 (Resident 4) of 1 sampled resident. The facility census was 46.Findings are:Review of a facility policy titled Abuse and Neglect dated 04/07/2025 revealed the location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse. Results of all investigations will be reported to officials in accordance with state law including to the state survey and certification agency with in five working days of the event or sooner as designated.A review of a admission Record indicated the facility admitted Resident 4 on 05/23/2025 with diagnoses of major depressive disorder (a mood disorder causing persistent sadness and loss of interest, affecting how one feels, thinks, and acts), and generalized anxiety disorder (a condition characterized by excessive anxiety and worry about a variety of events or activities (e.g., work or school performance) that occurs more days than not, for at least 6 months), chronic pain, and age related osteoporosis (a condition that is characterized by decrease in bone mass with decreased density and enlargement of bone spaces producing porosity and fragility).The comprehensive 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 10/17/2025 revealed that the resident was coded as to be understood and to understand others and had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 indicating the resident was cognitively intact.A.In an interview completed on 12/29/2025 at 3:50 PM with Resident 4, Resident 4 stated that they have had episodes where staff have yelled at them and been rude. The residents stated that they reported these incidents by telling staff and completing a grievance form.Record review of a facility supplied document titled Suggestion or Concern and dated 08/07/2025 revealed Resident 4 completed the form and writing that a named staff member yelled at them several times and was rude to them. The residents wrote that they did not want the staff member to ever return to their room. Documentation on the other side of the form dated 08/12/2025 and signed by the facility Director of Nursing (DON), stated that the DON reached out to the employee in question and the employee resigned their position with the facility written in the investigatory section of the form, in the resolution portion it is documented that the employee resigned. In an interview completed on 12/30/2025 at 09:10 AM with the facility Director of Nursing, the DON stated that when attempted to speak with the staff member in question to validate the complaint made by Resident 4 the staff member resigned do did not investigate the matter further. The DON stated that they did not notify the regulatory agencies of the allegation or submit a report of the allegation's investigation to the regulatory agencies. The DON confirmed that staff yelling and being rude to residents met the definition of abuse.

Licensure Reference Number 175 NAC 12-006.09 (G)(i)Based on record review and interviews, the facility failed to provide evidence that the required information was conveyed to the hospital at the time of transfer and failed to notify the resident or responsible party of the facility bed hold policy at the time of transfer for 1 Resident (Resident 5) of 1 sample resident. Facility census was 46Findings are:A.Review of a facility policy titled Discharge and Transfer dated 12/18/2025 revealed when a transfer or discharge occurs, the location must ensure that the transfer or discharge is documented in the medical record and appropriate information is communicated to the receiving healthcare center or provider.Review of Resident 5's medical record revealed an admission date of 09/30/2025 and a discharge date of 12/19/2025.Review of Resident 5's Progress Notes revealed a late entry with effective date of 12/19/2025 stating that Resident 5's primary care physician was notified of the resident's condition and the resident's power of attorney and spouse wished for the resident to be transported to the hospital. Further documentation stated that the resident was transported to the hospital via ambulance. There is no documentation indicating the receiving hospital/facility or provider were notified of the appropriate information needed to care for Resident 5. In an interview completed on 12/29/2025 at 11:49 AM with the facility Director of Nursing (DON), The DON stated they were not aware of the facility contacting the receiving facility or provider with the appropriate information needed to care for the resident. The DON stated that they provide information to the ambulance personnel only. The DON confirmed that there was no documentation of information being communicated to the ambulance personnel or the receiving facility or provider needed to care for Resident 5.B.Review of a facility policy titled Bed Hold and dated 12/23/2025 revealed at the time of transfer the facility will provide written information to the resident or representative that specified the duration of the bed hold policy. At the time of transfer the social worker or designated individual will provide the notice of bed hold.Review of Resident 5's medical record revealed an admission date of 09/30/2025 and a discharge date of 12/19/2025.Review of a facility supplied document titled Notice of Bed Hold Policy and dated 12/22/2025 revealed the residents written name and the resident's spouses signature dated 12/22/2025. The residents discharge date to the hospital was 12/19/2025.In an interview completed on 12/29/2025 at 11:47 AM with the facility Social Service Director (SSD), the SSD stated that in the absence of the SSD the nurse in charge is to provide the bed hold policy to the resident or representative. The SSD stated that the nurse then records the communication of the bed hold policy in the residents progress notes. The SSD confirmed that the nurse did not complete Resident 5's notification of bed hold policy when the resident was transferred on 11/19/2025 so the SSD completed it on 12/22/2025.

Licensure Reference Number 175 NAC 12-006.09(H) (iii)(2)Based on observation, record review, and interview the facility failed to ensure that pressure ulcer (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) assessments including wound size were documented as required to determine healing or worsening of the pressure ulcers for 1 of 1 residents reviewed (Resident 2). The facility census was 46.Findings are:A.Record review of the facility policy titled Pressure Ulcers dated 2/17/25 revealed that the purpose is to provide assessment and prevention of pressure ulcers as well as treatment when necessary. The facility will use prevention and assessment interventions to ensure that residents entering the facility without pressure ulcers do not develop a pressure ulcer. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing. Residents will receive assessments and services to promote and maintain skin integrity. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 2 dated 4/1/25 revealed that it was the admission assessment for Resident 2. The MDS revealed that Resident 2 admitted into the facility on 3/26/25. Resident 2 required moderate staff assistance to roll left and right in bed. Resident 2 required maximal staff assistance for going from lying in bed to sitting on the side of the bed. Resident 2 required maximal staff assistance for standing from a sitting position. The MDS revealed that Resident 2 did not have any unhealed pressure ulcers.Record review of the current MDS for Resident 2 dated 12/23/25 revealed that Resident 2 now had two unstageable pressure ulcers (a severe wound where the base is hidden by dead, sloughy (yellow, tan, brown) or leathery eschar (black) tissue, making its true depth and stage (like Stage 3 or 4) impossible to determine until the dead tissue is removed (debrided)). These wounds indicate full-thickness tissue loss and require urgent care, as they can mask extensive damage, potentially revealing deep muscle or bone involvement) that were not present on admission. Interview on 12/22/25 at 1:25 PM with Resident 2 confirmed that the resident has pressure ulcers on the left and right heels that developed after admission. Resident 2 revealed that they hurt real bad. Record review of the Order Summary Report dated 12/29/25 for Resident 2 revealed the prescriber order to complete wound care to the left and right heels every other day and as needed. Cleanse the areas and cover with 2-3 layers of xeroform gauze (a sterile, fine-mesh gauze dressing infused with moisturizer and antimicrobial compounds that creates a moist healing environment), and cover with ABD pad (abdominal pad) (a highly absorbent, multi-layered gauze dressing). Secure with kerlix (a woven gauze bandage) and tape. Observation on 12/30/25 at 9:38 AM in the room of Resident 2 revealed that Licensed Practical Nurse-F (LPN-F) entered the resident's room to perform wound care on the left and right heel pressure ulcers. LPN-F removed the kerlix dressing from the left heel and removed the ABD pad with the xeroform dressing. The back of the left heel had a pressure ulcer measuring approximately 2.8 centimeters (cm) long, 1.7 cm wide, and 0.1 cm deep per visual measurement. The wound was covered with 90% yellow slough (a soft, stringy, or creamy yellowish tissue in a wound, composed of dead cells, proteins, and fibers) and had a small 10% area of eschar (a hard, black, layer of dead skin) at the bottom of the wound bed. LPN-F completed the wound care on the left heel. LPN-F removed the kerlix dressing from the right foot and removed the ABD pad with the xeroform dressing. The back of the right heel had a pressure ulcer that measured approximately 1.5 cm long, 1.7 cm wide and no depth per visual measurement. The wound bed was covered with yellow crusty tissue. LPN-F completed the wound care on the right heel.Record review of the Wound RN (Registered Nurse) Assessment for Resident 2 dated 11/6/25 revealed that Resident 2 had a pressure ulcer on the left heel that was unstageable. The assessment documented that the pressure ulcer was not present on admission.Record review of the Wound Data Collection Assessment (A facility assessment form containing the documentation of the assessment of a wound. The assessment documentation includes the wound's characteristics, tracking changes to guide treatment, including resident info, location, size (length, width, depth), tissue type (granulation, slough, eschar), drainage (amount, color, odor), wound edges, skin condition of the skin surrounding the wound, and pain.) for Resident 2 dated 11/6/25 revealed that it was completed for the initial data collection of the pressure ulcer on the left heel of Resident 2. The wound measurements were 1.5 centimeters (cm) long, 1.3 cm wide, and a depth of 0.1 cm. The assessment form revealed that wound measurements are required every 7 days.Record review of the Wound Data Collection for Resident 2 dated 11/22/25 revealed that the left heel pressure ulcer measured 1.5 cm long, 1.5 cm wide, and 0.1 cm deep. The wound bed was 100% covered with slough (a soft, stringy, or creamy yellowish tissue in a wound, composed of dead cells, proteins, and fibers). Record review of the Outpatient Nursing Home Wound Care Progress Note for Resident 2 dated 12/3/25 revealed that the non-facility Nurse Practitioner saw Resident 2. Resident 2 had an unstageable pressure ulcer on the left heel that measured 1.7 cm long, 1.2 cm wide, and had a depth of 0.1cm per the nurse practitioner. The bed of the pressure ulcer wound was 50% covered with yellow slough (a soft, stringy, or creamy yellowish tissue in a wound, composed of dead cells, proteins, and fibers) and 50% covered with eschar (a hard, black, layer of dead skin). The surrounding skin had redness and swelling. (This assessment was 11 days after the previous assessment of Resident 2's left heel pressure ulcer by the facility on 11/22/25.)Record review of the Wound Data Collection for Resident 2 dated 12/4/25 revealed that the left heel pressure ulcer measured 1.7 cm long, 1.2 cm wide, and 0.1 cm deep. The wound bed was covered with 50% slough and 50% eschar. (This assessment by the facility was 12 days after the previous facility wound assessment of Resident 2's left heel pressure ulcer on 11/22/25.)Record review of the Wound Data Collection for Resident 2 dated 12/18/25 revealed that the left heel pressure ulcer measured 1.7 cm long, 1.4 cm wide, and 0.1 cm deep. The wound bed was covered with 10% granulation tissue, 40% slough, and 40% eschar. Record review of the Wound Data Collection for Resident 2 dated 12/24/25 revealed that it contained no measurements or wound characteristics of the left heel pressure ulcer.Record review of the Wound Data Collection for Resident 2 dated 12/26/25 revealed that it contained no measurements or wound characteristics of the left heel pressure ulcer.Record review of the Wound Data Collection for Resident 2 dated 12/28/25 revealed that it contained no measurements or wound characteristics of the left heel pressure ulcer.Record review of the Wound Data Collection for Resident 2 dated 12/29/25 revealed that it contained no measurements or wound characteristics of the left heel pressure ulcer. (This assessment by the facility was 11 days after the previous facility wound assessment of Resident 2's left heel pressure ulcer on 12/18/25.)Interview on 12/30/25 at 11:14 AM with the facility Director of Nursing (DON) confirmed that resident pressure ulcers are to be monitored weekly by the facility wound nurse. The DON confirmed that measurements and description of pressure ulcers are required to be completed at least every 7 days to determine if a wound is improving or getting worse. The DON revealed that the Nurse Practitioner comes to the facility weekly for wound care rounds. Interview on 12/30/25 at 2:55 PM with the facility DON confirmed that the facility did not measure the pressure ulcers for Resident 2 every 7 days as required. B.Record review of the Wound RN (Registered Nurse) Assessment for Resident 2 dated 11/10/25 revealed that Resident 2 had a pressure ulcer on the right heel that was classified as a stage 3 (full-thickness skin loss, where the wound deepens through the skin into the fatty (subcutaneous) tissue, appearing as a deep crater but without exposing bone, muscle, or tendon. These painful wounds can involve rolled edges, dead tissue (slough/eschar), and may have signs of infection). The assessment documented that the pressure ulcer was not present on admission.Record review of the Wound Data Collection for Resident 2 dated 11/10/25 revealed that it was completed for the initial data collection of the pressure ulcer on the right heel of Resident 2. The assessment did not include any measurements of the wound. The assessment revealed that the wound bed was 100% covered with slough. Record review of the Wound Data Collection for Resident 2 dated 11/13/25 revealed that the right heel pressure ulcer measured 1.1 cm long, 2.0 cm wide, and 0.0 cm deep. The assessment contained no wound characteristics of the right heel pressure ulcer. Record review of the Wound Data Collection for Resident 2 dated 11/21/25 revealed that the right heel pressure ulcer measured 1.2 cm long, 2.5 cm wide, and 0.1 cm deep. The wound was covered with 90% slough and 10% granulation tissue.Record review of the Outpatient Nursing Home Wound Care Progress Note for Resident 2 dated 12/3/25 revealed that the non-facility Nurse Practitioner saw Resident 2. Resident 2 had a stage 3 pressure ulcer on the right heel that measured 1.8 cm long, 1.5 cm wide, and had a depth of 0.1cm per the nurse practitioner. The bed of the pressure ulcer wound was covered in 90% tan crusting and 10% light pink moist tissue with a moderate amount of drainage. The surrounding skin had redness and swelling. (This assessment was 12 days after the previous assessment of Resident 2's right heel pressure ulcer by the facility on 11/21/25.)Record review of the Wound Data Collection for Resident 2 dated 12/4/25 revealed that the right heel pressure ulcer measured 1.8 cm long, 1.5 cm wide, and 0.1 cm deep. The wound was covered with 90% eschar and 10% granulation tissue. (This assessment by the facility was 13 days after the previous facility wound assessment of Resident 2's right heel pressure ulcer on 11/21/25.)Record review of the Wound Data Collection for Resident 2 dated 12/18/25 revealed that the right heel pressure ulcer measured 1.2 cm long, 1.3 cm wide, and had no depth. The wound bed was covered with 100% eschar. Record review of the Wound Data Collection for Resident 2 dated 12/24/25 revealed that it contained no measurements or wound characteristics of the right heel pressure ulcer.Record review of the Wound Data Collection for Resident 2 dated 12/26/25 revealed that it contained no measurements of the right heel pressure ulcer. The right heel pressure ulcer was covered with 100% slough.Record review of the Wound Data Collection for Resident 2 dated 12/28/25 revealed that it contained no measurements or wound characteristics of the right heel pressure ulcer. Record review of the Wound Data Collection for Resident 2 dated 12/29/25 revealed that it contained no measurements or wound characteristics of the right heel pressure ulcer. (This assessment by the facility was 11 days after the previous facility wound assessment data was documented for Resident 2's right heel pressure ulcer on 12/18/25.)Interview on 12/30/25 at 2:55 PM with the facility DON confirmed that the facility did not measure the pressure ulcers for Resident 2 every 7 days as required.

Licensure Reference Number 175 NAC 12-006.12(D)Licensure Reference Number 175 NAC 12-006.12(D)(i)(2) Based on record review, observation, and interview, the facility failed to ensure that medications that are subject to abuse were counted correctly in order to easily account for these medications on individual resident's narcotic count sheets. This had the potential to affect one of one resident sampled (Resident 1) . The facility census was 46. Findings were:Record review of the facility policy dated 04/08/2025 Medication Administration Including Scheduling and Medication Aides revealed that the purpose of the policy is to provide direction regarding medication aides and to administer medications correctly and in a timely manner among other purposes. Record review of the Individual Resident's Narcotic Record with a start date of 12/29/2025 revealed that the count sheet was for Tramadol illegible (50) milligrams (mg) to be given by mouth 1 tab po q qid (one tablet orally every 4 times a day). The first count was completed and revealed on 12/29/2025 the beginning total was 6 tablets at 6:30 AM. Signed by Medication Aide (MA) A and one other person initials whose were illegible. On 12/29/2025 at 7:30 AM, one tablet was administered and there were 5 tablets remaining. Signed by MA-AOn 12/29/2025 at 12:15 PM one tablet was administered and there were 4 tablets remaining. Signed by MA-A Observation on 12/29/2025 at 12:18 of MA-A who entered that medication count for Resident 1 into the Individual Resident's Narcotic Record. In an interview on 12/29/2025 at 1:00 PM with MA-A it was revealed that the process is to prepare the medication for the residents, administer the medication for the residents, and any medications that must be counted are then recorded on the narcotic count record sheet to ensure that all of the medications are accounted for. When asked about the narcotic count sheet, MA-A revealed uncertainty as to how many milligrams the narcotic count sheet for the tramadol belonging to Resident 1 indicated on the sheet. It did state that the resident was to receive 1/2 tablet of the medication and that is what MA-A had given to Resident 1 and that the number of tablets left in the bubble packet of the Tramadol matched the number of tablets that the narcotic record indicated. MA-A indicated that Resident 1 had received 25 mg (1/2 tablet of a 50 mg tablet) of tramadol as was indicated on the bubble packet. MA-A stated I thought when we were taught about medications and orders, we were taught that we were to be accurate and we were to write legibly. In an interview on 12/29/2025 at 1:05 PM, the charge nurse Licensed Practical Nurse (LPN) B revealed the medication written on the Individual Resident's Narcotic Record for Resident 1's Tramadol was for 50 mg tablets and that for each tablet signed out, 50 mg of tramadol would have been given. When LPN B reviewed that orders for Resident 1, LPN B confirmed that the narcotic sheet needed to be rewritten as the amount of milligrams being counted was very hard to read, but did feel that it said 50 mg of Tramadol. In a confirmation interview on 12/29/2025 at 1:20 PM with the Director of Nursing confirmed that the Individual Resident's Narcotic Record for the tramadol belonging to Resident 1 was very difficult to read, but did say 50 mg tablets of Tramadol. Because those giving the medication had to sign this medication out on this narcotic count sheet to ensure that medications at risk of abuse could be easily accounted for, the DON was to review the narcotic count sheets on all medication carts to ensure that the count sheets were legible and accurate. The DON also confirmed that because resident 1 was only receiving Tramadol 25 mg (a 1/2 tablet of a 50 mg tablet) that the count was incorrect as the count on the narcotic sheets stated Resident 1 was receiving Tramadol 50 mg. However, the DON also confirmed that this could have had a bad outcome trying to track medications had this not been found and corrected.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review and interviews, the facility failed to ensure the dishwashing machine achieved the manufacturer designated temperature during the rinse cycle to ensure sanitization of dishes used by the residents and kitchen staff. This had the potential to affect all the residents' receiving food from the kitchen. The facility census was 46.Findings are:Review of a document titled [NAME] Service dishwasher Manual revealed hot water sanitization wash cycle temperature of 150 degrees Fahrenheit and rinse temperature 180 degrees Fahrenheit. In an observation completed on 12/22/2025 at 8:36 AM of the facility dishwashing machine the following was observed.-Activation of a washing cycle wash cycle temperature was 152 degrees Fahrenheit. The rinse cycle temperature was 172 degrees Fahrenheit.-In the bottom right hand corner of the dish machine clearly visible was a manufacturer label stating wash temperature of 150 degrees Fahrenheit and rinse temperature of 180 degrees Fahrenheit.A review of a facility document titled Dish Machine Temperature Log Thermal Sanitizing dated December 2025 revealed temperature is to be based on federal, state and manufacturer's guidelines for the dish machine. Enter and follow the strictest guidelines and the following documentation.-On December 4th the rinse temperature was recorded as 172 degrees Fahrenheit on the Morning shift, 178 degrees Fahrenheit on the Noon shift, and 153 degrees Fahrenheit on the Evening shift. In the action taken column there is nothing written indicating an action was taken to correct the temperature not meeting manufacturer recommendations. -On December 8th for the Evening shift there is no temperatures recorded for the dish machine.-On December 13th for the Evening shift the rinse temperature was recorded as 159 degrees Fahrenheit. In the action taken column there is nothing written in the column indicating an action was taken to correct the temperature not meeting manufacturer recommendations. -On December 15th for the Evening shift the rinse temperature was recorded as 160 degrees Fahrenheit. In the action taken column there is nothing written in the column indicating an action was taken to correct the temperature not meeting manufacturer recommendations. -On December 19th for the Evening shift the rinse temperature was recorded as 160 degrees Fahrenheit. In the action taken column there is nothing written in the column indicating an action was taken to correct the temperature not meeting manufacturer recommendations. -On December 21st for the Evening shift the rinse temperature was recorded as 160 degrees Fahrenheit. In the action taken column there is nothing written in the column indicating an action was taken to correct the temperature not meeting manufacturer recommendations. In an observation completed on 12/22/2025 at 8:40 AM of the facility dishwashing machine the following was observed.-Activation of a washing cycle wash cycle temperature was 152 degrees Fahrenheit. The rinse cycle temperature was 178 degrees Fahrenheit.In an interview completed on 12/22/2025 at 8:40 AM with the Dietary Manager (DM), the DM confirmed that the facility dishwashing machine should reach a temperature of 180 degrees Fahrenheit during the rinse cycle. The DM confirmed that the observed reading of 178 degrees Fahrenheit did not reach the manufacturers recommended temperature for sanitization. The DM confirmed the documentation of the temperatures recorded on the Dish Machine Temperature Log Thermal Sanitizing that were below 180 degrees should have had a action taken documented reflecting what was done to ensure the temperature of 180 degrees Fahrenheit was achieved prior to washing the dishes and was not and that there was a missing entry in the log.In an observation completed on 12/30/2025 at 10:17 AM Cook-C placed soiled dishware items into the facility dish washing machine and activated the dishwashing cycle. The [NAME] then returned to the main kitchen area out of site of the facility dishwashing machine. The [NAME] did not observe the dishwashing machine for temperatures during the washing and rinse cycle. In an observation completed on 12/30/2025 at 10:18 AM the dishwashing machine rinse cycle was observed to be 172 degrees Fahrenheit.In an interview completed on 12/30/2025 at 10:19 AM with the DM the DM confirmed that the dishwashing machine did not achieve the manufacturers recommended temperature of 180 degrees for sanitization and the [NAME] did not observe this ensuring the dish ware items were sanitized by the dish machine.

Licensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 1-005.06(F)Licensure Reference Number 175 NAC 12-006.18Based on observation, record review, and interview the facility failed to ensure that staff performed disinfection of mechanical lifts between resident use to prevent cross-contamination, failed to ensure that staff performed hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) before putting on gloves and after removing gloves, and failed to perform hand washing to prevent the potential for cross contamination for 1 resident (Resident 22) during resident transfers and cares. The facility census was 46.Findings are:A.Record review of the facility policy titled Safe Resident Handling Program dated 7/7/25 revealed that there are basic responsibilities for every employee to ensure that the work environment is safe. Staff follow infection control practice to clean lifts after each use. Record review of the facility Standard, Enhanced Barrier, and Transmission-Based Precautions dated 7/7/25 revealed the purpose is to prevent the spread of infection and communicable diseases. The section titled Enhanced Barrier Precautions (EBP) revealed that the use of gown and gloves during high contact resident care activities prevent opportunities for transfer of multidrug-resistant organisms to staff hands and clothing. High contact resident care activities include transfers, dressing, bathing, providing hygiene, changing briefs or assisting with toileting, changing linens, indwelling medical device care, and wound care. Record review of the facility policy titled Hand Hygiene dated 11/13/25 revealed that the purpose is to guide compliance for hand hygiene with Centers for Disease Control (CDC) and World Health Organization (WHO) hand hygiene recommendations and establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to residents and staff. Hand hygiene should be performed after glove removal. The section titled Washing with soap and water revealed to wet the hands and apply soap. Rub hands together briskly for 15-20 seconds. Rinse hands with water and dry thoroughly. Record review of the current care plan for Resident 14 dated 12/22/25 revealed that Resident 14 is dependent on staff for transfers with 2 staff and the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own). The care plan revealed that Resident 14 requires Enhanced Barrier Precautions. Staff are to use gown and gloves when transferring the resident. Observation on 12/29/25 at 1:13 PM outside the room of Resident 14 revealed that a visitor exited the room of Resident 14. Enhanced Barrier Precautions signs (required use of gown and gloves during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organisms and residents at increased risk) were posted on the door of the resident room. A white container outside of the resident room contained personal protective equipment (gowns and gloves). Nurse Aide-G (NA-G) and Nurse Aide-H (NA-H) were in the room of Resident 14 with the resident and the mechanical total body lift. The visitor closed the room door and stood by the commons area outside the resident room. NA-G opened the resident room door at 1:27 PM. The visitor re-entered the room. Resident 14 was now seated in the motorized wheelchair in the center of the room. The mechanical total body lift was parked beside the resident bed between the bed and the resident wheelchair. NA-H exited the resident room. Licensed Practical Nurse-B (LPN-B) entered the room of Resident 14. NA-G and LPN-B adjusted the resident oxygen tank and applied the oxygen to Resident 14. NA-G exited the room with the mechanical total body lift (the lift had not been disinfected) and pushed it into the room of Resident 22. Resident 22 sat in a wheelchair in the room. NA-H entered the room of Resident 22. NA-G and NA-H put on gloves (no hand hygiene was performed prior to putting the gloves on). NA-G and NA-H hooked the lift sling to the mechanical total body lift and lifted Resident 22 from the wheelchair and transferred Resident 22 onto the bed. NA-H removed the gloves and exited the room to get more wipes (NA-H did not perform hand hygiene after removing the gloves). NA-G removed the resident's shoes and pulled down the resident's pants to the ankles. NA-G unhooked the brief soiled with bowel movement (BM) and began to wipe the BM from the skin of Resident 22 with the gloved hands and disposable wipes. The time was now 1:38 PM and NA-H returned into the room. NA-H put on gloves (NA-H did not perform hand hygiene prior to putting on the gloves). Resident 22 was rolled onto their left side and NA-G continued to clean BM from the resident. NA-G then removed the gloves and went into the resident's bathroom. NA-G performed hand washing by wetting the hands and applying soap. NA-G scrubbed the hands together with soap for a total of 10 seconds and then rinsed and dried the hands (NA-G did not scrub the hands with soap for 15-20 seconds as required). NA-H placed a new brief under the resident. NA-G put on gloves and assisted to hook the brief. NA-H removed the gloves and did not perform hand hygiene. NA-H got a new pair of pants to replace the soiled pair on Resident 22. NA-G removed the gloves and began to gather the trash bag of soiled wipes and the soiled brief. (NA-G did not perform hand hygiene after removing the gloves). NA-G put on a pair of gloves and picked up the soiled left sling and soiled pad from the bed and placed them into a plastic bag. NA-G exited the resident room with the bag of trash and the bag with the soiled lift sling. NA-G returned to the resident room with a clean lift sling. NA-G and NA-H placed the sling underneath Resident 22. NA-G moved the mechanical total body lift to the bedside and NA-G and NA-H hooked the lift sling to the lift. NA-G lifted Resident 22 from the bed with the mechanical total body lift and transferred the resident into the wheelchair. NA-G and NA-H removed their gloves and tucked the lift sling straps into the wheelchair (NA-G and NA-H did not perform hand hygiene after removing the gloves). NA-H assisted Resident 22 to remove their shirt and replaced it with a button up shirt. NA-H exited the resident room and performed hand sanitization with alcohol based hand sanitizer. NA-G exited the room with the mechanical total body lift. NA-G performed hand sanitization with alcohol based hand sanitizer. NA-G parked the mechanical total body lift outside the room and removed disinfectant wipes from the bag on the lift. NA-G used the wipes to disinfect the lift. The time was now 1:50 PM. Interview on 12/29/25 at 1:50 PM with NA-G confirmed that the mechanical lifts are to be disinfected between residents. NA-G confirmed that the mechanical total body lift was not disinfected after it was used for Resident 14. NA-G confirmed that the mechanical total body lift was not disinfected before it was used to transfer Resident 22. NA-G revealed that they do not always have time to disinfect the lifts between residents. NA-G confirmed that staff are supposed to perform hand hygiene before putting on gloves and after removing gloves. Interview on 12/30/25 at 12:10 PM with the facility Infection Preventionist (IP) confirmed that hand hygiene is to be performed prior to putting on gloves and after taking off gloves. The IP confirmed that staff are expected to disinfect the mechanical lift on exit from the resident room prior to next use. The IP confirmed that the expectation for hand washing with soap and water is to scrub the hands with soap for 15-20 seconds before rinsing and drying the hands.

Licensure Reference Number 175 NAC 12-006.04(F)(i) Based on record reviews and interview, the facility failed to ensure the licensed nurse had the knowledge and training to provide care for a Pleurex catheter for Resident 9. This affected 1 of 3 residents reviewed for use of a Pleurex catheter. The facility's census was 55. Findings are: A review of Resident 9's Clinical Census printed 05/05/2025 revealed the resident was admitted to the facility on [DATE] and was hospitalized on [DATE]. A review of Resident 9's Admission Record printed 05/05/2025 revealed the resident had diagnoses of an infection to the left arm, kidney failure, heart disease, irregular heart rate, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and a pleural effusion (a buildup of extra fluid in the space around your lungs). A review of Resident 9's Post-Discharge Non-Medication Orders contained in the Summary of Care Document from the hospital printed 12/17/2024 revealed an order for Drain Pleurex catheter Monday, Wednesday and Friday with a date and time ordered of 12/17/2024 at 9:48 AM. A review of Resident 9's Order Summary printed 05/05/2025 revealed an order to drain the Pleurex catheter (a thin, flexible tube surgically placed in the chest to drain fluid from your pleural space [the space between the lungs and the chest wall]) every Monday, Wednesday, and Friday. This order had an order date of 12/19/2024 and a start date of 12/20/2024. A review of Resident 9's Medication Administration Record (MAR) for December 2024 revealed the order to drain the Pleurex catheter on Monday, Wednesday, and Friday was blank in the space to sign for 12/20/2024, indicating it had not been done. A record review of the Pleurex Drainage System Nursing Education documentation provided by the facility revealed it was performed on 01/21/2025. An interview on 05/05/2025 at 3:27 PM with the Director of Nursing (DON) confirmed that Resident 9 was admitted [DATE] with the order to drain the Pleurex catheter, and the order to drain the Pleurex catheter was not entered until 12/19/2024. The DON further confirmed that it was not drained on Wednesday 12/18/2024 or Friday 12/20/2024. The DON confirmed that the nurse who worked on Friday 12/20/2024 had stated they did not do the treatment because they did not know how. The DON further stated they had printed out the policy and procedure for draining a Pleurex catheter for the station Resident 9 was being admitted to, but did not do any other education or training on the device prior to the resident's admission.

Licensure Reference Number 175 NAC 12.006.17 The facility failed to ensure that staff perform hand washing between glove changes and to wear EBP for Resident #5 while performing wound cares to prevent the potential for cross contamination. The facility census was 55. Record review of Resident 5's Admission record dated 5/5/25 revealed admission to the facility was 3/31/22. Record Review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 4/2/25 revealed: 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) was 15 indicating the resident was cognitively intact. -Section GG - dependent assist with footwear and maximum assist with repositioning. Physicians Orders dated 5/5/25 revealed: -Wound care to left heel: cleanse with saline/wound cleanser, apply betadine moistened gauze, cover with ABD pad and secure with kerlix and tape. Change daily and as needed for drainage every day shift for wound treatment -Start Date- 3/8/2025. -Tubi-grip to bilateral lower extremities; on in AM & off at HS two times a day for edema -Start Date- 3/13/2025. -foam booties on at all times every shift for pressure reduction -Start Date-1/3/2025 Observation on 5/5/25 at 9:45 AM for wound cares of left heel for Resident #5 by RN-A with NA-B assisting with holding the foot off the bed. RN-A and NA-B performed hand hygiene x 20 seconds and donned (put on) gloves. RN-A cut the old kerlex dressing off, then sprayed some saline cleansing spray to help remove the telfa old dressing that was on the wound. RN-A removed the gloves and donned new ones without performing hand hygiene. RN-A cleansed the wound with saline spray while spraying it onto wound. RN-A removed gloves and donned new ones without hand hygiene. RN-A placed the telfa dressing that was soaked in betadine onto the wound, covered with ABD dressing, wrapped with kerlix, taped it, and then dated the tape. The NA-B placed the new Tubi-grip and foam boot back onto the left lower extremity. RN-A removed gloves and washed hands with soap and water for 22 seconds. NA-B removed the gloves and washed hands with soap and water for 20 seconds. Interview on 5/5/25 at 10:00 AM with RN-A revealed [gender] should have worn a gown when working with a wound and perform hand hygiene when changing gloves. Interview on 5/5/25 at 10:05 AM with NA-B revealed [gender] should have worn a gown when working with a nurse during a dressing change. Interview on 5/5/25 at 10:08 AM with DON confirmed the staff are to wear a gown, gloves and face shield with doing a wound dressing and perform hand hygiene when changing gloves. Record review of Hand Hygiene policy dated 3/29/22 revealed: -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. -Before clean task -After Bodily Fluid/Glove Removal Record review of Standard and Transmission Based Precautions policy dated 4/2/24 revealed: -Enhanced Barrier Precautions (EBP) (rehab/skilled only). - Enhanced barrier precautions expand the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (multidrug resistant organism) to staff hands and clothing. -High-Contact Resident Care Activities include: wound care.

Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent accidents for 1 (Resident 1) of 3 sampled residents. The facility census was 44. Findings are: A record review of the facility's Fall Prevention And Management policy dated 07/29/2024 revealed a fall is an unintentional coming to rest on the ground. An accident is any unexpected or unintentional incident which may result in injury or illness to a resident. Root cause analysis is a method for identifying the cause or problem so that the best solutions can be identified and put into place. Following a fall, the staff should complete a falls tool, document if teaching was done, communicate the fall to administration, provider, and family, and review and update the care plan with any new/changes to the care plan interventions. A. A record review of Resident 1's Clinical Census dated 03/26/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 03/26/2025 revealed the resident had diagnoses of Cerebral Infarction (stroke), Traumatic Subdural Hemorrhage (bleeding near the brain caused by a head injury), Repeated Falls, Parkinsonism (syndrome with muscle rigidity, tremors, unstable posture, leading to abnormal walking), Vertigo (dizziness), Muscle Weakness, Lack Of Coordination, and Need For Assistance With Personal Care. A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 02/12/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 14 which indicated the resident was cognitively aware. The resident had limited range of motion on one side of the upper extremities (shoulder to hand or hip to toe). The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with toileting, dressing, footwear, and personal hygiene, and substantial/maximal assistance with bathing. The resident required partial/moderate assistance with positioning and transfers. The resident was not on a toileting program. The resident did not have pain or hurting at any time. The resident had 0 falls with no injury, 0 falls with major injury, and 2 falls with injury in the lookback period. A record review of the facility's Incidents By Incident Type report dated 09/26/2024 - 03/26/2025 revealed Resident 1 had fallen on: -10/02/2024, -10/05/2024, -10/28/2024, -11/17/2024, -02/01/2025, -03/02/2025. A record review of the facility's Found on Floor dated 11/17/2024 revealed Registered Nurse (RN)-A was called to the room after the Nursing Assistant (NA) found the resident on the floor next to the toilet with a small cut above the right eye. Resident 1 reported the resident stood up to pull up the resident's pants and lost (gender) balance. NA-B's statement revealed NA-B put Resident 1 on the toilet and left the room to get the nurse to get a bandage for a scratch on the resident's hand and when NA-B went back in the room, Resident 1 was on the floor. A record review of Resident 1's Progress Notes dated 11/18/2024 at 1:13 AM revealed the resident was sent to the hospital following an unwitnessed fall, and the resident suffered a compression fracture of the first thoracic vertebrae (T1, bone in the middle section of the spine) and a left closed rib fracture. A record review of Resident 1's Care Plan with an admitted [DATE] revealed: A focus area of falls, 10/02/2024 fall with no injury, 10/05/2024 witnessed fall, 10/28/2024 lowered to the floor, 11/17/2024 fall with major injury, 02/01/2025 fall out of the facility with minor injury, and 03/02/2025 fall with major injury. Interventions included provide a safe environment with call light in reach with a dated initiated 10/02/2024, toileting schedule with a date initiated of 11/21/2024, staff to stay with resident at all times when in the bathroom with a date initiated of 11/22/2024, and moved rooms to benefit using the resident's right side in the bathroom with a dated initiated of 03/10/2025. A record review of the facility's Cottonwood East/Cottonwood [NAME] report sheet revealed the resident was a sit-to-stand (a mechanical lift), **FALLS**DO NOT LEAVE ALONE IN RESTROOM. A record review of the facility's Investigation Report dated 03/07/2025 revealed on 03/02/2025 Resident 1 fell from the toilet and hit the resident's head, there was a small amount of blood on the floor, and the resident was transferred to the hospital for a possible head injury. The resident returned a couple of hours later with no head injury noted and an order for a follow-up magnetic resonance imaging (MRI, detailed images of the body's internal structures). The resident continued to complain of back and right flank (side of the lower back) pain and pain medicine was administered. The resident was sent back to the hospital and an Xray of the back revealed a hairline fracture of the first lumbar vertebrae (L1, bone in the lower spine). The outcome of the facility investigation was the resident attempted to stand and pull up the resident's pants without assistance. The permanent measure put in place to prevent it from happening again was to move the resident to a different room that would have a restroom that would be set up better for the resident to utilize the resident's stronger side. A record review of the facility's Found on Floor dated 03/02/2025 revealed Registered Nurse (RN)-A heard a loud noise while in the hallway outside of Resident 1's room, entered the room, and the resident was lying on the resident's left side on the floor in the bathroom. Blood was seen under the resident's head, and 911 was called to take the resident to the hospital. A note on the Found on Floor dated 03/02/2025 revealed the resident was left alone in the bathroom and staff was educated that the resident should not be left in the bathroom alone. A record review of Resident 1's Emergency Department (ED) Provider Notes dated 03/02/2025 revealed the resident was evaluated for a head injury and the resident had a l-shaped 2 centimeter right posterior (back) scalp laceration (cut) that required 5 staples to close. The resident complained of low back pain and a computer tomography (CT, detailed cross-sectional images of the body) revealed degenerative (declining) changes of the lumbar spine without acute finding (no specific findings). A record review of Resident 1's Progress Notes dated 03/04/2025 revealed resident continued to complain of back pain and right flank pain. The daughter requested to resident be sent back to the ED for pain control related to the resident's fall. The provider was contacted, and the resident was transferred to the ED. A record review of Resident 1's Emergency Department (ED) Provider Notes dated 03/04/2025 revealed resident was complaining of 8 out of 10 back pain that radiated (went) down the bilateral lower extremities. Results of the MRI and another CT scan revealed the resident had an acute L1 compression fracture and recommended kyphoplasty (surgical procedure to treat painful vertebral compression fractures). In an interview on 03/26/2025 at 10:50 AM, Resident 1 confirmed on 03/02/2025 the NA took the resident to the bathroom and told the resident not to move, and the next thing the resident remembered was waking up on the floor in the bathroom. The resident got a cut on the back of the head and fractured something or the other. The resident confirmed the resident was in pain until after the surgery. The resident confirmed the NA left the resident alone in the restroom to go get something. The only changes the resident was aware of to prevent the falls from happening again was to call for help and changed room to where everything was on the right side not the left. The resident confirmed the resident was just very right-handed. In an interview on 03/27/2025 at 10:20 AM, Physical Therapy Assistant (PTA)-D confirmed prior to Resident 1's 03/02/2025 fall. Resident 1 was a stand-pivot (a technique to assist transferring a resident from one surface to another) transfer with 1 staff assistance. PTA-D confirmed the resident should not have been left alone in the bathroom. In a telephone interview on 03/26/2025 at 5:15 PM, RN-A confirmed RN-A was the charge nurse on the night of Resident 1's fall (03/02/2025). RN-A confirmed RN-A was the one that heard the resident fall and found the resident on the bathroom floor bleeding. RN-A confirmed there was no other staff in the room when RN-A entered the resident's room. NA-C was the NA that had taken the resident to the bathroom and left the resident alone in the bathroom and should not have. In a telephone interview on 03/27/2025 at 7:53 AM, NA-C confirmed NA-C was the NA that had Resident 1 the night of the fall on 03/02/2025. Resident 1 called NA-C to use the restroom and NA-C got the resident up and took Resident 1 to the bathroom. There was a NA on the other side of the hall that needed help with a resident, so NA-C left to help the other NA. NA-C confirmed just as NA-C left Resident 1's room, NA-C heard a loud boom and NA-C seen RN-A run into Resident 1's room. NA-C confirmed this was not the first time NA-C had left a resident in the restroom alone. NA-C likes to give the residents privacy so NA-C walks out and does something else. NA-C then confirmed that NA-C left Resident 1 standing in front of the toilet, not seated on the toilet. NA-C confirmed again that NA-C helped Resident 1 into the restroom and left Resident 1 standing there and the resident fell getting onto the toilet. Resident 1 transferred the resident's self before the fall, they (staff) never put Resident 1 on the toilet. In an interview on 03/26/2025 at 4:03 PM, the facility's Director of Nursing (DON) confirmed that Resident 1's new intervention for the 03/02/2025 fall of moved rooms to benefit using the resident's right side in the bathroom with a dated initiated of 03/10/2025 was not a direct intervention related to the cause of the fall, the intervention related to the 03/02/2025 fall was already in place to not leave the resident on the bathroom alone, it was just not followed and should have been. In an interview on 03/27/2025 at 10:34 AM. The DON confirmed Resident 1 should not have been left in the restroom alone. B. A record of the facility's Bowel & Bladder: Evaluation, Assessment, Toileting Programs policy dated 05/21/2024 revealed Habit Training/Scheduled Toileting is a behavior technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident's voiding (evacuating bowels or bladder) habits or needs. Voiding intervals are adjusted to match the individuals voiding patterns/incontinence (inability to control) patterns to the toileting schedule usually every 2-3 hours. A record review of the facility's Incidents By Incident Type report dated 09/26/2024 - 03/26/2025 revealed Resident 1 had fallen on: 10/02/2024 10/05/2024 10/28/2024 11/17/2024 02/01/2025 03/02/2025 A record review of the facility's Found on Floor dated 11/17/2024 revealed Registered Nurse (RN)-A was called to the room after the Nursing Assistant (NA) found the resident on the floor next to the toilet with a small cut above the right eye. Resident 1 reported the resident stood up to pull up the resident's pants and lost (gender) balance. NA-B's statement revealed NA-B put Resident 1 on the toilet and left the room to get the nurse to get a bandage for a scratch on the resident's hand and when NA-B went back in the room Resident 1 was on the floor. A record review of Resident 1's Progress Notes dated 11/18/2024 at 1:13 AM revealed the resident was sent to the hospital following an unwitnessed fall and the resident suffered a compression fracture of the first thoracic vertebrae (T1)(bone in the middle section of the spine) and a left closed rib fracture. A record review of Resident 1's Care Plan with an admitted [DATE] revealed: A focus area of falls, 10/02/2024 fall with no injury, 10/05/2024 witnessed fall, 10/28/2024 lowered to the floor, 11/17/2024 fall with major injury, 02/01/2025 fall out of the facility with minor injury, and 03/02/2025 fall with major injury. Interventions included provide a safe environment with call light in reach with a dated initiated 10/02/2024, toileting schedule with a date initiated of 11/21/2024, and staff to stay with resident at all times when in the bathroom with a date initiated of 11/22/2024. A record review of Resident 1's Task: Toileting dated 03/26/2025 revealed that the resident was toileted: 03/26/2025 at 5:59 AM and 10:04 AM 03/25/2025 at 2:29 PM and 11:29 PM 03/24/2025 at 10:33 AM 03/23/2025 at 6:29 AM 03/22/2025 at 12:29 AM, 6:40 AM, and 10:29 PM 03/21/2025 at 2:22 AM, 2:29 PM, 10:29 PM, and 11:06 PM 03/20/2025 at 4:47 AM 03/19/2025 at 10:29 PM 03/18/2025 at 2:29 PM and 10:29 PM 03/17/2025 at 3:48 AM and 10:41 AM 03/16/2025 at 5:59 AM, 10:28 AM, 3:25 PM 03/15/2025 at 4:38 AM and 10:44 AM 03/14/2025 at 5:25 AM and 10:29 PM A record review of the white board in the nurse's station did not reveal fall interventions for Resident 1, just transfer method. An observation on 03/26/2025 at 12:53 PM revealed NA-E assisted Resident 1 to restroom using a sit-to-stand lift without concern. An observation on 03/27/2025 at 7:01 AM revealed Resident 1 was seated in the wheelchair watching television with the resident's call light curled up on the bed about 4 feet behind the resident and not in reach. In an interview on 03/26/2025 at 1:20 PM, NA-E confirmed NA-E can look care plan interventions for falls in the electronic medical record (EMR) or can ask the nurse. The only fall interventions NA-E knew for Resident 1 was to keep the call light in reach and don't leave alone in the restroom. NA-E confirmed there were report sheets the staff has for specific resident needs, but NA-E did not grab one today. NA-E confirmed there was not a specific toileting schedule for Resident 1. In an interview on 03/26/2025 at 4:31 PM, NA-F confirmed there was not really a schedule to toilet any of the residents. In an interview on 03/26/2025 at 4:55 PM, NA-E confirmed NA-E checks all residents every odd hour to see if they need to use the restroom, NA-E was not sure of a specific schedule for any of the residents. In an interview on 03/27/2025 at 7:20 PM, NA-F confirmed that Resident 1 was not on a toileting schedule. NA-F confirmed that NA-F was the NA that got Resident 1 out of bed and transferred into the wheelchair and that NA-F did not clip the call light to the resident and it was not in reach. In an interview on 03/27/2025 at 7:37 AM, NA-H confirmed not sure what fall care plan interventions were for each resident other than the basis ones of don't leave unattended in the restroom, frequent checks, and keep call light in reach. NA-H would ask the nurse to look at the care plan. There was a board in the nurse station that would have the interventions. NA-H did not know how to access the Kardex and did not have a report sheet. In an interview on 03/26/2025 at 6:04 PM, the DON confirmed that a resident's fall interventions are listed in the Kardex in the resident's EMR, and staff is trained how to access the Kardex on hire and all staff should know how to access the Kardex. The staff should also put the information on the white board in the nurse's station and pass the information along and report and staff should have a detailed report sheet with them. In an interview on 3/27/2025 at 10:34 PM, the DON confirmed there was not a true, specific, toileting schedules for residents. The staff was just supposed to do before and after meals and at bedtime and the staff should have known that.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review; the facility failed to use the correct sling size to transfer a resident, and failed to asses and monitor a resident after a fall for 1 (Resident 6) of 3 sampled residents. The facility census was 41. Findings are: Record review of Resident 6's Census List revealed Resident 6 admitted to facility of 06/14/2024 with the following diagnoses: acquired Absence of left leg above knee (a surgical procedure that removed part of the leg), encephalopathy ( a general term for brain disorders or diseases), sepsis (a serious condition when the body's immune system overreacts to an infection or injury), Type 2 Diabetes Mellitus (condition when the body develops insulin resistance and can result in high blood sugars) with diabetic polyneuropathy (occurs when there is damage to multiple nerves in the peripheral nervous system), chronic obstructive pulmonary disease (is a common lung disease that causes breathing problems and restricted airflow). Record review of Resident 6's Care Plan printed 09/25/2024 revealed a focus on ADLs (Activities of Daily Living) which stated that Resident 6 has an ADL self-care performance deficit related to left above the knee amputation, impaired physical mobility, congested heart failure, congestive heart failure (a chronic condition that occurs when the heart is unable to pump enough blood to meet the body's needs), chronic obstructive pulmonary disease, chronic pain, Diabetes Mellitus with polyneuropathy. The goal stated that the resident will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Interventions included: Ambulation: Non-ambulatory. Bed mobility: Resident requires substantial to dependent assistance by 1-2 staff for bed mobility and repositioning. Care plan also identified the potential for Falls with interventions that included to monitor resident for significant changes in mobility, positioning device, standing/sitting balance on right leg/foot and right lower extremity joint function. Record review of Resident 6's Minimum Data Set (MDS, a federally mandated assessment that assists staff to develop/modify a resident's plan of care), Admission assessment dated [DATE] revealed Resident 6 needed substantial assistance with lower body dressing, toileting hygiene, and putting on and taking off footwear, was dependent (helper does all of the effort to complete the activity) on staff to come to help stand up, transfer to and from a bed to chair, and toilet transfers. A Brief Interview for Mental Status (BIMS), a simple screening that can aide in detecting the presence of cognitive impairment in older adults, revealed a score of 11 which indicated moderate cognitive impairment. Observation and Interview on 09/23/24 at 3:05 PM with Resident 6 was conducted. Resident 6 reported that they had a recent fall when the staff member didn't have the EZ stand (transfer device) sling in the right position, and I ended up in the chicken wing position (abnormal shoulder abduction or flexion with combined internal rotation) and then I fell on the floor. Resident 6 reported that their left shoulder was sore and that [gender] left stump (from amputation of leg above the knee) is swollen and sore. Resident 6 also reported that their left stump appliance did not fit today because their stump is swollen from the fall. Observation revealed that Resident 6 was able to move left shoulder joint but grimaces. Resident 6 reports that [gender] left shoulder hurts the most and rates pain as a 9 or 10 from pain scale of 0-10 with movement of left shoulder. Ten is the highest pain level. Resident 6 reported that they took a Tylenol and that it helped a little. A record review of Resident 6's September 2024 Medication Record, printed on 09/23/2024 at 2:37 PM revealed that the only documented administration entry for Tylenol 325 miligrams (MG) - give 2 tablets by mouth every 4 hours as needed for pain was administered one time on 09/12/2024 at 5:02 PM. An interview with the Director of Nursing (DON) on 09/24/204 at 11:47 AM revealed that the facility had no knowledge of and no documentation of any incident/accident reports for Resident 6 in the past 30 days. An interview on 09/24/2024 at 1:00 PM with Licensed Practical Nurse (LPN)-F revealed that [gender] did not have direct knowledge that Resident 6 fell out of the transfer sling but states that [gender] heard Medication Aide (MA)-I talking about this incident. An Interview with MA-I on 09/24/2024 at 1:10 PM confirmed that MA-I received a report that Resident 6 was lowered to the ground this weekend with no injury using the EZ Stand (Sit to stand transfer equipment) because Resident 6's knee buckled. A phone interview with Nurse Aide-K on 09/24/2024 at 1:40 PM revealed that on 09/22/2024 at approximately 10:00 PM, MA-J called NA-K via walkie talkie to come into Resident 6's room. NA-K stated that Resident 6 was sitting on the floor with the EZ stand sling was under Resident 6's arm pits. NA-K stated that the Resident was chicken winged. NA-K reported that they called for Nurse (LPN-H) to come and assess the resident. NA-K stated that LPN-H came to Resident 6's room and after the staff updated LPN-H that Resident 6 slipped out of the sling and was lowered to the floor and that Resident 6 did not hit [gender] head, LPN-H instructed NA-K and MA-J to use a Hoyer lift (equipment to move/transfer someone) to get Resident 6 off the floor and get them into bed. A phone interview with MA-J on 09/24/2024 at 2:16 PM revealed that on 09/22/2024 around 10:00 PM MA-J was assisting Resident 6 from the chair to the bed using the EZ stand. MA-J stated that [gender] did not have the appropriate size of the EZ sling for the resident, The jacket (EZ sling) was too small. MA-J reports that transferring Resident 6 using the EZ Stand and Resident 6 was standing up when they (Resident 6) began to complain of pain in their right leg and then Resident 6's right leg buckled, and [gender] started to slip down out of the sling. MA-J stated that Resident 6 chicken winged in the sling and began to help lower [gender] to the floor using the emergency release button on the EZ stand. MA-J reports that Resident 6 never hit [gender] head, called for staff assistance, and then assisted to remove the EZ Stand sling. MA-J reported that NA-K and LPN-H did come to help. MA-J reported that Resident 6 did have some redness and pain under their left arm which was reported to LPN-H. Record review of Safe Resident Handling dated 09/6/24 and 09/02/24 revealed that MA-J did receive competency training on how to use the lift equipment according to manufactures instructions. A record review on 09/24/2024 of Resident 6's medical record revealed a Progress Note nurse entry on 09/23/2024 at 1:46 PM Resident was out to see Innovative prosthetics this date. Unable to complete diagnostic fitting as leg is swollen. Will see again in 2 weeks. A record review on 09/24/2024 of Resident 6's medical record revealed no documentation of any falls in the last 30 days. A phone interview with LPN-H on 09/23/2024 at 8:45 PM was conducted. LPN-H reported that on 09/22/2024 at approximately 10:00 PM, Resident 6 was lowered to the floor by MA-J and that NA-K was called to assist. LPN-H reported that they went to Resident 6's room after being called on the walkie talkie and received a report from MA-J that Resident 6 slipped out of the EZ Stand sling and was lowered to the floor but did not hit head. LPN-H stated that they instructed staff to use the Hoyer Lift to get the resident off the floor and put back into bed. When questioned, LPN-H reported that because there was no injury to Resident 6, they did not document this fall in the medical record or follow the facilities fall protocol. LPN-H reported that they were very busy helping other residents at the time of the fall but later came back to assess Resident 6 while in bed and provided passive range of motion (gentle movement) of all of Resident 6's extremities and stated that there was no injury. An interview with the Director of Nursing (DON) on 09/26/2024 at 10:00 AM confirmed that all resident falls need to be reported to the DON, documented in the resident's medical record and investigated by the facility's Fall Prevention Team.

Licensure Reference Number 175 NAC 12.006.18 Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review; the facility failed to ensure the required isolation sign was posted and staff donned (put on) and doffed (took off) the required Personal Protective Equipment (PPE) for 1 (Resident 146) of 1 sampled residents that had been identified as positive for COVID-19, this had the potential to affect all residents in the facility. The facility failed to ensure 3 (Residents 10, 11, and 12) of 3 sampled resident's oxygen tubing was changed and dated weekly and was stored in a bag when not in use, and failed to clean and store 1 (Resident 40) of 1 sampled resident's nebulizer kit (neb)(a kit used to deliver liquid medication to the lungs) daily to prevent cross-contamination (transfer of bacteria from one surface to another). The facility census was 41. A. A record review of the facility's Surveillance and Mitigation Plan for SNFs (Skilled Nursing Facilities) dated 04/26/2024 revealed for all residents that have tested positive for COVID-19, staff are to wear gloves, gown, N-95 respirator (a tight-fitting mask that filters out very small bacteria) and eye protection when taking care of these residents. PPE should be doffed and discarded prior to leaving a room. A record review of the CDC's Infection Control Guidance: SARS-CoV-2 (COVID-19) with updates as of May 8, 2023, revealed healthcare providers who enter the room of a resident with suspected or confirmed COVID-19 should wear an N-95 or higher mask, gown, gloves, and eye protection. https://www.cdc.gov/covid/hcp/infection-control/index.html An observation on 09/23/2024 at 10:52 AM revealed Nursing Assistant (NA)-B was in Resident 146's room without any PPE on. The resident's door was open. There was a visitor in the room with a surgical mask on. Licensed Practical Nurse (LPN)-A was standing in the open doorway with no PPE on. The visitor, NA-B, and LPN-A were all within 6 feet of the resident. The sign on the resident's door revealed Stop, contact precautions everyone must: clean their hands including entering and when leaving the room. Providers must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. An observation on 09/23/2024 at 1:51 PM revealed the facility's Social Worker (SW)-C was in Resident 146's room withing 6 feet of the resident without a mask, gown, gloves, or eye protection on. SW-C had placed a laptop computer and paperwork on the resident's bed. SW-C did not sanitize the laptop when SW-C came out of the room. An observation on 09/23/2024 at 2:10 PM revealed Physical Therapist (PT)-D was in Resident 146's room with a gown, gloves, and N-95 mask on, no eye protection. PT-D then exited the room into the hallway still wearing PPE, re-entered the room, came back out in the same PPE to get a face shield, then re-entered the resident's room with all the required PPE on. An observation on 09/23/2024 at 2:58 PM with the Director of Nursing (DON) revealed the DON observed the room sign was for contact isolation sign which did not include the recommended PPE to be used. An observation on 09/23/2024 at 3:35 PM did not reveal any of the doorways to the facility indicated there was a COVID-19 resident in the facility or what the expectations of visitors or staff are. An observation on 09/24/2024 at 7:28 AM revealed the sign now posted on Resident 146's door was a sign that said stop, in addition to routine practices: Droplet Precautions box was check, hand hygiene before entering and after leaving the room was checked, gloves box was checked, mask box was checked, but surgical mask was checked not N-95, and eye protection was not checked. An observation on 09/24/2024 at 12:18 PM revealed NA-E entered Resident 146's room with a lunch tray and no PPE on and assisted the resident to get all meal items ready. NA-E then exited the room and got another tray from the meal cart. The observation revealed the signs on the resident's door contained, gown, gloves, N-95 mask, and eye protection. In an interview on 09/23/2024 at 10:52 AM, LPN-A confirmed the resident was just admitted to the facility from the hospital on 9/21/24 and had COVID-19. In an interview on 09/23/2024 at 11:00 AM, the Director of Nursing (DON) confirmed the DON said there was no COVID-19 residents in the facility, but just found out Resident 146 did have COVID-19 and was admitted over the weekend. In an interview on 09/23/2024 at 1:54 PM, SW-C confirmed that when SW-C entered the room SW-C put on PPE but had removed it prior to getting the laptop and paperwork off the resident's bed while talking with the resident within 6 feet of the resident. SW-C confirmed [gender] did not sanitize the laptop after leaving the room, used a surgical mask when in the room not an N-95, and did not wear eye protection. In an interview on 09/24/2024 at 12:21 PM, NA-E confirmed NA-E did not put on PPE when NA-E entered Resident 146's room and NA-E was aware the resident was in isolation due to COVID-19. In an interview on 09/23/2024 at 2:58 PM, the DON confirmed the DON observed the room sign was a contact isolation sign and the DON confirmed it was the incorrect room sign for a resident with COVID-19. In an interview on 09/24/2024 at 7:28 AM, the DON confirmed the sign on Resident 146's door that did not have the N-95 mask or eye protection checked was still not the correct sign for a COVID-19 isolation room. In an interview on 09/25/2024 at 11:54 AM, the DON confirmed there was not signage posted at any of the entrance door to the facility and should have been, especially when they had a COVID-19 resident in isolation. In an interview on 09/23/2024 at 2:58 PM, the DON confirmed the signs on a resident's room that was in COVID-19 isolation should have been a gown, gloves, N-95 mask, and eye protection and the staff should be wearing all PPE when entering the room. The DON confirmed PT-D should not have exited Resident 146's room with PPE on. B. A record review of the facility's Oxygen Administration, Safety, Mask Types dated 07/08/2024 revealed the purpose of the policy was to administer and store oxygen in a safe manner and to keep oxygen equipment clean. Oxygen equipment will be clean, safe, and functional at all times. When oxygen is not in use, store cannula and tubing in zip-lock bag/plastic bag secured to oxygen cylinder (tank) or concentrator (machine that purifies air to oxygen). Disposable equipment should be changed weekly or according to manufacturer's instruction and marked with date and initials. A record review of Resident 10's Order Summary dated 09/24/2024 revealed an order to change and date the oxygen tubing every week on Saturday night shift for infection control. A record review of Resident 10's Treatment Administration Record (TAR) dated July, August, and September 2024 with the DON revealed the order to change and date the oxygen tubing every week on Saturday night shift for infection control was not showing up on the TAR to be completed. An observation on 09/23/2024 at 11:22 AM revealed Resident 10's oxygen tubing or nasal cannula (tubing that goes in a resident's nose to deliver oxygen) and humidifier was not dated or initialed. In an interview on 09/23/2024 at 11:22 AM, Resident 10 confirmed the staff did not change the resident's oxygen nasal cannula or humidifier unless the resident asked. The resident confirmed the resident knows it was time to be changed due to it starts to get hard and irritating to the nose. In an interview on 09/24/2024 at 12:49 PM, Resident 10 confirmed they just put stickers with the date on the tubing and humidifier, they did not change either one of them. In an interview on 09/24/2024 at 1:13 PM, LPN-A confirmed the oxygen tubing was now dated, but LPN-A confirmed LPN-A was not sure when the tubing was changed, LPN-A just made sure the tubing was dated. In an interview on 09/24/2024 at 2:05 PM, the DON confirmed the order to change and date the oxygen tubing every week on Saturday night shift for infection control was not entered in the Electronic Medical Record (EMR) correctly and was not showing up on the TAR so staff would know it needed to be completed. C. A record review of the facility's Oxygen Administration, Safety, Mask Types dated 07/08/2024 revealed the purpose of the policy was to administer and store oxygen in a safe manner and to keep oxygen equipment clean. Oxygen equipment will be clean, safe, and functional at all times. When oxygen is not in use, store cannula and tubing in zip-lock bag/plastic bag secured to oxygen cylinder or concentrator. Disposable equipment should be changed weekly or according to manufacturer's instruction and marked with date and initials. A record review of Resident 12's Order Summary dated 09/24/2024 revealed an order to change the oxygen tubing every Sunday night shift for infection control. A record review of Resident 12's TAR dated July, August, and September 2024 with the DON did not reveal the resident's oxygen tubing had been changed weekly on: -07/21/2024, -07/27/2024, -08/11/2024, -08/18/2024, -08/25/2024, -09/01/2024, -09/08/2024. An observation on 09/23/2024 at 11:37 AM revealed Resident 12's oxygen nasal cannula was laying on the floor and was not dated or initialed. An observation on 09/24/2024 at 12:35 PM revealed Resident 12's oxygen tubing or nasal cannula and humidifier was not dated and initialed and was kinked. The resident's oxygen tubing on the wheelchair was coiled around the tank and not in a bag. The nasal cannula was touching the wheelchair. In an interview on 09/23/2024 at 12:25 AM, Resident 12 confirmed the staff did not change the resident's oxygen nasal cannula or humidifier weekly and did not store the tubing in a bag when not in use. In an interview on 09/24/2024 at 1:13 PM, LPN-A confirmed Resident 12's oxygen tubing was not dated and initialed and the resident's nasal cannula on the portable tank was not in use and not in a bag, and was dated 6/6. In an interview on 09/24/2024 at 2:05 PM, the DON confirmed the Resident 12's oxygen tubing was not changed weekly and should have been. 50683 D. An observation on 09/23/24 at 10:30 AM in resident's room revealed that Resident 11 was receiving 2.5 liters of Oxygen through an undated nasal canula tubing (tubing that goes in a resident's nose to deliver oxygen) via oxygen concentrator (a machine that purifies air to oxygen). Resident 11's storage bag connected to the back of Resident 11's wheelchair contained a portable oxygen tank with an attached nasal cannula tubing dated 7.14.24. Tubing was touching surfaces and other contents in the wheelchair storage bag. An observation on 09/23/24 at 2:30 PM revealed Resident 11 continued to receive oxygen at 2.5 liters through an undated nasal canula tubing via oxygen concentrator. A record review on 09/23/24 of Resident 11's September 2024's Treatment Record revealed an entry to change and date oxygen tubing every week on Saturday night shift. Saturday, September 7, 2024 reveals a blank entry that indicated that this task was not documented as completed. Saturday, September 14, 2024 revealed staff initials that indicated that this task was completed. Saturday, September 21, 2024 revealed a blank entry that indicated that this task was not documented as completed. An observation on 09/24/24 at 10:30 AM in Resident 11's room revealed that Resident 11 was receiving 2.5 liters of Oxygen through a nasal canula tubing dated September 18, 2024. A nasal canula tubing dated September 18, 2024 was connected to a portable tank of oxygen stored in the back of the Resident 11's wheelchair. An observation on 09/26/24 at 07:45 AM revealed Resident 11's oxygen nasal canula tubing (connected to oxygen concentrator and to portable oxygen tank) both dated 09.18.24, indicating that oxygen tubing was not changed for 8 (eight) days. A record review of the facility's Oxygen Administration, Safety, Mask Types dated 07/08/2024 revealed the purpose of the policy was to administer and store oxygen in a safe manner and to keep oxygen equipment clean. Oxygen equipment will be clean, safe, and functional at all times. When oxygen is not is use, store cannula and tubing in zip-lock bag/plastic bag secured to oxygen cylinder or concentrator. Disposable equipment should be changed weekly or according to manufacture's instructions and marked with date and initials. An Interview with Director of Nursing on 09/26/2024 at08:40 AM confirmed that oxygen tubing should be changed weekly, and tubing should be dated, initialed and documented in the Resident's Treatment Record. 42861 E. An observation on 9/23/24 at 3:25 PM revealed Resident 40 had a nebulizer kit, intact with a mask attached, undated, still connected to the nebulizer machine and resting on the tray table. An observation on 9/24/24 at 10:00 AM revealed Resident 40 had a nebulizer kit, intact with a mask attached, undated, still connected to the nebulizer machine and resting on the tray table. A record review of the Order Summary printed on 9/24/24 revealed Resident 40 had the following order in place; DuoNeb Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 inhalation inhale orally via nebulizer three times a day for cough. An interview on 9/24/24 at 10:10 AM with LPN-F confirmed that the facility process was to rinse the nebulizer kit and mask after each use and allow to dry on a paper towel then the kit and mask was to be placed in a bag for storage until the next use. The interview confirmed that the kit, mask, and tubing was to be changed weekly and should be dated when changed. During the interview with LPN-F, after accompanying surveyor to bedside and visualizing the current placement and storage of the nebulizer kit and mask for Resident 40, confirmed that it had not been rinsed or stored properly to prevent the potential for cross contamination. A record review of the facility policy titled Nebulizer - R/S, LTC, AL, MCAL and dated 11/1/23 revealed it contained the following guidance related to nebulizer treatments: Following medication administration clean nebulizer after each use: -Separate the nebulizer parts (mask/mouthpiece, cup) and wash in warm soapy water and rinse thoroughly. -Place mask or mouthpiece and cup on paper towel and air-dry until the next use. Cover with clean cloth or towel.

Licensure Reference Number 175 NAC 12.006.12(D)(i) Based on observation, interview, and record review; the facility failed to safely store medications by leaving unattended medications at resident's bedside for 1(Resident 3) of 1 sampled residents. The facility census was 41. A record review of Resident 3's Admission Record revealed Resident 3 admitted to the facility on [DATE] and was admitted to the hospital on 09/22/2024. An observation on 09/23/24 at 9:51 AM revealed an unattended medication cup containing 12 medications varying in size and color sitting on a bedside table in Resident 3's room. An interview with Licensed Practical Nurse (LPN)-G on 09/23/2024 at 9:52 AM was conducted. LPN-G revealed that These (the pills in the medication cup) look like Resident 3's morning pills. LPN-G further revealed [gender] did not leave those medications at Resident 3's bedside and that the medications must be from the weekend. A record review of Resident 3's September 2024's Medication Record revealed that on 9/22/24 the AM (morning) pass of medications of the following medications was documented as administered by Medication Aide (MA)-I: -Aspirin Delayed Release 81 mg (for heart health), -Benzonatate 100 mg (for related cough), -Clopidogrel 75 mg (for Chronic Systolic (Congestive) Heart Failure), -Crestor 5 mg (for Hyperlipidemia), -Dapagliflozin 10 mg (for Type 2 Diabetes Mellitus with Hyperglycemia), -Losartan Potassium 50 mg (for Hypertension), -Metoprolol Succinate ER 50 (for Atherosclerotic Heart Disease), -Prednisone 1 mg - 2 tabs (for Rheumatoid Arthritis), -Prednisone 5 mg (for Rheumatoid Arthritis), -Augmentin 8.75/125 (for wound infection), -Prerevision- AREDS (for eye health). A record review of Resident's 3's Progress Notes from 09/22/2024 at 7:29 AM revealed that the Resident 3 was transferred to the hospital per medical order for complaints of right back pain with a pain rating of 10 out of 10 using the 0-10 pain scale where 10 is the highest pain level. Record review of facility policy Medications: Acquisition Receiving Dispensing and Storage- R/S, LTC dated 03.29.2024 revealed that Medications will be stored in a locked medication cart, drawer or cupboard. An interview with the Director of Nursing on 09/26/2024 at 10:00 AM confirmed that medications should not be left unattended, and that these 12 medications found in Resident 3's room should not have been left there.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to follow infection control guidelines to prevent cross contamination related to peri cares and catheter cares for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 41. Findings are: A record review of the document titled Admission Record revealed Resident 4 had been accepted into the facility on [DATE] with a primary diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and Cognitive/communication deficit. An observation on 9/3/24 at 3:37 PM of peri-cares for Resident 4, being accompanied by the DON and completed by MA-A and MA-B revealed that MA-A had gathered supplies to perform peri-cares (a bottle of spray skin cleanser, a hand towel and a container of wet wipes) and placed the supplies directly on Resident 4's bed with no barrier placed throughout the procedure. The observation revealed that Resident 4 had a catheter in place. MA-A then sprayed Resident 4's groin area with skin cleanser. MA-A had pulled down Resident 4's pants to the knees and had placed Resident 4's catheter bag on the bed during the cares which was not below the level of the bladder. MA-A then obtained a wet wipe and cleansed the catheter tubing towards Resident 4's urethra (the tube that empties urine from the bladder) instead of away from the urethra. During the observation of peri cares, it was revealed that Resident 4 had been incontinent of bowel. MA-A was observed using wet wipes to clean Resident 4's buttocks and rectal area. The observation of the peri cares revealed that MA-A had not changed gloves or perform hand hygiene during the peri and rectal cares. The observation also revealed that MA-A and MA-B had removed their gloves, did not perform hand hygiene, and placed a new incontinence brief on Resident 4 with ungloved hands. An interview on 9/3/24 at 4:12 PM with the Director of Nursing (DON) when questioned how (gender) felt the peri cares went, the DON confirmed that the observation of the peri cares for Resident 4 provided by MA-A did not follow infection control guidelines or facility policy. DON confirmed that MA-A should have cleansed the tubing away from the resident and MA-A and MA-B should have changed gloves and performed hand hyigene during peri cares. DON also confirmed both MAs should have wore gloves when applying a clean brief. An interview on 9/3/24 at 11:40 AM with the IP revealed that the facility had 6 residents with a UTI in July 2024 and 8 residents with a UTI in August 2024 and no UTI's thus far in September 2024. The document titled Hand Hygiene Clinical Skill Checklist read as follows: Hand hygiene (i.e. alcohol-based hand sanitizer, soap and water) is performed at the Moments of Hand Hygiene which includes, but is not limited to: -Before entering a room; -Before performing a clean task; -After bodily fluid/glove removal, and -After exiting a room A record review of the facility policy titled Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen and dated 7/30/2024 read as follows: Procedure: -Cleanse away from the meatus (urethal opening) to remove secretions or encrustation to avoid contaminating the urinary tract. A record review of the facility policy titled Perineal Care and dated 7/29/2024 contained the following guidelines: Fold covers down and remove soiled pad. If BM (bowel movement) is present, use soiled pad to remove as much solid waste as possible. Apply gloves prior to assisting with incontinent pad placement and/or assisting with clean clothing if there may be contact with bodily fluids during the tasks.

Licensure Reference Number 175 NAC 12.006.04B2c Based on observation, interview and record review, the facility failed to ensure the kitchen had a qualified Dietary Manager. This had the potential to affect all 47 residents that consumed food from the kitchen. The total facility census was 47. Findings are: A record review of the facility's Dietary Manager's (DM) training revealed the DM was enrolled in the Pathway III(b) - Dietary Manager Training course with a start date of 10/16/2023 and an end date of 10/16/2024 but had not successfully completed the course. A record review of the Job History for the DM confirmed the DM was hired at the previous facility 07/25/2019 and left the facility 12/31/2021 and had not completed the Dietary Manager training course at that time. In an interview on 11/15/2023 at 10:25 AM, the facility's Registered Dietician (RD) confirmed the RD was only at the facility 1 day per week and the DM had not completed the Dietary Manager training course.

Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview and record review, the facility failed to ensure open food items in the kitchen were dated and/or labeled and failed to ensure the kitchen equipment was clean to prevent the potential for foodborne illness. This had the potential to affect all 47 residents that consumed food from the kitchen. The total facility census was 47. Findings are: A. A record review of the of the Food-Supply Storage - Food and Nutrition Services policy dated 05/11/2023 revealed foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly. An observation on 11/13/2023 at 8:20 AM of the reach in refrigerator on the left side as you enter the kitchen revealed: -1 white open container unknown substance not labeled or dated. -2 open clear containers of fruit not labeled or dated. -1 open container of a thick creamy white substance not labeled or dated. -1 can with a label of mandarin oranges covered with plastic wrap not sealed or dated. -1 container yellow substance covered with aluminum foil not labeled or dated. -1 container Reslers Deli Salads not labeled or dated. -1 can labeled carrots covered with aluminum foil not dated. -2 plastic containers with red lids with green leafy substance not labeled or dated. -2 zip lock style bags of seasoned fish strips not labeled or dated. -1 container labeled olives not dated. -1 container labeled vinaigrette not dated. -2 warmer pans of sandwiches covered with plastic wrap not labeled or dated. -1 container of a green and brown leafy substance not labeled or dated. -1 zip lock style bag of brown meat slices not labeled or dated. -1 plastic container with red lid of a chunky orange substance not labeled or dated. An observation on 11/13/2023 at 8:20 AM of the dry storage area revealed: -6 bags different pasta not dated, 1 bag was open. -2 boxes Rice pilaf opened and not dated. -1 container with red top with white flaky substance not labeled or dated. -1 open bag raspberry gelatin not sealed or dated. -1 bag brown powder substance not labeled or dated. -1 zip lock style bag with white powder substance not labeled or dated. -1 bag of a tan powder substance not labeled or dated. An observation on 11/13/2023 at 8:20 AM of the walk-in refrigerator revealed: -1 container with red top with yellow cheese slices not dated. -1 container with red top with white cheese slices not dated. -1 opened white plastic container Grated Parmesan Cheese not dated. -1 opened plastic tray of soup not labeled or dated. -1 open can Diet Shasta Twist, opened, not dated. -1 steam pan of turkey partially covered with foil not labeled or dated. -1 bag of white chucks with red coating on 1 side not labeled or dated. -1 opened container Resers Deli Salads not labeled but not dated. An observation on 11/13/2023 at 8:20 AM of the walk-in freezer revealed: -1 open bag labeled polish sausage not dated. -1 open bag small brown balls not labeled or dated. -1 opened bag cauliflower not dated. -1 opened bag carrots not dated. -1 opened bag wax beans not dated. -1 large box assorted opened bags of vegetables not dated. A record review of the Main Kitchen Cleaning Schedule dated 11/1/23 - 12/1/23 revealed the kitchen refrigerator should have been cleaned out and throw out outdated food 2 times per week, last done 11/12/2023. In an observation on 11/13/2023 at 12:15 PM with the facility's Registered Dietician (RD) revealed the following observed items: the dry storage area contained: -6 bags different pasta not dated, 1 bag was open. -2 boxes Rice pilaf opened and not dated. -1 container with red top with white flaky substance not labeled or dated. -1 open bag raspberry gelatin not sealed or dated. -1 bag brown powder substance not labeled or dated. -1 zip lock style bag with white powder substance not labeled or dated. -1 bag of a tan powder substance not labeled or dated. the walk-in refrigerator contained: -1 container with red top with yellow cheese slices not dated. -1 container with red top with white cheese slices not dated. -1 opened white plastic container Grated Parmesan Cheese not dated. -1 opened plastic tray of soup not labeled or dated. -1 open can Diet Shasta Twist, opened, not dated. -1 steam pan of turkey partially covered with foil not labeled or dated. -1 bag of white chucks with red coating on 1 side not labeled or dated. -1 opened container Resers Deli Salads not labeled but not dated. The walk-in freezer contained: -1 open bag labeled polish sausage not dated. -1 open bag small brown balls not labeled or dated. -1 opened bag cauliflower not dated. -1 opened bag carrots not dated. -1 opened bag wax beans not dated. -1 large box assorted opened bags of vegetables not dated. In an interview on 11/13/2023 at 12:15 PM, the RD confirmed the RD and Dietary Manager (DM) went through the reach-in refrigerator located on the left side as you enter the kitchen and removed all the opened, uncovered, unlabeled, and undated items above. The RD confirmed the items identified above were opened, uncovered, unlabeled, and/or undated. The RD Further reported all food items stored in the kitchen should be in a sealed container, labeled, and dated. B. A record review of the Main Kitchen Cleaning Schedule dated 11/1/23 - 12/1/23 revealed: -The oven cleaned and racks done weekly, last done 11/10/2023 & 11/14/2023 -The outside of ovens cleaned daily, done all days -The stove top cleaned daily, last done 11/12/2023, not done 11/13/2023, done 11/14/2023 An observation on 11/13/2023 at 8:20 AM of the kitchen revealed: -The top of stacked Vulcan ovens had 4 cooking racks stacked on top and a thick sticky coat of black and brown substance with scattered black debris throughout the surface and 4 loose screws were located on the top, both ovens had thick black scattered crust on the bottoms and the Vulcan stove top/grill grates had a thick crust of a black charcoal substance throughout the surface. In an observation on 11/13/2023 at 12:15 PM with the facility's Registered Dietician (RD) revealed the following observed issues: -The top of stacked Vulcan ovens had 4 cooking racks stacked on top and a thick sticky coat of black and brown substance with scattered black debris throughout the surface and 4 loose screws were placed on the top. -Both ovens had thick black scattered crust on the bottoms. -The Vulcan stove top/grill grates had a thick crust of a black charcoal substance throughout the surface. In an observation on 11/15/2023 at 0:25 AM with the facility's Registered Dietician (RD) revealed the RD observed: The top of stacked Vulcan ovens had 4 cooking racks stacked on top and a thick sticky coat of black and brown substance with scattered black debris throughout the surface and 4 loose screws were placed on the top. Both ovens had thick black scattered crust on the bottoms. In an interview on 11/13/2023 at 12:15 PM, the RD confirmed the top of stacked Vulcan ovens had 4 cooking racks stacked on top and a thick sticky coat of black and brown substance with scattered black debris throughout the surface and 4 loose screws were placed on the top, both ovens had thick black scattered crust on the bottoms, and the Vulcan stove top/grill grates had a thick crust of a black charcoal substance throughout the surface and they should have been clean.

Licensure Reference Number 175 NAC 12.006.10D Based on observation, interview and record review, the facility failed to ensure 1 (Resident 100) of 2 sampled residents received an antibiotic (a medication used to treat an infection) as scheduled and failed to ensure food was given after sliding scale Insulin (progressive increase in pre-meal or nighttime insulin doses based on pre-defined blood glucose (sugar) ranges) was administered for 2 (Residents 100 and 107) of 3 sampled residents per manufacturer's specifications. The total facility census was 47. Findings are: A record review of the facility's Medication Errors policy dated 03/02/2023 revealed medication errors were when the observed or identified administration of medications were not in accordance (conformity) with the prescriber's order, manufacturer's specifications, or accepted professional standards. A significant medication error was one which causes the resident discomfort or jeopardizes the resident's health and safety. A. A record review of Resident 100's Order Summary Report dated 11/14/2023 revealed an order for: Cefazolin Sodium Chloride (an antibiotic used to treat a wide variety of bacterial infections). Use 9 grams intravenously (IV, administered in the vein) every 24 hours related to Infection and Inflammatory Reaction Due to Other Internal Joint Prosthesis (infection in a joint due to replacement hardware), knee infection, that was ordered on admission. A record review of Resident 100's Clinical Census dated 11/14/2023 revealed Resident 100 was admitted to the facility on [DATE]. A record review of Resident 100's Medical Diagnosis dated 11/14/2023 revealed the resident had diagnoses of infection and inflammatory reaction due to other internal joint prosthesis, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, fatty liver, acute kidney failure, presence of unspecified artificial knee joint. A record review of Resident 100's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 11/03/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 15 of 15 which indicates the resident was cognitive aware. The resident needed setup or clean-up assistance with personal and oral hygiene (cleaning), and dressing, and substantial/maximal assistance with Shower/bathing. The MDS revealed the resident had a surgical wound, was receiving IV antibiotics, and the resident had a central line IV access (a catheter directly in the vein). A record review of Resident 100's Care Plan with and admitted [DATE] revealed a focus area that the resident was receiving antibiotics for a hardware infection, and an intervention of administer IV medications as ordered through the PICC (a catheter inserted in a peripheral vein that the tip is close to the heart). [NAME] An observation on 11/13/2023 at 10:00 AM revealed Resident 100 had an elastomeric IV (pump of medication hooked up to a PICC line. In an interview on 11/13/2023 at 10:00 AM, Resident 100 confirmed that the elastomeric IV pump connected to the PICC line was the resident's antibiotic that ran 24 hours per day for a knee infection. A record review of the Medication Administration Record (MAR) dated [DATE] revealed Resident 100's order for Cefazolin Sodium Chloride was applied 11/14/2023 at 7:35 PM. In an interview on 11/15/2023 at 8:51 AM, Resident 100 confirmed the staff changed the IV pump at about 8:00 PM the night before but did not release the clip on the tubing that kept the antibiotic from running. The resident confirmed that the IV pump was still solid about 8:21 AM so the resident seen the clip on the tubing was not released so the resident released it. The resident confirmed that MA-A was notified. In an interview on 11/15/2023 at 9:04 AM, Medication Aide (MA)-A confirmed Resident 100 notified MA-A about the IV pump not running since it was put the previous night and MA-A notified Licensed Practical Nurse (LPN)-B. In an interview on 11/15/2023 at 9:04 AM, LPN-B confirmed MA-A notified LPN-B of the antibiotic IV pump not running since the previous night at about 8:00 PM. LPN-B confirmed that LPN-B did not see or assess Resident 100's IV pump to ensure it was working after MA-A notified LPN-B the IV pump had not ran and the resident released the clip so it would run. LPN-B confirmed the the resident was on a premeasured Cefazolin Sodium Chloride elestomeric ball antibiotic that was set to infuse continuously over a 24 hour period and the resident not receiving the antibiotic flow since the scheduled time of every 24 hours at about 8:00 PM would be a significant medication error. An observation on 11/15/2023 at 1:49 PM revealed Resident 100's antibiotic elastomeric IV pump appeared unchanged in size. In an interview on 11/15/2023 at 1:49 PM, Resident 100 confirmed the size of the IV pump had not changed and it should have shrunk as the antibiotic flows from the IV pump. Resident 100 confirmed that LPN-B was just in and flushed the PICC line and re-applied the IV pump. In an interview on 11/15/2023 at 2:00 PM, LPN-B confirmed that Resident 100's antibiotic IV pump was still not running when the resident returned from the provider appointment, so RN-B flushed the PICC line and re-applied the IV pump. In an interview on 11/16/2023 at 8:017 AM, the Director of Nursing (DON) confirmed that Resident 100's antibiotic IV pump had not run from 11/14/2023 when it was applied at 7:35 PM until the following day when LPN-B flushed and ensured the IV pump was running and that the resident did not receive the prescribed antibiotic during that timeframe. B. A record review of the article found at https://www.humalog.com/fast-acting-mealtime-insulin#managing-blood-sugar About Humalog dated 10/2023 revealed Humalog (medication used to treat Diabetes) is a fast-acting insulin that starts working fast and Humalog was to be taken with 15 minutes before eating or right after eating a meal. Humalog and Insulin Lispro injection may cause serious side effects. Some of these can lead to death such as low blood sugar, severe allergic reaction, low blood potassium, heart failure, high blood sugar, and ketoacidosis (a serious, possible life threating complication of diabetes). A record review of the American Family Physician's article Using Insulin Lispro dated 01/15/1998 revealed: Insulin Lispro should be injected under the skin within 15 minutes before you eat. Your doctor will tell you how much Insulin Lispro to inject. Remember, you must eat 15 minutes after you take this insulin shot. A record review of Resident 100's Clinical Census dated 11/14/2023 revealed Resident 100 was admitted to the facility on [DATE]. A record review of Resident 100's Medical Diagnosis dated 11/14/2023 revealed the resident had diagnoses of Type 2 Diabetes Mellitus with Diabetic Neuropathy (uncontrolled blood sugar with nerve damage), Hyperkalemia (high blood potassium), Fatty Liver, Acute Kidney Failure, Presence of Unspecified Artificial Knee Joint, and many others. A record review of Resident 100's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status of 15 of 15 which indicates the resident was cognitive aware. The resident needed setup or clean-up assistance with personal and oral hygiene, and dressing, and substantial/maximal assistance with shower/bathing. The MDS revealed the resident was receiving Insulin. A record review of Resident 100's Care Plan with and admitted [DATE] revealed several Focus areas that included the diagnosis of Diabetes but did not reveal a Focus area or Interventions specific to Resident 100's Diabetes. An observation on 11/14/2023 at 11:02 AM revealed MA-A entered Resident 100's room and explained to the resident that it was time for an Insulin injection and injected the resident in the abdomen. A record review of the MAR dated November 2023 revealed Resident 100 had an order for Insulin Lispro Subcutaneous (under the skin) Solution Cartridge 100 unit/ML inject as per sliding scale subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Neuropathy. The resident was given 2 units of Insulin Lispro Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Lispro) for a blood sugar of 169 milligrams/deciliter (a metric unit of measure). An observation on 11/14/2023 at 11:02 through 11/14/2023 at 11:43 AM revealed Resident 100 had not left the room, did not [NAME] snack, or been served a meal after the Insulin injection. In an interview on 11/14/2023 at 11:43 AM, MA-A confirmed MA-A administered Humalog Lispro Insulin injection to Resident 100 and had not given the resident a meal. MA-A confirmed the resident had a bag of unspecific size of popcorn prior to the injection but had not had a meal. In an interview on 11/15/2023 at 2:58 PM, the DON confirmed that Resident 100 not getting a meal before or after the Humalog Lispro Insulin injection was a significant medication error due to the inability to determine the nutritional value in a unspecified size bag of popcorn. C. A record review of the How To Take Novolog / Novolog (insulin aspart) Injection 100 units per milliliter (U/mL) (a medication used to treat Diabetes) dated March 2023 found at https://www.mynovoinsulin.com/insulin-roducts/novolog/taking-novolog.html revealed Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. Possible side effects can lead to death, including low blood sugar and many other serious side effects. A record review of Resident 107's Clinical Census dated 11/14/2023 revealed Resident 107 was admitted to the facility on [DATE]. A record review of Resident 107's Medical Diagnosis dated 11/14/2023 revealed the resident had diagnoses of Type 2 Diabetes Mellitus with Diabetic, Hypokalemia (low blood potassium), Hyperlipidemia (high cholesterol), Presence of Unspecified Artificial Knee, Bilateral (both sides), and many others. A record review of Resident 107's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status of 12 of 15 which indicates the resident had moderate cognitive impairment. The resident needed setup or clean-up assistance with oral hygiene, and dressing, and substantial/maximal assistance with toileting, shower/bathing, and personal hygiene. The MDS revealed the resident was receiving Insulin. A record review of Resident 107's Care Plan with and admitted [DATE] revealed a Focus areas of Hypoglycemia (Diabetes) medications and multiple indications for it including discussion of mealtimes, portion sizes, and snacks allowed in daily nutrition plan. An observation on 11/14/2023 at 11:09 AM revealed MA-A entered Resident 107's room and explained to the resident that it was time for an Insulin injection and administered the resident's insulin. A record review of the MAR dated November 2023 revealed Resident 107 had an order for Novolog FlexPen Subcutaneous (under the skin) Solution Pen-Injector 100 unit/ML (Insulin Aspart) Inject as per sliding scale subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Neuropathy. Give 15 minutes before meal. The resident was given 12 units of Novolog FlexPen Subcutaneous (under the skin) Solution Pen-Injector 100 unit/ML for a blood sugar of 362 milligrams/deciliter. An observation on 11/14/2023 at 11:02 through 11/14/2023 at 11:43 AM revealed Resident 107 had not left the room, had a snack, or been served a meal after the Insulin injection. In an interview on 11/14/2023 at 11:43 AM, MA-A confirmed MA-A administered Novolog FlexPen Insulin injection to Resident 107 and had not given the resident a meal. In an interview on 11/15/2023 at 2:58 PM, the DON confirmed that Resident 107 did not get a meal within 15 minutes after the 12 unites of Novolog FlexPen Insulin was administered and should have.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility failed to implement interventions for (Moisture Associated Skin Damage) MASD (skin erosion caused by prolonged exposure to a source of moisture) and shearing ( pressure and friction, injuring the skin at the same time) for Resident 3 which resulted in a stage III (involves full-thickness of the skin) pressure ulcer. The facility staff identified a census of 37. The findings are: Review of the (Catholic Health Initiative) CHI Wound Note for Resident 3 dated 11/30/22 revealed the following: -To the left buttocks the stage III pressure ulcer measures 0.5X0.5cm (centimeter) and is complicated by shearing with crusting and pealing skin to the direct periwound skin and light maceration noted. The open area is 100% red moist tissue with a scant amount of serosanguinous (a pink watery fluid in response to tissue damage) drainage. The area of shearing to the left buttocks now has 1 open area that is now a stage III pressure ulcer that measure 1X1.2cm and is covered in 100% pink moist tissue with a scant amount of serosanguinous drainage noted. Resident 3 does have moisture associated dermatitis. Review of progress note dated 11/9/22 for Resident 3 revealed the following: -Resident 3 was seen in facility by Advanced Practice Registered Nurse from CHI Wound Care Clinic. Stage III pressure ulcer to the left buttock is worsening by shearing with crusting and peeling skin to the direct periwound skin and light maceration. The open area is covered in 100% red moist tissue with scant amt serosanguineous drainage noted. Resident 3 does have moisture associated dermatitis. Review of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 09/13/22 revealed Resident 3 requires extensive assistance with toilet use X 1 staff. Resident 3 is frequently incontinent of bladder and is not on a toileting program. Review of the Bladder evaluation dated 08/22/22 revealed Resident 3 is incontinent daily but less than every shift. Resident 3 is incontinent daytime and nighttime and has no impaired cognitive ability affecting toileting. Further review revealed functional incontinence with no recommendations. The Bladder Care Planning addressed in the Bladder evaluation as follows: Goal Resident will be free from skin breakdown due to incontinence. Interventions are 1. Provide a pull up. 2. Monitor for signs and symptoms of Urinary Tract Infection. 3. Resident 3 is to drink more fluids. Review of the current comprehensive care plan date initiated 09/03/20 revealed a goal of Resident 3 will remain free from skin breakdown due to incontinence and brief use. Further review revealed no indication of interventions for toileting or shearing. Review of the policy and procedure for Bladder evaluation dated 4/26/22 revealed the following: -A nursing diagnosis for the probable type of incontinence is determined based on resident's incontinence characteristics. An appropriate toileting program should be implemented based on the type of incontinence and information obtained and evaluated using the Bladder Evaluation . On 12/12/22 at 10:49 AM an observation of wound care with LPN-A (Licensed Practical Nurse) revealed an approximate 1.5cm circular open area on the left buttocks and another area below approximately 1cm circular. The surrounding tissue had some small open areas and was dark red. There were several areas of dry flaky skin. Interview with the (Director of Nursing) DON on 12/12/22 at 11:38 AM confirmed that Moisture Associated Dermatitis has a root cause of moisture incontinence and the expectation is for a bowel and bladder assessment to be completed and admission, re-admission and at least quarterly. The DON confirmed that Resident 3's incontinence should have been addressed with an assessment of toileting program. The DON confirmed the policy said to initiate toileting program according to the assessment. The DON also confirmed that Resident 3 had a new stage 3 pressure ulcer that measured 1 x 1.2cm on the left buttocks where the shearing and maceration was noted. Interview with DON at 12:15 PM on 12/12/22 revealed there was no further documentation addressing the MASD or the shearing.

Licensure Reference Number 175 NAC 12-006.04C Based on observation, interview, and record review, the facility failed to ensure sufficient staff to care for residents in the Cottonwood Unit of the facility. This failure resulted in a resident waiting over 2 hours for pain medication, residents not being assisted with meals or ADLs (Activities of Daily Living), residents with pressure ulcers not being assessed or provided treatments as ordered by their physicians, and residents waiting extended periods of time for call lights to be answered. This affected 32 of the 46 residents that resided in the facility. The findings are: A. In an interview on 5/16/22 at 12:35 PM, Resident 7's family members reported they ensure 2 people from their family were in the facility daily from 8:00 AM - 11:00 PM to help with things like repositioning Resident 7 since the facility was so short of staff. Resident 7's family members reported Resident 7 was currently on hospice and sometimes had to wait 1 - 3 hours for their call light to be answered for things like repositioning, incontinence care, and pain medication, especially during the evening hours. Resident 7's family stated a recent example of waiting a long time for assistance was Friday, 5/13/22. In an interview on 5/18/22 at 9:23 AM, Resident 7's family member reported calling to request pain medication for Resident 7 the evening of 5/17/22 around via the call light. Resident 7's family member reported the call light did not get answered for 2 hours and the staff member who answered the call light stated they were almost done with their current task and would return in a moment. Resident 7's family member stated the staff member did not return to administer the [MEDICATION(S)] to Resident 7 until approximately 9:30 PM. Resident 7's family member also reported there were only 2 staff working on Cottonwood (32 residents) the evening and night of 5/17/22. Resident 7's family member reported Resident 7 does not like to complain but they did experience general aches and discomfort from being bed-bound, which was why the [MEDICATION(S)] was requested. A review of a call light report for Resident 7 revealed the following: -5/13/22 at 7:05 PM - call light was on for 2 hours and 12 minutes -5/17/22 at 6:58 PM - call light was on for 1 hour and 51 minutes A review of Resident 7's May 2022 MAR (Medication Administration Record) revealed Resident 7 was administered PRN (as needed) [MEDICATION(S)] on 5/17/22 at 9:35 PM. B. Observation on 5/16/22 at 12:30 PM revealed Resident 5's blood sugar being checked by Registered Nurse F in the facility dining room. In an interview on 5/16/22 at 12:57 PM after Resident 5 finished eating, Resident 5 reported that Resident 5 had not received any insulin and that blood sugar was 244. A review of Resident 5's 5/22 MAR [Medication Administration Record] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] =2 units; 181-240=4 units; 241-300=6 units; 301-350=8 units; 351-400=10 units 401 plus-12 units and call physician. Resident 5's blood sugar level was recorded as 244 for 1200 PM check on 5/16/22. In an interview on 5/16/22 at 2:24 PM, Registered Nurse F reported giving Resident 5 insulin at 1:08 PM after completion of lunch. Registered Nurse F confirmed that medications were given late as finished giving morning medications at 11:35 AM. In interviews on 5/16/22 at 2:22 PM and on 5/18/22 at 1:25 PM, Licensed Practical Nurse A reported on 5/16/22 Licensed Practical Nurse A had come to work at 3 AM and worked without help on the floor until Registered Nurse F was asked to assist with passing medications around 8:30 AM. C. Observations on 5/16/22 at 2:31 PM revealed Registered Nurse F administering the following medications to Resident 4: -Carb/levo tab [a medication for [CONDITION(S)]] 25-100 mg 1 tab -[MEDICATION(S)] [a medication for pain] 50 mg, 1 tab A review of Resident 4's 5/22 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] tablet 25-100mg ([MEDICATION(S)]-Levodpa) 1 tablet by mouth 3 times per day with meals with times listed as 8 AM, 12 PM, and 6 PM -[MEDICATION(S)] 50 mg give 2 times per day with times listed as 12 PM and 6 PM In an interview on 5/16/22 at 2:31 PM, Registered Nurse F reported administering Resident 4's morning medications at 11:40 AM. In interviews on 5/16/22 at 2:22 PM and on 5/18/22 at 1:25 PM, Licensed Practical Nurse A reported on 5/16/22 Licensed Practical Nurse A had come to work at 3 AM and worked without help on the floor until Registered Nurse F was asked to assist with passing medications around 8:30 AM. D. Observations on 5/16/22 at between 6:49-7:41 PM revealed Activities Director M and Social Services Staff U assisting with clean up in the dining area. In an interview on 5/16/22 at 6:49 PM, Activities Director M reported staying to help-out. In an interview on 5/16/22 at 6:50 PM Social Service Staff U reported staying to help out E. In confidential interviews completed between 5/16/22 at 12:15 PM and 5/18/22 at 12:53 PM, residents reported the following: -Resident reported waiting until 10 PM to get assistance to go to bed on Friday night (5/13/22) and call light was on for 2.5 hours before answered -Resident reported that takes over an hour to get a call light answered when the regular crew is not working -Resident reported staff is too busy to assist Resident in the bathroom and Resident is not supposed to go without help -Resident reported waiting until 1:00 AM to get assistance to bed on Friday night (5/13/22) due to no staff available to assist them. -Resident reported waiting until 11:15 PM to get assistance to bed Friday night (5/13/22) due to no staff available to assist them. This resident also reported a different night they had their call light on for over 3 hours and finally had to go into the hall to find assistance to go to bed. -Resident reported long wait times for call light to be answered and sometimes will have to yell for help when no one comes. A review of staffing schedule as worked for 5/13/22 revealed the following staff worked at night: -Registered Nurse R worked 6 AM until 9:46 PM -Nurse Aide Z worked 6 PM-6 AM on Saturday AM -Medication Aide Y worked 6 PM-10:29 PM -Licensed Practical Nurse AA worked 6 PM-6 AM on Saturday AM Schedule as worked on night of 5/13/22 indicated only 2 staff members in the building between 10 PM on Friday night and 6 AM on Saturday morning A review of staffing schedule as worked for 5/14/22 revealed the following staff at night: -Medication Aide A worked from 6 AM until 7:55 PM -Medication aide G worked from 6 AM until 8:15 PM -Registered Nurse W worked from 6 AM until 8:28 PM -Licensed Practical Nurse X worked from 6:39 PM until 6:41 AM on Sunday AM -Licensed Practical Nurse BB worked from 6 pm to 6 AM on Sunday AM Schedule as worked on 5/14/22 indicated only 2 staff members in the building between 8:28 PM on Saturday night and 6 AM on Sunday morning A review of staffing schedule as worked for 5/15/22 revealed the following staff at night: -Medication Aide H worked from 6 AM until 8:02 PM -Registered Nurse W worked form 6 AM until 7:48 PM -Licensed Practical Nurse BB worked from 6 PM until 6:30 AM on Monday AM -Licensed Practical Nurse A clocked in at 3:24 AM Schedule as worked for night 5/15/22 indicated only one staff member in the building between 8:02 PM on Saturday night and 3:24 AM on Monday morning In an interview on 5/17/22 at 8:54 AM, Medication Aide H confirmed Medication Aide H had worked on 300 hall by self with assist of 400 aide over the weekend. Medication Aide H confirmed that there was only one aide on the 300 hallway and some resident did not get to bed until after midnight on Friday. Medication Aide H confirmed there was only 2 staff in the building on Friday night. Medication Aide H reported staying late on Saturday and Sunday night to help with assisting residents to bed. A review of the facility staffing plan for a census of 48 dated 5/18/22 revealed the following: -12 hour shifts AM and PM for each hallway: Ash-Licensed Nurse and 2 CMA/NA; Cottonwood-Licensed Nurse and 3 CMA/NA; 2 nurse aides that work 8 hour shifts leave at 10 PM -Alternate plan if only 1 licensed nurse available for facility: Medication Aides will pass oral medications on the hallways (1 in Ash hallway, 2 in Cottonwood hallway); Nurse to be available to perform tasks that only licensed nurses can do; Nurse Aides 1 on Ash hallway, 2 on Cottonwood and Medication Aides to assist nurse aides with resident cares as needed The emergency staffing will include department managers assisting the direct care staff with meeting resident needs such as transporting to dining room/activities, answering call lights and serving meals etc. Staff will be asked to work extra shifts or extra hours to meet the need. Also staff shared between sister facilities to meet staffing needs. F. A review of call light logs between 5/13/22-5/18/22 revealed the following: -Resident 1 had 30 call lights on for over 10 minutes and 5 call lights on for over 1 hour with the longest call light being 2 hours and 3 minutes -Resident 8 had 10 call lights on for over 10 minutes and 2 call lights on for over 1 hours with the longest being 2 hours and 40 minutes -Resident 5 had 7 call lights on for over 10 minutes and 1 call light on for over an hour with that one being on for 1 hour and 24 minutes -Resident 7 had 15 call lights on for over 10 minutes and 4 call lights on for over 45 minutes, with the longest call light being 2 hours and 12 minutes -Resident 10 had 11 call lights on for over 10 minutes and 4 call lights on for over 45 minutes, with the longest call light being 1 hour and 4 minutes -Resident 9 had 18 call lights on for over 10 minutes, with the longest call light being 41 minutes -Resident 11 had 13 call lights on for over 10 minutes and 2 call lights on for over an hour, with the longest call light being 1 hour and 34 minutes In an interview on 5/18/22 at 3:47 PM, the Administrator reported a goal of having call lights answered within 10 minutes. G. In an interview on 5/18/22 at 3:47 PM, the Administrator reported struggling to get staff and expected approval for use of outside agency staff that day. H. Observations, interviews, and record review revealed the facility failed to evaluate pressures sores and provide treatment to aid in healing of pressure sores for Residents 1 and 3. See F686 for additional information regarding Resident 1 and Resident 3's pressure sores and related staffing concerns. I. Observations, interviews, and record review revealed the facility failed to provide assistance with activities of daily living including eating, bathing, toileting and grooming for Residents 1, 3, 4, and 6. See F677 for additional information regarding Resident 1, 3, 4, and 6 assistance with activities of daily living and related staffing concerns. J. Observations, interviews, and record reviews revealed the facility failed to provide interventions to prevent weight loss for Resident 3. See F692 for addtional information regarding Resident 3's weight loss and related staffing concerns.

Licensure Reference Number 175 NAC 12-006.09D2b Based on observations, interviews, and record review, the facility failed to evaluate pressure sores and provide treatment to aid in healing of pressure sores for 2 (Resident 1 and 3) of 11 sampled residents. The facility had a total census of 46 residents. Findings are: A. Observation on 5/16/22 at 7:15 PM revealed a wound vacuum in place on Resident 1's right buttock. A review of Wound Data Collection record dated 1/2/22 for Resident 1 revealed it was the initial data collection sheet for right buttock wound. The wound was measured as having a length of .75 cm [centimeters], a width of .5 cm, and a depth of .75 cm. The section under wound characteristics to include wound bed percentage, percent epithelized, percent granulation, percent slough, and percent eschar was not completed. Drainage was identified as minimum serosanguineous with no odor. A review of Wound Data Collection record dated 1/25/22 for Resident 1 identified the right buttock wound as having a length of 1.5 cm, a width of 1.5 cm and a depth of .75 cm. The section under wound characteristics to include wound bed percentage, percent epithelized, percent granulation, percent slough, and percent eschar was not completed. Drainage was identified as minimum serosanguineous with no odor. A review of Wound RN assessment dated [DATE] for Resident 1 identified the right buttock wound as unstageable pressure ulcer. The section regarding healing process and deterioration of wound were not completed. The assessment identified that the current plan of treatment would be continued. A review of Wound Clinic Progress Notes dated 3/23/22 for Resident 1's right ischial area revealed a wound size of 1.2 cm length, 1.7 cm width, and 1.2 cm depth with undermining from 2-4 o'clock of 2 cm and gray necrotic tissue. The area was identified as not improved and debrided at the wound clinic. A review Wound Clinic Progress Note dated 4/7/22 for Resident 1's right ischial area revealed a length of 1.6 a width of 1 cm and a dept of 1.2 cm with undermining from 12-4 o'clock of 1.5 cm. Area is identified as improved with red granular tissue to wound bed. A review of Wound Data Collection records for Resident 1 between 3/30/22-4/14/22 did not reveal any assessment of tunneling in right buttock wound. A review of Wound Data Collection record dated 4/14/22 for Resident 1 identified the right buttock wound as having a length of 2 cm, a width of 2.5 cm and a depth of 2 cm with tunneling noted at top .5 cm at 12 o'clock, 2 cm at 9 o'clock/right, 2.5 cm at 3 o'clock, and .75 cm at 5 o'clock which indicated a decline in the wound compared to assessment dated [DATE]. The section under wound characteristics to include wound bed percentage, percent epithelized, percent granulation, percent slough, and percent eschar was not completed. Drainage was identified as minimum serous. A review of Progress Note for Resident 1 dated 4/14/22 revealed wound clinic was faxed regarding tunneling with a note that facility was waiting a reply. A review of Wound Data Collection record dated 4/16/22 for Resident 1 identified the right buttock wound as having a length of 2 cm, a width of 2 cm, and depth of 2 cm. The section under wound characteristics to include wound bed percentage, percent epithelized, percent granulation, percent slough, and percent eschar was not completed. Wound bed was noted to be within normal limits with no drainage or odor. A review of Wound Data Collection record dated 4/20/22 for Resident 1 identified right buttock wound as having a length of 2 cm, a width of 1.1 cm and a depth of 1.5 cm. Wound appearance is unchanged with moderate amount of serosanguineous drainage. Tunneling is identified as 2.5 cm at 12 o'clock, 3 cm at 1 o'clock, 1.9 cm and at 5 o'clock. The section under wound characteristics to include wound bed percentage, percent epithelized, percent granulation, percent slough, and percent eschar was not completed. A review of Wound Data Collection record dated 4/23/22 for Resident 1right buttock wound was not completed for measurements, wound characteristics, or drainage. Wound Data Collection noted that wound was cleansed, packed with prism and cover with dressing. A review of Wound Data Collection record dated 4/24/22 for Resident 1 right buttock wound was not completed for measurements, wound characteristics, or drainage. Wound Data Collection identified that dressing was intact and no drainage was leaking around dressing. A review of Resident 1's 4/22 MAR (Medication Administration Record) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] dressing was documented as being changed 4/10/22, 4/13/22, 4/16/22, 4/19/22, and 4/23/22. A review Wound Clinic Progress Note dated 4/7/22 for Resident 1's right ischial area revealed a length of 1.6 a width of 1 cm and a dept of 1.2 cm with undermining from 12-4 o'clock of 1.5 cm. Area is identified as improved with red granular tissue to wound bed. A review of Wound Clinic Progress Note dated 4/25/22 for Resident 1's right ischial area revealed a length of 1.5 cm, width of 2 cm and 1.3 cm depth with undermining from 12-5 with deepest at 1 o'clock of 3.5. Gray necrotic tissue to wound bed. Foul odor and purulent serosaninous drainage. [CONDITION(S)] surrounding of 9 x cm and induration present 6.5 cm x 5 cm. Treatment plan included being sent to emergency room for evaluation for surgical I&D and an intravenous antibiotics. A review of Progress Notes dated 5/9/22 for Resident 1 revealed Resident 1 was readmitted with Stage IV pressure ulcer to right buttock that was surgically debrided and wound vacuum is in place. In an interview on 5/18/22 at 2:52 PM, Licensed Practical Nurse/Unit Manager A confirmed that wound assessments were not getting done. In an interview on 5/18/22 at4 PM, the Director of Nursing confirmed wound data collection assessment record should be filled out completely. A review of facility policy titled Wound and Pressure Ulcer Management dated 5/25/21 revealed the following: -The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment UDA. If the resident is on Medicare, document daily on the Wound Data Collection UDA with every treatment change. 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, durounding skin, etc. -Presence of pain -Current treatments Progress toward healing and any modifications to the plan of care/treatments should be assessed and evaluated by the registered nurse. Licensure Reference Number 175 NAC 12-006.09D2b B. An observation on 5/16/22 at 7:29 PM revealed NA (Nursing Assistant) E and PT (Physical Therapist) D assisted Resident 3 to the toilet. When NA E pulled Resident 3's pants down, a Duoderm dressing (a [MEDICATION(S)] dressing - used to create a protective barrier and a moist healing environment for wounds) was observed to be in Resident 3's soiled brief. An observation with NA E at this time confirmed there was no date on the dressing in Resident 3's soiled brief and no dressings remained on Resident 3's buttocks or coccyx. NA E or PT D were not observed notifying a nurse that Resident 3's dressing had fallen off during toileting. An observation on 5/17/22 at 9:32 AM revealed MA (Medication Aide) J and NA V were changing Resident 3's soiled brief in bed. Observation at this time revealed Resident 3 had 2 shallow, open ulcerations - one on the coccyx (tailbone) and one on the right buttock. Both areas were uncovered with no dressing in place. MA J and NA V were not observed notifying a nurse that Resident 3's ulcerations were uncovered with no dressing in place. A review of an update sent to Resident 3's physician on 4/29/22 at 6:30 PM revealed the following: -Open areas on resident's left buttock from resident itching noted. #1 - 4cm (centimeters) x 1cm x 0.1cm, #2 - 7cm x 6cm, #3 - 1cm x 4cm and set of 3 scratches together: 4cm, 8.5cm, and 7.5cm. Areas were cleansed. Skin prep applied around areas. Collagen powder placed on wound beds of #1, #2, and #3 and thin Duoderm placed over to protect. Will change every 3 days and PRN (as needed). The order was signed by Resident 3's physician on 5/2/22. A review of a visit note from the Wound APRN (Advanced Practice Registered Nurse) dated 5/4/22 for Resident 3 revealed the following: -Patient is sitting in tilt in space wheelchair and I am unable to assess (gender) buttock at this time, nursing did not have time to get patient into bed before my arrival. Nurse did let me assess a photograph taken of the area. (Nurse) does state that (gender) witnessed the patient scratching this area and did have skin underneath of (gender) nails at that time. This wound does look as though it is an abrasion/excoriation from scratching as it does extend linear from the coccyx across to (gender) right buttock. These wounds according to the photograph do look full thickness and do have some slough (dead tissue - usually cream or yellow in color) to the wound bed. Also according to this picture these areas do not look infected at this time. A review of Resident 3's May 2022 TAR (Treatment Administration Record) revealed the following order: -Apply collagen powder to right buttock and coccyx (tailbone) ulcerations and cover with an extra thin Duoderm. Change every 3 days and PRN - Start 5/14/22 A review of all available Wound Data Collection documentation for Resident 3 revealed the following: -5/14/22 -Wound Name: Coccyx. Wound Site and Description: Sacrum - superficial open, no redness, no drainage, no c/o pain. Skin surrounding the wound is pink. No further assessment or measurements of the wound were documented. -5/15/22 - Wound Name: Coccyx PU (Pressure Ulcer). Wound Site and Description: Sacrum - superficial open ulcer, no drainage. Wound Bed Percentage: 100% granulation (pink or beefy red tissue). No further assessment or measurements of the wound were documented. A review of an RN (Registered Nurse) Wound Assessment for Resident 3 dated 5/15/22 revealed the following: -Wound Name: Coccyx Superficial Wound -Type of Wound: Pressure Ulcer -Staging: Stage 2 -Healing process: Pinkness tissue, no drainage A review of Resident 3's electronic medical record revealed no further wound data collection or assessments were completed for Resident 3 from 4/29/22 - 5/17/22. In an interview on 5/18/22 at 1:25 PM, UM (Unit Manager) A reported the expectation is that facility staff document daily on pressure ulcers, with measurements required every 7 days. UM A further reported any open areas were required to be documented on weekly, including measurements. UM A confirmed there was no documentation indicating when Resident 3's pressure ulcer began and no documentation or monitoring of open areas on Resident 3's coccyx or buttocks until 5/14/22. UM A stated when the wound APRN visited the facility on 5/4/22 to assess Resident 3's ulcerations to bilateral buttocks and coccyx, staff should have laid Resident 3 in bed so the APRN could assess the wounds instead of doing it via photograph. UM A further reported staff should have notified a nurse when Resident 3's dressing(s) fell off on 5/16/22, as there was a PRN order to utilize in that case as ordered by Resident 3's provider. UM A further confirmed Resident 3 was incontinent and leaving the ulcerated areas with no dressing could potentially worsen them, as they would be exposed to urine.

Licensure Reference Number 12-006.09D8b Licensure Reference Number 12-006.09D9 Based on observation, interview, and record review, the facility failed to implement interventions to prevent a significant weight loss for 1 (Resident 3) of 4 residents reviewed. The facility also failed to ensure water was available for 1(Resident 3) of 7 sampled residents. The facility had a total census of 46 residents. The findings are: A. A review of Resident 3's medical record revealed an admitted [DATE]. A review of Resident 3's listed MDSs (Minimum Data Set - a federally mandated assessment tool used for resident care planning) revealed a significant change MDS was completed for Resident 3 on 4/25/22. Resident 3's weight was recorded as 194 lbs (pounds) and the box for significant weight loss was checked as no. Section G of the MDS was coded for extensive assistance of 1 staff for eating. A review of Resident 3's CCP (Comprehensive Care Plan - a document that outlines how to care for a resident), last revised 5/5/22, revealed the following: -Focus: The resident has nutritional problem or potential nutritional problem .5/2022 - significant weight loss with increased need for assistance at meals. -Interventions included: -Resident has order for medical nutritional supplement. See MAR (Medication Administration Record) (Date initiated 5/11/22). -Provide supervision/observation at meals. Finger foods offered to increase independent eating as (Resident 3) is able. Assist with eating/drinking as (Resident 3) needs (Date Revised 5/11/22). A review of Resident 3's weight record revealed the following recorded weights since Resident 3's admission to the facility: -2/1/22 - 185.2 lbs -2/9/22 - 183 lbs -2/12/22 - 184 lbs -2/16/22 - 184.2 lbs -2/23/22 - 185.2 lbs -2/26/22 - 185 lbs -3/2/22 - 186 lbs -3/9/22 - 187 lbs -3/12/22 - 188.4 lbs -3/16/22 - 190.4 lbs -3/26/22 - 192 lbs -3/30/22 - 193.8 lbs -4/6/22 - 194.5 lbs -4/9/22 - 194 lbs -4/23/22 - 193.5 lbs -4/27/22 - 191 lbs -4/30/22 - 157.9 lbs -5/4/22 - 156.3 lbs -5/10/22 - 157 lbs -5/11/22 - 157.9 lbs Further review of Resident 3's weight record revealed a 30 day weight loss of 36.1 lbs, or 18.6%. A review of a progress note for Resident 3 written by RD (Registered Dietitian) L on 4/27/22 revealed a Significant Change RD Nutrition Assessment was completed. RD L wrote the following: -Weight has been stable since admission to the facility .variable po (by mouth) intake approximately 50% or less .(Resident 3) requires limited to extensive assistance eating meals .Inadequate intake due to decline in po intake AEB (as evidenced by) meal intakes of approximately 50%. Recommend Med Pass 2.0 (a fortified nutritional shake used to supplement calories and protein in order to gain or maintain weight status) 120mL (milliliters) BID (twice daily) to avoid weight loss. Report significant changes to the RD. A review of Resident 3's electronic medical record did not reveal any documentation of Resident 3's physician being notified about Resident 3's significant weight loss or any orders from Resident 3's physician for weight loss. A review of Resident 3's April and May 2022 MAR (Medication Administration Record) and TAR (Treatment Administration Record) did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Boost order was implemented on the evening of 5/10/22. An observation on 5/16/22 at 11:05 AM, revealed Resident 3 was lying flat in bed holding a Boost Breeze (a nutritional supplement drink) with a straw in it. Resident 3 was attempting to drink the Boost Breeze, but was having difficulty getting the straw in their mouth. An observation on 5/16/22 at 12:12 PM revealed Resident 3 was lying flat in bed. The Boost Breeze was observed to be lying on one side of Resident 3 in the bed and the straw on the other side of Resident 3. In an interview on 5/16/22 at 12:24 PM, UM (Unit Manager) A reported they were the only person working on the Cottonwood side (32 residents) of the facility. UM A stated they had come in at 3:20 AM due to there being only one person working in the building overnight and then had been working alone since 6:00 AM. Observations on 5/16/22 from 12:55 PM - 1:26 PM revealed Resident 3 sat in the dining room for lunch. Resident 3 was using their fingers to eat green beans. Resident 3's spoon was on the floor and there was food spilled on the floor around Resident 3. Resident 3 sat in a wheelchair and was about 2 feet from the table. Resident 3 attempted to eat a piece of cake with their fingers, but most was spilled on their lap and on the floor. No staff were observed assisting or cueing Resident 3 and Resident 3 ate less than 25% of the meal. Observations on 5/16/22 from 6:44 PM - 7:05 PM revealed Resident 3 sat in the dining room with a bedside table in front of them. Resident 3 had a cold cut sandwich cut in half, chips, and a few cookies on the bedside table in front of them. Resident 3 consumed approximately 25% of the meal. No staff were observed assisting Resident 3 with the meal. Observations on 5/17/22 from 8:44 AM - 9:01 AM revealed Resident 3 sat in the dining room for breakfast. Resident 3 had scrambled eggs and toast with jelly on a paper plate in front of them. Resident 3 consumed one bite of the toast and none of the eggs. No staff were observed assisting Resident 3 with the meal. In an interview on 5/17/22 at 12:25 PM, UM A reported Resident 3 needed assistance with meals, but it varied by the day from supervision and cueing to hands-on feeding assistance. UM A confirmed Resident 3 required some type of assistance from staff for eating. A review of the facility's Weight and Height Policy, last revised 5/3/22, revealed the following: Purpose: -To ensure that the resident maintains acceptable parameters of nutritional status regarding weight -To report changes in a resident's clinical condition (significant weight change) immediately to physician and family and/or resident -To accurately measure weight and height -To monitor weight loss or gain in a resident Policy: -Initial resident weights and heights are completed within 24 hours of admission and a weight upon readmission to the location. All residents are weighed at a minimum of weekly for the first four weeks following admission and then monthly thereafter. Weights should be obtained during a consistent week of the month and at the same time of the day. -Residents at nutritional risk will be weighed weekly. -The location will immediately inform the resident, consult with the resident's physician and, if known, notify the resident's legal representative when there is a significant change in the resident's weight . Procedure: Weight Procedure: -7. If weight varies by more than three percent, reweight resident and document. Report weight to licensed nurse. -8. The licensed nurse should notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. Significant weight change is defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. -9. The license nurse should immediately notify the medical provider regarding any significant weight change as defined in step 8. In an interview on 5/18/22 at 1:25 PM, UM A confirmed the Med Pass 2.0 recommended by RD L to prevent weight loss for Resident 3 on 4/27/22 was never implemented. UM A stated the facility's current process did not involve any communication of orders or recommendations from the RD to facility staff, just a note in the progress notes. UM A reported they had not had time to read all of the RD's progress notes due to working the floor a lot, as the facility was short of staff. UM A further confirmed Resident 3 did not get assistance with observed meals on 5/16/22 and 5/17/22 as there were not enough staff to assist them. In an interview on 5/18/22 at 4:00 PM, UM A confirmed any communication to Resident 3's physician regarding their weight loss would have been done via phone and recorded in the progress notes. B. An observation on 5/16/22 at 11:05 AM revealed Resident 3 was lying in bed flat on their back. Resident 3's water pitcher was empty and placed on a bedside table at the end of Resident 3's bed, out of their reach. An observation on 5/16/22 at 12:12 PM revealed Resident 3 was lying flat in bed on their back. Resident 3's water pitcher remained empty and out of their reach at the end of the bed. In an interview on 5/16/22 at 12:24 PM, UM (Unit Manager) A reported they were the only person working on the Cottonwood side (32 residents) of the facility. UM A stated they had come in at 3:20 AM due to their being only one person working overnight and then had been working alone since 6:00 AM. An observation on 5/17/22 at 9:01 AM revealed NA (Nurse Aide) V assisted Resident 3 back to their room after breakfast. NA V left Resident 3 in their wheelchair with a bedside table next to them. There was a water pitcher on the bedside table that was empty. NA V gave Resident 3 their call light and exited the room. In an interview at this time, Resident 3 requested water. In an interview on 5/17/22 at 8:52 AM, MA (Medication Aide) H reported staff are supposed to pass water pitchers at 3:00 AM and 3:00 PM.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to implement measures to prevent the potential spread of Covid-19 by failing to store disposable PPE (Personal Protective Equipment) to prevent potential cross contamination which had the potential to affect 2 of the 23 residents residing on the Cottonwood unit (Residents 14 and 15); failing to change gloves and perform hand hygiene during cares for Resident 11; failing to clean the STS (Sit to Stand) lift between residents to prevent potential cross contamination which had the potential to affect 10 of 37 residents residing on the Cottonwood and Ash Grove units (Residents 16, 9, 17, 18, 11, 20, 12, 21, 22, and 8); failing to distribute clean clothing to prevent potential cross contamination for 1 of 3 residents observed (Resident 13); failing to clean the whirlpool bathtub to prevent potential cross contamination for 6 of 6 residents who used the whirlpool bathtub on the Cottonwood unit (Residents 19, 11, 20, 13, 21, and 23); failing to cover drinks during the distribution of meal trays which affected all 22 of the residents on the Cottonwood unit who received a meal tray; and the facility failed to ensure that staff used N95 masks (a filtering facemask worn to protect healthcare professionals from inhaling infectious particles and preventing the spread of respiratory infection between healthcare professionals and patients) to prevent the potential for cross contamination of Covid-19 for 3 residents (Residents 1, 5, and 6) in the facility gray zone (a dedicated unit in the facility used to quarantine newly admitted residents who are at higher risk of getting exposed to COVID-19 but have no known exposure to COVID-19). The facility identified a census of 43 at the time of survey. Findings are: A. Observation on 6/17/2020 at 10:03 AM revealed 2 blue plastic gowns were hanging outside the door of Residents 14 and 15 (who resided in the room together) and 1 blue gown was hanging over the hand rail by their room that was touching the floor. The blue gowns hanging on the wall were touching each other. Observation on 6/17/2020 at 10:55 AM revealed the gowns were still hanging touching each other by the door and the gown was hanging over the hand rail touching the floor by the room occupied by Residents 14 and 15. Observation on 6/17/2020 at 11:31 AM revealed LPN-F (Licensed Practical Nurse) took one of the gowns off the wall hanging outside the door of the room occupied by Residents 14 and 15. It was a blue thin plastic gown that was hanging on the wall touching another gown hanging on the wall next to it. LPN-F put it on over their head and had to adjust the face shield they were wearing to get the gown on over it. LPN-F entered the room and did a BS (Blood Sugar) check for Resident 14. LPN-F then left the room and stopped outside the room door. LPN-F removed the gown from over their head and hung it back up on the wall, touching the gown hanging next to it. Interview with LPN-F at this time revealed they had to wear a gown and gloves in addition to a face shield and surgical mask when they went into the room being occupied by Resident 14 and 15 because Resident 15 went out of the facility to [MEDICAL TREATMENT] 3 times a week so the staff always had to gown up when they entered that room. Observation on 6/17/2020 at 12:30 PM revealed the blue gowns were still hanging by the door touching each other and over the hand rail touching the floor by the room occupied by Residents 14 and 15. B. Observation on 6/17/2020 at 10:23 AM revealed NA-H (Nursing Assistant) using the STS lift to transfer Resident 11. NA-H took a STS lift from the hall and wheeled it into Resident 11's room. NA-H donned gloves. NA-H touched Resident 11's control on Resident 11's power wheelchair and the STS lift. NA-H tried to put shoes on Resident 11's feet by handling the bottom and sides of the shoes. They did not fit over the thick socks Resident 11 was wearing so NA-H took them off as they were tight. NA-H felt the bottom of Resident 11's foot which had a sock on it and said Resident 11 has the grippers on their socks. NA-H helped Resident 11 sit up by touching their shoulders and arms then NA-H grabbed the lift. NA-H then put the sling around Resident 11's mid torso. NA-H still had the same gloves on. NA-H was touching the sling, the resident, and the lift with the same gloves NA-H touched Resident 11's shoes and the bottom of their socks with. Resident 11 then grabbed the hand rails on the lift. NA-H then adjusted NA-H's face mask with the same gloved hands. NA-H then touched Resident 11's hand when NA-H was helping Resident 11 get into the STS. NA-H touched the controls to stand Resident 11 and positioned Resident 11 in front of their power wheelchair. Resident 11 let go of the STS lift after they were seated in their wheelchair and NA-H removed the sling with the same gloved hands. NA-H then touched Resident 11 on the shoulder to help Resident 11 slide back into the wheelchair. NA-H then removed the gloves and got Resident 11 a blanket. NA-H did not perform hand hygiene after removing their gloves. NA-H then tucked the blanket around Resident 11's waist and legs. NA-H touched the STS lift with bare hands to move it so NA-H could get into the bathroom as the lift was in front of the bathroom door. NA-H then went into the bathroom and washed hands. NA-H touched the door knobs on the room door and bathroom door and put the lift back out into the hall. NA-H did not clean the STS lift. NA-H put the STS lift in the hall and left it after NA-H and Resident 11 touched it. NA-H did not have Resident 11 do any hand hygiene. Resident 11 then used the control on the power wheelchair to drive down the hall. NA-H reported they were headed to the bath house for Resident 11's whirlpool bath. Review of the EZ Way Floor Lift & Stand Cleaning Guide revised 8/14/18 revealed the following: To keep your EZ Way floor lifts and stands clean and in good condition, recommend that you use a standard germicidal spray, Sani-Wipe, or similar product and that you follow these guidelines: Do not spray product directly on the machine. Spray the cleaner onto a cloth or paper towel then wipe the unit to clean it. The germicidal spray, Sani-Wipe, or similar product and be used on the control panel and front panel graphics. If not using a wipe, make sure to spray the cleaner onto a cloth or paper towel then wipe the unit to clean it. Review of the undated facility Safe Resident Handling Equipment Competency Validation Checklist revealed the following: Clean Sit-to Stand after use. Interview on 6/17/2020 at 10:35 AM with NA-K revealed they used the lifts for more than 1 resident. The unit had two STS lifts and they used whichever one was available for the residents. Observation on 6/17/2020 at 11:14 AM the STS that NA-H had not cleaned was still sitting in the hall on Cottonwood east. Observation on 6/17/2020 at 11:16 AM revealed Resident 11 was going down the hall with NA-H. Resident 11 was touching the control on their power wheelchair and driving down the hall. Observation on 6/17/2020 at 12:30 PM revealed the STS lift was in the hall on the Cottonwood unit. Record review of the list of residents who used the STS lift on Cottonwood received from the facility Administrator on 6/18/2020 revealed these residents used the STS on the Cottonwood unit: Residents 16, 9, 17, 18, 11, 20, 12, 21, and 22. Review of the facility policy Hand Hygiene and Handwashing date reviewed/revised 4/14/2020 revealed the following: The goal is to prevent the spread of infection between residents. Handwashing and changing gloves occurs after care is delivered to prevent the spread of organisms to other residents. During Patient Care: Wash hands with plain soap and water or with anti-microbial soap and water: if hands are visibly soiled, if hands are visibly contaminated with blood or body fluids. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning hands: before having direct contact with residents, patients and children; after having direct contact with another person's skin; after having contact with body fluids, wounds or broken skin; after touching equipment or furniture near the resident/patient; after removing gloves. Review of the facility policy Putting On and Taking Off Personal Protective Equipment (PPE) revised 2/18 revealed the following: Gloves should be worn any time there is reasonably anticipated occupational exposure. Disposable gloves should be replaced as soon as practical when contaminated or as soon as feasible. When performing care services, remove gloves after contact with resident, patient and children and/or the surrounding environment using proper technique to prevent hand contamination. Change gloves during resident, patient and child care if the hands will move from a contaminated body site to a clean body site. Always wash hands between gloving. C. Observation on 6/17/2020 at 10:55 AM revealed HA-L (Housekeeping Assistant) was in Resident 12's room touching the drawers to put clothes away. HA-L came back out of Resident 12's room and retrieved a shirt from the clothing cart in the hall and took it into Resident 12's room and hung it up in the closet. HA-L exited Resident 12's room and did not do any hand hygiene. HA-L then removed clothing from the cart and entered Resident 13's room doorway then brought the clothes back out and hung them back on the cart as Resident 13 was trying to get up unassisted. After HA-L got assistance for Resident 13, HA-L went back out to the cart and retrieved the clothes hanging on the cart and took them into Resident 13's room. As HA-L was waiting to get to the closet, HA-L draped the clothing over their arm and held the clothing up against their smock/top. HA-L also touched Resident 13's walker as Resident 13 was being assisted by another staff member. HA-L then hung the clothes in Resident 13's closet and gave Resident 13 the call light. HA-L then took clothing out of a bin that was in Resident 13's room and opened the drawers before placing the clothing into the drawers. Review of the facility policy Laundering and Drying Clothes and Linens date reviewed/revised 1/1/2018 revealed the following: Package, transport and store clean clothes and linens to ensure their cleanliness and to reasonably protect them from dust and soil. D. Observation on 6/17/2020 at 11:20 AM revealed NA-H cleaned the Penner Spa whirlpool bathtub in the bath house on the Cottonwood Cottage. Interview with NA-H at this time revealed more than 1 resident used the whirlpool. NA-H revealed they gave a couple of whirlpool baths a day. NA-H donned gloves then NA-H pushed the disinfect jets button and filled the reservoir in the bottom of the whirlpool. NA-H scrubbed the inside of the tub and the whirlpool chair with a brush at 11:21 AM. NA-H got all surfaces on the inside of the tub and the seat and back portion of the whirlpool lift seat wet which was completed at 11:22 AM then NA-H drained the whirlpool. NA-H rinsed the whirlpool and shower chair with the sprayer attachment on the whirlpool at 11:23 AM. NA-H was done rinsing the inside of the tub at 11:24 AM. NA-H rinsed the jets on the whirlpool for 3 seconds. NA-H did not run the air blower, clean the outside of the tub or the lift part of the chair and NA-H did not allow the disinfectant to sit on the tub and chair surfaces. NA-H removed gloves and did hand hygiene at 11:25 AM and reported they were done cleaning the whirlpool. NA-H then left the bath house. Review of the facility policy Bathing date reviewed/revised 11/1/2019 revealed the following: Procedure for Cleaning Tub and Shower Stall: 1. Wearing gloves, use cleaning brush and spray bottle of approved cleaner/disinfectant solution. 2. Spray walls of tub or shower stall with disinfectant and brush across surfaces. Allow disinfectant to remain on surfaces for at least 10 minutes or according to manufacturer's recommendations. 3. Rinse walls with hot water for faucet/shower head. 4. Remove gloves, dispose of equipment and perform hand hygiene. Review of the undated Penner Manual on System Cleaning revealed the following: System Cleaning (After Every Bath) Note. Penner Cleaner/Disinfectant is a special non-abrasive cleaning and disinfecting solution that will not harm the tub's fiberglass surface. Penner Cleaner/Disinfectant is the only cleaning solution designed and recommended for use with your Cascade Contour Tub. 1. With the Swivel Lift position inside the tub. 2. Close and lock the door. 3. Press the Tub Fill Button and turn the Temperature Control Knob all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness. 4. Remove any visible tissue, residue, or fluids from the tub by pressing the Shower Button and rinsing the inside tube surfaces with the shower sprayer. 5. Press the Fill Button again to turn off the water. Allow the tub to drain, and place the drain plug over the drain. 6. Press and hold the Disinfect Button located on the control panel. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 ½ gallons of disinfectant solution in the foot well of the tub. 7. Using the long-handled brush, available from your Penner distributor, thoroughly scrub all interior surfaces of the tub and Swivel Lift chair with the solution that remains in the foot well of the tub. Let disinfectant stay on surface for 10 minutes (or, as recommended by the instructions on the disinfectant concentrate container.) 8. Remove the plug from the drain. 9. Rinse the tub's interior surfaces thoroughly with the shower sprayer. 10. Rinse most of the soapy water away with the shower sprayer. 11. Press and hold the Rinse button located on the control panel until clear water runs from all the air jets. Then release the Rinse button. 12. Finish rinsing the interior surfaces of the tub with the shower sprayer. 13. Start the air blower by pushing the Aqua-Aire Button. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. 14. Stop the Aqua-Aire blower by again pushing the Aqua-Aire button. 15. Visibly check that the tub and reservoir was effectively cleaned during the disinfecting procedure. If not, repeat the procedure. 16. If there is a delay of one or more hours before the next bath, we recommend using a towel to wipe off all excess water. Review of the undated Instructions for Classic Whirlpool Disinfectant Cleaner revealed the following: For broad spectrum disinfection of gram negative and gram positive bacteria, including Pseudomonas aeruginosa and Staphylococcus aureus, add two ounces Classic Whirlpool Disinfectant Cleaner to one gallon of water. Remove heavy soil or gross filth from the surface to be disinfected, then apply properly diluted solution with a mop, cloth, sponge, or hand pump trigger sprayer so as to wet the surface thoroughly. Allow to remain wet for 10 minutes and then let air dry. If higher detergency is desired, increase dilution to 4 to 6 ounces per gallon of water. Prepare a fresh solution for each use or when solution becomes visibly dirty. To disinfect hard, non-porous, inanimate surfaces (such as fiberglass and stainless steel tubs and chair surfaces, chrome plated intakes and lefts, etc.), apply properly diluted Classic Whirlpool Disinfectant Cleaner so as to wet all surfaces thoroughly. For routine disinfection, proper dilution is 1:64 (2 ounces of product per gallon of water). Allow to remain wet for 10 minutes, then let air dry. For heavily soiled areas, a pre-cleaning step is required. Prepare a fresh solution of reach use as above. For cleaning bath and therapy equipment: after using the whirlpool unit, drain the water and refill with fresh water to just cover the intake valve. Add 2 ounces of Classic Whirlpool Disinfectant Cleaner for each gallon of water in the unit at this point. Briefly start the pump to circulate the solutions. Turn off pump. Wash down the unit sides, seat of the chairlift and any/all related equipment with a clean swab or sponge. After the unit has been thoroughly cleaned, drain solutions from the unit and rinse any/all clean surfaces with fresh water. Review of the facility Monthly Infection Control Reports revealed the following UTI (Urinary Tract Infection) rates: April 2020: 10 nosocomial (facility acquired) UTI (Urinary Tract Infection). May 2020: 6 Nosocomial UTI. June 2020: 5 Nosocomial UTI. Record review of the list of residents who used the whirlpool on Cottonwood received from the facility Administrator revealed the following residents used the whirlpool bath: Residents 19, 11, 20, 13, 21, and 23. Review of Resident 21's Order Summary Report for Active Orders as of 5/28/2020 revealed an order for [REDACTED]. Review of Resident 21's MAR for May and June 2020 revealed documentation [MEDICATION NAME] 100 mg by mouth every morning and at bedtime for UTI was administered to Resident 21. Review of Resident 21's Progress Notes from April 1st to June 18, 2020 revealed documentation of a UTI on 5/27/2020: Received order from PCP (Primary Care Provider) for a urinalysis (UA) .5/28/2020 UA results called to PCP office. Awaiting orders from PCP. Orders received from PCP for [MEDICATION NAME] (antibiotic) 100 mg PO BID (by mouth twice daily) for 10 days. On 6/1/2020 it was documented Resident 21 was on antibiotic for UTI. Review of the POC (Point of Care) Response History Type of Bath for 5/19/2020 to 6/19/2020 revealed documentation Resident 21 received a whirlpool bath on June 1, 4, 8, 11, 15, and 18. Review of Resident 20's Progress Notes dated 6/1/2020 revealed the following documentation: Resident has a UTI (Urinary Tract Infection). Dr ordered [MEDICATION NAME] (antibiotic) twice daily until C&S (Culture & Sensitivity) is back from lab. Review of Resident 20's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/20/2020 revealed Resident 20 was dependent upon staff for bathing. Review of Resident 20's MAR (Medication Administration Record) for June 2020 revealed documentation [MEDICATION NAME] (antibiotic) Capsule 100 mg by mouth two times a day for UTI was administered to Resident 20 from 6/1/2020 to 6/4/2020 and [MEDICATION NAME] (antibiotic) 1 tablet by mouth two times a day for UTI was administered to Resident 20 from 6/4/2020 to 6/14/2020. Review of Resident 20's Order Summary Report for June 1, 2020 revealed an order for [REDACTED]. Review of the POC (Point of Care) Response History Type of Bath for 5/19/2020 to 6/19/2020 revealed documentation Resident 20 received a whirlpool bath on May 21, 25; June 1, 4, 8, 11, 15 and 18. Review of Resident 21's quarterly MDS dated [DATE] revealed Resident 21 was dependent upon staff for bathing and had a UTI in the last 30 days. Review of the POC (Point of Care) Response History Type of Bath for 5/19/2020 to 6/19/2020 revealed documentation Resident 13 received a whirlpool bath on June 18. Review of the POC (Point of Care) Response History Type of Bath for 5/19/2020 to 6/19/2020 revealed documentation Resident 19 received a whirlpool bath on May 22, 26, 29; June 2, 5, 9, 12, 16 and 19. Review of the POC (Point of Care) Response History Type of Bath for 5/19/2020 to 6/19/2020 revealed documentation Resident 11 received a whirlpool bath on May 22, 25, 27, 29; June 1, 3, 5, 8, 10, 12, 15, 17 and 19. E. Observation on 12:03 PM revealed NA-I, NA-J, and NA-K were lined up at the meal tray line at the kitchen area on the Cottonwood unit. NA-K was wearing a surgical mask and their face shield was flipped up and not covering their eyes or surgical mask. NA-K was not wearing any other eye protection. NA-K was observed pouring the drinks on the trays. At 12:08 PM all of the drinks were poured onto 22 trays. The drinks were not covered. At 12:11 PM the cook started plating the food then put the plates of food onto the trays. NA-I, NA-J, and NA-K covered the plates of food and took them down the hall to the residents. All of the trays had drinks on them and none of the drinks were covered. By 12:30 PM all 22 trays had gone out to the resident rooms without the drinks covered. Review of the facility policy Room-Tray Service-Food and Nutrition date reviewed/revised 5/18/2020 revealed the following: Deliver room/tray service in a sanitary manner (covered during transport, plated at the proper serving temperature by employees who have washed their hands, etc.) Interview with the facility Administrator on 6/18/2020 at 9:43 AM confirmed the whirlpool was used for more than 1 resident and the facility staff were expected to clean the whirlpool in between use of residents. The Administrator confirmed the lifts, including the STS lifts, were used for more than 1 resident and the staff were expected to clean them between residents. The Administrator revealed it was their expectation the facility staff changed gloves when they were contaminated and performed hand hygiene with both soap and water or hand sanitizer when hands were contaminated. The Administrator revealed the blue plastic gowns were disposable; however, based on need versus supply, the facility was utilizing conservation with gowns following the guidance. The Administrator revealed the room that had the PPE by the doors belonged to residents who had been outside of the facility for a medically necessary appointment within the last 14 days and as an extra precautionary measure, they were utilizing gowns for high contact cares. The Administrator revealed the expectation for staff was to deliver the meals covered to the residents' rooms. At 11:21 AM the Administrator revealed the facility staff were expected to follow the manufacturer's instruction for the contact or wet set time on the disinfectant for the whirlpool. The Administrator revealed facility staff were not allowed to hang the blue gowns touching each other or hanging over the hallway hand rails touching the floor. The Administrator revealed the facility staff were not allowed to hold clean resident clothing up against their smocks/scrub tops. F. Observation on 6/17/20 at 11:22 AM on the Ash Grove household revealed that Resident 8 had the resident's legs over the side of the bed. NA-D asked Resident 8 if they needed to use the bathroom. NA-C performed hand hygiene with alcohol based hand sanitizer (ABHR) and put on disposable gloves. NA-D performed hand hygiene with ABHR and put on disposable gloves. NA-D brought the sit to stand lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own from a seated position) from the hallway into the resident's room. NA-C and NA-D placed the sit to stand lift sling (a fabric device with straps that is placed around the back of a resident when a sit to stand lift is used to transfer a resident with difficulty or inability to stand up on their own from a seated position) around Resident 8 and connected the sling to the sit to stand lift. NA-C connected the leg strap around the resident's shins. NA-C instructed Resident 8 to hold onto the hand grips on the lift and to look up. NA-C operated the sit to stand lift and Resident 8 was transferred from a seated position on the bed to a standing position on the lift. NA-C and NA-D transferred Resident 8 from the bed into the bathroom with the sit to stand lift and lowered Resident 8 onto the toilet. NA-C and NA-D exited the bathroom and closed the bathroom door approximately half way. Resident 8 notified NA-C and NA-D that the resident was finished on the toilet. NA-C and NA-D reentered the resident's bathroom. NA-C and NA-D each performed hand hygiene with ABHR and each put on disposable gloves. NA-D assisted the resident with wiping the private areas of the resident. A new brief was placed on the resident. NA-D removed the disposable gloves and performed hand hygiene using soap and water. NA- C removed the disposable gloves and performed hand hygiene with soap and water. NA-C and NA-D transferred Resident 8 from the bathroom to the bed with the sit to stand lift. The resident was lowered to a sitting position on the edge of the bed and the lift sling was removed. Resident was assisted from a sitting position on the edge of the bed to lying on the bed by NA-C and NA-D. NA-C performed hand hygiene with ABHR as NA-C exited the resident's room. NA-D removed the sit to stand lift from the room of Resident 8 and parked the lift along the wall between the rooms of Resident 8 and the empty room across the hall from Resident 8. NA-D did not disinfect the sit to stand lift. NA-D walked to the kitchen area and performed hand hygiene with ABHR and placed cups on resident meal trays. Record review of the facility policy titled SAFE RESIDENT HANDLING EQUIPMENT COMPETENCY VALIDATION CHECKLIST dated 4/20 revealed section D: Transfers Surface to Surface with Stand Aid Competency Validation Checklist step 15. Clean stand aid after use. Interview on 6/18/20 at 3:15 PM with the facility administrator (FA) confirmed that the expectation for cleaning the lifts is that staff perform cleaning of the lift between resident use. G. Record review of the Nebraska Infection Control Assessment and Promotion Program (ICAP) document titled Cohorting (an imposed grouping of residents within a similar risk status) Plan For Long Term Care Facilities (LTCF) dated 4/17/20 revealed that facilities should plan to identify red, yellow and green zones where the residents can be cohorted based on their symptoms and exposure risks to COVID-19. Facilities are also recommended to establish a transitional zone (gray zone) for asymptomatic patients who are being transferred from other healthcare facility. Establishing Transitional (Gray) Zones: -All nursing homes should consider establishing a transitional zone for new admissions, returning residents from the hospital or those who are travelling in and out of the nursing home (such as the residents who are on [MEDICAL TREATMENT]). Transitional zones/units are established to quarantine those residents who are at somewhat higher risk of getting exposed to COVID-19 but have no known exposure to COVID-19. -Facilities should also consider dedicating separate staff to take care of residents in transitional (gray) zone/unit. -Facilities should implement COVID-level precautions for the residents admitted to the transition unit. If PPE supply is inadequate, nursing homes can consider limiting COVID-level precautions to only high-contact resident care-activities or aerosol generating procedures within the transition zone. -These units should be established even when no COVID-case is identified at the facility and may consist dedicating a geographically distinct area/unit/rooms to returning residents. -The residents are usually kept in this zone for 14 days and if remains asymptomatic at the end of 14 day will be moved to the Green zone. Interview on 6/17/20 at 8:57 AM in the west parking lot of the facility with the Facility Administrator revealed that the Cedar Creek cottage is a gray zone for new residents to the facility. An Email received on 6/17/20 at 6:22 PM from the Facility Administrator (FA) confirmed that the facility is working with the Central District Health Department, ICAP, and the Department of Health and Human Services to perform covid testing for all staff and residents. The FA confirmed that the facility began to isolate new admissions to the facility on [DATE]. Record review of the Centers for Disease Control (CDC) guidance titled Preparing for COVID-19 in Nursing Homes updated 6/19/20 revealed the section Core Practices: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. oDepending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Health Care Professionals (HCP) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Interview on 6/17/20 at 9:38 AM Licensed Practical Nurse-A (LPN-A) at the treatment cart outside of the nurse's station in the Cedar Creek cottage revealed that LPN-A was wearing a surgical mask (not an N95 mask) and face shield. LPN-A revealed that the residents in the Cedar Creek cottage are new admissions to the facility and that the residents are isolated for 14 days to monitor them for Covid-19. Interview 6/17/20 at 9:38 AM with Nursing Assistant (NA-B) outside of the nurse's station in the Cedar Creek cottage revealed that NA-B was wearing a surgical mask (not an N95 mask) and face shield. NA-B revealed that NA-B cares for the residents in this cottage. Observation on 6/17/20 at 9:30 AM in the Cedar Creek cottage (the facility gray zone quarantine unit) revealed that the facility Social Services Director (SSD) was wearing a surgical mask (not an N95 mask) and a face shield. The SSD put on a gown and no gloves while outside of the room of Resident 1. SSD entered the room of Resident 1. The SSD sat on a chair in the resident's room and talked to the resident seated in the recliner. The facility Therapy Director (TD) was observed in Resident 1's room wearing a surgical mask (not an N95 mask), face shield, gown, and gloves. TD assisted Resident 1 to ambulate from the recliner to the room door and back to the recliner with a walker. Observation on 6/17/20 at 11:05 AM in the Cedar Creek cottage revealed that Licensed Practical Nurse-A (LPN-A) wore a surgical mask (not an N95 mask) and face shield and put on a gown and gloves while outside of the room of Resident 5. LPN-A entered Resident 5's room with a glucometer (a medical device used to measure and display the amount of sugar in the blood for residents with diabetes) and supplies used for obtaining the resident blood glucose (sugar) level. LPN-A pricked a finger on the resident's right hand and obtained a blood sample for the glucometer. LPN-A told the resident that the blood sugar level was high at 227 today. Resident 5 stated that the resident had eaten some cookies. LPN-A carried the glucometer to the treatment cart in the hall and sat the glucometer on the top of the cart and removed the disposable gloves. LPN-A performed hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) using ABHR. LPN-A removed the gown and hung the gown on the handrail in the hallway outside of the resident's room. LPN-A performed ABHR and put on disposable gloves. LPN-A wiped all surfaces of the glucometer with a Sani Cloth (disinfectant) wipe. LPN-A placed a new Sani Cloth wipe on the top of the treatment cart and sat the glucometer on the Sani Cloth wipe on the cart. Observation on 6/17/20 at 11:12 AM in the Cedar Creek cotta (TRUNCATED)

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record reviews and interviews, the facility failed to ensure 2 out of 3 residents (Resident 1 and Resident 7) received weekly baths to promote cleanliness and well-being. The facility census was 61. Findings are: [NAME] Review of the Admission Record dated 8-22-19 revealed a date of admission of 12-18-18 and [DIAGNOSES REDACTED]. Interview on 8-22-19 at 9:15 AM with Resident 1 in the resident's room revealed the resident had a bad sore on the the heel of the left foot and on the 5th little toe. The resident had been to the Wound Clinic and the facility nurses' performed treatments to the wounds. The 5th toe became infected and then that thing happened with the bath. The resident went on to explain the facility had missed providing the resident with baths and then when at the Doctor's office, the Physician found maggots inside the heel wound. The resident revealed the Physician explained to the resident during the time frame when the resident did not receive a bath would have been enough time for a fly to have laved eggs on the wound and the eggs hatched into the maggots. The resident revealed the resident had been very satisfied with the care the resident received at the facility prior but when the resident discovered maggots were found in the wound, the resident was very angry and distraught. Review of the Clinic Referral form dated 8-6-19 revealed maggots in left heel wound today. Review of the bathing documentation from P[NAME] (Point of Care: the computer program where the Nurse Aides document) performed by the Bath Aides for the last 3 months of June, July, and (MONTH) 2019, provided by the Administrator, revealed two time frames when Resident 1 did not receive a weekly bath. During (MONTH) 13 to (MONTH) 21 a period of 9 days revealed absence of documentation of Resident 1 receiving any type of bath or shower. During (MONTH) 27 to (MONTH) 8, a period of 13 day (nearly two weeks) revealed absence of documentation of Resident 1 receiving any type of bath or shower. Review of current bath schedule dated 6-9-19 revealed Resident 1 was to receive a bath/shower on Monday's and Friday's every week. Interview on 8-26-19 at 9:40 AM with NA-C (Nurse Aide) confirmed Resident 1 had never refused to take a bath or shower for NA-C whenever offered and NA-C had never heard any of the other staff talk about Resident 1 refusing baths before. Interview on 8-26-19 at 9:44 AM with LPN-B (Licensed Practical Nurse) revealed LPN-B was not aware of Resident 1 ever refusing to take a bath or shower before. LPN-B revealed LPN-B doubted the resident would refused to bathe because the resident always seemed eager to bathe. LPN-B also revealed the resident did not refuse the nurse to perform the dressing changes to the left foot wounds either. LPN-B revealed the resident would ask at times if the dressing change could be done the next day with the bath instead of today because the dressing changes were to be done either every other day or sometimes every 3 day, depended on the wound treatment at the time. LPN-B revealed the nurses would accommodate and take the dressing off prior to the shower so that the wound would be cleansed in the shower. Interview on 8-26-19 at 11:00 AM with the DON (Director of Nursing) confirmed the documentation from the P[NAME] bathing documentation revealed Resident 1 did not have any type of bath/shower for 9 days from (MONTH) 13 to 21 and for 13 days from (MONTH) 27 to (MONTH) 8, 2019. The DON also confirmed that on (MONTH) 6, 2019 the Physician found maggots in Resident 1 left heel wound which was on the 11 day of the resident not having had a bath/shower. The DON revealed the facility did an investigation and was unable to find an answer as to how the resident was found with the maggots in the wound. The DON revealed the DON could not find any other documentation to refute the resident not having had a bath during the times frames. B. Review of bathing documentation completed by the Bath Aides for the last 3 months for Resident 7. The months of June, July, and August, revealed no baths documented from (MONTH) 1, 2019 until a bath was given on (MONTH) 17, 2019. This was 16 days with no bath given. The next bath documented was (MONTH) 1, 2019 and the next bath documented was (MONTH) 19, 2019. This was 17 days with no bath given. Review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) dated 7/10/19 revealed that resident was able to make self- understood and was able to understand others. For Section G (Functional Status) revealed Resident 7 was totally dependence with one person physical assist for bathing. An interview on 8/26/19 at 11:35 AM with LPN-A (Licensed Practical Nurse) revealed that when a resident refuses a bath there was a documentation made in the progress notes. Review of the bath schedule for Resident 7 for Cedar Creek revealed Resident 7 was to receive a bath on Mondays and Thursdays. Review of Progress Notes for Resident 7 dated 8/1/2019 through 8/26/2019 revealed no documentation of refusals of baths. Review of Physician order [REDACTED].