Every finding on record at Heritage of Bel Air

S483.60(i) Food safety requirements. The facility must - S483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to serve food in a manner to prevent potential food borne illnesses. The facility failed to ensure bare hands were not used to touch ready-to-eat food items. This practice had the potential to affect all residents in the facility who ate meals from the kitchen. The facility staff identified a census of 98. Findings are:A. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 81-2,272.10*(Replaces 2013 Food Code 3-301.11 (B), (C), (D), and (E) Preventing Contamination from Hands). -Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. This may be accomplished with the use of suitable utensils such as deli tissues, spatulas, tongs, single-use gloves, or dispensing equipment. B. During observation of the noon meal on 7/29/25 from 11:45 AM to 12:35 PM the following was observed:-Culinary Lead-X picked up a cheese sandwich with bare hands, cut the sandwich in half and placed the sandwich on a serving plate with bare hands,-Culinary Lead-X then picked up a meat/cheese sandwich with bare hands, cut the sandwich in half and placed the sandwich on a serving plate with bare hands. C. An interview with the Dietary Manager (DM-Z) confirmed that staff should not have used bare hands to touch ready-to-eat food items.

S483.60(d) Food and drink Each resident receives and the facility provides- S483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; S483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.Licensure Reference Number 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to serve room trays at a palatable temperature. The sample size was 9 and the facility census was 98. Findings are: Review of the Nebraska Food Code effective 3/8/12 revealed the following:-refrigerated potentially hazardous food (time/temperature control for safety food) would be at a temperature of 41 degrees or below when received, and-potentially hazardous food that was cooked to a temperature and for a time specified and received hot would be at a temperature of 135 degrees or above. During an interview on 7/28/25 at 10:20 AM Resident 66 reported that they sometimes eat meals in their room and the food is cold most of the time. The following observations were made on 7/29/25:-at 12:04 PM the hot box (a specialized container designed to keep prepared food warm, safe, and at a palatable temperature during transportation) containing the lunch trays was moved from the kitchen to the resident hallway and plugged into the wall,-at 12:23 PM Nursing Assistant (NA)-P started serving the lunch trays and the temperature of the hot box was 167 degrees, and-at 12:35 PM Chef-O obtained the following temperatures on a test tray: Pork Roast-130 degrees, Macaroni and Cheese-130 degrees, and Carrots-124 degrees. Interview on 7/29/25 at 12:35 PM with Chef-O revealed the food temperatures obtained were too cold to serve the residents. Interview on 7/29/25 at 1:30 PM interview with the Certified Dietary Manager (CDM) confirmed the facility did not have a policy related to what temperature food should be served at, but the facility uses the Nebraska Food Code as a guideline. Further interview confirmed that hot foods should have been served above 135 degrees, and cold foods should have been served at 41 degrees and below. The CDM confirmed the facility served 9 room trays out of the hot box. Interview on 7/30/25 at 3:40 PM with the Administrator confirmed the hot food should be served at 135 degrees or higher and the food on 7/29/25 was not at a palatable temperature.

S483.45(f) Medication Errors. The facility must ensure that its- S483.45(f)(1) Medication error rates are not 5 percent or greater;This REQUIREMENT is not met as evidenced by Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5 percent (%). Observations of 25 medications administered revealed 2 errors resulting in an error rate of 8%. The medication errors were related to 1 (Resident 6) of 5 residents sampled. The facility identified a census of 98.Findings are:A. Review of the facility policy Medication Errors with a revision date of 2/18 revealed the facility was to ensure residents were free of medication error rates of 5% or greater. A medication error was defined as the observed or identified preparation or administration medications which were not in accordance with the prescriber's order or the manufacturers specifications regarding the preparation and administration of the medication. B. Review of the Prefilled Insulin Pen Competency Form used by the facility to competency test staff regarding insulin administration revealed the following procedural steps:-attach the capped needle onto the end of the pen by turning clockwise until tight. -to prime the pen, make sure the arrow is in the center of the dose window. -pull the dose knob out in the direction of the arrow until a 0 is seen. -turn the knob clockwise until the number 2 is seen. -hold the pen with the needle pointing straight up, tapping the clear cartridge holder so any air bubbles collect near the top. Push the injection button completely using the thumb. Keep pressing and continue to hold the injection button firmly. A stream of insulin should come out the tip of the needle. -upon completion of priming, a diamond must be seen in the center of the dose window. -turn the dose knob clockwise until the arrow is seen in the center of the dose window and the notches on the pen and dose knob are in line. -pull the dose knob out in the direction of the arrow until a 0 is seen in the dose window. Review of Resident 6's Medication Administration Record dated 7/2025 revealed the resident had orders for the following:-Lantus (long lasting insulin used to manage blood sugar levels) inject 50 units twice a day.-Humalog (rapid acting insulin used to control blood sugar levels) 20 units with meals three times a day. During an observation on 7/29/25 at 8:15 AM, Licensed Practical Nurse (LPN)-G, removed 2 insulin pens from a drawer of the medication cart for Resident 6. LPN-G detached the pen cap from the Lantus insulin pen and attached a needle cap. LPN-G turned the dose knob to 40 and indicated only 40 units remained in the pen and an additional 10 units would need to be administered from a second pen with Lantus insulin. LPN-G failed to prime the pen prior to administering the 40 units of insulin to the resident's right abdomen. LPN-G then removed the pen cap from the Humalog insulin pen and connected a needle cap. LPN-G, without priming the insulin pen, turned the dose knob to 10 units and administered the Humalog insulin to the resident's left abdomen. An interview conducted with LPN-G on 7/29/25 at 8:25 AM confirmed the insulin pens were not primed prior to administration of the Lantus Insulin and the Humalog insulins.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18(B)Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE-items such as gowns and gloves that are worn to protect care givers during the provision of care and to protect other residents from being exposed to potential communicable disease) during the provision of care for Resident 35. The facility census was 98.Findings are: A. Review of the facility policy [NAME] Senior Living (VSL) Policy for Enhanced Barrier Precautions (EBP) dated 4/12/24 revealed the following:-EBP referred to an infection control intervention designed to reduce transmission of multidrug resistant organisms (germ that is resistant to medications) (MDRO) that required the use of gowns and glove use during high contact resident cares,-EBP would be initiated on residents with an infection with a targeted MDRO.-PPE for EBP is only necessary when performing high-contact care activities in resident room and spa-room. -high-contact resident care activities included bathing and changing linens.B. Review of Resident 35's Minimum Data Set (MDS - a mandatory comprehensive assessment tool used for care planning) dated 6/18/25 revealed the resident required partial assist with bathing cares. Review of Resident 35's care plan revealed the resident:-had a history of MDRO,-EBP were in place,-resident required extensive 1 assist with bathing cares.Observation on 7/28/25 at 8:35 AM revealed an EBP magnet on the door entering Resident 35's room and stated:-Providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities including changing linens and bathing cares.An observation on 7/28/25 at 2:10 PM revealed the resident was in the bathing room receiving a whirlpool bath. Nursing Assistant (NA-L) was giving Resident 35 a whirlpool bath with no PPE on. An observation on 7/30/25 at 7:30 AM revealed NA-N had removed sheets, pillowcase and bedding from the resident's bed with no gown or gloves on. NA-N picked up the linens and hugged them against her uniform when exiting the room with no PPE on. An interview with Registered Nurse (RN-K) on 7/29/25 at 7:40 AM confirmed that Resident 35 was on EBP due to an MDRO in urine and staff should wear PPE when bathing the resident. An interview with NA-L on 7/29/25 at 8:00 AM confirmed that PPE was not worn when giving the resident a whirlpool on 7/28/25 and gown and gloves should have been worn.An interview on 7/30/25 at 7:45 AM with the Director of Nursing (DON) confirmed that staff should have had PPE on when changing the residents bed linens.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i) Based on record review and interview; the facility failed to implement assessed fall interventions, and to revise and/or develop new interventions for the prevention of ongoing falls for Resident 12. The facility census was 101 and the sample size was 5. Findings are: A. Review of the facility Fall Prevention Management Standards with revision date of 1/2024 revealed all residents were to be reviewed during pre-admission/admission to determine their risk for falls. When a resident was identified at risk for falls, the resident's care plan was to be updated to reflect the potential safety hazard. Approaches/ interventions were to be implemented and maintained related to identified areas of risk. If a fall was to occur, staff were to investigate and collect factual evidence related to the fall. A Root Clause Analysis was to be completed to find out what happened and to determine what could be done to prevent it from happening again. B. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/27/24 revealed diagnoses of Parkinson's disease, arthritis, osteoporosis, seizure disorder, anxiety, depression, respiratory failure, and Schizophrenia. The MDS further indicated the resident had severe cognitive impairment; was dependent with toileting hygiene, personal hygiene, dressing, bed mobility and transfer; was frequently incontinent; and had 2 falls with injury (except major) since the previous assessment. Review of a Nursing Progress Note dated 3/10/24 at 11:45 AM revealed the resident was found on the floor of the resident's room. The resident reported the need to use the bathroom. Review of a Root Cause Analysis form dated 3/12/24 revealed the resident's fall occurred when the resident was attempting to utilize the bathroom before going out to the noon meal. New interventions included educating staff to toilet the resident before all meals and to initiate a bowel and bladder assessment to determine the resident's toileting routine. Review of a Nursing Progress Note dated 4/1/24 at 5:05 PM revealed the resident was lowered to the floor during a pivot transfer (resident bears at least some weight on one or both legs and spins to move their bottom from one surface to another) with one staff member. Review of a Root Cause Analysis Form dated 4/3/24 revealed the resident had been transferred with only 1 assist and staff failed to follow the resident's care plan which called for 2 staff to assist with transfers. A new intervention was initiated to use the sit-to-stand lift (a mechanical lift that allows for resident transfers from a seated position to a standing position. The lift is designed to support only the upper body and requires the resident to have some weight bearing capability). Review of the resident's undated care plan revealed the resident had a deterioration in ability to complete activities of daily living related to impaired decision-making skills, Parkinson's disease, and Schizophrenia. An intervention dated 5/9/24 revealed the staff were to use the full body lift (mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance from the resident) and 2 staff for assistance with all transfers. Review of a Nursing Progress Note dated 5/11/24 at 9:30 PM revealed staff had transferred the resident by themselves using the sit-to-stand lift and the resident began to slide out of the lift. The resident was placed in the wheelchair and staff then attempted to pivot transfer the resident onto the bed without further staff assistance. Resident 12 then slid off the edge of the bed and onto the floor. Review of a Root Cause Analysis Form dated 5/14/24 revealed an intervention for staff to use the full body lift (which was to have been initiated 5/9/24) with 2 assists for all transfers. Review of a Nursing Progress Note dated 6/18/24 at 8:35 PM revealed the resident was on the floor of the resident's room. Staff had attempted to transfer the resident by themselves using the sit-to-stand lift and the resident fell backwards out of the lift. The resident obtained a small hematoma to the back of the head. Review of a Root Cause Analysis Form dated 6/19/24 revealed the staff failed to follow the resident's care plan related to safe transfers. Staff were to receive re-education regarding how to safely transfer the resident. Interview with the Director of Nurses (DON) on 7/29/24 at 11:17 AM confirmed the following: -after the resident's fall on 3/10/24 at 11:45 AM, there was no evidence staff received re-education regarding the need to toilet the resident prior to meals. In addition, an Hourly Elimination Dairy was completed over 3 days, but no trends were identified regarding the resident's elimination schedule and no new interventions were developed, -when the resident fell on [DATE] at 5:05 PM, the resident had been transferred with only 1 staff. Resident 12's plan of care at the time indicated there were to be 2 staff for all transfers. A new intervention was developed for staff to use the sit-to-stand lift for all transfers, -an intervention to use the full body lift with 2 staff was initiated 5/9/24 to assure safe transfers for the resident, -5/11/24 at 9:30 PM the resident had a fall in the resident's room when the staff attempted to use the sit-to-stand lift to transfer the resident and then when this failed, tried to pivot transfer the resident without assistance. The DON verified at this time, all transfers for Resident 12 were to include 2 staff and the full body lift. Fall interventions were not revised and no new interventions were developed, and -6/18/24 at 8:35 PM the resident had another fall in their room related to staff failure to correctly transfer the resident.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to have physician documented, resident specific clinical rationale for not attempting gradual dose reductions for Resident 7's psychoactive (medications that affect brain activity associated with mental processes and behavior) medication. The sample size was 5 and the facility census was 101. Findings are: Review of the facility management standard Psychoactive Medications and Medication Regimen Review dated 6/2024 revealed the following: -Each psychoactive medication had an appropriate diagnosis to support the use of the medication. -Gradual Dose Reductions were required for all psychoactive medications. -The interdisciplinary Team acted as the resident advocate to ensure psychoactive medications were necessary, to ensure quality of life for each resident. -The facility utilized appropriate resources to assist in managing psychoactive medications that were prescribed for residents, including the attending physician, the medical director as needed, the consulting pharmacist, the facility team, behavioral services, regulations, and other published clinical resources. -Excessive Duration was described as medications administered beyond the length of time advised by the current standards of practice, clinical practice guidelines, clinical studies, or evidence-based review or without evidence of additional therapeutic benefit to the resident or clinical evidence that warranted continued use of the medication. -Gradual Dose Reduction was the stepwise tapering of a dose to determine if symptoms, conditions, or risks could be managed by a lower dose or if the dose could be discontinued. Guidance emphasized the importance of seeking an appropriate dose of each medication and minimizing the risk of adverse consequences and determining whether continued use is benefitting the resident. -For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer's recommendations for duration of use, the facility attempted to taper the medication quarterly unless clinically contraindicated including a clinical rationale for why attempting dose reduction would likely impair the resident's function or cause psychiatric instability, by exacerbating an underlying medical or psychiatric disorder. -After the first year of use of antidepressant medications a gradual dose reduction was attempted annually unless documented by a physician as clinically contraindicated. -For as long as a resident remained on a hypnotic/sedative medication used routinely beyond the manufacturer's recommendations for duration of use, the facility attempted to taper the medication quarterly unless clinically contraindicated (the physician documented why any attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating and underlying medical of psychiatric disorder). -If there was to be no change in medications, the attending physician documented the rationale in the resident's medical record. Review of Resident 7's Care Plan with a revision date of 12/22/23 revealed the resident took psychoactive medication, had anxiety, depression, and insomnia and gradual dose reduction guidelines were followed. The facility monitored for adverse effects of the medication including monitoring for drowsiness, dizziness, confusion, and falls. Review of Resident 7's Minimum Data Set (MDS- federally mandated comprehensive assessment used to develop resident care plans) dated 5/30/24 revealed the resident received substantial assistance with dressing, toileting hygiene, and dressing, had diagnoses of anxiety and depression, and took antidepressant and hypnotic medication daily over the previous seven days. In addition, the resident had 2 or more falls since the previous assessment. Review of the Note to Attending Physician/Prescriber dated 7/12/23 regarding Resident 7, generated by the pharmacy revealed the following: -The Center for Medicare and Medicaid Services (CMS) guidelines recommended a dose reduction attempt to psychotropic medications twice within the first year for newly admitted residents and then in modest increments over adequate periods of time to minimize withdrawal symptoms and monitor for symptom recurrence. -The resident was taking Sertraline 125mg daily for depression and a review for a dose reduction was appropriate. -The was no resident specific clinical rationale given for not attempting to reduce the medication dose. Review of the Note to Attending Physician/Prescriber dated 9/11/23 regarding Resident 7, generated by the pharmacy revealed the following: -The Center for Medicare and Medicaid Services (CMS) guidelines recommended a dose reduction attempt to psychotropic medications twice within the first year for newly admitted residents and then in modest increments over adequate periods of time to minimize withdrawal symptoms and monitor for symptom recurrence. -The resident was taking Sertraline 125mg daily for depression and a review for a dose reduction was appropriate at that time. -The provider did not decrease the dose and there was no resident specific clinical rationale given, for not attempting to reduce the medication dose. Review of the Note to Attending Physician/Prescriber dated 12/8/23 regarding Resident 7, generated by the pharmacy revealed the following: -The Center for Medicare and Medicaid Services (CMS) guidelines recommended a dose reduction attempt to psychotropic medications twice within the first year for newly admitted residents and then in modest increments over adequate periods of time to minimize withdrawal symptoms and monitor for symptom recurrence. -The resident was taking Ambien 5mg daily for insomnia and the medication needed to be evaluated for a gradual dose reduction to 2.5mg daily. -The physician agreed to attempt the reduction; however, the resident refused this medication change. -There was no evidence the facility provided the resident education regarding the reason for or benefits of a dose reduction or no resident specific documented rationale from the physician stating the rationale for continuing the medication at the same dose. Review of the Note to Attending Physician/Prescriber dated 6/7/24 regarding Resident 7, generated by the pharmacy revealed the following: -The Center for Medicare and Medicaid Services (CMS) guidelines recommended a dose reduction attempt to psychotropic medications twice within the first year for newly admitted residents and then in modest increments over adequate periods of time to minimize withdrawal symptoms and monitor for symptom recurrence. -The resident was taking Ambien 5mg daily for insomnia and the medication needed to be evaluated for a gradual dose reduction to 2.5mg daily. -The physician did not agree to the change the medication dose and did not document a resident specific rationale for not attempting a dose reduction. Review of the active Order Summary Report dated 7/29/24 revealed orders for the following psychoactive medication: -Ambien (hypnotic medication) 5 mg (milligrams) by mouth daily at bedtime for chronic insomnia. -Sertraline (antidepressant medication) 125 mg by mouth one time daily for depression. During an interview on 7/29/24 at 9:25 AM the Director of Nursing confirmed the provider did not document clinical rationale for not attempting dose reductions for Resident 7's Sertraline (antidepressant) and Ambien (hypnotic) medications. In addition, the facility did not provide education to the resident regarding the risks and benefits of attempting gradual dose reductions of psychoactive medication.

Licensure Reference Number 175 NAC 12-006.18 (B) Licensure Reference Number 175 NAC 12-006.18 (D) Based on observation, interview, and record review; the facility failed to implement Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multi-drug resistant organisms [MDRO's]) during wound care and perform hand hygiene at appropriate intervals during high contact care activities for Resident 30, and to correctly use Personal Protective Equipment (PPE) to prevent the potential spread of Covid-19 related to resident 37. The total sample size was 28. The facility census was 101. Findings are: A. Review of the facility policy Standard and Transmission Based Precautions (TBP), undated, revealed the following: -TBP would be implemented for residents known or suspected to be infected with an infectious agent requiring additional control measures, -hand hygiene would be performed after contact with blood, body fluids, contaminated items, and immediately after removal of gloves, -gowns would be worn during procedures and resident care activities when clothing could have made contact with blood/body fluids and secretions, and -masks and eye protection would be worn during procedures and resident care activities likely to generate splashes or sprays of blood, body fluids, and secretions. B. Review of the facility policy Enhanced Barrier Precautions, dated 4/12/2024 revealed the following: -all staff were expected to comply with all designated precautions, -EBP would be initiated on residents that had wounds, -gowns and gloves would be available near or outside the resident's room (face protection may also be needed if performing activity with the risk of splash or spray such as wound irrigation), and -high contact resident care activities included dressing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting and wound care. C. Review of Resident 30's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 5/16/24 revealed the following: -diagnoses of anemia, high blood pressure, and polyneuropathy (a condition that caused decreased ability to move and feel sensation because of nerve damage, -the resident was cognitively intact, and -the resident required substantial assistance with dressing and personal hygiene and was dependent with toileting and transfers. Review of Resident 30's Care Plan, last revised 7/15/24 revealed the resident had a chronic pressure wound to the right buttock and required EBP. Observation of Resident 30 on 7/25/24 at 10:05 AM revealed a magnet on the door frame of the resident room that indicated the resident needed EBP such as mask, gown, and gloves with high-risk care activities and an isolation caddy that contained gown, gloves, and goggles outside of the resident room. Observation of Resident 30 on 7/29/24 at 7:00 AM the isolation caddy with gown, gloves and goggles was outside of the resident room along with a magnet on the door frame that indicated the resident required EBP during high-risk care activities. Medication Aide (MA)-F entered the resident room wearing an N95 mask and no gown in place. The resident was in the bathroom hooked up to a sit to stand lift (a mobile lift that allows for resident transfers from a seated position to a standing position, it supports the upper body and requires the resident to have some weight bearing capability). MA-F performed hand hygiene and put on gloves. MA-F still without a gown, removed the old dressing from the residents wound. MA-F grabbed the wound wash, while still wearing the same pair of gloves, cleansed the wound, then applied the new dressing to the wound bed and covered the dressing with a foam backed dressing. MA-F, continued to wear the same pair of gloves, obtained the control to the sit to stand lift and lowered the resident onto the toilet. MA-F removed the gloves and performed hand hygiene and left the resident room. Interview on 7/29/24 at 7:10 AM with MA-F confirmed that MA-F did not wear a gown during the dressing change. Further interview confirmed MA-F did not change gloves during the dressing change. Interview on 7/29/24 at 7:10 AM with Licensed Practical Nurse (LPN)-A confirmed the resident was on EBP and a gown should have been worn during the dressing change and when assisting the resident with toileting. Interview on 7/29/24 at 7:55 AM with the Director of Nursing confirmed gowns were to be worn with high-contact care activities for resident's on EBP and gloves should have been changed after removing the old dressing. 42679 D. Review of the facility document Donning and Doffing Competency (Donning means to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure. Doffing means removing PPE in a way that avoids self-contamination.) dated 3/2021 revealed the following procedures: Donning- -perform hand hygiene, -apply an approved N95 respirator or higher. If the respirator has a nosepiece, it should be fitted to the nose with both hands, respirator should be extended under the chin so both nose and mouth are protected, -respirator straps would be placed on the crown of the head (top strap) and base of neck (bottom strap), -apply goggles or face shield, -apply the gown-tie all ties on the gown, -apply gloves, gloves should cover the cuff of the gown, Doffing- -remove gloves without causing additional contamination of hands, -remove gown by untying all ties, reach to shoulders and pull gown down and away from the body then dispose, -perform hand hygiene, -exit the room, -remove face shield or goggles by grabbing the strap and pulling upwards and away from the head, -perform hand hygiene, -remove and discard respirator (do not touch the front of the respirator or facemask), remove the bottom strap by touching only the strap and bringing it carefully over the head, grasp the top strap and bring it over the head then pull the respirator away from the face without touching the respirator, and -perform hand hygiene. Review of the undated CDC guidance sequence for donning personal protective equipment revealed the following: -gown-fully cover torso from neck to knees, arms to end of wrists, and wrap around the back, -mask or respirator- secure ties or elastic bands at middle of head and neck, fit snug to face and below chin and fit check respirator, -place face shield over face and eyes or goggles and adjust to fit, and -gloved to cover the wrist of the isolation gown. Review of the undated CDC guidance sequence for removing personal protective equipment revealed the following: -gloves-grasp outside of the glove with the opposite hand and peel off, hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist and peel off, discard in waste container, -to remove goggles or face shield handle by the head band or earpieces, place in designated receptacle, -unfasten gown ties, pull away from neck and shoulders, turn gown inside out, fold or roll into a bundle and discard, and -to remove the mask or respirator, grasp bottom, then top ties or elastics and remove then discard in waste container. E. An observation on 7/24/24 at 0850 AM revealed the following: -resident room [ROOM NUMBER] had signage that indicated the resident was on Transmission-Based Precautions under the Red Zone category and anyone that entered was required to wear PPE (isolation gown, gloves, eye protection and N95 mask); -housekeeper-K had on an isolation gown, gloves, and N95 respirator mask (the bottom strap of the mask was dangling and not secured and there was a surgical mask underneath the N95 mask); -housekeeper-K exited room [ROOM NUMBER] holding a trash bag and had not removed any of the potentially contaminated PPE, then walked across the hall, opened the door to a room and disposed of the trash; -housekeeper-K walked back to room [ROOM NUMBER], removed the isolation gown outside the room, opened the door to the room and disposed of the gown inside the resident's room; -housekeeper-K was wearing the same pair of contaminated gloves and face mask, walked down the hallway to a cleaning cart and removed the contaminated gloves and disposed of them in the cart's trash receptacle in the hallway; and -housekeeper-K sanitized hands, put on a clean pair of gloves and entered Resident 37's room [the resident was not under any transmission-based precautions and was not positive for Covid-19] while wearing the same N95 face mask with the surgical mask underneath that was worn in resident room [ROOM NUMBER]. The wearing of a surgical mask under the N95 mask prevented a proper seal and fit for the N95 mask. On 7/24/24 at 08:55 AM an interview with housekeeper-K confirmed [gender] had not removed the potentially contaminated isolation gown and gloves before exiting room [ROOM NUMBER], was wearing the same N95 mask that was worn in room [ROOM NUMBER], and then entered Resident 37's room. On 7/25/24 at 10:20 AM an interview with Licensed Practical Nurse (LPN)-A confirmed the following: -the resident in room [ROOM NUMBER] was positive for Covid-19 and on Red Zone transmission-based precautions and Resident 37 was not on transmission-based precautions during the time frame housekeeper-K exited and entered both resident's rooms; and -housekeeper-K should have removed the isolation gown and gloves and performed hand hygiene before exiting resident room [ROOM NUMBER] and should have put on a new N95 mask before entering Resident 37's room. In addition, LPN-A confirmed housekeeper-K had not worn the N95 face mask properly and should have secured both the top and bottom straps. An interview with the Director of Nurses (DON) on 7/25/24 at 3:30 PM confirmed staff should not wear a surgical mask under the N95 face mask related to failure of a proper seal for the N95 mask.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on interview and record review; the facility failed to implement interventions to protect Resident 153 from aspiration (breathing foreign material into the lungs) and/or choking as a puree diet was not provided in accordance with physician's orders. In addition, the facility failed to determine causal factors, to develop and/or revise interventions and failed to implement assessed fall prevention interventions for Residents 79 and 88. The sample size was 10 and the facility census was 101. Findings are: A. Review of Resident 153's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/22 revealed diagnoses of previous stroke, Alzheimer's disease, epilepsy, depression, high blood pressure and dysphagia (difficulty swallowing). The following was assessed regarding Resident 153: -cognition was moderately impaired; -no behaviors identified; -required supervision and set-up assistance with eating; -weight loss of 5 percent (%) or more in the last month or 10% or more in the last 6 months without a physician prescribed weight loss regimen; and -mechanically altered, therapeutic diet. Review of the resident's Nursing Progress Notes revealed the following: -4/9/22 at 3:58 PM the resident's teeth were hanging partially out of mouth and mouth noted to be full of food. The resident was unable to speak and pointed at mouth while moaning. A Speech Therapy consult was requested; -4/10/22 at 9:59 PM when the evening meal was delivered to the resident, the resident was chewing on peaches which had been served at the previous meal. After completion of the evening meal, the resident's mouth was full of food with drool running down from the side of the resident's mouth. Staff manually removed food from the resident's mouth; -5/23/22 at 6:31 PM staff were called to the resident's room by dietary as the resident was coughing. The resident spit out a small piece of bread with phlegm. A request was sent to Speech Therapy for another evaluation of the resident's diet; -6/7/22 at 2:35 PM the resident was brought to the Charge Nurse as the resident was choking. The resident had unchewed grapes and hamburger in the resident's mouth; -6/7/22 at 4:10 PM the resident continued to work with Speech Therapy once a week and remained on a regular diet with thin liquids; -6/7/22 at 6:00 PM the resident was in the dining room, head was hyperextended backwards, face was turning blue and was unable to speak. After several abdominal thrusts the resident was able to spit out unchewed hamburger meat and began coughing. Staff manually removed the rest of the unchewed hamburger from the resident's mouth; -6/9/22 at 1:00 PM the physician ordered a mechanical soft diet (foods are mashed, chopped, ground or pureed to assist with chewing and swallowing) and ground meats; -8/15/22 at 5:00 AM the resident had a bulge to the left cheek and staff removed 5 chunks of pineapple from the resident's mouth; -9/13/22 at 2:06 PM the resident continued to work with Speech Therapy twice a week, but therapy was to be reduced to once a week. Diet order remained for mechanical soft with thin liquids; -9/13/22 at 9:45 PM the resident was in room and observed choking on pocketed food. Stridor (high pitched respiratory sound caused by an obstruction in an upper airway) noted to bilateral lung fields. The resident was then able to cough and clear breathing; -9/13/22 at 10:41 PM the resident's physician was notified of the resident's aspiration and of coarse lung sounds. Staff were to monitor the resident; -9/14/22 at 11:22 AM new order received for a puree diet; -9/20/22 at 1:57 PM resident continued to work with Speech Therapy with a plan to reduce to 1 time per week. Therapy note indicated the resident was on a mechanical soft diet and not a puree diet as ordered on 9/13/22; -9/30/22 at 11:32 PM the resident had a large emesis in the resident's bed. Emesis consisted mostly of undigested food; -11/20/22 at 6:00 PM the resident was being fed by Nursing Assistant (NA)-II. After the resident was given 3 bites of puree meat, the resident started to cough, and carrots were visualized in the resident's mouth. The resident did not respond to verbal or tactile stimulation. A padded tongue blade was inserted between the resident's teeth by Registered Nurse (RN)-FF and the RN manually removed partially ground steamed carrots from the resident's mouth. Staff attempted to suction with only a few particles of carrots returning. The resident's oxygen saturation (amount of oxygen in the blood stream) level was 63% (normal oxygen saturation level is 95-100 %). The resident was started on 4 liters of oxygen, but oxygen saturation level remained at 58-60%; -11/20/22 at 6:20 PM the resident was transferred to the emergency room per ambulance; and -11/20/22 at 9:30 PM the resident was admitted to the hospital. The resident's family indicated the resident was not doing well and the family had been told the resident had choked on some carrots. Review of a History and Physical from the hospital dated 11/21/22 at 9:23 AM revealed the resident presented to the emergency room for a choking episode. The note indicated the resident had an order for a pureed diet however, it appeared the resident was fed solid food shortly before arriving at the hospital. The resident had multiple large carrot particles extracted from the left upper lobe of lungs. During an interview on 7/20/23 at 3:33 PM the Administrator and the Director of Nursing (DON) confirmed the following regarding Resident 153: -multiple incidents over the past few months of choking. The resident had been working with the Speech Therapist but continued to pocket food and had difficulty swallowing at times; -at high risk for choking/aspiration and had an order for a puree diet; -received total assist from staff with eating and drinking; -ate all meals in the resident's room and not in the dining room; and -11/20/22 during the evening meal, the resident began to cough, and the resident's oxygen saturation level dropped. The facility staff documented partially ground carrots were removed from the resident's mouth and the resident was unresponsive. The resident was sent to the hospital and a hospital report indicated particles of carrots were removed from the resident's lungs indicating the resident did not receive a puree diet as ordered by the physician. B. Review of the facility Fall Prevention/Management Standard policy with a revision date of 2/2019 revealed each resident was to receive adequate supervision and assistance to prevent accidents. The following guidelines were to be followed for fall management and prevention: -identify risk factors for falls based on review of the Fall Assessment results; -implement fall prevention interventions based on individual risk; -if a fall occurs, staff to complete an investigation; -factual evidence to be collected related to the fall event; and -use the Root Cause Analysis process to find out what happened, why it happened and to determine what can be done to prevent it from happening again. C. Review of Resident 88's MDS revealed the resident was admitted [DATE] with diagnoses of depression, heart disease, dementia, anemia, Alzheimer's disease, previous hip fracture and depression. The resident's cognition was severely impaired, the resident required extensive staff assistance with bed mobility, transfers, dressing and toilet use and the resident was frequently incontinent of urine. Review of the resident's current Care Plan with a date of 12/12/22 revealed the resident was at risk for falls related to a right hip fracture, acute respiratory failure and Alzheimer's dementia. The following interventions were indicated: -pressure alarm to bed and to chair. Staff to monitor function of alarm twice a day; -not to leave unattended in the bathroom; -anticipate and meet resident's needs; -call light within reach and encourage use; and -proper fitting, non-skid footwear. Review of an Incident Report dated 1/31/23 at 5:45 PM revealed the resident was found lying on the floor of the resident's room. The resident did not know what had happened and failed to use the call light as the resident was too impatient. Review of the root cause analysis revealed causal factors were not identified, no new interventions were developed and/or current interventions revised to prevent further falls for Resident 88. D. Review of Resident 79's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of skin cancer, chronic obstructive pulmonary disease, previous stroke, anxiety, insomnia and dementia. The resident's cognition was moderately impaired, the resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene and the resident was frequently incontinent of bowel and bladder. Review of the resident's current Care Plan dated 5/18/22 revealed the resident was at risk for falls related to impaired balance, psychoactive medication use, incontinence, anxiety, pain, depression and tremors. The following fall prevention interventions were identified: -gripper socks, slippers or shoes to be worn when up; -silent alarm on always; -non-slip pad to seat of wheelchair; -staff to remain with resident in the bathroom; -after meals if resident seems anxious follow back to room and assist with positioning in recliner; and -review information on past falls and attempt to determine cause of falls. Review of an Incident Report dated 1/4/23 at 12:45 PM revealed the staff had been assisting the resident to the bathroom, the resident's legs buckled, and the resident was lowered to the floor. Review of the Root Cause Analysis for the resident's fall revealed a new intervention for 2 staff to assist the resident with standing and for pivot transfers. Review of an Incident Report dated 1/27/23 at 9:56 AM revealed the Activity staff had attempted to transfer the resident to the wheelchair from the recliner. The resident started to sit too early and was lowered to the floor. Review of the Root Cause Analysis revealed staff failed to implement the intervention developed on 1/4/23 for 2 staff to be used for all transfers with the resident. Physical Therapy evaluated the resident for safe transfers and confirmed 2 staff were to be used for all transfers. No new interventions were identified regarding the residents fall. Review of an Incident Report dated 3/7/23 at 9:10 PM revealed staff attempted to stand the resident from the recliner, the resident's legs became weak, and the resident was lowered to the floor. Review of the Root Cause Analysis revealed staff had again attempted to transfer the resident with only 1 person instead of 2 as indicated after the residents falls on 1/4/23 at 12:45 PM and on 1/27/23 at 9:56 AM. Further review of the report revealed no additional interventions were developed and/or current interventions revised for fall prevention. Review of an Incident Report dated 5/11/23 at 4:05 PM revealed staff were in the middle of transferring the resident, the resident lost strength and was lowered to the floor. Review of the Root Cause Analysis revealed staff had tried to transfer the resident alone instead of using the 2 assists as indicated after the residents falls on 1/4/23 at 12:45 PM, on 1/27/23 at 9:56 AM and on 3/7/23 at 9:10 PM. In addition, no new interventions were developed and/or current interventions revised for fall prevention. E. During an interview with the DON on 7/25/23 at 6:48 AM the following was confirmed regarding falls for Residents 88 and 79: -2 staff were to be used for all transfers for Resident 79; -Residents 88 and 79 had repeated falls and remained at risk for continued falls; -nursing staff were to complete a Root Cause Analysis after each fall to determine causal factors for falls; and -causal factors were to be used to develop new interventions or to revise current interventions to prevent further falls.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, interview and record review, the facility failed to implement infection control measures to prevent the potential spread of Covid-19 for 1 (Resident 62) of 6 sampled residents. The facility census was 101. Findings are: A. Review of the facility policy Covid-19 Guidelines dated 5/11/23 revealed the purpose of the policy was to provide clarification regarding Covid-19, to minimize exposure and promptly identify residents, team members and visitors with clinical features and risk for Covid-19. Transmission-Based Precautions should be implemented in the event of ongoing Covid-19 transmission within the facility that is not controlled with initial interventions. Residents that are identified at high risk are placed in a yellow zone related to transmission-based precautions and staff should wear an N95 mask and eye protection (face shield or goggles) when providing resident cares. B. An observation of 3 staff members entering room [ROOM NUMBER] (Resident 62) on 7/25/23 at 6:30 AM revealed the following: -A yellow colored sign was posted outside the door of room [ROOM NUMBER] that indicated the resident was on transmission-based precautions in a yellow zone and staff were required to wear an N95 mask and eye protection (face shield or goggles) before entering the room. -Nurse Aide (NA)-S, NA-X, and Licensed Practical Nurse (LPN)-L entered Resident 62's room and did not have an N95 mask or eye protection (face shield or goggles) upon entering. C. An interview with Registered Nurse (RN)-P on 7/25/23 at 07:30 AM, confirmed there was a yellow zone sign posted outside of Resident 62's room (113) and staff should wear an N95 mask and eye protection before entering the room. D. An interview with the Director of Nurses (DON) on 7/25/23 at 2:10 PM, confirmed the resident in room [ROOM NUMBER] (Resident 62) had a high-risk exposure to another resident who had tested positive for Covid-19 and was on transmission-based precautions in a yellow zone related to this. In addition, the DON confirmed staff were expected to wear an N95 mask and eye protection before entering a resident room identified as a yellow zone area.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview, the facility failed to administer insulin medication as ordered for 1 (Resident 21) of 39 sampled residents. The facility census was 101. Findings are: A. Review of Resident 21's undated care plan revealed the resident had a diagnosis of Diabetes and was at risk for abnormal blood sugar levels related to this. The care plan goal was to maintain blood sugars within normal range using the following interventions: 1) follow diet as ordered 2) discuss meal times, portion sizes, restrictions, snacks, and compliance with nutritional regimen as needed and 3) give medications as ordered. Review of Resident 21's Medication Administration Records dated April, May and June of 2023 revealed the following: -physician's order dated 11/29/2022 for Insulin (Novolog) injection solution, give 3 units subcutaneously (under the skin) two times a day for blood sugar levels over 200; -on 4/10/23 at 9:00 AM, blood sugar = 158 and resident was administered 3 units of Novolog insulin to the abdomen, left upper quadrant; -4/20/23 at 7:00 PM, blood sugar = 163 and resident was administered 3 units of Novolog insulin to the right rear upper arm; -4/25/23 at 7:00 PM, blood sugar = 107 and resident was administered 3 units of Novolog insulin to the abdomen, right upper quadrant; -4/27/23 at 7:00 PM, blood sugar = 181 and resident was administered 3 units of Novolog insulin to the left upper arm; -5/2/23 at 9:00 AM, blood sugar = 169 and resident was administered 3 units of Novolog insulin to the right arm; -5/5/23 at 7:00 PM, blood sugar = 196 and resident was administered 3 units of Novolog insulin to the right rear upper arm; -5/6/23 at 9:00 AM, blood sugar = 158 and resident was administered 3 unit of Novolog insulin to the left arm; -6/18/23 at 9:00 AM, blood sugar = 189 and resident was administered 3 units of Novolog insulin to the abdomen, left lower quadrant; and -6/27/23 at 9:00 AM, blood sugar = 187 and resident was administered 3 units of Novolog insulin to the abdomen, right lower quadrant. -The resident's blood sugar levels were below the parameter of 200 as ordered by the physician and the resident should not have been administered the 3 units of Novolog insulin. An interview with the Director of Nurses on 7/24/23 at 3:55 PM confirmed the following related to Resident 21's physician order for Novolog insulin; -the resident was to be given 3 units of Novolog insulin subcutaneously for blood sugars over 200; and -the resident was administered the Novolog insulin when blood sugar levels were below the established parameter and should not have been given on 4/10/23, 4/20/23, 4/25/23, 4/27/23, 5/2/23, 5/5/23, 5/6/23, 6/18/23 and 6/27/23.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure residents were free from unnecessary medications related to long term use of antibiotic medications for 2 residents (Resident 79 and 96) that did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 2 and the facility census was 101. Findings are: A. Review of the facility policy Antimicrobial Stewardship Program with a revised date 4/2023 revealed the following: -The overall goal of the Antibiotic Stewardship Program (ASP) is to prevent undesirable outcomes related to antibiotic misuse by optimizing the selection of drug, dose, route and duration of therapy. Antibiotic use protocols and systems to monitor antibiotic use will be implemented to achieve ASP goals. -The Antimicrobial Stewardship Committee has been established to provide support and oversee activities of the ASP. The committee and the ASP will be part of the Infection Prevention and Control Program (IPCP). The IPCP will directly report all ASP-related activities and outcomes to the Quality Assurance and Performance Improvement (QAPI) Committee. The QAPI Committee will in turn report all ASP activities and outcomes to nursing staff, prescribing clinicians and other relevant staff. -Committee members included, the Medical Director/Physician, Director of Nursing, Infection Preventionist, Consultant Pharmacist and additional members as deemed appropriate. -Members will regularly review appropriateness of antibiotic courses and make recommendations for adjustment in practice where necessary, establish new or revise existing protocols relevant to appropriate antibiotic prescribing, monitor and report patterns of antibiotic use and resistance; and provide education on responsible use of antibiotics. B. Review of Resident 79's Minimum Data Set (MDS-a federally mandated assessment tool used in the development of resident care plans) dated 5/9/23 revealed the resident was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, non-Alzheimer's dementia, anxiety, depression, insomnia, previous stroke and skin cancer. The following was assessed regarding Resident 79: -moderate cognitive impairment; -required extensive assistance with transfers, toileting, and personal hygiene; -occasional urinary incontinence; and -took antibiotics routinely. Review of Resident 79's current Care Plan dated 9/22/21 revealed the resident had a potential for alteration in bladder function related to pain, depression, history of falls, frequency of urination and recurrent urinary tract infections (UTI's). The plan of care revealed the resident was on prophylactic (intended to prevent disease) antibiotic therapy related to a history of recurrent UTI's. Review of Resident 79's Medication Administration Record (MAR) dated 7/1/23 - 7/25/23 revealed the resident received the antibiotic Nitrofurantoin (antibiotic)100 milligrams (mg) daily)since 5/11/22 for a history of UTI's and no stop date or specified duration was indicated for the prescribed antibiotic. C. Review of Resident 96's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of neurogenic bladder, a UTI in the last 30 days, anxiety, depression and a left femur fracture. The following was assessed regarding the resident: -cognition was moderately impaired; -indwelling urinary catheter and occasional bowel incontinence; and -required extensive staff assistance with transfers, bed mobility, dressing, toilet use and personal hygiene. Review of Resident 96's undated current Care Plan revealed the resident had an indwelling urinary catheter related to diagnosis of neurogenic bladder. Interventions were identified for use of Bactrim (antibiotic) and Macrodantin (antibiotic) to be taken routinely for prophylaxis of chronic UTI's. Review of Resident 96's MAR dated 7/1/23-7/25/23 revealed the resident had an order dated 6/19/23 for Bactrim 400-60 mg 1 tablet daily and an order dated 6/1/23 for Macrodantin 100 mg 1 capsule every other day for prophylaxis of UTI's. There was no stop date or duration specified for the ordered antibiotics. D. During an interview on 7/24/23 at 2:00 PM, the Infection Preventionist confirmed residents who have orders for antibiotic therapy should have a duration specified when an antibiotic is ordered and Resident 79's order for Nitrofurantoin and Resident 96's Macrodantin and Bactrim did not have specified durations or stop dates as well as no documentation of clinical rationale for continued use.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.17B and 12-006.17D Based on observations, interviews, and record reviews the facility failed to prevent the potential for cross contamination related to: 1) completion of hand hygiene at appropriate intervals and for required duration during the provision of toileting and incontinence cares for Residents 37, 45, 54 and 84; 2) handling of Resident 37's urinary catheter drainage bag; and 3) cleaning of re-useable resident care equipment for use with Resident 75. The total sample size was 34 and the facility census was 98. Findings are: A. Review of a Hand Hygiene Competency form with revision date 12/19 revealed when washing hands, staff were to; apply soap, using friction, rub hands together, clean under and around nails and jewelry and between fingers and to wash up approximately 2 inches above the wrist. Staff were to lather and rub hands together a full 20 seconds before rinsing. In addition, staff could use hand sanitizer for completion of hand hygiene if hands were free from dirt, organic material and were not visibly soiled. Use of hand sanitizer should have a duration of 20-30 seconds. The following was identified regarding when staff were to wash hands: -before each resident contact; -after touching a resident or handling their belongings; -whenever hands were soiled; -after any contact with body fluids; -after handling contaminated items; and -before and after gloving. The following was identified as to when staff could use hand sanitizer: -before and after direct contact with resident; -preparing and handling medications; -after contact with intact resident's skin; -after contact with medical equipment; and -after removing gloves or between changing gloves. B. Observations of toileting/incontinence cares for Resident 37 on 5/12/22 from 10:20 AM to 10:40 AM revealed the following: -Nursing Assistant (NA)-A walked the resident into the bathroom and attached the resident's urinary catheter drainage bag to the outside of a trash receptacle which was positioned next to the toilet; -without performing hand hygiene, NA-A put on a clean pair of gloves and removed the resident's urinary incontinence brief which was soiled with feces. NA-A proceeded to dispose of the incontinence brief into the trash receptacle with the catheter drainage bag; -without removing soiled gloves, NA-A placed a clean incontinence brief on the resident and proceeded to empty the urinary catheter drainage bag; -Resident 37 began to cough and while still wearing soiled gloves, NA-A gave the resident a Kleenex, exited the bathroom, obtained a water glass then returned to the bathroom and offered to the resident to drink; -while still wearing soiled gloves, NA-A used pre-moistened cleansing cloths to provide perineal hygiene, cleansed around the catheter insertion site and then approximately 4 inches down the catheter tubing; -while still using soiled gloves, NA-A stood the resident and provided hygiene to the buttocks. NA-A used multiple wipes to remove feces from buttocks and continued wearing the same gloves until NA-A observed gloves were visibly soiled with feces. NA-A disposed of gloves and soiled cleansing cloths into the trash receptacle which still had the urinary catheter drainage bag attached to the outside; -NA-A without performing hand hygiene, placed on clean gloves; -NA-A completed cleansing the resident, secured the clean incontinence brief, adjusted the resident's slacks and proceeded to assist the resident out of the bathroom and into the resident's recliner; and -NA-A positioned the catheter drainage bag into a privacy bag and attached to a trash receptacle next to the recliner, elevated the resident's legs and removed the gait belt before finally removing gloves and washing hands. C. During an observation on 5/16/22 at 6:50 AM, Medication Aide (MA)-H removed a pulse oximetry machine (electronic device placed on a finger used to measure the level of oxygen carried in the red blood cells) from the MA's uniform pocket. Without disinfecting or cleansing the device, MA-H placed on Resident 75's finger and obtained a reading. When the test was completed, MA-H without cleaning returned to pocket of uniform. MA-H proceeded to use the device for checking the oxygen levels of other residents on Resident 75's corridor and failed to clean and/or disinfect between resident uses. D. Observation of NA-A providing toileting cares for Resident 84 on 5/16/22 at 7:34 AM revealed the following: -assisted the resident out of bed and into the resident's bathroom. NA-A without use of gloves, lowered the resident's incontinence brief which was heavily soiled with urine and transferred the resident onto the toilet: -without washing or completing hand hygiene, placed on a clear pair of gloves and removed the soiled incontinence brief; -placed a clean incontinence brief on the resident and while still wearing gloves exited the bathroom and opened the resident's dresser drawers and closet to remove clean clothing; -returned to the bathroom and proceeded to dress the resident before removing gloves; -without washing or completing hand hygiene, NA-A placed on clean gloves; -provided incontinence cares and without removing gloves, adjusted the resident's clothing and transferred out of the bathroom and into a wheelchair; and -removed gloves and washed hands in the resident's bathroom. E. Observation of incontinence cares for Resident 45 on 5/16/22 at 10:38 AM revealed the following: -NA-O and NA-P performed hand hygiene and placed on clean gloves; -the resident's disposable incontinence brief was soiled with urine and feces. NA-O used pre-moistened cleansing cloths to complete hygiene for the resident; -the resident continued to ooze feces as staff attempted to cleanse and change incontinence brief. NA-P completed incontinence cares and disposed of soiled brief and cleansing cloths; -NA-P and NA-O removed soiled gloves but failed to complete hand hygiene before putting on clean gloves; -NA-P and NA-O dressed the resident and while still wearing soiled gloves, opened all of the dresser drawers in the resident's room looking for a gait belt; -when unable to find a gait belt and while still wearing soiled gloves, NA-P exited the resident's room and then returned with a gait belt; and -the resident was assisted out of bed and into a wheelchair. Staff adjusted the resident's positioning and placed a pillow under legs before removing gloves and washing hands. During an interview on 5/16/22 10:55 at AM, NA-O and NA-P confirmed staff had been trained to complete wash hands or perform hand hygiene before putting on clean gloves and when removing soiled gloves especially if gloves were soiled. F. During an interview on 5/17/22 at 10:17 AM, the facility Administrator verified the potential for cross contamination related to: -attaching a urinary catheter drainage bag to a trash receptacle which contained soiled cleansing cloths and a soiled incontinence brief; -storing re-usable resident care equipment in staff's uniform pocket and not cleaning/disinfecting between resident uses; -completing resident cares while wearing soiled gloves; and -not performing hand hygiene when putting on clean gloves or removing soiled gloves. G. Observation of incontinence cares for Resident 54 on 5/16/22 from 9:05 to 9:15 AM, revealed the following: - NA-B assisted the resident to ambulate using a walker and gait belt, from the hallway into [gender] bathroom. NA-B lowered the resident's pants and without washing or completing hand hygiene, put on a pair of gloves and removed an incontinence brief that was soiled with BM and placed it inside the trashcan; - While wearing the soiled gloves, NA-B touched the handle on the cabinet above the toilet and opened the door, then removed the soiled gloves and put on clean gloves without washing or completing hand hygiene in between; - NA-B retrieved a clean incontinence brief from the cabinet above the toilet, touched the handle and closed the cabinet door, then walked out of room with the gloves on and opened a glass cabinet door outside of the room to retrieve a package of cleansing wipes; - Upon return, NA-B placed the package of wipes in the bathroom, removed the gloves and reached inside [gender] shirt pocket and pulled out a small bottle of hand sanitizer; - NA-B applied the hand sanitizer and rubbed hands together for approximately 10 seconds; - after the resident finished toileting, NA-B put on a pair of clean gloves and cleansed the resident's front and back areas of BM, then removed the soiled gloves and without washing or sanitizing hands pulled the resident's pants up and assisted the resident to lie down in bed; and - then NA-B washed hands (including rinse time) in the resident's bathroom sink for a total of 10 seconds. An interview with NA-B on 5/16/22 at 9:15 AM, confirmed hand hygiene should have been completed after removing the soiled incontinence brief, before touching surfaces with soiled gloves and between removing soiled gloves and putting on clean gloves. H. Review of Resident 37's undated plan of care revealed the resident had an indwelling suprapubic catheter (a flexible tube inserted into a person's bladder through an opening in the lower abdomen that is attached to a sterile drainage bag used to collect the urine). The catheter drainage bag is to have a bag cover on at all times to prevent potential contamination and infection. An observation of Resident 37 on 05/11/22 at 10:35 AM, revealed the resident was sitting in a recliner and next to the recliner [gender] catheter drainage bag was lying directly on the floor without a protective bag covering. An observation of Resident 37 on 5/12/22 at 9:50 AM, revealed the resident was sitting in recliner with feet elevated. Next to the chair, the resident's catheter drainage bag was hooked on the side of a small trash can that had several crumpled kleenex tissues inside and no protective covering was on the bag. During an interview on 5/12/22 at 3:40 PM, the Director of Nurses (DON) confirmed the resident's catheter drainage bag should not have been on the floor or attached to the trash can and should have been inside a protective bag covering.

Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to: 1) ensure [MEDICATION(S)] (medication used to treat anxiety and panic disorders) which was ordered to be used as needed, was reviewed by the practitioner after 14 days as required, to determine the need to continue the medication; and 2) complete required assessments to determine potential adverse side effects from use of [MEDICATION(S)] (an antipsychotic medication used to alter certain chemicals in the brain to effect change in behavior, mood and emotions) for 1 (Resident 84) of 5 sampled residents. The facility census was 98 Findings are: Review of Resident 84's Medication Administration Record (MAR) dated 5/2022 revealed the following orders; -4/22/22 [MEDICATION(S)] give 12.5 milligrams (mg) at bedtime for increasing behaviors and delirium; and -4/22/22 [MEDICATION(S)] 0.25 mg give 1 tablet as needed for anxiety three times a day. Review of the resident's current Care Plan dated 4/25/22 revealed the resident was using psychoactive medications related to diagnosis of [CONDITION(S)]. Interventions included completion of an AIMS (Abnormal Involuntary Movement Scale- assessment used to identify and monitor abnormal movement as a potential side effect from use of antipsychotic medications) with use of an antipsychotic which was to be completed initially, quarterly and as needed and a gradual dose reduction (the periodic physician review of the amount of a medication that a resident is receiving to consider a decrease in the amount of the medication) was attempted for psychoactive medications. Review of the resident's medical record revealed no evidence an AIMs assessment had been completed to monitor for potential adverse side effects from use of the [MEDICATION(S)]. Review of Resident 84's medical record revealed no evidence of an ordered duration of use for the, as needed [MEDICATION(S)]. During an interview on 5/17/22 at 8:09 AM, the Director of Nursing (DON) verified the resident's physician had not evaluated the resident's use of the as needed [MEDICATION(S)] to determine a potential stop date and the facility had failed to complete an initial AIMS assessment related to the resident's routine use of [MEDICATION(S)].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview, the facility failed to identify and assess Resident 63's areas of bruising to assure healing and to put interventions in place to prevent ongoing bruising. The sample size was 5 and the facility census was 84. Findings are: A. Review of the facility policy for Skin and Wound Management Standard with revision date 4/2019 revealed staff were to perform routine skin inspections with bathing and with cares as well as a weekly skin check. Any identified concerns were to be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Non-pressure skin conditions were to be assessed and measured every 7 days or more frequently if indicated until the areas were resolved. B. Review of Resident 63's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/12/22 revealed the resident was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was identified as needing extensive staff assistance with transfers, bed mobility, toilet use, dressing and personal hygiene. In addition, the resident was assessed as having occasional bladder incontinence. During an observation on 5/11/22 at 11:01 AM, the resident was noted to have 17.5 centimeter (cm) by 8 cm scattered areas of bruising to the resident's left forearm, a 6.5 cm by 6.5 cm area of bruising to the right wrist and 4 cm by 3 cm bruise to the top of right hand. All areas of bruising were a dark purple in color. Interview with the resident on 5/11/22 at 11:31 AM revealed the resident was uncertain as to the cause of the bruising but thought it had probably occurred by the resident bumping arms/hands on the doorframe leading into the resident's bathroom. The resident further revealed use of a sit-to-stand lift (a mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) for toilet transfers. The resident indicated the facility was aware of this concern and no interventions had been put into place to prevent from reoccurring. Observation of Resident 63's right wrist and hand and left forearm on 5/12/22 at 9:00 AM and at 1:47 PM revealed no changes regarding areas of bruising. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on 5/12/22 at 2:30 PM the DON confirmed the resident required extensive staff assistance with cares and the sit-to-stand lift was used to transfer the resident into/out of the bathroom. The DON identified if the direct care staff saw an area of skin break down, they were to report to the Charge Nurse, an assessment was to be completed and staff were to determine why/how bruising had occurred and then develop new interventions to prevent ongoing bruises. Interview with Nursing Assistant (NA)-O on 5/17/22 at 10:00 AM revealed the resident frequently bumped hands/arms on the bathroom door frame when transferring in the sit-to-stand lift but no interventions had been put into place to prevent further potential injuries.

Licensure Reference Number 175 NAC 12-006.09B(14) Based on record review and interview; the facility failed to code the Minimum Data Set (MDS-federally mandated assessed used to develop resident care plans) to reflect the resident's current status at the time of the assessment regarding medication use for Resident 41 and 61. The sample size was 33 and the facility census was 98. Findings are: A. Review of Resident 41's MDS dated [DATE] revealed the following; -the resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -received anticoagulant, antidepressant, and opioid medication 7 out of 7 days. Review of Resident 41's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Review of Resident 61's MDS dated [DATE] revealed the following; -the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -received anticoagulant, antidepressant, and insulin medication 7 out of 7 days. Review of Resident 61's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Interview on 5/16/22 at 9:33 AM with RN-BB (Registered Nurse) confirmed Resident 41's and Resident 61's MDS's had not been coded to relfect the resident's status at the time of the assessment, Resident 41 had not received anticoagulant medication, and Resident 61 had not received insulin or an anticoagulant medication during the MDS reference period.

Licensure Reference Number 175 NAC 12-006.09D7 Based on interviews and record review, the facility failed to ensure new interventions were implemented to prevent a fall with injury for Resident 72. The total sample size was 34 and the facility census was 98. Findings are: A. Review of the facility's Fall Prevention/Management Standard with a revised date of 2/2019 revealed the following related to fall prevention and interventions: - Facility staff should implement appropriate interventions that will prevent future falls; - the comprehensive plan of care will be reviewed and revised with dated interventions added; - the Interdisciplinary Team reviews and ensures new interventions are appropriate and in place; - the most effective interventions are strong actions rather than educational or memory recall alone; and - staff should review a resident's previous falls for patterns, trends and effectiveness of the interventions. B. Review of Resident 72's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) dated 4/20/22, revealed the resident was admitted on [DATE], was frequently incontinent of urine, and required extensive assistance with bed mobility, transferring from one place to another, toileting and personal hygiene. The resident also had diagnoses of Dementia, Hypertension (elevated blood pressure) and a history of a traumatic injury. Review of Resident 72's undated plan of care, revealed the resident was at risk for falls related to having had a fall prior to admission that resulted in a fracture of the right leg, had dementia, a history of stroke, [CONDITION(S)] (a decrease red blood cells that results in weakness) and was incontinent of urine. The following interventions were included on the plan of care for Resident 72 upon admission to the facilty: -6/15/21, ensure the call light was in reach and encourage the resident to use; -6/15/21, ensure properly fitting non-skid footwear is worn for ambulation; -6/15/21, give verbal reminders not to ambulate or transfer without assistance; -6/15/21, give instructions on the appropriate use of assistive devices; -6/15/21, encourage participation in group exercises; -6/15/21, maintain the environment free of clutter; -6/15/21, place frequently used items within reach of the resident; -6/15/21, provide the environment with adequate lighting; -6/15/21, review information on past falls and attempt to determine causes and alter the potential causes; and -6/15/21, therapy staff are to evaluate the resident for assistive devices quarterly and as needed. Review of the facility's Fall Scene Investigation Report/Interdisciplinary Team Reviews for Resident 72's falls revealed the following: - On 9/25/21 at 3:00 AM, the resident had self-transferred in the room and was found on the floor by a staff member. The cause was determined to be related to the resident self-transferring and interventions implemented were to educate the resident on using the call light, maintenance was asked to evaluate the function of the call light and a pressure pad call light (a device that is sensitive to touch when pressed) was placed in the room. - On 2/24/22 at 10:15 AM, a staff member found the resident sitting on the floor in the resident's room and was observed to have [gender] pants down. The cause was determined to be related to the resident self-transferring from the bathroom and tripped on [gender] pants. The intervention implemented was to encourage the resident to call for help and place the call light within reach of the resident (this was not a new intervention). - On 3/15/22 at 3:30 PM, a staff member heard the resident moaning from the resident's room and found the resident sitting on the floor in front of [gender] wheelchair and the brake handles were not engaged on the chair. The resident complained of left arm pain and was incontinent. The cause of the fall was determined to be related to the resident self-transferring from the wheelchair to the recliner without applying the brakes to the wheelchair. It was also noted the resident did not have non-skid footwear on. Interventions implemented were to have therapy evaluate for a wheelchair assessment and the resident was to wear gripper socks when transferring. (The resident previously had interventions for 1) therapy to evaluate for assistive devices as needed and 2) wear non-skid footwear when ambulating. - On 3/21/22 at 10:30 AM, a housekeeping staff member observed the resident sitting on the floor in [gender] room. The resident had reported [gender] was going to the bathroom when the fall occurred. Interventions implemented were to offer toileting at 10:00 AM. An interview with Nurse Aide (NA-AA) on 5/17/22 at 8:55 AM, revealed NA-AA had no knowledge Resident 72 was to be toileted at a specific time of the day (10:00 AM) according to the resident's plan of care related to fall prevention interventions. Review of Resident 72's record of care provided by nursing staff dated between 3/22/22 and 3/31/22 revealed the following related to times the resident had been toileted: - On 3/22/22 at 05:25 AM, 12:56 PM, 9:33 AM and 11:05 PM; - on 3/24/22 at 04:36 AM, 11:49 AM and 9:59 PM; - on 3/25/22 at 05:31 AM, 07:46 AM and 9:37 PM; - on 3/26/22 at 04:25 AM, 06:56 AM and 8:42 PM; - on 3/28/22 at 00:06 AM, 1:06 PM, and 8:40 PM; - on 3/30/22 at 07:18 AM, 9:15 PM and 11:37 PM; and - on 3/31/22 at 3:58 AM, 8:12 AM and 5:01 PM. Review of the facility's Investigative report dated 3/30/22 for Resident 72 revealed the resident had an initial x-ray of the left arm completed on 3/15/22 after a fall and complaints of left arm pain. The x-ray indicated a subtle abnormality and the physician had ordered a sling be worn for 1 month, a follow up x-ray in 2 weeks and to start physical therapy in 1 month. The follow up x-ray on 3/30/22 revealed the resident's left arm had been fractured with minimal healing. An interview with the Directory of Nurses (DON) on 5/17/22 at 9:30 AM, confirmed facility staff had not implemented new fall prevention interventions for Resident 72 after falls occurred on 9/25/21, 2/24/22 and 3/15/22. The DON also confirmed staff should have been toileting the resident according to the plan of care and designated times.

Licensure Reference Number: 12-006.09D8 Based on observations, record reviews, and interviews, the facility failed to evaluate, revise and implement interventions for 1 (Resident 28) of 4 sampled residents at risk for ongoing weight loss. The facility census was 93. Findings are: Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/19/21 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive assistance with eating and/or drinking and was identified as having a mechanically altered, therapeutic diet. Review of a Weights and Vitals Summary Sheet (form used to document a resident's weights, blood pressure, respirations, temperature and pulse) revealed on 1/14/21 the resident's weight was 193 pounds. Review of a Nursing Progress Note dated 1/14/21 at 4:50 PM revealed a new order was received for the resident to have a pureed diet (food items which have been cooked and blended to the consistency of a creamy paste or liquid) with regular thin liquids. Review of a Nutrition/Dietary Progress Note dated 1/18/21 at 8:58 AM revealed a recommendation to start the resident on 6 ounces of a fortified (additional calories and protein) shake once a day at snack time due to the resident consuming only 50% or less of food at meals. Review of a Speech Therapy Daily Treatment Sheet Note dated 1/25/21 at 2:53 PM revealed the resident was treated for [REDACTED]. The resident indicated a dislike for the taste of puree food items but was unable to swallow a bite sized piece of toast with butter and jelly dipped in coffee. Review of a Speech Therapy Daily Treatment Note dated 1/27/21 at 3:22 PM revealed a recommendation for adaptive cups with lids and handles. Review of a Weights and Vitals Summary Sheet dated 1/28/21 revealed the resident's weight was 187 pounds (down 6 pounds in 2 weeks) Review of a Speech Therapy Daily Treatment Note dated 2/3/21 at 12:59 PM revealed the resident required maximum assistance during meal intake. The resident was unable to swallow any lumps in mashed potatoes and either coughed or expelled when eating. The resident was encouraged to alternate sips of fluids with bites of food. The Charge Nurse was informed regarding swallowing concerns. Review of a Speech and Therapy Daily Treatment Note dated 2/4/21 at 12:42 PM revealed had 4 coughing episodes with therapy and the resident required verbal cues to initiate and continue intakes throughout the meal. Review of a Weights and Vitals Summary Sheet dated 2/11/21 revealed the resident's weight was 179 pounds (down 14 pounds or a 7% loss in 1 month). Review of a Speech Therapy Daily Treatment Notes revealed the following: -2/9/21 at 5:47 PM revealed a recommendation to change the resident's diet to mechanical soft with ground meats and extra gravy/sauces due to poor intakes; -2/10/21 at 4:15 PM the resident directed a therapeutic trial of a mechanical soft diet and the resident had 2 coughing episodes noted; and -2/11/21 at 1:38 PM the resident had coughing noted x3 with therapy. Review of a Nutrition/Dietary Progress Note dated 2/12/21 at 6:57 PM revealed a recommendation to increase the resident's fortified shake to twice a day until the resident's weight stabilized. Review of Speech Therapy Daily Treatment Notes dated 2/16/21 at 5:09 PM, 2/17/21 at 11:47 AM and on 2/18/21 at 1:09 PM revealed the resident continued to require verbal and visual cues with safe swallowing techniques. Review of Speech Therapy Daily Treatment Notes revealed the following: -3/3/21 at 4:05 PM the resident was provided instruction for methods to reduce risk for coughing and choking with intakes. The resident was encouraged to tuck chin to chest with swallowing, take small bites, to eat at a slow rate to take small controlled sips of fluids to double swallow food/fluids and to alternate consistencies of food items; and -3/8/21 at 2:52 PM the resident continued to required verbal cues for safe swallowing techniques and was unable to put in upper dentures. Review of a Weights and Vitals Summary Sheet dated 3/11/21 revealed the resident's weight on 3/11/21 was 181 pounds. Review of Speech Therapy Daily Treatment Notes revealed the following: -3/11/21 at 1:58 PM the resident required verbal cues to clear oral cavity; and -3/16/21 at 11:07 AM the resident was heard to cough twice with intake of mechanical soft ground meat and required instruction with safe swallowing techniques. Observations on 3/16/21 revealed the following: -1:00 PM, Resident 28 was seated upright in a wheelchair in the resident's room. A bedside table was positioned in front of the resident. The table contained the resident's noon meal which consisted of a green bean casserole, mashed potatoes with gravy, ground meat and a garlic stick which was pulled apart into 2 sections. The resident's back was turned to the open door so the resident was not visible to anyone in the corridor outside of the room. The resident was attempting to eat and there were bites of ground meat and green beans observed on the resident's clothing protector and on the bedside table. No staff were in the room with the resident to provide cues related to safe swallowing techniques. Resident 28 was heard to have intermittent periods of coughing; and -1:28 PM the resident continued to have periods of coughing with dietary intake. The resident indicated the hamburger just won't go down. Interview with Registered Nurse (RN)-C on 3/16/21 at 2:20 PM confirmed Resident 28 has been eating meals alone and unsupervised in the resident's room. RN-C confirmed the resident was on a mechanically altered diet, had a [DIAGNOSES REDACTED]. During an observation on 3/17/21 at 8:16 AM to 8:42 AM Resident 28 was positioned in a wheelchair in the resident's room. The bedside table was in front of the resident with the breakfast meal. The resident was served scrambled eggs, ground sausage with gravy and a slice of toast. The resident's back was facing the door and staff were unable to observe the resident during the meal. Further observations revealed the resident's eyes were closed and the resident had made no attempt to eat any of the breakfast meal. The resident verified being hungry but continued to sit with eyes closed making no attempt to eat and/or drink. No staff entered the room to assist the resident with eating or to cue the resident to wake and start to eat. Review of facility documentation related to the percentage of food the resident consumed at meals revealed the following from 3/1/21 to 3/17/21: -breakfast meal the resident consumed 0-25% on 3/2, 3/3, 3/4 and 3/9 (4 out of 17 days), 26-50% on 3/1, 3/8, 3/10, 3/11, 3/12 and 3/16 (6 out of 17 days), 51-75% on 3/5, 3/6, 3/7, 3/13, 3/14, 3/15 and on 3/17 (7 out of 17 days): -noon meal the resident consumed 0-25% on 3/4, 3/5 and on 3/14 (3 out of 17 days), 25-50% on 3/2, 3/13, 3/15 and on 3/17 (4 out of 17 days) and 51-75% on 3/1, 3/3, 3/6, 3/7, 3/8, 3/9, 3/10. 3/12 and on 3/16 (9 out of 17 days) and 76-100% on 3/11/21; and -evening meal the resident consumed 0-25% on 3/5 and 3/15 (2 out of 16 days), 26-50% on 3/1, 3/4, 3/6, 3/9, 3/16 and 3/11 (6 out of 16 days), 51-75% on 3/2, 3/8 and 3/9 (3 out of 16 days) and 76-100% on 3/3, 3/7, 3/10, 3/11, 3/12, 3/13 and on 3/14 (7 out of 16 days). Interview with the Speech Therapist on 3/17/21 at 2:20 PM revealed the resident had been eating in a supervised area where staff could provide cues and assistance as needed. The Speech Therapist was uncertain why the resident was now eating alone in the resident's room and verified the resident required supervision to assure the resident was following safe swallowing techniques and was receiving cues and assist to assure the resident was eating.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, record review, and interview, the facility failed to implement and to revise Resident 28's Care Plan related to weight loss and dysphagia (difficulty swallowing). The sample size was 4 and the facility census was 93. Findings are: Review of Resident 28's current Care Plan dated 1/31/21 revealed the resident was at risk for altered nutrition related to a previous stroke with left sided weakness and difficulty swallowing. Interventions included the following: -6 ounces of fortified shake (nutritional supplement with added calories and protein) twice a day; -puree diet; -refer to the registered dietician as needed; and -set up assist and cues to extensive assistance with eating, adaptive drinking cups with lid and 2 handles with meals and to eat in the main area. Review of a Speech Therapy Daily Treatment Note dated 2/9/21 at 5:47 PM revealed a recommendation to change the resident's diet to mechanical soft with ground meats and extra gravy/sauces due to poor intakes. Observations on 3/16/21 revealed the following: -1:00 PM, Resident 28 was seated upright in a wheelchair in the resident's room. A bedside table was positioned in front of the resident. The table contained the resident's noon meal which consisted of a green bean casserole, mashed potatoes with gravy, ground meat and a garlic stick which was pulled apart into 2 sections. The resident's back was turned to the open door so the resident was not visible to anyone in the corridor outside of the room. The resident had regular drinking glasses which contained orange juice and a chocolate drink. The resident's drinks were not served in adaptive drinking cups with lids or handles. The resident was attempting to eat and there were bites of ground meat and green beans observed on the resident's clothing protector and on the bedside table. No staff were in the room with the resident to provide assistance to eat or cues related to safe swallowing techniques. Resident 28 was heard to have intermittent periods of coughing; and -1:28 PM the resident continued to have periods of coughing with dietary intake. The resident indicated the hamburger just won't go down. Interview with Registered Nurse (RN)-C on 3/16/21 at 2:20 PM confirmed Resident 28 has been eating meals alone and unsupervised in the resident's room. RN-C confirmed the resident was on a mechanically altered diet, had a [DIAGNOSES REDACTED]. During an observation on 3/17/21 at 8:16 AM to 8:42 AM Resident 28 was positioned in a wheelchair in the resident's room. The bedside table was in front of the resident with the breakfast meal. The resident was served scrambled eggs, ground sausage with gravy and a slice of toast. No adaptive drinking glasses were provided with the meal. The resident's back was facing the door and staff were unable to observe the resident during the meal. Further observations revealed the resident's eyes were closed and the resident had made no attempt to eat any of the breakfast meal. The resident verified being hungry but continued to sit with eyes closed making no attempt to eat and/or drink. No staff entered the room to assist the resident with eating or to cue the resident to wake and start to eat. Interview with the Speech Therapist on 3/17/21 at 2:20 PM revealed the resident had been eating in a supervised area where staff could provide cues and assistance as needed. The Speech Therapist was uncertain why the resident was now eating alone in the resident's room and verified the resident required supervision to assure the resident was following safe swallowing techniques and was receiving cues and assist to assure the resident was eating. An interview with the Director of Nursing on 3/17/21 at 2:41 PM confirmed the resident's current Care Plan had not been updated regarding the resident's current nutritional interventions for dysphagia management and for weight loss.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to implement interventions to prevent potential choking episodes for Resident 41. The sample size was 1 and the facility census was 84. Findings are: Review of a Progress Note dated 5/12/19 revealed at 12:50 PM Resident 41 began coughing during lunch. The resident had increased difficulty breathing and talking. The resident shook no when asked if the resident could talk. Back blows were performed with no improvement. The resident became unresponsive and cyanotic (bluish discoloration usually caused by low oxygen levels) with fixed pupils. The resident's chin was lifted, to obtain optimal airway, and the resident then coughed and was able to take breaths at that time. The resident's physician and Power of Attorney (POA) were notified per telephone. The resident's POA requested the resident's current diet remain unchanged. Review of a ST (Speech Therapy) Daily Treatment Note dated 5/14/19 revealed ST recommended a mechanical soft diet with extra sauces/gravies and no raw fruits or vegetables. Review of a Progress Note dated 5/14/19 at 10:30 PM, revealed Resident 41 was offered a ground meat sandwich. The resident coughed and had strider (high-pitched, wheezing sound caused by disrupted airflow) type respirations. The nurse attempted the [MEDICATION NAME] maneuver and performed back blows with no change. The resident began to have cyanosis to the lips, ears, and nail beds. The resident became unresponsive to tactile (sensory stimulation involving touch) and verbal stimulation. The resident was transferred out of the wheel chair, to the floor, rolled on side, and back blows were performed again. Oxygen was started and the resident started coughing. Review of a Progress Note dated 5/17/19 at 8:50 AM revealed Resident 41 had another choking/wheezing episode at the breakfast table. The wheezing lasted for a few seconds and then the resident stopped wheezing and took a drink of water. The resident did this a few times at the breakfast table, and then had more wheezing when seated in the recliner in the day area. The resident became cyanotic in the face. Oxygen was applied and a breathing treatment was completed. Review of a Progress Note dated 5/20/19 at 10:00 AM revealed Resident 41 choked on Cream of Wheat cereal. The Cream of Wheat cereal was stuck to the resident's throat. The resident was encouraged to drink more fluids and was able to drink the fluids. The staff were educated to add some milk to the Cream of Wheat cereal to help with swallowing. Review of Resident 41's current Care Plan revealed the Care Plan was updated on 5/20/19 to include the following interventions related to the resident's choking episodes: - Monitor for signs and symptoms of aspiration (sucking food into the airway), - All staff were informed of special dietary and safety needs, - Check the resident's mouth after meal for pocketed food and debris, - Follow the diet as prescribed with no raw fruits and vegetable, - Monitor for shortness of breath, choking, labored respiration, and lung congestion, and - Refer to speech therapist for swallowing screen/evaluation as needed. Review of a Progress Note dated 5/24/19 at 12:21 PM revealed Resident 41 was seated at the dining room table and had an extreme episode of wheezing/food stuck in the resident's throat. Back blows and [MEDICATION NAME] maneuver were performed with no change. Sips of water were given to clear the throat with no relief. The resident went unresponsive and turned blue/grey. The resident was transferred to bed and oxygen was started. Once the resident was laid down, color came back slowly and the resident coughed numerous times. Review of a ST Daily Treatment Note dated 5/27/19 revealed it was reported that Resident 41 had an extreme choking episode over the past weekend where the resident's airway was blocked for several minutes. The nurse stated that the meal provided during the incident did not have extra sauces/gravies. Resident 41's Therapist Progress and Updated Plan of Care dated 5/28/19 identified a list of foods to avoid to prevent potential choking while on the mechanical soft diet. Food items to avoid included rice, corn, cheese, bread, pie crusts, cookies, raw fruits, raw vegetables, potato chips, pineapple, sticky foods (such as chewy candies), lettuce, and dry cereal. Review of a ST Daily Treatment Note dated 5/30/19 revealed Resident 41 had oral residue post swallow of ground meats. On 6/20/19 at 12:20 PM Resident 41 was seated in the dining room for lunch. The resident was served a lettuce salad with dressing, which was placed in front of the resident ready for consumption. Interview with the Assistant Dietary Manager on 6/20/19 at 12:20 PM confirmed Resident 41 had dietary restrictions which included no raw fruits or vegetables. The Assistant Dietary Manager confirmed the resident should not have been served a lettuce salad. Resident 41 was observed on 6/24/19 from 9:20 AM to 9:37 AM. The resident was seated in the dining room eating breakfast. The resident was served hot cereal with milk, ground meat, and scrambled eggs with a variety of drinks. The resident ate independently. After eating, the resident was transferred from the dining room table to a recliner in the day area by Nursing Assistant (NA)-C and NA-L. The resident's mouth was not checked to ensure no food items were pocketed. Interviews with NA-B, NA-L, and Registered Nurse-M on 6/24/19 from 9:32 AM to 9:37 AM, confirmed Resident 41's mouth was not checked after breakfast on 6/24/19. Further interview confirmed the staff did not check Resident 41's mouth after meals. Review of Resident 41's Medical Record on 6/24/19 revealed no evidence to indicate oral inspections were completed after meals to check for pocketed food items.

LICENSURE REFERENCE 175 NAC 12-006.04C3a (6) Based on interview and record review, the facility failed to notify the attending physician of a change in condition for 2 of 2 sampled residents. This involved weight changes for Resident 64 and 79. The facility census was 84. Findings are: [NAME] Review of Resident 64's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/10/19 revealed a [DIAGNOSES REDACTED]. Review of an Order Summary Report dated 6/2019 revealed an order dated 5/31/19 to report to the resident's physician if the resident has a weight gain of 2-4 pounds in 1-3 days. Review of a Weights and Vitals Summary Report revealed the resident's weight on 6/11/19 was 242 pounds. Further review revealed the resident's weight on 6/18/19 was 245 pounds (a weight gain of 3 pounds). review of the resident's medical record revealed [REDACTED]. B. Review of Resident 79's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 79's admission orders [REDACTED]. Review of the resident's Weights and Vitals Summary Report revealed the following regarding the resident's daily weights: -6/9/19 weight was 200 pounds; -6/10/19 weight was 204 pounds (up 4 pounds in 1 day); and -6/12/19 weight was 205 pounds (up 5 pounds in 3 days). review of the resident's medical record revealed [REDACTED]. Review of the Weights and Vitals Summary Report revealed the resident's weight on 6/14/19 was 209 pounds (up 9 pounds in 5 days). Interview with the Director of Nurses (DON) on 6/20/19 at 3:24 PM confirmed the following: -Resident 64 had an order to notify the resident's physician if the resident had a weight gain of 2-4 pounds in 1-3 days; -Resident 64 had a 3 pound weight gain from 6/11/19 to 6/18/19; -Resident 64's physician was not notified of the resident's weight gain; -Resident 79 was admitted on [DATE] with an order for [REDACTED].>-Resident 79 had a 4 pound weight gain from 6/9/19 to 6/10/19 and a 5 pound weight gain from 6/9/19 to 6/12/19; and -Resident 79's physician was not notified of the resident's continued weight gain until 6/14/19 when the resident had gained 9 pounds in 5 days.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and staff interview; the facility failed to develop and implement interventions for the prevention of falls for Resident 47 who was admitted from the hospital following surgery for [REDACTED]. Facility census was 100. Findings are: A. Review of the facility Fall Prevention and Management policy/procedure dated 9/09 revealed all residents were to be evaluated prior to admission for concerns related to fall history. In addition, the policy/procedure identified a fall risk assessment was to be completed upon admission to the facility and " In the event that the resident is determined to be at risk for falls, appropriate interventions will be implemented immediately, i.e., low bed, floor mats, alarm, toileting schedule, etc. " B. Review of Resident 47 ' s admission Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/12/11 revealed the resident was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Clinical Admission Documentation dated 7/2/11 at 11:34 AM indicated the resident had short term memory problems, required limited assistance with transfers and balance was not steady. Review of a Fall Risk assessment dated [DATE] at 2:46 PM revealed the resident was alert and oriented at all times, had balance problems while standing/walking, had a history of [REDACTED]. The Fall Risk Assessment indicated referrals to Occupational Therapy (OT) and Physical Therapy (PT) " may be appropriate " and action taken was to " Initiate Plan of Care " . Review of the Interim Plan of Care dated 7/2/11 indicated the resident was to have assistance with transfers and toileting and OT and PT services were to be provided. The Interim Plan of Care indicated the resident was alert and forgetful and the intervention was provision of reality orientation. Further review of the Interim Plan of Care revealed there were no additional interventions for the prevention of falls although the resident had identified short term memory problems and was at high risk for falls. Review of Resident Progress Notes revealed the following: 7/2/11 at 7:50 PM- " Alert and confused at times ...Call light in reach, able to make needs known. " 7/3/11 at 1:10 AM- " ...Resident asks if it ' s cold outside ...Note resident has a fever of 101.3 at this time ... " 7/3/11 at 9:40 AM- " Alert and pleasant. Confused to time and place. Forgets that (resident) had broken hip, but remembers when someone reminds ... " 7/3/11 at 10:20 AM- " Res (resident) found lying on back on floor. States ' I was trying to get to church ' . " The resident was subsequently transferred to the hospital. Review of a hospital consultation report dated 7/3/11 indicated the resident sustained [REDACTED]. Review of a hospital progress note dated 7/5/11 revealed additional surgery was not warranted. Review of Resident Progress Notes dated 7/5/11 at 1:45 PM revealed Resident 47 was readmitted to the facility from the hospital that day. Documentation indicated a sit/stand alarm (a device which sounds an alarm to alert staff members when a resident attempts to get up without assistance) was in place due to the resident ' s history of falls. The Director of Nursing (DON) verified during interview on 9/7/11 from 11:44 AM until 12:05 PM that Resident 47 was at high risk for falls when admitted to the facility on [DATE] and interventions such as the use of a sit/stand alarm were not implemented until after the resident fell .