Every finding on record at Jefferson Community Health & Life Gardenside

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an incident related to elopement for 1 (Resident 1) of 3 sampled residents. This had the potential to affect 10 residents identified as at risk for elopement. The facility census was 31. Findings are: A record review of the facility policy Missing Resident revised on 9/19/24, revealed the following: -Elopement is defined as an event in which a resident who needs supervision leaves a safe area without supervision. -5. The Director of Nursing (DON) or designee will make the report to the Department of Health & Human Services and to Adult Protective Services per facility policy. A record review of the facility's December 2024 QA/QI (Quality Assurance/Quality Improvement) log revealed the following entry: -12/31/24 at 1555 (3:55 PM) Resident 1 exited dining room door, returned safely. An interview on 1/8/25 at 9:47 AM with the Registered Nurse (RN) revealed that [gender] was working on 12/31/24 and around 4:00 PM that day Resident 1 went outside through the dining room door facing west, walked around the building to a door on the east side of the building and was let in by a dietary staff member. The RN further revealed that Resident 1 was outside for approximately 2 minutes. The RN confirmed that no one from nursing saw Resident 1 go outside. An interview on 1/8/25 at 11:12 AM with the DON revealed that [gender] had visited with staff after Resident 1 was back in the facility about what had happened. [Gender] stated [gender] was told that someone from dietary had seen Resident 1 exit the facility through the dining room door and had their eyes on Resident 1 while [gender] was outside. The DON revealed that [gender] did not investigate which dietary staff member it was that visualized Resident 1 while [gender] was outside and had not investigated the elopement because [gender] was told that someone had their eyes on Resident 1 the entire time [gender] was outside. The DON confirmed that [gender] should have done a thorough investigation of the elopement, that included which dietary staff member visualized the incident to determine if the elopement needed to be reported. The DON further confirmed that because the elopement was not investigated, it was not reported as required.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to investigate an incident related to elopement for 1 (Resident 1) of 3 sampled residents. This had the potential to affect 10 residents identified as at risk for elopement. The facility census was 31. Findings are: A record review of the facility policy Missing Resident revised 9/19/24, revealed the following: -Elopement is defined as an event in which a resident who needs supervision leaves a safe area without supervision. -4. The Charge Nurse will complete an incident report and forward it to the Director of Nursing (DON). -5. The DON or designee will make the report to the Department of Health & Human Services and to Adult Protective Services per facility policy. A record review of the facility's December 2024 QA/QI (Quality Assurance/Quality Improvement) log revealed the following entry: -12/31/24 at 1555 (3:55 PM) Resident 1 exited dining room door, returned safely. An interview on 1/8/25 at 9:47 AM with the Registered Nurse (RN) revealed that [gender] was working on 12/31/24 and around 4:00 PM that day Resident 1 went outside through the dining room door facing west, walked around the building to a door on the east side of the building and was let in by a dietary staff member. The RN further revealed that Resident 1 was outside for approximately 2 minutes. The RN confirmed that no one from nursing saw Resident 1 go outside. An interview on 1/8/25 at 10:44 AM with the Assistant Director of Nursing (ADON) revealed that [gender] was unsure if there was a complete investigation of the elopement due to it being reported that a member of dietary had visualized Resident 1 the whole time [gender] was outside. The ADON confirmed that [gender] was unaware of what dietary staff member had visualized Resident 1. An interview on 1/8/25 at 11:12 AM with the DON revealed that [gender] had visited with staff after Resident 1 was back in the facility about what had happened. [Gender] stated [gender] was told that someone from dietary had seen Resident 1 exit the facility through the dining room door and had their eyes on Resident 1 while [gender] was outside. The DON revealed that [gender] did not investigate which dietary staff member it was that visualized Resident 1 while [gender] was outside and had not investigated the elopement because [gender] was told that someone had their eyes on Resident 1 the entire time [gender] was outside. The DON confirmed that [gender] should have done a thorough investigation of the elopement, that included which dietary staff member visualized the incident to determine if the elopement needed to be reported. An interview on 1/8/25 at 11:12 AM with the [NAME] revealed that [gender] was working on 12/31/24 at the time Resident 1 went out the dining room door and did not visualize Resident 1 exiting the facility because [gender] was in the kitchen area. The [NAME] revealed that there was only one other dietary staff member present at that time and that was the Dietary Aide (DA). An interview on 1/8/25 at 11:44 AM with the DA confirmed that [gender] was working on 12/31/24 at the time Resident 1 went out the dining room door and that [gender] did not visualize Resident 1 exiting the facility because [gender] was in the dietary breakroom. The DA confirmed that [gender] and the [NAME] were the only two dietary staff members working at that time.

Licensure Reference Number 175 NAC 12-006.09D7b Based on interview and record review; the facility failed to conduct a thorough investigation to determine the root-cause of falls and failed to develop and implement effective interventions to minimize and/or prevent falls for 3 (Residents 5, 16, and 18) of 3 sampled residents. The facility census was 32. Findings are: Review of the facility Fall Assessment policy, updated 2/2023, revealed the following: -Interventions for residents at risk for falls will be found in the care plan and are specific for that resident. -The Quality Improvement Coordinator will be responsible for trending falls/looking for patterns. This will be done by the following criteria: place of fall, time of fall, day of week of fall, injuries vs. no injuries, medical diagnosis/contributing factors. Review of the facility Fall Committee notes, dated 7/15/24 and 8/19/24, revealed the following: The number of falls in May, June, July (up to 7/15/24 in July notes and all of July in 8/19/24 notes) and those that had occurred in August as of 8/19/24. There was a brief description of how the fall occurred. The notes do not mention a root-cause analysis for each of the falls or the intervention developed and implemented for the falls. Review of the facility QAPI minutes, dated 9/5/24, revealed the following: -PIP (Performance Improvement Project): Falls: Each resident who does have falls is tracked for fall score, safety features in use, etc. In an interview on 11/13/24 at 10:30 AM, Licensed Practical Nurse (LPN)-B revealed after a resident has a fall that the nurse is to fill out a post fall evaluation which would include where it occurred, if anyone was involved, how the resident was found, what contributed to the fall, medical practitioner, and family notification, and if there were any injuries. LPN-B further revealed that the interventions typically put into place are to make sure the bed is in low position, a padded mat is next to the bed, personal items are within reach or an alarm to notify staff if the resident were to attempt to get up. LPN-B further revealed that [gender] will try to come up with a new intervention based on the root cause but usually does not. LPN-B confirmed that the previously listed interventions are not directly related to the root cause of a fall and that an intervention should be put into place that is specific to the cause of the fall. An interview on 11/13/24 at 12:36 PM the Assistant Director of Nursing (ADON) revealed that Performance Improvement Plans (PIP) are audited routinely and changed as needed. The ADON further revealed that there were no audits available that tracked the root-cause of a resident's fall was determined and that a new intervention was developed and implemented for that specific fall the resident had. A. Review of the facility Fall Log 2024 revealed the following entries for Resident 16: -10/19/24 at 6:10 AM was in bed, rolled out of bed onto padded mat, low bed -10/22/24 at 1:40 AM was in bed, found sitting on padded mat beside bed Review of Resident 16's comprehensive care plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 7/14/21 revealed the following: -Problem/Need: Falls: History of falling. Resident 16 is admitted to Gardenside with a history of falling at home due to weakness, and 4 falls while [gender] was in the ALF (Assisted Living Facility) for just over 1 month. Resident 16 is at high risk for falls due to right sided weakness, status post Cardiovascular Accident (CVA-interruption of blood flow to the brain), dementia as [gender] forgets [gender] limitations and has some short-term memory problems, incontinence. -Approach(es): remind to ask staff for assistance with ambulation-keep call light in place at all times; refer to restorative nursing program, no longer walks but does AROM (Active Range of Motion); provide with non-slip shoes/footwear; ensure an environment free of clutter/clear pathways; assess for changes in condition that may warrant increased supervision/assistance and notify the physician as needed; transfers with 1 assist and sit to stand; bed in low position Review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 9/11/24, revealed the following: -admitted : 6/30/21 -Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 3 which indicate sever cognitive impairment. -Transferred from chair/bed-to-chair transfer with maximum assistance and did not walk. -Active Diagnoses: Non-Alzheimer's Dementia and hemiplegia or hemiparesis (loss of muscle function on one side of the body). -No falls since the prior assessment. -Chair alarm used daily. Review of Resident 16's Post Fall Evaluation, dated 10/19/24, revealed the following: -Description of Fall Activity: roll from low bed to mat. -Injury type: No apparent injury -Post Fall Analysis: Environmental Safety Plan Fall Prevent: adequate room lighting, bed in low position, call device within reach, encourage handrail/safety bar use, non-slip footwear, patient specific safety measure, personal items within reach -Interventions in place at time of fall: no qualifying data available. Review of Resident 16's Post Fall Evaluation, dated 10/22/24, revealed the following: -Description of Fall Activity: from hi/low bed -Injury type: No apparent injury -Post Fall Analysis: Environmental Safety Plan Fall Prevent: adequate room lighting, bed in low position, call device within reach, night light -Interventions in place at time of fall: no qualifying data available -Interventions in place to prevent falls: remind to use call light An interview on 11/13/24 at 11:35 AM, the ADON confirmed that a root cause had not been determined when Resident 16 had fallen on 10/19/24 and 10/22/24 and that a new intervention based on the root cause was not developed or implemented to be put on the care plan for either fall. B. Review of the facility Fall Log 2024 revealed the following entries for Resident 18: -5/9/24 at 11:00 PM sitting on floor by bed, -5/18/24 at 6:50 AM top half of left side still on bed, bottom half sitting on floor, -9/9/24 at 1:40 AM was in bed, found sitting on floor back against bed, low bed, padded mat, -10/16/24 at 11:10 PM was in bed, found sitting on padded mat on floor holding onto body pillow. Review of Resident 18's comprehensive CCP, dated 5/26/22 revealed the following: -Problem/Need: Falls: Resident 18 is no longer able to ambulate and is dependent on 2 staff to use a full body lift for all transfers. [Gender] doesn't attempt to get out of [gender] wheelchair. [Gender] will occasionally roll out of bed, whether it be on purpose trying to get up or just being restless and rolling out of bed on accident is unknown. Bed is in low position with padded mat next to bed for this reason. Current fall risk is 55 which puts [gender] at high risk still. -Approach(es): anticipate and meet needs; be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. Coordinate with appropriate staff to ensure a safe environment with: Floors even and free from spills or clutter. Adequate, glare-free light. Call light. Bed in low position at night. Side rails as ordered. Handrails on walls. Personal items within reach; Use silent wheelchair and floor alarm when in bed, does not use call light to ask for help. Padded gray mat beside bed. Bed in low position when in bed. 5/9/24 was in bed, found sitting on floor, back against bed, stated she didn't fall, just slid out of bed. 5/18/24 attempted to get out of bed on [gender] own. Top half of left side including elbow/arm still on bed. Bottom on floor, sitting on floor mat. Bed in low position. Review of Resident 18's MDS, dated [DATE], revealed the following: -admitted : 5/10/22. -Severely impaired cognitive skills for daily decision making. -Transferred from chair/bed-to-chair transfer with total dependence and did not walk. -Active Diagnoses: Schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). -2 or more falls with no injury since the prior assessment. -Chair alarm and floor mat alarm in place daily. Review of Resident 18's nursing narrative note, dated 5/9/24 at 11:35 PM revealed the following: -summoned to room at 11:00 PM, note resident sitting on floor with back against bed. [Gender] stated, I didn't fall, I slid out of bed. Was incontinent of urine at time of fall. Review of Resident 18's Post Fall Evaluation, dated 5/9/24, revealed the following: -Description of Fall Activity: roll from low bed to mat. -Injury type: No apparent injury. -Post Fall Analysis: Environmental Safety Plan Fall Prevent: bed in low position, call device within reach, mobility support items readily available. -Interventions in place at time of fall: no qualifying data available. -Intervention in place to prevent falls: frequent observations. Review of Resident 18's nursing narrative note, dated 5/18/24 at 10:50 AM, revealed the following: -6:50 AM staff call this nurse to room, noted Resident 18 sitting on floor, next to bed, [gender] had attempted to get out of bed. [Gender] top half (left side), elbow/arm remained in bed, while [gender] bottom was sitting on floor, on top of padded fall mat, bed was in low position. Noted to be incontinent of bowel/bladder once in bed. Staff assist with cleaning/peri cares. Review of Resident 18's electronic health record (EHR) revealed no post fall evaluation completed for 5/18/24 fall. Review of Resident 18's nursing narrative note, dated 9/9/24 at 2:34 AM, revealed the following: -At 1:40 AM note that floor alarm is sounding, entered room, and found resident in sitting position, with back against the bed, sitting on floor. Body pillow behind [gender]. Resident incontinent of urine, was changed. Bed remains in low position, mat beside bed. Review of Resident 18's Post Fall Evaluation, dated 09/9/24, revealed the following: -Description of Fall Activity: roll from low bed to mat. -Injury type: No apparent injury. -Post Fall Analysis: Environmental Safety Plan Fall Prevent: adequate room lighting, bed in low position, call device within reach, patient specific safety measures. -Interventions in place at time of fall: frequent observations. -Interventions in place to prevent falls: frequent observations, low bed with mat, mat placed on floor next to bed. Review of Resident 18's nursing narrative note, dated 10/16/24 at 11:43 PM, revealed the following: -Floor alarm sounded at 11:10 P, entered room and resident sitting on floor beside bed holding on to body pillow. Asked resident what [gender] was doing, and [gender] just stated, Shut the light off asked [gender] how [gender] fell out of bed and [gender] stated, I didn't fall. Resident incontinent of bowel at time of fall. Review of Resident 18's Post Fall Evaluation, dated 10/16/24, revealed the following: -Description of Fall Activity: roll from low bed to mat. -Injury type: No apparent injury. -Post Fall Analysis: Environmental Safety Plan Fall Prevent: bed in low position, call device within reach, encourage handrail/safety bar use, encourage personal mobility support item use, mobility support items readily available. -Interventions in place at time of fall: frequent observations, low bed with mat, mat placed on floor next to bed. -Interventions in place to prevent falls: frequent observations, low bed with mat, mat placed on floor next to bed. An interview on 11/13/24 at 11:35 AM, the ADON confirmed that a root cause had not been determined when Resident 18 had fallen on 5/9/24, 5/18/24,9/9/24 and 10/16/24 and that a new intervention based on the root cause was not developed or implemented to be put on the care plan for any of the falls. 45613 C. Review of the facility provided fall log revealed that Resident 5 had falls on 9/13/24, 9/28/24, 10/4/24, and 10/18/24. Review of Resident 5's Quarterly MDS dated [DATE] revealed an admitted [DATE] to the facility and a BIMS score of 99 which indicated the resident was unable to complete the interview due to cognitive decline and the following: -2 falls without injuries and 1 fall with an injury. -Resident uses a walker and a wheelchair. -Resident needs assistance with ambulation, transfers, and toileting. Review of Resident 5's Significant change MDS dated [DATE] revealed: -A fall without an injury. -Resident uses a walker and a wheelchair. -Resident needs assistance with ambulation, transfers, and toileting. Review of Resident 5's CCP dated 10/23/24 revealed: - Fall focus dated 7/25/24 which stated the resident is at risk for falls due to forgetting to use assistive devices and being unaware of surroundings. Resident is unsteady while walking. - Goal of the resident is to be free of falls - Approaches included anticipate needs, call light within reach, ensure a safe environment - no clutter, adequate light, call light, bed in low position, personal items within reach, and appropriate footwear. -Falls were listed on 9/13, 9/28, 10/4, 10/18. Post Fall Evaluations for Resident 5 revealed the following: -Fall dated 9/13/24 the resident fell from her recliner chair with no injury. No interventions in place at the time of fall. New interventions in place to prevent falls were adequate lighting, chair alarm and frequent observations. -Fall dated 9/28/24 another resident reported that this resident was seated on seat of walker and reached down for something and fell . Neurological assessment was initiated. Interventions in place at the time of fall were adequate lighting, chair alarm and frequent observations. Environmental Safety Plan fall prevention was adequate lighting, encourage mobility support, and non-slip footwear. -Fall dated 10/4/24 resident fell while walking and hit head. Neurological assessment initiated. Interventions in place at the time of fall were adequate lighting, chair alarm and frequent observations. Environmental safety plan fall prevention was to encourage person mobility support and nonslip footwear. -Fall dated 10/18/24 resident fell from recliner chair in the general TV room. Interventions in place at the time of fall were adequate lighting, chair alarm and frequent observations. Environmental Safety plan of fall prevention was non-slip footwear and keep personal items within reach. Interview on 11/13/24 at 11:14 AM with LPN - A confirmed that if a resident falls and it is unwitnessed they would start neuro checks, then they should put a new intervention into place that is related to the fall and put it on the fall report. Floor staff does not update the careplan but the fall committee does. Interview on 11/13/24 at 11:35 AM with ADON confirmed that the root cause of the falls had not been identified and new interventions had not been updated to the careplan Interview on 11/13/24 at 12:08 PM with ADON confirmed that new interventions after each resident fall are not listed on the careplan and should have been.

Licensure reference number 175 NAC 12-006.09B2 Based on observations, interview, and record review, the facility failed to code oxygen use on the Minimum Data Set assessment (MDS is a standardized assessment tool that measures health status in nursing home residents) for 1 (Resident 10) of 1 sampled residents. The facility census was 27. Findings are: A record review of Resident 10's Face Sheet dated 2/12/2017 revealed diagnoses of: iron deficiency anemia secondary to blood loss (a condition in which blood lacks adequate healthy red blood cells), pulmonary hypertension due to left heat disease (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart) and Covid-19 (a sickness caused by a virus that causes mild to severe respiratory illness). A record review of Resident 10's quarterly MDS assessment dated [DATE] revealed, Resident 10 did not use oxygen during the assessment period. A record review of the Electronic Treatment Administration Record (ETAR) revealed Resident 10 had oxygen administered between 10/1/23 through 10/18/2023. An interview on 12/21/23 at 10:20 AM with Registered Nurse (RN)-A revealed Resident 10 used oxygen during the month of October, and the MDS was not documented for the oxygen section of the MDS dated [DATE]. An interview on 12/21/23 at 10:50 with RN-A revealed [gender] used the Resident Assessment Instrument (RAI) Manual to ensure the accuracy of MDS.

Licensure reference number 175 NAC 12-006.17B Based on observations, interviews, and record review, the facility failed to ensure respiratory equipment was stored and oxygen tubing changed in a manner to prevent cross contamination for 1 resident (Resident 10) of 1 resident sampled. The facility identified a census of 27 residents. Findings are: A record review of the facility policy titled Oxygen Administration-Nasal Cannula dated 04/17/2023 revealed: - Oxygen tubing must be kept off the floor as able due to trip hazard. - Nasal cannula to be changed every week. - Longer O2 cannula/connection tubing to be changed monthly on the 1st. A record review of Resident 10's Face Sheet dated 2/12/2017 revealed diagnoses of: iron deficiency anemia secondary to blood loss (a condition in which blood lacks adequate healthy red blood cells), pulmonary hypertension due to left heat disease (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart) and Covid- 19 (a sickness caused by a virus that causes mild to severe respiratory illness). A record review of Resident 10's Electronic Treatment Administration Record (ETAR) revealed, that Resident 10 had oxygen administered on 12/19/2023 at 5 AM. A record review of Resident 10's ETAR revealed an order to change the oxygen tubing every Monday. The ETAR documentation for December 2023 revealed documentation of Resident 10's oxygen tubing completed on 12/04/2023, 12/11/2023, and 12/19/2023. An observation on 12/18/2023 at 7:59 AM of Resident 10's room revealed, the one piece oxygen tubing with nasal cannula was marked with a sticker dated 12/04/23. An observation on 12/18/23 at 1:49 PM revealed, Resident 10 was in [gender] room in a wheelchair, applying makeup to their face. The oxygen concentrator was turned off and not in use. The one piece oxygen tubing with the nasal cannula was found on the floor. A cloth bag for was tied to the dresser that was directly behind the concentrator. An observation on 12/18/23 at 3:54 PM revealed, the oxygen concentrator was off and the one piece tubing with nasal cannula was on the floor. A bag was tied to the dresser that was directly behind the concentrator. An interview on 12/18/23 at 7:52 AM with Resident 10 revealed, that [gender] does not touch the concentrator or the tubing, unless [gender] is in bed, and it falls off. Resident 10 further revealed, [gender] does not know how to use the concentrator, and [gender] does not like to mess with the tubing. Resident 10 revealed, [gender] only uses the oxygen while in bed and staff remove the oxygen when [gender]gets up for the day. An observation on 12/19/2023 at 8:00 AM revealed, that the concentrator was turned off and the one piece tubing with the nasal cannula was on the floor, and a cloth bag was on the dresser behind the concentrator. The oxygen tubing was dated 12/04/23. An observation 12/19/2023 at 4:04 PM revealed, that the oxygen concentrator was off and oxygen tubing with nasal cannula was on the floor. The cloth bag observed tied to the dresser that was directly behind the concentrator. An interview on 12/19/23 at 8:00 AM with Resident 10 revealed, that [gender] did not take her oxygen off this day. An observation on 12/20/23 at 9:10 AM revealed, that the concentrator was off and one piece tubing with nasal cannula was across the bed. The bag was tied to the dresser that was directly behind the concentrator. The oxygen tubing was dated of 12/04/23. An interview on 12/20/23 at 10:10 AM with Resident 10 revealed, [gender] did not remove [gender] oxygen. An observation on 12/20/23 at 12:10 PM revealed, that the concentrator was off and the one piece oxygen tubing with nasal cannula was laying across the bed. A cloth bag was tied to the dresser that was directly behind the concentrator. The date found on the oxygen tubing dated 12/04/23. An observation on 12/21/23 at 8:10 AM revealed, that concentrator was off and the one piece oxygen tubing with nasal cannula was laying across the bed. The cloth bag was tied to the dresser that was directly behind the concentrator. The date of oxygen tubing was 12/04/2023. An interview on 12/21/23 at 8:45 AM with Resident 10 revealed, that [gender]did not take the oxygen off. An observation 12/21/2023 at 8:50 AM revealed, that concentrator was off and the one piece oxygen tubing with nasal cannula was laying across the bed. The cloth bag was tied to the dresser that was directly behind the concentrator. The date of oxygen tubing was 12/04/2023. An interview on 12/21/23 at 8:50 AM with Nurse Assistant (NA)-B revealed, that the nurses are the only staff who can apply or remove the oxygen. The medication aide are allowed to turn the concentrator off but nothing else. NA-B further revealed, that if [gender] found the oxygen tubing and cannula on the floor, [gender]would pick it up and hang it over the bottle part of the concentrator. An interview on 12/21/23 at 8:55 AM with Registered Nurse (RN)-C revealed, if [gender] saw oxygen tubing with the nasal cannula on the floor they would clean it with cleaning wipes and place it in the storage bag behind the concentrator. An interview on 12/21/23 at 8:58 AM with RN-A revealed, that when the oxygen tubing was not in use it was to be stored in the cloth bag behind the concentrator to keep it clean. If the tubing and/or cannula was found on the floor, the staff are to replace it with new tubing.

Based on record review and staff interview, the facility failed to update the staff posting with the total number and actual hours worked each shift for Registered nurses, Licensed Practical Nurses and Nurse Aides. This had the potential to inaccurately inform all residents that resided in the building and visitors of the facility's staffing. The facility census was 27. Findings are: Review of the staff posting from 9/1/21 through 9/14/21 lacked the required posting of total and actual hours worked by each staff type. An interview with the Director of Nursing on 9/15/21 at 2:28 PM confirmed the total number of hours worked were not documented on the daily staff postings and confirmed the hours worked were not updated to reflect the actual number of hours worked by each discipline.

Licensure Reference Number 175 NAC 12-006.11C Based on observation and interview, the facility failed to maintain the cleanliness and condition of equipment as evidenced by the presence of dust and grease on the top of the steamer, oven, shelf above the stove top, hard water and lime buildup on the tray and wire rack of the ice machine. The facility failed to ensure that dishes were completely dry prior to putting them away. This had the potential to affect all residents that consumed food and fluids from the facility kitchen. The facility census was 27. Findings are: A. Observation on 09/13/21 between 9:05 - 09:30 AM revealed a fan in the dishwashing room on top of a wire rack. The fan was on and positioned toward the clean area of the dish washer unit where clean dishes were present. When it was turned off, a dark brown substance that resembled dust covered the edges of the fan blades. Further observation revealed the presence of grease and dust present on the shelf above the stove top, the top of the steamer and the top of the oven. Interview on 9/13/21 at 9:20 AM with the Dietary Manager [DM] confirmed the presence of dust on blades of the fan, the presence of grease and dust on the top of the Oven, Steamer and the shelf above the stove top. The DM confirmed those areas needed to be cleaned. B. Observation on 09/14/21 between 9:25 AM - 9:45 AM in the facility dining area revealed the presence of an ice machine and glasses placed upside down on trays with a rubber shelf liner underneath the glasses. There was a build up of hard water and lime on the tray and wire rack of the ice machine. Observation of the glasses on the tray revealed that the glasses had water condensation on the inside of the glasses. Interview on 09/15/21 at 1:10 PM with the DM confirmed the hard water buildup on the exterior of the ice machine tray and wire rack and the presence of condensation inside the glasses. The DM confirmed that the ice machine was not on a routine cleaning schedule but that it is delimed yearly. The DM confirmed that the glasses should not be put away while wet and should be thoroughly dry before being taken out to the storage area in the dining room. The DM confirmed that all residents in the facility ate foods and fluids prepared in the facility kitchen.

Licensure Reference Number 175 NAC 12-006.10 Based on observation, interview, and record review, the facility failed to ensure medications were provided in accordance with the five rights (Right Resident, Right Medication, Right Dosage, Right Time, Right Route) for 2 (Residents 2 and 26) of 4 residents observed for medication administration. The facility had a total census of 27 residents. The findings are: A. During observations of medication administration, 3 errors were observed out of a total of 25 opportunities for error. This resulted in a medication error rate of 12%. B. An observation on 9/15/21 at 8:43 AM revealed RN - B (Registered Nurse) administered the following medication to Resident 26: -[MEDICATION(S)] 75mcg tablet (a medication used to treat [CONDITION(S)]) A review of Resident 26's September 2021 MAR (Medication Administration Record) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 75mcg tablet by mouth daily - scheduled at 7:00 AM In an interview on 9/15/21 at 9:59 AM, RN - B reported Resident 26 ate breakfast just prior to receiving medications at 8:43 AM. C. An observation on 9/15/21 at 8:46 AM revealed RN - B administered the following medications to Resident 2: -[MEDICATION(S)] 75mcg -[MEDICATION(S)]/[MEDICATION(S)] 25/100mg (a medication used to treat the symptoms of [CONDITION(S)]) A review of Resident 2's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 75mcg tablet by mouth daily - scheduled at 7:00 AM -[MEDICATION(S)]/[MEDICATION(S)] 25/100mg by mouth four times daily - scheduled at 7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM In an interview on 9/15/21 at 9:59 AM, RN - B reported Resident 2 ate breakfast just prior to receiving medications at 8:46 AM. D. A review of mayoclinic.org, accessed on 9/20/21, revealed the following information about [MEDICATION(S)]: -It is best to take this medicine on an empty stomach. Take it with a full glass of water at least 30 minutes to 1 hour before eating breakfast. E. A review of the facility's Medication Administration Policy, last revised 3/2021, revealed the following: -Policy: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. -Guidelines: -3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. -5. The individual administering the medication must ensure that the right medication, right dosage, right time, and right method of administration are verified before the medication is administered (e.g., review of drug label, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] F. An interview was conducted with the DON (Director of Nursing) on 9/15/21 at 4:47 PM. During the interview, the DON confirmed the [MEDICATION(S)] for Resident 26 and Resident 2 was scheduled at 7:00 AM because it was supposed to be given on an empty stomach. The DON also confirmed the [MEDICATION(S)]/[MEDICATION(S)] for Resident 2 was scheduled at 7:00 AM because it was supposed to be given first thing in the morning to help with Resident 2's [CONDITION(S)] symptoms. The DON confirmed all 3 medications were given at the wrong time.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed in accordance with accepted standards of practice and prevent potential cross-contamination during the provision of catheter care for 1 (Resident 2) resident and failed to ensure medications were handled in a manner to prevent cross-contamination for 1 (Resident 2) of 4 residents observed for medication administration. The facility had a total census of 27 residents. The sample size was 21 residents. The findings are: A. An observation on 9/13/21 at 10:36 AM revealed Resident 2 sitting in a recliner chair. Resident 2 had a urinary catheter (a tube inserted into the bladder through the urethra to drain urine into a collection bag) with the drainage bag placed in a bath basin on the floor next to Resident 2's recliner chair. The bath basin was lined with a paper towel and the drainage bag was in a catheter bag cover. An observation on 9/15/21 at 7:25 am revealed NA - C (Nurse Aide) providing urinary catheter care to Resident 2. NA - C performed hand hygiene with alcohol-based handrub upon entering Resident 2's room. NA - C applied gloves, gathered the supplies necessary to complete catheter care for Resident 2, and then performed hand hygiene with alcohol-based handrub on top of the gloves. NA - C then got a graduated cylinder from the back of the toilet in Resident 2's bathroom dated August 2021 and brought it to the bedside of Resident 2. NA - C placed the graduated cylinder in the bottom of the bath basin where Resident 2's catheter drainage bag rested on the floor by Resident 2's bed. NA - C lifted the drainage bag, unhooked the drainage valve from the bag, and used an alcohol wipe to clean the drainage valve. NA - C emptied the urine from the drainage bag into the graduated cylinder, then closed the valve and cleaned it with an alcohol wipe before reinserting it into the drainage bag. NA - C dumped the urine into the toilet, rinsed the graduated cylinder, and then replaced it on the back of Resident 2's bathroom toilet. NA - C removed (gender) gloves and put on a new pair of gloves. No hand hygiene was performed on NA - C's hands. NA - C placed Resident 2's catheter drainage bag into a catheter bag cover and then performed hand hygiene with alcohol-based handrub on top of NA - C's gloves. NA - C prepared Resident 2 for peri-care and then performed hand hygiene with alcohol-based handrub on top of NA - C's gloves. NA - C provided peri-care to Resident 2 and then performed hand hygiene with alcohol-based handrub on top of NA - C's gloves. NA - C got more supplies out of Resident 2's closet to dress Resident 2 and moved Resident 2's trash can next to Resident 2's bed. NA - C performed hand hygiene with alcohol-based handrub on top of NA - C's gloves and then continued to assist Resident 2 with getting ready for the day. In an interview on 9/15/21 at 8:07 AM, NA - C confirmed NA - C performed hand hygiene on top of gloves during the provision of catheter and peri-care for Resident 2. A review of the facility's Hand Hygiene Policy, last revised 10/2019, revealed hand hygiene should be performed at the following times: -When coming on duty. -Before and after direct patient contact. -Before handling an invasive device for patient care, regardless of whether or not gloves are used (e.g., central venous catheters, urinary catheters, peripheral intravenous catheters). -After contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings. -When moving from a contaminated body site to a clean body site during patient care. -After contact with a patient's intact skin - as in taking a pulse or blood pressure, or lifting a patient. -After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. -Before preparing or handling medications. -After removing sterile or not sterile gloves or other personal protective equipment. -After using the restroom, blowing the nose, covering a cough, sneezing, combing hair, or smoking. -Before and after meals. -Before going home. In an interview on 9/15/21 at 11:13 AM, the Infection Preventionist (IP) confirmed facility staff performing hand hygiene on top of gloves was not an accepted practice at the facility. In an interview on 9/15/21 at 3:20 PM, the Director of Nursing (DON) reported Resident 2's catheter bag was kept in a bath basin because it was getting pulled too tight when it was hung from the bed, walker, or chair. The DON stated it was placed in a bath basin so it did not touch the floor. The DON confirmed the graduated cylinder used to empty Resident 2's catheter should not have been placed in the bath basin after it had been on the toilet in Resident 2's bathroom. The DON also confirmed hand hygiene performed on top of gloves was not an accepted practice at the facility and hand hygiene should be performed after the removal of gloves. B. An observation on 9/15/21 at 8:46 AM revealed RN - B (Registered Nurse) preparing medications for Resident 2. RN - B removed each of Resident 2's medications by popping the plastic top off of the medication cassette packaging system for each medication. After RN - B had finished removing all of the medications, RN - B dumped the medication cup of Resident 2's medications into RN - B's ungloved hand. RN - B stated at this time that the plastic pieces break from the medication cassette system and end up in the medication cup. RN - B reported RN - B was removing any small, broken plastic pieces from Resident 2's medications. RN - B then returned the medications to the medication cup and continued with administering them to Resident 2. In an interview on 9/15/21 at 4:47 PM, the DON confirmed RN - B should not have poured Resident 2's medications into RN - B's ungloved hand. The DON stated a glove should have been used to prevent potential cross contamination.

Based on observation, record review and interview; the facility failed to ensure that protocols for antibiotic stewardship were followed as evidenced by failure to obtain a Urinary Analysis [UA, a lab test of the urine for bacteria that indicate an infection] or UA Culture and Sensitivity [C & S]a lab test that tells you what the organism of infection is and provides information on antibiotic susceptibilities] prior to start of an antibiotic for Resident 9. The facility sample size was 21 and the facility census was 27. Findings are: Record review of an undated facility Protocol for Identification and Possible Pharmacological treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - If a resident has any combination of the following symptoms, obtain a dipstick [a simple test of the urine on a thin plastic strip treated with chemicals that react with the urine to show levels in the urine]prior to calling the MD [Medical Doctor]: Nausea, vomiting, abdominal pain and or flank pain, temperature elevation above 99 degrees Fahrenheit, Hematuria on 2 successive occasions or intense pain with urination. If the dipstick urine is positive for Nitrates, Leukocytes or blood, begin the following protocol: - Obtain a sterile catheterized specimen (no mid stream) - Order a UA from lab and C & S - When UA results are available, SBAR [Situation, Background, Assessment and Recommendation Form] physician with results, drug allergies and infection log for resident. - Check for drug sensitivity when C and S results are available. - Monitor closely for side effects. Interview on 9/14/21 at 8:18 AM with Resident 9 revealed that an antibiotic was in use for a current Urinary Tract Infection [[CONDITION(S)], an infection of the urinary system]. Resident 9 stated that [gender] frequently gets [CONDITION(S)]'s and that antibiotics have helped in the past. The resident stated there was pain present in the bladder area and burning with urination. Observation on 9/14/21 at 10:12 AM revealed that Nurse Aide [NA] A entered Resident 9's room and provided assistance with toileting. Record review of Resident 9's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/7/21 revealed a Brief Interview of Mental Status [BIMS] score of 15 which indicated Resident 9 was cognitively intact. Section G of the MDS identified that Resident 9 required extensive assistance from staff for toileting and personal hygiene needs, was frequently incontinent, had no [CONDITION(S)] in the past 30 days and had occasional severe pain. Record review of Resident 9's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 9's Physicians orders dated 7/21/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Culture if positive. A review of Resident 9's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a SBAR faxed to the Physician dated 7/22/21 revealed a Physician response /new order: no culture, just did in July. 100 mg [milligrams] [MEDICATION(S)] [an antibiotic used to treat bladder infections. It's generic name is [MEDICATION(S)]] PO [by mouth] BID [twice a day]. Review of Resident 9's Medication Administration Record's [MAR] dated July and August 2021 showed the [MEDICATION(S)] was started on 7/23/21 and stopped on 8/6/21. Record review of a follow up SBAR faxed to the Physician dated 7/29/21 revealed that Resident 9 continued to complain of burning with urination and a new dipstick UA, UA lab and C & S were ordered on 7/29/21. The dip stick test result dated 7/29/21 showed positive results for Nitrates, Large amount blood and large Leukocytes. The physician responded with orders to continue the [MEDICATION(S)]. Record review of a laboratory report of the Urine C & S dated as collected on 7/29/21 revealed 2 different organisms were present: Morganella morganii and Escherichia coli. The lab report indicated that Morganella morganii is resistant to [MEDICATION(S)] [[MEDICATION(S)]] use [This would mean this drug wound not be an effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The lab result also identified that Escherichia coli was susceptible to [MEDICATION(S)] use. [This would be an effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a fax to the Physician dated 9/8/21 revealed that Resident 9 continued to complain of burning with urination and a dipstick UA was performed on 9/8/21. The dip stick test result showed positive results for Nitrates, moderate amount blood and large Leukocytes. Record review of Resident 9's record revealed no UA LAB or UA C & S was completed. Record review of Physicians Telephone Order dated 9/9/21 revealed an order to start [MEDICATION(S)] 100 mg PO BID for 14 days. The progress record with the order read: Reviewed dip stick results with DR. History of Chronic [CONDITION(S)]. Do not need to straight cath due to signs and symptoms and dip stick results per MD [Medical Doctor]. Record review of Resident 9's Loebs Minimum Criteria for Initiating Antibiotic Therapy identified that the minimum criteria for starting antibiotic therapy was either acute Dysuria [painful urination] or a temperature greater than 100 degrees Fahrenheit and one of the following new or worse symptoms. : [CONDITION(S)] without catheter: Dysuria and Supra pubic pain. Written by hand at the side was a note that identified: Burning with urination, bladder pain and a history of chronic [CONDITION(S)]'s. A note on the form identified that a Urine Culture should be sent prior to starting antibiotics. Review of Resident 9's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 09/15/21 at 11:24 AM with the Infection Preventionist [IP] confirmed that Resident 9 did not have a Lab UA or C & S done prior to the start of the [MEDICATION(S)] on 9/8/21. The IP identified that there was a gap in Resident 9's symptoms between 8/17/21 and 9/2/21 when there was no documentation of complaints of burning with urination or symptoms of [CONDITION(S)]. The IP stated that if there was a gap in symptoms and if a new infectious process then started, it would be best practice to do a UA and a C & S before starting a new antibiotic. The IP confirmed that this had not been done for Resident 9 prior to starting the [MEDICATION(S)] on 9/9/21. Record review of the Antibiotic Stewardship Program dated revised on 02/2021 revealed that the IP would track whether appropriate tests such as cultures were obtained prior to starting an antibiotic. A review of the antibiotic tracking log for September 2021 revealed no information related to Resident 9 and the use of the [MEDICATION(S)].

Based on interview and record review, the facility failed to ensure facility residents had the right to choose their attending physician upon admission to the facility. This had the potential to affect all residents residing in the facility. The facility had a total census of 27 residents. The findings are: A review of an undated facility information packet for prospective residents revealed the following: -Residents must have an attending physician that is on staff at (local health system name). A review of the facility's admission packet revealed the following information related to personal physician choice: -Each resident must have admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician does need to be a member of the (local health system name) approved medical staff. A review of the facility's website, jchealthandlife.org, revealed the following: -In order to be admitted to (facility name), you must have a primary care physician at (local health system name). In an interview on 9/15/21 at 4:11 PM, the Administrator reported facility residents had the option to choose any physician, as long as the physician was a part of the local health system. If a facility resident had a doctor in a neighboring town, they would be required to switch to a doctor within the local health system. The Administrator stated the practice had been in place as long as the Administrator had been at the facility. The Administrator confirmed the facility was not contained within a CCRC (Continuing Care Retirement Community).

Licensure Reference Number 175 NAC 12-006.02(8) Based on interview and record review, the facility failed to report incidents of abuse to the State Agency on 1 of 4 sampled residents (Resident 1). The facility census was 32. Findings are: Record review of an Investigation related to an alleged abuse revealed on 10/29/20 at 7:00 AM the DON had a conversation with RN B related to Resident 1 and an allegation related to slapping the arm of Resident 1. DON told RN B under NO circumstances would they EVER slap at the patch on a person's body to warm it up. RN B reported they tapped on it. The DON told RN B you can massage or rub the patch on the skin, but the perception of others seeing this, observing this could be teetering on abuse. RN B was reminded of previous discussions related to Resident 3's wishes not being met continued behavior would not be tolerated. RN B was given a written warning. An interview on 11/17/20 at 2:50 PM with the DON confirmed the facility had not reported the staff to resident alleged abuse to the SA (State Agency). The DON had a conversation with Resident 1 and the resident revealed; the staff and (gender) would joke around.

Licensure Reference Number 175 NAC 12-006.05 (21), 12-006.05(9) Based on record review and interview, the facility failed to complete investigations related to abuse for 2 residents (Residents 1 and 3). Sample size was 4. Facility census was 32. Findings are: An interview on 11/17/20 at 12:11 PM with Staff Member A reported the staff to resident abuse was reported to the DON (Director of Nurses) the next day. The next day they spoke to the DON related to Resident 1 and RN B. Record review of an Investigation related to an alleged abuse revealed on 10/29/20 at 7:00 AM the DON had a conversation with RN B related to Resident 1 and an allegation related to slapping the arm of Resident 1. DON told RN B under NO circumstances would they EVER slap at the patch on a person's body to warm it up. RN B reported they tapped on it. The DON told RN B you can massage or rub the patch on the skin, but the perception of others seeing this, observing this could be teetering on abuse. RN B was reminded of previous discussions related to Resident 3's wishes not being met continued behavior would not be tolerated. RN B was given a written warning. Record review of a Resident Family Complaint/Concerns form dated 10/27/20 revealed there was no form completed related to the abuse allegation. An interview on 11/17/20 at 2:50 PM with the DON confirmed the facility had not completed the investigations related to alleged abuse, RN B had not been suspended pending the investigation, other residents had not been interviewed to ensure they felt safe, other staff interviews had not been documented. The DON confirmed they did not report the incident to the SA (State Agency). The DON reported they would talk the incidents over with HR and the Administrator.

Licensure Reference Numbers 12-006.17A and 12-006.17B Based on observation, interview, and record review; the facility failed to implement appropriate transmission-based precautions related to the potential spread of COVID-19 for new admissions for 1 (Resident 1) of 3 residents reviewed and failed to ensure staff did not screen themselves for signs and symptoms of COVID-19. This had the potential to affect all residents residing in the facility. The facility had a total census of 34 residents. The findings are: Transmission-Based Precautions/Resident Cohorting A. A review of the facility's Novel Coronavirus Policy, last revised 5/2020 revealed the following: Resident Cohorting: -Preference is to establish red, yellow and green zones in geographically distinct areas with the facility, however with the limited space within (Facility Name), staff will work with NE ICAP (Nebraska Infection Control Assessment and Promotion Program - supported by the Nebraska Department of Health and Human Services Healthcare Associated Infections Program via a CDC grant) in determining cohorting plan. -Extended use of PPE (Personal Protective Equipment) may be considered within zones, but may not be used between color zones. Definitions: -Yellow Zone - asymptomatic residents who may have been exposed to COVID-19. Goal: separating people who are, or may have been, exposed to a pathogen, but are not showing signs of illness. -Red Zone - Light Red-symptoms present or high-risk exposure and awaiting test results, Dark Red-symptoms present with confirmed positive test results. Goal: to separate people who are sick from those who are not sick. -Green Zone - no significant exposure and asymptomatic residents. -Gray Zone asymptomatic: New admissions or readmission and is asymptomatic and no known exposure. Goal: to prevent inadvertent exposure, residents who are not ill to possible asymptomatic individual. -Gray Zone symptomatic: Possible symptoms but tests negative upon admission/readmission. Goal: to prevent inadvertent exposure, residents who are not ill to possible positive individual. PPE: -Work in cooperation with ICAP and local Public Health District in determining appropriate interventions/precautions and in establishing proper zones. B. An interview with the Administrator on 6/30/20 at 7:30 AM revealed the facility considered themselves in Phase 2 of their reopening plan. A review of the facility's undated Reopening Plan revealed the following related to resident cohorting in Phase 2: -Two private rooms have been established as dedicated space for new admissions or readmissions to establish a gray zone where the new admission/readmission will quarantine for 14 days. C. A review of Resident 1's medical record revealed an admission date of [DATE]. Resident 1 was admitted from the local hospital where Resident 1 had been since 6/21/20 with a [DIAGNOSES REDACTED]. In an interview on 6/30/20 at 9:15 AM, Resident 1 reported being admitted to the facility the day before. Resident 1 stated Resident 1 was receiving meals in the room and only came out for a bath last evening. An observation at this time revealed a sign outside Resident 1's door stated, Observation Zone. Standard Precautions with Procedure Mask. The sign indicated Resident 1 started observation on 6/21/20 and would end observation on 7/5/20. There was a box of gloves and a bottle of hand sanitizer outside of Resident 1's room on the handrail. In an interview on 6/30/20 at 8:20 AM, LPN (Licensed Practical Nurse)-C reported Resident 1 was admitted the day before (6/29/20). LPN-C stated PPE required in Resident 1's room was a mask and gloves only. LPN-C reported it was the same procedure facemask staff wore in other resident rooms and throughout the building. In interviews on 6/30/20 between 9:30 AM and 10:07 AM, the DON (Director of Nursing) and Administrator reported Resident 1 was in the gray zone at the attached hospital for 8 days and was finishing the 14-day isolation period at the facility. The DON stated after 6 days in isolation at the facility, Resident 1 would move to a semi-private room with a roommate. The DON and Administrator also reported the hospital generally quarantines the facility's new admissions for 14 days prior to them moving to the facility. The Administrator stated the facility used to have a gray zone, but now call it an observation zone as of 6/25/20. An observation on 6/30/20 at 11:20 AM revealed LPN-A exited Resident 1's room wearing a procedure mask and entered another resident room across the hall wearing the same procedure mask. The resident in the second room did not have any signage to indicate they were in transmission-based precautions. An observation and interview on 6/30/20 at 11:38 PM with OT (Occupational Therapist)-B revealed OT-B was exiting Resident 1's room wearing a procedure mask. OT-B stated the only PPE required when working with Resident 1 was a procedure mask and gloves if there was contact with Resident 1. OT-B reported the same procedure mask was worn when working with other residents in the facility. D. A review of recommendations from Nebraska ICAP related to resident cohorting and zones revealed the following PPE should be worn in the gray zone: gown, gloves, eye protection and N95 mask (N95 preferred, if no N95, then surgical mask with face shield). E. In an interview on 7/01/20 at 9:15 AM, the Administrator confirmed the facility was not following the guidelines that had been recommended by Nebraska ICAP related to resident cohorting for Phase 2. Staff Screening F. An observation and interview on 6/30/20 at 7:10 AM revealed the ADON (Assistant Director of Nursing) entered the locked front door of the facility and took (gender) own temperature in the lobby. The ADON reported that staff can screen each other when they come to work or can screen themselves. In an interview on 6/30/20 at 7:28 AM, the Administrator reported staff were responsible for screening themselves when they arrive to work and the DON and IP (Infection Preventionist) review the screenings. The Administrator reported staff had to call the Charge Nurse if they have a temperature greater than 99.5. In an interview on 6/30/20 at 8:05 AM, the IP reported staff screen themselves in the facility lobby when they arrive to work for symptoms of COVID-19 and take their own temperatures. The staff were to call the Charge Nurse if they had a temperature greater than 100.0 and the Charge Nurse would assess the staff member further. In an interview on 6/30/20 at 8:30 AM, LPN-C (also the Charge Nurse) reported staff screen themselves for symptoms when they arrive to work and take their own temperatures. LPN-C stated if staff have symptoms or a temperature greater than 100.0, they were to call the DON. In an interview on 6/30/20 at 10:55 AM the IP reported dietary staff screen themselves for signs and symptoms of COVID-19 and increased temperature. The IP also stated the DON is responsible for making sure staff are doing the screening and temperature checks at the start of their shift. A review of the facility's Novel Coronavirus Policy, last revised 5/2020 revealed the following information about staff screening: -All staff will be screened upon coming to work and when leaving work for symptoms of COVID-19 and temperature. G. Interview on 6/30/20 at 7:50 AM with Nursing Assistant (NA) D and NA E on 6/30/20 at 8:03 AM revealed that the staff wear surgical masks and gloves only when going into room [ROOM NUMBER] the isolation room. NA D and NA E confirmed that staff do not wear gowns, eye protection or an N 95 mask and they do not discard their surgical mask after being in the isolation room. NA D stated they receive one mask when they come on duty and wear it all day. Interview on 6/30/20 at 8:32 AM with LPN A confirmed that staff wear gloves and surgical masks when going into room [ROOM NUMBER], the isolation room. They do not wear gowns, goggles or N 95 masks and do not change their surgical masks after being in the isolation room.

Licensure Reference Number 175 NAC 12-006.12E1a Based on observation, interview, and record review; the facility failed to ensure controlled medications were stored in a separately locked, permanently affixed compartment. This practice had the potential to affect all residents that resided in the facility. The facility had a census of 37. The findings are: On 9/25/19 at 2:15 PM, an observation of Medication Cart One revealed it had two separate locks on top of the cart. The controlled medications were stored with the other non-controlled medications in the drawers of the cart. There was no separate locking compartment seen. [MEDICATION NAME] (a narcotic pain medication) Patches were observed in the same drawers as non-controlled medications at that time. An interview on 9/25/19 at 2:15 PM with RN X confirmed the controlled medications were stored with the non-controlled medications in both medication carts and were considered double locked because there were two locks on top of the medication cart. An observation of Medication Cart Two on 9/25/19 at 4:10 PM revealed it also had two separate locks on top of the cart. The controlled medications were stored with the other non-controlled medications in the drawers of the cart. There was no separate locking compartment seen. [MEDICATION NAME] Patches and [MEDICATION NAME] (a narcotic pain medication) were observed in the same drawers as non-contolled medications at that time. An interview with LPN Y on 9/25/19 at 4:10 PM revealed there were two separate keys for the two locks on top of the medication carts. An interview on 9/25/19 at 4:18 PM with the MDS Coordinator confirmed there was no narcotic box in either medication cart, just the two separately keyed locks. On 9/26/19 at 8:11 AM an interview and observation with RN Z confirmed controlled medications were stored in cassettes in the same drawers of the medication cart as other non-controlled medications. [MEDICATION NAME], [MEDICATION NAME] Patches, and [MEDICATION NAME] (narcotic pain medications) were among the controlled medications observed at that time. A record review of the facility's policy titled Narcotics and Controlled Drugs last revised 3/2019 revealed: 1. Controlled drugs shall refer to Narcotics that are Schedule II, III, or IV or those decided upon by the Pharmacy and Theraputics Committee that should be maintained with a Controlled Drug Record. These controlled drugs are to be handled in accordance with The Controlled Drugs and Substance Act and as outlined in this policy. 2. All controlled drugs are to be stored in double locked med cart. The assigned nurse will carry the narcotic keys at all times.

Licensure Reference Number 175 NAC ,[DATE].09C Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP) (an individualized plan for resident care) related to Advanced Directives (a written document that describes the residents wishes for extraordinary treatment the patient desires in the future) treatment for 2 residents (Residents 18 and 7) of 8 residents reviewed. The facility census was 37. Findings are: [NAME] Record review of Resident 18's Cardio-Pulmonary Resuscitation (CPR) (the attempt to restore breathing, heart function and brain function after a sudden stop of heart circulation) / No CPR Authorization - Surrogate Decision Maker form dated and signed [DATE] revealed that Resident 18 did not wish CPR under any circumstances. Record review of Resident 18's CCP dated [DATE] revealed no information related to Resident 18's wishes for No CPR to be performed under any circumstances in the care plan. Interview on [DATE] at 09:22 AM with Minimum Data Set (MDS) Coordinator confirmed that Resident 18's CCP did not contain information related to Resident 18's CPR status and confirmed that their wishes for No CPR should have been identified in the CCP. B. Review of Resident 7's Advanced Directive revealed Do Not Resuscitate signed and dated [DATE]. Review of Resident 7's comprehensive care plan (a document outlining how to care for the resident) revealed no Advance Directive listed on the care plan. Interview with MDS (Minimum Data Set) Coordinator on [DATE] at 09:22 AM confirmed that the Advance Directive was not on the current care plan for Resident 7 and confirmed that it should be placed on the care plan.

Licensure Reference Number 175 NAC 12-006.9C1c Based on observation, interview, and record review; the facility failed to revise the comprehensive care plan (a document outlining how to care for the resident) to reflect a code status change for 1 (Resident 12) of 8 residents reviewed. The facility had a census of 37. The findings are: An observation on 9/23/19 at 9:06 AM revealed a red heart sticker next to Resident 12's name on the name plate outside (gender) door. An interview with the MDS Coordinator on 9/23/19 at 11:29 AM confirmed the red heart stickers next to resident names on name plates indicated the resident was a full code. A record review of Resident 12's hard chart revealed a DNR (Do Not Resuscitate) form signed (MONTH) 31, 2019 by Resident 12's Power of Attorney and signed by Resident 12's physician on (MONTH) 5, 2019. A record review of the care plan titled Assist, revealed an intervention of FULL CODE with a start date of 8/30/19. An interview with the MDS Coordinator on 9/24/19 at 2:00 PM confirmed Resident 12's care plan and heart sticker on (gender) name plate indicated FULL CODE and did not match the signed form in the chart indicating resident was a DNR. The MDS Coordinator also confirmed Resident 12 was supposed to be a DNR code status.

Licensure Reference Number 175 NAC 12-006.09D2 Based on observation, interview, and record review; the facility failed to monitor bruising for residents receiving anticoagulant therapy for 2 (Resident 3 and 31) of 2 residents reviewed. The facility had a census of 37. The findings are: [NAME] An observation on 9/23/19 at 10:02 AM of Resident 3 revealed multiple bruises in various stages of healing to right and left posterior forearms A record review of Resident 3's (MONTH) 2019 MAR (Medication Administration Record) revealed a skin check was done weekly on Thursday. The order stated to, Observe and chart skin condition. A record review of the (MONTH) 2019 MAR indicated [REDACTED]. A record review of the Cardiovascular section of the Care Plan (a document outlining how to care for the resident) dated 4/4/2019 revealed an intervention of: Monitor for side effects related to Aspirin and Eliquis use: blood in eyes, urine, or stool; excessive bruising; hemoptysis (coughing up blood); decreased alertness. A record review of Resident 3's skin documentation from 6/27/19 - 9/19/19 revealed no current documentation on bruising to bilateral arms. All documentation during these dates stated skin was intact. An interview on 9/25/19 at 8:15 AM with the ADON (Assistant Director of Nursing) confirmed there was no documentation on Resident 3's bruising to right and left forearms. The ADON stated that the expectation was that there should be documentation on bruising and that was something they are working on with staff. B. An observation on 9/23/19 at 10:57 AM revealed Resident 31 had scattered small bruises to the left forearm and to the back of the left hand. A record review of the (MONTH) 2019 MAR (Medication Administration Record) revealed a skin check was done weekly on Monday. The order stated to, Observe and chart skin condition. A record review of the (MONTH) 2019 MAR indicated [REDACTED]. A record review of the ANTICOAGULANTS section of the Care Plan dated 6/5/2019 identified an intervention to: Monitor for bruising and report bruising. Nursing will report bruising to the physician. An observation of Resident 31 on 9/25/19 at 10:16 AM revealed scattered small bruises remain to L) forearm and back of L) hand. A record review of Resident 31's skin documentation from 7/01/19 - 9/23/19 revealed no current documentation on bruising to left forearm or left hand. All documentation during these dates stated skin was intact. On 9/25/19 at 10:58 AM, an interview and observation with the ADON of Resident 31's left forearm and left hand confirmed bruising was present and should be monitored. The ADON also confirmed at this time (gender) was unable to find any current documentation for Resident 31's bruising.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a-b Based on interviews and record reviews, the facility failed to ensure the resident did not develop new or worsening pressure areas. This had the potential to affect 1 (Resident 27)out of 3 residents sampled. The facility census was 35. Findings are: Record review of Resident #27's Face Sheet revealed the resident was admitted on [DATE] and discharged [DATE] for 'death in facility with a catheter and pressure sore greater than stage 1. (Stage 1: Non-blanch able [CONDITION(S)]: Intact skin with non-blanch able redness of a localized area usually over a bony prominence. Its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.) To resident's left heel. Record Review of Resident 27's Wound Assessment Report dated 12/14/17 revealed Pressure Ulcer, left pad of foot on lateral side of left pad of foot Staged unstageable due to slough/eschar. (Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) Record Review of the resident's Baseline Care Plan dated 12/14/17 revealed 'current pressure area to left heel and Other skin concern or wound: left ball of foot purple callous interventions included low loss air mattress and blue heel float boot left foot. Record Review of the resident's Admission Assessment. Re-admission Progress Notes dated 12/14/17 revealed Resident #27 was admitted with one pressure area to left heel that was debrided. Record Review revealed no Wound Assessment Reports for Left Heel documented after 1/18/18 assessment until 4/16/18 Record Review of Progress Note dated 4/6/18 revealed left foot large toe is pink; toe is getting less dark and is warm to touch. Toe is pink around the brownish/black areas. Blue boots remain on both feet and bed cradle on. 4/6/18 left foot large toe is pink 'toe is getting less dark and is warm to touch. Toe is pink around the brownish/black areas. Blue boots remain on both feet and bed cradle on.' Record Review of Behavior Note on 4/12/18 at 11:14 PM revealed left toe big toe and heel are looking better. The big toe has a dark red area (blood blister look) and heel has a scab that is getting smaller. Continues to wear blue boots and the foot cradle over his lower legs. Record Review of Wound Assessment Manger and EZ Graph Wound Assessments revealed no documented wound assessments for big toe/toes. Record Review of HoriSun Hospice Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Progress Note dated 4/16/18 at 2:09 PM resident noted to have a pink are to left buttocks 2 small areas not open. Record Review of Wound Assessment Report dated 4/16/18 revealed Pressure ulcer to left heel Stage 2. (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) Record Review of Wound Assessment Report dated 4/16/18 revealed Pressure ulcer to left buttock Stage 1 measures 7 x 4.5 ( Stage 1: Non-blanch able [CONDITION(S)]: Intact skin with non-blanch able redness of a localized area usually over a bony prominence. Its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue) Record Review of Focus Note dated 4/21/18 at 02:47 PM revealed 1400 resident noted to have copious amounts of cream colored drainage with scant amount of red drainage from heel and complains of pain in whole leg. Record Review of Focus Note dated 4/21/18 at 09:30 PM revealed left buttocks has an area that was bleeding, area looks abraised complains of right heel discomfort and moans and hollers during treatment Record Review of Wound Assessment Report dated 4/23/18 revealed Pressure ulcer to left heel Stage 2. Record Review of EZ Graph Wound assessment dated [DATE] revealed wound to left heel, stage not marked. Record Review of Skin and Wound Care; Assessment and Interventions revised 10/17 page 3 revealed with each dressing change or at least weekly (more often when indicated by wound complications or changes in wound characteristics) and evaluation of the pressure wound should be documented and an E. T. Nurse will be consulted for all stage III and stage 4 wounds. (Stage 3: Full thickness skin loss: Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) On 06/07/18 at 11:06 AM Observation of cares and interview with LPN G revealed Resident #27 has an area to his left heel, not sure if it's pressure. Resident does get out of bed occasionally, usually when daughter is here. On 06/07/18 at 12:14 PM Interview with RN E (Registered Nurse) revealed Resident #27 was admitted with pressure area to left heel that had been debrided prior to admit, and it had healed and it came back again The pressure area is dark, not stageable, and draining. Dressing changes are daily. Resident has an air mattress and heel boots to float heels. Not currently eating at this time, only Hospice medications, no food by mouth. DNR and chose no tube feeding. On 06/11/18 at 01:51 PM interview with the Administrator revealed there is not a bath aide documentation form. The bath aid either calls the nurse in to look at skin changes or gives the nurse a note. All of the documentation is done by the nurses. On 06/11/18 03:02 PM iInterview and record review with RN E revealed that the bath aide was to notify the charge nurse of any new reddened or open areas during baths, that it is documented 'by exception', only when a new area was found. The facility does not document skin checks on residents with each bath/shower. If the bath aid finds any kind of new skin area, redness to skin folds, abdomen or feet, the bath aid notified the wound nurse via a piece of paper. The wound nurse then documents the skin area with an EZ graft wound assessment and a wound assessment in the computer. The wound nurse notifies the Administrator, DON and MDS coordinator of all new wounds in stand up every morning and then the MDS coordinator is the person responsible to update the care plans for all new skin areas. RN E revealed that Resident #27 on admission had one pressure area to the resident's left heel that was debrided and one to the ball of resident's left foot that was healed. On 1/4/18 the area to the ball of the left foot was healed. The left heel was just a rough callous on 1/18/18 but no undermining or boggy areas. The area to resident left heel opened back up on 4/17/18 and area to coccyx was never pressure more rash, friction or shear and moisture had a catheter that leaked. On 4/23/18 areas to left toes dark little area for precautionary reasons put the foot cradle on, but didn't know what caused it and between 1/1/18 and 4/23/18 heel protectors and pressure relief mattress was used. RN E confirmed no documented weekly skin checks from 2/20/2018 through 4/17/2018. On 6/12/18 at 11:03 AM Record Review and interview with DON, MDS coordinator and RN E revealed an E.T. nurse had not been consulted for Resident #27's wounds.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to ensure residents were accurately assessed for comprehensive assessments and care plan development. This had the potential to affect 1 of the residents surveyed. Resident #27. Facility census was 35. Findings are: Record review of Resident #27's Face Sheet revealed the resident was admitted on [DATE] and discharged [DATE] for 'death in facility with a catheter and pressure sore greater than stage 1. (Stage 1: Non-blanch able [DIAGNOSES REDACTED]: Intact skin with non-blanch able redness of a localized area usually over a bony prominence. Its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.) to the resident's left heel. Record Review of Resident 27's Wound Assessment Report dated 12/14/17 revealed Pressure Ulcer, left pad of foot on lateral side of left pad of foot Staged unstageable due to slough/eschar. (Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) Record Review of Resident 27's Baseline Care Plan dated 12/14/17 revealed 'current pressure ulcer to left heel and Other skin concern or wound: left ball of foot purple callous interventions included low loss air mattress and blue heel float boot left foot. Record Review of the resident's Admission Assessment. Re-admission Progress Notes dated 12/14/17 revealed Resident #27 was admitted with one pressure ulcer to left heel that was debrided. Record Review of the resident's MDS (Minimum Data Set) admitted d 12/ 17 /17 revealed 2 unstageable pressure areas present, 2 present on admit. 2 present on admit with eschar present. Record Review of EZ Graph Wound assessment dated [DATE] revealed wound location outside lateral ball of foot left foot Stage not marked. However wound base marked brown and purple (can indicate eschar or Deep Tissue Injury) and description marked callous/dry. Record Review of EZ Graph Wound assessment dated [DATE] revealed wound to Left heel, stage (not marked/unstageable not marked) Record Review revealed no Wound Assessment Reports for left heel documented after 1/18/18 assessment until 4/16/18. Record Review of Significant Change MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/22/18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated Resident 27's cognition was moderately impaired. Section O revealed Hospice Care. Section M revealed 1 unstageable pressure area present on admit and 1 current unstageable pressure area with eschar present. Record Review of Progress Note dated 4/6/18 revealed left foot large toe is pink; toe is getting less dark and is warm to touch. Toe is pink around the brownish/black areas. Blue boots remain on both feet and bed cradle on. 4/6/18 left foot large toe is pink 'toe is getting less dark and is warm to touch. Toe is pink around the brownish/black areas. Blue boots remain on both feet and bed cradle on.' Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Behavior Note on 4/12/18 at 11:14 PM revealed left toe big toe and heel are looking better. The big toe has a dark red area (blood blister look) and heel has a scab that is getting smaller. Continues to wear blue boots and the foot cradle over his lower legs. Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Wound Assessment Manger and EZ Graph Wound Assessments revealed no documented wound assessments for big toe/toes. Record Review of HoriSun Hospice Physician order [REDACTED]. Record Review of Progress Note dated 4/16/18 at 2:09 PM resident noted to have a pink are to left buttocks 2 small areas not open. Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Wound Assessment Report dated 4/16/18 revealed Pressure ulcer to left heel Stage 2. (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Wound Assessment Report dated 4/16/18 revealed Pressure ulcer to left buttock Stage 1 measures 7 x 4.5 ( Stage 1: Non-blanch able [DIAGNOSES REDACTED]: Intact skin with non-blanch able redness of a localized area usually over a bony prominence. Its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue) Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Focus Note dated 4/21/18 at 02:47 PM revealed Resident noted to have copious amounts of cream colored drainage with scant amount of red drainage from heel and complains of pain in whole leg. Record Review of Wound Assessment Report dated 4/23/18 revealed Pressure ulcer to left heel Stage 2. Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Quarterly MDS dated [DATE] revealed has a Stage 2 pressure area 4/16/18 and MO700 documented slough is present. By definition a Stage 2 pressure area does not have slough present. (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of EZ Graph Wound assessment dated [DATE] revealed wound to left heel, stage not marked. Record Review of Care Plan received 6/11/8 revealed the care plan was not updated for this wound. Record Review of Skin and Wound Care; Assessment and Interventions revised 10/17 page 3 revealed with each dressing change or at least weekly (more often when indicated by wound complications or changes in wound characteristics) and evaluation of the pressure wound should be documented and an E. T. Nurse will be consulted for all stage III and stage 4 wounds. (Stage 3: Full thickness skin loss: Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) On 06/07/18 at 11:06 AM Observation of cares and interview with LPN G revealed Resident #27 has an area to his left heel, not sure if it's pressure. Resident does get out of bed occasionally, usually when daughter is here. On 06/07/18 at 12:14 PM Interview with RN [NAME] revealed 'Resident #27 was admitted with pressure area to left heel that had been debrided prior to admit, and it had healed and it came back again, I don't remember when. It's dark, not stageable, draining. Dressing changes are daily. Resident has an air mattress and heel boots to float heels. Not currently eating at this time, only Hospice medications, no food by mouth. DNR and chose no tube feeding. Record Review of Care Plan received on 6/11/18 revealed Problem onset 12/27/17 Potential for skin breakdown d/t decreased mobility, occasional incontinence of bowel. admitted with 2 pressure ulcer present on left heel. Goal is to maintain intact skin integrity Approaches included: skin checks during cares each shift, report to nurse any concerns (CNA); complete skin check weekly with bath (BATH). Blue boots to L foot at all times. Care plan does not include skin wounds/pressure area to coccyx or toes. On 06/11/18 03:02 PM Interview and record review with RN [NAME] revealed that the bath aide is to notify the charge nurse of any new reddened or open areas during baths, that it is documented 'by exception', only when a new area is found. The facility does not document skin checks on residents with each bath/shower. If the bath aid finds any kind of new skin area, redness to skin folds, abdomen or feet, the bath aid notified the wound nurse via a piece of paper. The wound nurse then documents the skin area with an EZ graft wound assessment and a wound assessment in the computer. The wound nurse notifies the Administrator, DON and MDS coordinator of all new wounds in stand up every morning and then the MDS coordinator is the person responsible to update the care plans for all new skin areas. RN [NAME] stated for Resident #27 On admit resident had one pressure area to resident's left heel that was debrided and one pressure area to the ball of residents left foot that was healed on1/4/18 . The left heel was just a rough callous on 1/18/18 but no undermining or boggy areas. The area to resident's left heel opened back up on 4/17/18 and area to coccyx was never pressure; more rash, friction or shear and moisture as had a catheter that leaked. On 4/23/18 areas to left toes dark little area; for precautionary reasons put the foot cradle on, I don't know what caused it (areas to left toes.) and between 1/1/18 and 4/23/18 we used heel protectors and pressure relief mattress. RN [NAME] revealed that there were no documented weekly skin checks from 2/20/2018 through 4/17/2018. On 06/12/18 at 11:03 Interview and record review with MDS coordinator; with DON present: revealed from progress notes on 4/6 and 4/12 and that area to left toe was not on any MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) including the Quarterly MDS dated [DATE]; or care plan for Resident #27. On 6/12/18 at 11:03 AM Record Review and interview with DON, MDS coordinator and RN revealed an E.T. nurse had not been consulted for Resident #27's wounds.