Every finding on record at Memorial Community Care

Licensure Reference Number 175 NAC 12-006.07(A) The facility failed to ensure the required members of the Quality Assurance and Performance Improvement (QAPI - a data-driven, proactive approach to Quality Assurance {meeting standards} and performance improvement {enhancing processes} to improve care, safety, and quality of life) Committee attended the quarterly meetings. This had the potential to affect 33 residents that resided in the facility at the time of the survey. The facility census was 33. Findings are: A record review of the facility's undated QAPI policy revealed the committee members included the Medical Director (Physician Review Committee). A record review of the facility QAPI meeting minutes dated 10.14.2025, 11.11.2026, 12.9.2025, and 1.13.2026 revealed the Medical Director was not in attendance at the meetings. During an interview on 2.2.2026 at 9:00 AM, the Administrator (ADM) confirmed the facility's Medical Director does not attend the QAPI' quarterly committee meetings, and only reviews the nursing facility's QAPI minutes.

Licensure Reference Number 175 NAC 12-006.11(E) Based on record reviews, observations, and interviews, the facility failed to ensure the water temperatures of the facility dishwasher reached the required temperature while washing and rinsing dishes and utensils. This affected all residents in the facility who received food and meals from the facility kitchen. The reported census was 37. Findings are: Record Review on 9/18/2024 of the undated [NAME] automatic dishwashing machine manufacturer panel decal revealed that the dishwasher was a high temperature machine which required a minimum water temperature during the wash cycle of 160 degrees Fahrenheit (F) and the rinse cycle of 180F degrees to activate the chemicals used for sanitization. This information was located on the upper right-hand corner of the dishwashing machine. Observation in the kitchen of the [NAME] dishwashing machine while in use on 9/18/2024 at 8:45 AM revealed the water for the wash cycle reached a temperature of 148F degrees. The temperature for the rinse cycle was over 180 degrees F. Observation on 9/18/24 at 8:45 AM of four wash/rinse cycles of the dishwasher revealed no temperatures above 150F degrees for the wash cycle. Interview with Dietary Aide-D (DA-D) on 9/18/2024 at 8:55 AM revealed the temperatures are recorded on the temperature log sheet by the doorway. We can't get the temperature to go above 150 most of the time for the wash cycle. When asked if the staff use the three-sink sanitization method for washing dishes, DA-D stated that the rinse cycle gets over 180 degrees, so they have been using the dishwasher not the three-sink sanitization method. Record review of the Dishwashing Temperature Log dated September (Sept) 2024 stated the required temperatures for the wash cycle is 160 degrees Fahrenheit and for the Rinse cycle is 180 Degrees Fahrenheit at the top of the log sheet. The log revealed the following temperatures during the wash cycle: -[DATE]: PM 150F, -[DATE]: AM 147F, PM 147F, -[DATE]: PM 147F, -[DATE]: AM 155F, PM 144F, -[DATE]: AM 155F, -[DATE]: AM 145F, -[DATE]: AM 146F, PM 145F, -[DATE]: PM 147F, -[DATE]: PM 156F, -[DATE]: AM 150F, PM 150F, -[DATE]: AM 159F, PM 150F, -[DATE]: AM 150F, PM 159F. Record review of the Daily Dishwashing Temperature Chart for the month of August (Aug) 2024 stated the required temperatures for the wash cycle was 160 degrees Fahrenheit and for the Rinse cycle is 180 Degrees Fahrenheit at the top of the log sheet. The log revealed the following temperatures during the wash cycle: -[DATE]: AM (morning)154F degrees F: PM (afternoon)144F degrees -[DATE]: PM 150F, -[DATE]: PM 150F, -[DATE]: PM 155F, -[DATE] PM 155F, -[DATE]: AM 148F, -[DATE]: AM 150F, -[DATE]: AM 145F, -[DATE]: AM 145F, -[DATE]: PM 159F, -[DATE]: PM 153F, -[DATE]: PM 145F, -[DATE]: AM 156F, PM 152F, -[DATE]:PM 148F, -[DATE]:PM 148F, -[DATE]: AM 148F, PM 145F, -[DATE]: AM 158F, PM 146F, -[DATE]: AM 158F, -[DATE]: AM 146F, PM 146F, -[DATE]: AM 158F, PM 146F, -[DATE]: AM 142F, PM 148F, -[DATE]: AM 146F, -[DATE]:PM 154F, -[DATE]: PM 154F, -[DATE]: PM 146F. During the Month of August 2024; The rinse cycle did not reach the minimum required temperature of 180 Degrees Fahrenheit on the following dates: -[DATE]th 160F, -[DATE]th 160F, -[DATE]th 170F, -[DATE]st 175F, -[DATE]nd 175F, and -[DATE]th 145F. Record review of an Email sent on 1/19/2024 to the FSS (Food Service Supervisor), regarding the dietary staff training courses, revealed that kitchen staff had gone through the National Restaurant Association ServSafe Training. (ServSafe training covers a variety of topics related to food safety and beverage handling including instructions on cleaning and sanitizing: How to clean and sanitize food preparation areas and utensils.) Interview with Facility Administrator (FA) on 9/18/2024 at 9:05 AM confirmed the temperature for the wash cycle was not at or above the required 160F degrees as mandated by the manufacturer instructions seen on the [NAME] dishwasher. Kitchen staff had to use the three-sink method of cleaning and sanitizing dishes until the dishwasher was fixed. I don't care how long it takes to fix it; the staff will be using the three-sink sanitization method until our temperatures are within the correct parameters. Interview with the Infection Control Nurse (ICC) on 9/18/2024 at 9:08 AM. When asked about the temperatures for the washing and rinse cycles, the ICC revealed that because the temperature of the Rinse cycle reached 180 degrees that the temperature for the wash cycle would not be as important. Interview with the Maintenance personnel (Maint) on 9/18/2024 at 9:15 AM confirmed the temperatures on the dishwasher didn't meet the required temperatures for the wash cycle as the temperatures did not reach the required 160 degrees F. Maint had worked on the machine. Maint is waiting on supplies and has been on the list for a technician to come to the facility for a while.

Licensure Reference Number 175 NAC 12-006.05(D)(E) Based on record reviews, observations and interviews, the facility failed to inform the resident of medication changes made by the provider for 1 (Resident 14) of 1 sampled residents, and failed to re-evaluate residents or responsible parties choices for eye care needs for 1 (Resident 17) of 1 sampled residents. The facility census was 37. Findings are: A. Review of the facility supplied document labeled Resident Rights and dated 2016 revealed the following: -The resident has the right to be informed of and participate in their treatment including the right to be fully informed of their total health status. -The resident has the right to be informed in advance of the care to be furnished. -The resident has the right to be informed in advance of the risks and benefits of proposed care of treatment and treatment alternatives or treatment options and to choose the option they prefer. Review of the facility supplied document labeled Facility Assessment and dated 08/02/2024 revealed under resident preferences the facility supports a culture of person-centered care with respect to personal preferences. In an interview on 09/18/2024 at 10:35 AM with Resident14, Resident14 expressed concern due to being started on the medication Metformin (a medication that helps regulate blood sugar levels) a while back and was not informed of the medication change. The resident stated I refused to take the medication until I got notified of why my medications changed. A review of an Admitting Record not dated revealed the facility admitted Resident 14 on 06/27/2022 with diagnoses that included diabetes (when the body has trouble controlling blood sugar and using it for energy). The quarterly Minimum Data Set (MDS, a federally mandated tool used to assess the health status of residents in long-term care facilities) with an ARD of 07/17/2024 revealed Resident 14's Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score was 15 indicating the resident was cognitively intact. Review of Resident 14 Care Plan dated July 2024 revealed a goal stated of the resident would like to continue to direct their care and stay as independent as possible. No interventions were listed for this documented goal. Review of Resident 14's Medication Administration Record (MAR) for the month of August 2024 revealed documentation that Resident 14 declined to take the medication Metformin on August 13th, 14th, 17th, and 18th. No reason for the declination is listed in the resident's medical record. A review of Resident 14 Physican Orders dated 09/19/2024 revealed on 08/13/2024 Resident 14 Metfromin medication orders were changed increasing the dosage and frequency of this medication. A review of Resident 14's Progress Notes for the month of August 2024 revealed no progress notes reflecting Resident 14 was notified and consented to the changes in their Metformin medication. In an interview on 09/23/2024 at 4:45 PM with the Director of Nursing (DON), the DON revealed when resident orders are changed the nurse is to notify the resident and or responsible party and documentation of this notification should be present in the resident's progress notes. The DON confirmed that there was no documentation present confirming the resident was notified about the medication change prior to being administered the medication. C. In an interview on 09/18/2024 at 1:45 PM with Resident 17's responsible party revaled [gender] has a concern due to the resident not seeing an eye doctor in years. A review of an Admitting Record not dated revealed the facility admitted Resident 17 on 11/23/2018 with diagnoses that included dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities). The comprehensive MDS with an ARD of 08/21/2024 revealed Resident 17 had adequate vision with the use of corrective lenses and had a BIMS score of 7 indicating the resident was severely cognitively impaired. Review of Resident 17's Care Plan dated August 2024 revealed under the heading Vision that the resident wore glasses, and their last appointment was probably 2-3 years ago. It is also documented that on admission to the facility the resident declined a vision exam. In an interview on 09/19/2024 at 1:24 PM with the Facility Administrator (FA), the FA confirmed that the resident was asked on admission about wanting an eye exam and had declined. The FA stated there was no documentation or records reflecting that the resident or their responsible party were re asked about wanting an appointment to have the residents vision checked since the resident admitted to the facility in 2018. The FA confirmed that the resident had not seen an eye doctor since being admitted to the facility.

Based on record review, and interview; the facility failed to accurately code residents Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) for 3 (Resident 4, 14, and 17) of 4 sampled residents. The facility stated census was 37. Findings are: A. A review of an Admitting Record not dated revealed the facility admitted Resident 4 on 09/10/2019 with diagnoses that included anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities), and psychosis(a severe mental disorder that causes abnormal thinking and perceptions). A review of a document titled Nebraska Summary of Findings Preadmission Screening and resident Review (PASRR), (a screening program mandated by the federal Centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness and intellectual/developmental disabilities are appropriately placed and receive necessary services to meet their needs), dated 10/29/2019 revealed in the section titled Is nursing facility an appropriate option for you to choose that the PASRR determination was that Resident 4 met criteria for serious mental illness based on their diagnoses of unspecified psychosis and major depression, symptoms, and treatment needs. The comprehensive MDS with an Assessment Reference Date (ARD) of 05/29/2024 revealed in section A1500 Preadmission Screening and Resident Review (PASRR) Conditions 0 indicating that the resident was not considered by the PASRR to have a serious mental illness or related condition. In an interview on 09/18/2024 at 5:37 PM with the Social Service Director (SSD), the SSD confirmed that Resident 4 had a PASRR level II completed and confirmed that the PASRR indicated Resident # had a serious mental illness and this was not coded in A1500 on the 05/29/2024 comprehensive MDS. In an interview on 09/19/2024 at 9:45 AM with the MDS Coordinator (MDSC), confirmed that Resident 4 having a serious mental illness was not coded on the Comprehensive MDS dated [DATE]. B. A review of an Admitting Record not dated revealed the facility admitted Resident 14 on 06/27/2022 with diagnoses that included anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities). The quarterly MDS with an ARD of 07/17/2024 revealed in section N the resident was coded to have received antipsychotic medications and the physician had not documented that a Gradual Dose Reduction (GDR) was clinically contraindicated. Review of Resident 14 Care Plan dated July 2024 revealed in the section titled Black Box Warning/Gradual Dose Reduction (GDR) that on 12/17/2023 Resident 14's primary provider had documented that no GDR is to be done due to the resident condition being stable. In an interview on 09/24/2024 at 9:13 AM with the MDSC, the MDSC confirmed that Resident 14 provider had documented on 12/17/2023 that a GDR for this resident was contraindicated and section N of the MDS dated [DATE] was not coded correctly to reflect this. C. A review of an Admitting Record not dated revealed the facility admitted Resident 17 on 11/23/2018 with diagnoses that included dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities). The comprehensive MDS with an ARD of 08/21/2024 revealed in section N the resident was coded to have received antipsychotic medications and the physician had not documented that a Gradual Dose Reduction (GDR) was clinically contraindicated. Review of Resident 17's Care Plan dated August 2024 revealed in the section titled Black Box Warning/Gradual Dose Reduction (GDR) that on 12/28/2023 Resident 17's psychiatric provider had documented that no GDR is to be done due to the risk of resident mood decompensation. In an interview on 09/24/2024 at 9:13 AM with the MDSC confirmed that Resident 17's provider had documented on 12/28/2023 that a GDR for this resident was contraindicated and section N of the MDS dated [DATE] was not coded correctly to reflect this.

Based on record reviews and interviews, the facility failed to ensure physician visits were completed within the required time intervals for 2 (Resident 7, and 23) of 4 sampled residents. The facility census was 37. Findings are: A. Record review of the June 2024 Care Plan for Resident 7 revealed no in-person physician (or advanced practice professional) visits with Resident 7 between the dates of 12/04/2023 and 04/8/2024. This resulted in no physician or an advanced practice professional visit for a period of 126 days. Record review of a handwritten undated list of physician visitation dates presented by the Facility Administrator (FA) revealed a physician visited Resident 7 on 12/04/2023 and 4/8/2024. Interview with the Director of Nursing (DON) on 9/24/2024 at 4:35 PM revealed the resident was not seen by a physician for a period of 126 days. The DON revealed each facility resident is seen yearly by a physician for their individual health updates and physicals. The DON confirmed residents do not see a physician as mandated every 60 days. We didn't know about that regulation requirement. Interview with the FA on 9/24/2024 at 4:36 PM confirmed Resident 7 was not seen by a physician for a period of 126 days. The FA recognized there was no process in place for the required 60-day visit and stated a process would be enacted. B. Record review of the July 2024 Care Plan for Resident 23 revealed there were no in person physician (or advanced practice professional) visits with Resident 23 between the dates of 10/26/2023 and 3/21/2024. This resulted in no physician or an advanced practice professional visit for a period of 147 days. Record review of a handwritten u ndated list of physician visitation dates presented by the Facility Administrator (FA) on 9/24/2024 revealed a physician visited Resident 23 on 10/26/2023 and 3/21/2024. Interview with the Director of Nursing (DON) on 9/24/2024 at 4:35 PM Resident 23 had not been seen by a physician for a period of 147 days. The DON confirmed that residents are not seen routinely every 60 days by a physician. Interview with FA on 9/24/2024 at 4:36 PM confirmed Resident 23 was not seen by a physician for a period of 147 days.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview, the facility failed to dispose of food in a timeframe to prevent foodborne illness and cross contamination. This had the potential to affect 40 residents that ate food prepared in the facility kitchen. The facility census was 40. Findings are: An observation on 09/11/23 from 8:19 AM to 8:30 AM revealed the following during the initial kitchen tour: -a carton of heavy whipping cream opened on 8/7 -a container of classic egg salad opened on 8/27 -a container of labeled cinnamon roll frosting dated 5/11 An observation on 9/14/23 from 8:18 AM to 8:28 AM revealed the following during the final kitchen tour: -a carton of heavy whipping cream opened on 8/7 -a container of classic egg salad opened on 8/27 -a container of labeled cinnamon roll frosting dated 5/11 -a pitcher labeled strawberry kiwi juice dated 9/8 -a container labeled chicken broth dated 9/10 Review of the facility policy, Food Service Policies and Procedure: Infection Prevent, dated 9/28/15 revealed the following: -10. Food mixture high in protein, such as cream soup, custards, egg mixtures, mayonnaise in meat are not to be kept longer than one day under refrigeration. -11. Main dishes, vegetables will be discarded after 3 days; fruits that are open and fruit juices within 4 days. An interview on 9/14/23 at 8:28 AM the Dietary Manager confirmed that the heavy whipping cream, egg salad, cinnamon roll frosting, and the strawberry kiwi juice should have been thrown out three days after the date on the container. An interview on 9/14/23 at 8:30 AM the Cook confirmed that the chicken broth should have been thrown out three days after the date on the container and confirmed that all 40 residents receive food from the kitchen.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview the facility failed to notify the physician of a significant weight loss for 1 (Resident 17) of 3 sampled residents. The facility identified a census of 40. Findings are: Record review of the H&P dated 8/18/23 for Resident 17 revealed Resident 17's admitting diagnoses included Coronary Artery Disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart) and Chronic Congestive Heart Failure (the heart works less efficiently than normal). Record review of the Comprehensive Care Plan (CCP) dated September 2023 revealed no indication of Resident 17 being at risk for weight loss. Record review of the Medication Administration Record and the Treatment Administration Record, both dated September 2023, indicated no monitoring of edema had occurred. Record review of the documented weights for the last 6 months for Resident 17 revealed on 03/11/2023, Resident 17 weighed 327.8 lbs (pounds) and on 09/07/2023, Resident 17 weighed 284.6 lbs which is a -13.18 % Loss. Record review of Resident 17's Dietary Note (DN) dated 8/22/23 revealed Resident 17 had a 11.9% weight loss in the previous 6 months. Further review of Resident 17's DN dated 8-22-23 revealed there was no indication Resident 17's practitioner had been notified of the weight loss. A record review of the Progress Notes dated 3/15/23 through 9/13/23 for Resident 17 revealed no documented notification to the physician regarding a significant weight loss. An interview on 09/14/23 at 01:33 PM with the DON confirmed that no evidence existed regarding physician notification of the significant weight loss for Resident 17.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1b Based on observation, record review and interview; the facility failed to assist 1 (Resident 2) of 1 sampled resident with meal intake within a time frame to ensure palatability and to prevent the potential for foodborne illness. The facility identified a census of 40. Findings are: Review of Resident 2's admitting record revealed that Resident 2 admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. Review of Resident 2's comprehensive care plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed: -Nutrition: Eating Habits: Please offer and encourage me to drink plenty of fluids at and between meals. I am at an assist table to help improve my intakes. Review of Resident 2's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 6/28/23, revealed: -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): 5 -Eating: required supervision (oversight, encouragement or cueing) after set up help from staff -Received a mechanically altered diet (a diet that requires a change in texture of food or liquids) Review of physician visit report, dated 8/21/23, revealed that Resident 2 required set up and max assist total care while eating. An observation on 9/13/23 at 11:28 AM revealed Resident 2's lunch plate and drinks were placed in front of Resident 2 by Medication Aide (MA)-A. The observation further revealed, Resident 2's head in a lowered position and both hands placed in Resident 2's lap. A continuous observation on 9/13/23 from 11:28 AM to 11:42 AM revealed Resident 2's positioned with Resident 2's head lowered, and hands placed in Resident 2's lap. The observation further revealed, no interaction between staff and Resident 2. An observation on 9/13/23 at 11:42, MA-B sat next to Resident 5, on the opposite side of Resident 2, and proceeded to assist Resident 5 with eating. A continuous observation on 9/13/23 from 11:42 AM to 12:04 PM revealed no interaction between MA-B and Resident 2. The observation further revealed, Resident 2's head lowered, and hands placed in Resident 2's lap. An interview on 9/13/23 at 12:05 PM, Nursing Assistant (NA)-C confirmed that Resident 2 needed assistance with eating and that Resident 2 had not been assisted with eating. NA-C further confirmed that Resident 2 should not have had to wait 36 minutes to be assisted with the meal and that MA-B should have assisted Resident 2 with the meal while MA-B assisted Resident 5. Review of the facility's, Serving and Feeding Residents, dated 8/14/22, revealed the following: -J. Offer assistance if necessary. -K. Feed patient when necessary. Place apron across patient's chest. Sit down at table with resident. Engage in conversation that revolves around resident. -N. Food should not be served to resident's that need assistance until staff is available to feed them immediately, so food does not get cold.

Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to ensure wound care was completed for 1 (Resident 38) of 1 sampled resident as ordered by the practitioner. The facility census was 40. Findings are: Record review of Resident 38's admitting record revealed that Resident 38 admitted to the facility on [DATE] with diagnosis of weakness and cellulitis (bacterial infection of the skin). Record review of Resident 38's initial 48-hour care plan, undated, revealed the following: -Medications/Treatments per Doctor's orders -Other care notes: significant edema- weeping on bilateral lower extremities (BLE), dressing changes Record review of Resident 38's treatment administration record (TAR) for September 2023 revealed the following orders: -Wound care to left second toe: wash with soap and water. Place Aquacel AG (AG-silver, dressing applied to wounds that are at risk for infection) on wound bed cover with bandaid on MWF (Monday, Wednesday, Friday) -Wound care: paint black areas daily on toes with betadine (antiseptic used for the treatment of skin infections) An observation on 9/13/23 from 1:39 PM to 1:40 PM of wound care provided by Licensed Practical Nurse (LPN)-D for Resident 38 revealed LPN-D placed gloves on hands and applied betadine to the anterior aspect of Resident 38's second toe and the posterior aspect of Resident 38's third toe. The observation further revealed a bandaid to the tip of Resident 38's third toe. An interview on 9/13/23 at 2:36 PM LPN-D confirmed that the bandaid was intact to Resident 38's third toe and that Resident 38's second toe had betadine applied. LPN-D further confirmed that the order for Resident 38's second toe was to wash with soap and water, apply Aquacel AG and then apply a bandaid and that LPN-D had not followed the orders when the treatment was completed. Review of the facility policy titled Dressings, dated 5/3/21, revealed that the policy did not address that wound care should be completed as ordered by the practitioner.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on record review and interview the facility failed to ensure pre-employment screening included APS/CPS (Adult Protective Services/Child Protective Services) checks of licensure for 2 of 3 newly hired staff prior to providing patient cares. This had the potential to affect all residents. The facility identified a census of 40. Findings are: A record review of the employee files of NA's hired within the last 6 months revealed that NA-E's file did not contain a license check from APS/CPS which would indicate any adverse allegations against NA-E's license prior to providing direct patient cares. A record review of the employee files of NA's hired within the last 6 months revealed that NA-F's file did not contain a license check from APS/CPS which would indicate any adverse allegations against NA-F's license prior to providing direct patient cares. An interview on 9/13/23 at 3:15 PM with the Human Resource (HR) Director confirmed that the APS/CPS license checks were not completed for NA-E and NA-F and should have been. A record review of the facility policy titled Pre-Employment Screening Policy with a revision date of 5/23/23 read as follows: IV. Process: 2. Upon receipt of the completed background report, the Human Resources Department will review the findings as soon as possible with the Hiring Manager. ii. If the background report contains information that is concerning, or contrary to the information found on the application, the Director of HR will review the background report with the Hiring Manager and/or CEO (Chief Executive Officer) to determine whether or not to continue with the employment process. 3. If the background check does not include information which may disqualify a candidate from employment eligibility, the candidate may begin employment prior to the Adult and Child Abuse Registry report being received. Continued employment would still be contingent upon the successful completion and status of this check.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B Based on record review and interview, the facility failed to identify target behaviors for residents with MI/DD (Mental Illness/Developmental Disability) and ensure behavior monitoring occurred related to [CONDITION(S)] medication use for Resident 1, 15, 17 and 19. The sample size was 4. The facility census was 30. FINDINGS ARE: A. A record review of the MAR/TAR dated July 2022 revealed Resident 1 takes the following medications which require some type of monitoring or follow up such as MMR's (Monthly Med Review) or GDR's (Gradual Dose Reductions), labs, vitals, pain levels, behavior monitoring etc; -[MEDICATION(S)] 200mg once daily for hypertension -[MEDICATION(S)] HCL XL150mg once daily for Major Depressive Disorder -Trazadone 100mg every bedtime for [CONDITION(S)] A record review of the document titled Behavior Detail Report dated 8/2/22 and covering the timeframe of 6/3/22 through 8/1/22 and documented by the CNA's revealed that on 6/29/22 Resident 1 had displayed sexually inappropriate behavior towards female staff. The Behavior Detail Report dated 8/2/22 and covering the timeframe of 6/3/22 through 8/1/22 revealed no other behaviors or s/s depression. A record review of the Progress Notes dated 5/17/22 through 7/8/22 for Resident 1 did not indicate any negative or sexually inappropriate behaviors during that time frame. An interview on 08/03/22 at 08:41 AM with the DON (Director of Nursing), after review of the behavior charting and progress notes for Resident 1 confirmed that the facility expectation related to negative behaviors was that if the CNA's (Certified Nurse Aide) documented behaviors occurring in their task charting, the nurses were expected to have follow up charting in the Progress Notes. The interview with the DON confirmed that the Progress Notes for Resident 1 did not address the sexual behaviors displayed on 6/29/22. The interview on 08/03/22 at 08:41 AM with the DON, after review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 1, confirmed that it did not indicate Resident 1 had a history of sexually inappropriate behaviors and should have. The interview on 08/03/22 at 08:41 AM with the DON, confirmed that target behaviors should be found on the Resident's CCP and was not. The interview confirmed that the facility had not assessed Resident 17 for target behaviors. A record review of the policy titled Medication Administration dated 2/2004 and revised 6/4/2020 revealed it did not contain direction related to hypnotic use. An interview on 08/03/22 at 10:35 AM with the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) confirmed that no sleep diary had been completed since Resident 1's admission related to the Trazadone use or diagnosis of [CONDITION(S)]. B. A record review of the MAR/TAR dated July 2022 revealed Resident 17 takes the following medications which require some type of monitoring or follow such as MMR's, GDR's, labs, vitals, pain levels, behavior monitoring etc; *Acetaminophen 325mg TID (Three times a day) for pain *Gabapentin 300mg BID (Two times a day) for pain *Ativan 1mg TID for anxiety disorder *[MEDICATION(S)] 25mg at bedtime for anxiety disorder *Trazadone 50mg 1/2 tab every bedtime for anxiety disorder An interview on 08/03/22 at 08:41 AM with the DON, after review of behavior documentation for Resident 17 confirmed that the facility expectation is that if negative behaviors are noted by NA's, it will be reported to the Nurse on duty and the Nurse will follow up and document in the Progress Notes. The interview confirmed that no follow up documentation by the nurses in the Progress Notes had been completed and should have. The interview on 08/03/22 at 08:41 AM with the DON, confirmed that target behaviors should be found on the Resident's CCP and was not. The interview confirmed that the facility had not assessed Resident 17 for target behaviors. C. A record review of current Physician's Orders for Resident 15 revealed orders for the following: [MEDICATION(S)] (a medication used to treat depression), [MEDICATION(S)] (a medication used to treat anxiety) and [MEDICATION(S)] (an antipsychotic medication used to treat certain mental or mood disorders.) A record review of Resident 15's Medication Administration Record (MAR) dated June 2022 through July 2022 revealed [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] medications were given every day in the months of June and July of 2022. A record review of Resident 15's Behavior Detail Report dated 5/24/22 through 7/2/22 revealed None of these behaviors apply were charted every day except for 3 days in the month of June. A record review of Resident 15's comprehensive care plan Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) last revised on 5/1/22 listed the medications [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and no target behaviors. An interview on 8/3/22 at 08:47 AM with the Director of Nursing (DON) confirmed the target behaviors should be listed on the CCP. D. A record review of current Physician's Orders for Resident 19 revealed orders for the following: Risperdone (an antipsychotic medication used to treat certain mental or mood disorders.) A record review of Resident 19's MAR dated June 2022 and July 2022 revealed risperdone was given every day in the months of June and July of 2022. A record review of Resident 19's Behavior Detail Report dated 7/5/22 through 8/3/22 revealed None of these behaviors apply was documented every day. A record review of Monthly Medication Review dated June and July 2022 revealed no pharmacy recommendations. A record review of Resident 19's CCP last revised 4/19/2022 listed risperdone medication and no target behaviors. An interview on 8/3/22 at 08:47 AM with the DON confirmed the target behaviors should be listed on the CCP.

Licensure Reference 175 NAC 12-006.11E Based on record review, observations, and interview; the facility failed to ensure food was served at temperatures to prevent the potential for food borne illness. This had the potential to affect all residents. The facility identified a census of 30 at the time of survey. Findings are: An observation of temperature checks on 08/03/22 at 11:15 AM of the steam table in the main dining room performed by Cook D revealed the following temperatures: Mixed fruit cup, 44 degrees chopped tomatoes, 46 degrees An observation of temperature checks on 08/03/22 at 12:10 PM, of the last room tray served, performed by Cook D, revealed the following temperatures: salmon, 115 degrees baked potato, 129 degrees cream corn,124 degrees Sour cream raisin bar, 74 degrees An interview on 8/3/22 at 12:15 with Cook D confirmed all the food on this tray was not within the required temperatures. Record review of the Nebraska State Food Code 81-2,272.01 Time/Temperature control for Safety Food, Hot and Cold holding revealed: Time/temperature control for safety food shall be maintained at: a.) One hundred thirty - five degrees Fahrenheit or above b.) Forty - one degrees Fahrenheit or less A record review of the facility policy, revised 9/28/2015 titled Food Service Policies and Procedures Infection Prevention revealed under Preparation and Service, #4 states that entry and growth of contaminants in food depends on the length of time these foods are held between 41-135 degrees Fahrenheit. In an interview on 08/03/22 at 01:02 PM with Dietary Manager (DM) confirmed the holding temperatures taken by Cook D were above 41 degrees and below 135 degrees and that the steam table temperature logs are not monitored and they should have been.

Licensure Reference NAC 12-006.17 Licensure Reference NAC 12-006.17D Based on record review, observations, and interviews; the facility failed to ensure hand hygiene was performed after glove removal in the kitchen, after touching hair and prior to assisting a resident with their meal and that dishes were carried in a manner to prevent potential cross contamination. This had the potential to affect all residents. The facility identified with a census of 30 at the time of survey. Findings are: A kitchen observation on 08/03/22 at 10:49 AM revealed Dietary Aide (DA) F taking off gloves in the kitchen, without performing hand hygiene and then picking up a bowl of dessert. An interview with DA F on 8/3/22 at 10: 51 AM confirmed hand hygiene should have been performed after removing gloves. An observation in the dining room on 08/03/22 at 11:40 AM revealed Nursing Assistant (NA) H touching hair, not doing hand hygiene prior to assisting residents with their meals. On 8/3/22 at 1:02 PM the Director of Nursing (DON) confirmed everyone should be doing hand hygiene in the dining room. A kitchen observation on 08/03/22 at 10:50 AM revealed DA G carrying clean plate lids against the employee's shirt. An interview on 8/3/22 at 10:55 AM with DA confirmed the clean dishes should not have touched the employee shirt. A kitchen observation on 08/03/22 at 10:42 AM revealed Cook D taking the temperature of the cooked food in the kitchen using the same alcohol wipe to clean off the thermometer in between foods in order to take the food temperatures. An interview on 8/3/22 at 10:45 AM with the cook confirmed that usually they just use one alcohol wipe. A record review of facility policy last reviewed on 9/13/2018 titled Hand Hygiene Policy and Procedure revealed the 6 moments for hand hygiene, # 5 states before and after handling food. A record review of facility policy last reviewed on 10/1/2017 titled Dress Code revealed under procedures in section F that all long and medium length hair should be worn up or tied securely back when working with residents. An interview with the Dietary Manager (DM) on 8/3/22 at 1:02 PM confirmed that the dietary staff should have washed their hands when removing gloves, nothing clean should touch the uniform, and the cook should have used a clean alcohol wipe in between foods in order to clean the thermometer. An interview with the DON on 8/3/22 at 1:05 PM confirmed the nursing assistant should have performed hand hygiene after touching hair and before assisting residents with their meals.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review, the facility failed to ensure respiratory equipment was stored in a manner to prevent potential cross contamination when not in use for Resident 4. The sample size was 2. The facility census was 30. FINDINGS ARE: An observation on 08/01/22 at 04:00 PM revealed Resident 4 to have a band-aid on the bridge of (gender) nose and voiced it was caused from the [CONDITION(S)] (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask. The observation on 08/01/22 at 04:00 PM revealed a [CONDITION(S)] mask and tubing to be intact and hanging over medicine cabinet in Resident 4's bathroom, with the mask touching the wall. The observation revealed an undated laminated sign sitting on the bathroom counter with instructions related to care of the [CONDITION(S)] equipment which read as follows: Steps to Cleaning [CONDITION(S)] Equipment 1,Remove the [CONDITION(S)] tubing from the device output valve and the water chamber from the device. Take the mask off the headgear. 2. Make a soapy solution using warm water and a few drops of mild dish soap. Instead of using soap, you can also make a 1:1 solution with white vinegar. 3. Place the parts in the solution. Allow each part to soak for a few minutes and make sure that the water and soap (or vinegar) is allowed to flow through the entire length of the hose. 4. Rinse each part with clean water. 5. Use a clean towel to remove any excess water and pat each piece dry. 6. Let them air dry for about an hour. 7. Once the parts are fully dry, carefully put them back together. Refer to the instruction manual if you are unsure how to reassemble the [CONDITION(S)] pieces correctly. During an interview on 08/02/22 at 11:28 AM, Resident 4 voiced wearing the [CONDITION(S)] last night. An observation on 08/02/22 at 11:28 AM, revealed Resident 4's [CONDITION(S)] mask to be intact, connected to the tubing but not the machine and hanging over the medicine cabinet in the bathroom with the mask touching the cabinet. An interview on 08/02/22 at 04:08 PM with the DON (Director of Nursing), after review of the [CONDITION(S)] mask findings for Resident 4, confirmed that the expectation of the facility is to use the black infection prevention bags when tubing was not in use. When a request was made for a copy of the facility respiratory equipment cleaning and storage policy, a copy of the laminated signage posted in Resident 4's bathroom was provided.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted and that pain monitoring documentation had been completed and reflected the need to continue duplicate pain medications for Resident 15 and 17. The sample size was 2. The facility census was 30. FINDINGS ARE: A. A record review of the MAR (Medication Administration Record) dated July 2022 revealed Resident 17 takes the following medications which require some type of monitoring or follow up such as labs, vitals, pain levels, behavior monitoring etc; -Acetaminophen 325mg TID for pain -[MEDICATION(S)] 300mg BID for pain -[MEDICATION(S)] 1mg TID for anxiety disorder -[MEDICATION(S)] 25mg at bedtime for anxiety disorder -Trazadone 50mg 1/2 tab every bedtime for anxiety disorder A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the policy titled Daily Pain Monitoring dated 4/2005, revised 6/27/17 revealed the following directions; II. Policy: All residents will be asked twice daily if they are having pain. B. For cognitively impaired residents, you may need to use more observational skills to detect pain: a. grimacing b. negative behaviors c. pacing d. wandering e. anything that is not routinely done An interview on 08/03/22 at 09:06 AM, with the DON (Director of Nursing), after review of the pain documentation, confirmed pain monitoring documentation did not indicate the need to continue with 2 pain medications and confirmed that non-pharmacological interventions had not been documented and should have been. B. A record review of current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain assessments documented in Resident 15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 15's Monthly Medication Review dated 6/14/22 revealed no pharmacy recommendations. A record review of Daily Pain Monitoring Policy last revised 6/27/17, revealed under documentation that pain rating (1-10) and interventions are to be recorded twice daily. A record review of the Pain Management Flow Sheet last revised 6/28/17, revealed under Documentation that pain rating (1-10) and interventions are to be recorded. An interview with the Director of Nurses (DON) on 8/3/22 at 9:06 AM confirmed that the pain documentation did not indicate the need to continue with 2 pain medications and confirmed that non pharmacological interventions had not been documented and should have been.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (The Long Term Care Minimum Data Set is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all resident in a Medicare and/or Medicaid-certified long term care facility) was coded to reflect a resident had a fall for 1 resident (Resident 3), was coded to reflect a resident (Resident and 33) had a fall with injury and was coded for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 37. Findings are: A. Record review of a Post Fall Investigation dated 8/25/20 for Resident 3 revealed that Resident 3 had a fall from a sitting position and the recliner tipped. Record review of Resident 3's Quarterly MDS assessment dated [DATE] Section J revealed Resident 3 had no falls since admission or last assessment. An interview on 04/08/21 at 08:45 AM with the MDS Coordinator revealed that the MDS Section J was coded incorrectly as Resident 3 had a fall on 8/25/20. B) Record review of an Incident Log revealed Resident 33 had falls on 12/15/20 and 12/28/20. Record review of a Post Fall Investigation for Resident 33 dated 12/28/20 revealed that Resident 33 was found on their left side on the floor between white shelves and the toilet. Resident 33 received the following abrasions and bruises post fall on 12/28/20: 2 x 0.4 cm (centimeters) abrasion right upper medial arm, 15 x 3 cm abrasion right lateral arm, 5 x 1 cm open area superficial left mid and right upper back, 1 x 1 cm superficial open area right upper back below shoulder, 14 x 0.5 cm superficial open area abraded area with purple bruising right upper mid back, 10 x 2 cm irregular open area superficial with purple bruising right mid upper back, 4 x 0.4 cm abrasion top right shoulder. Record review of Resident 33's MDS Quarterly assessment dated [DATE] revealed that Section J showed Resident 33 had a fall with no injury since admission/entry or prior assessment. An interview on 04/08/21 at 08:50 AM with the MDS Coordinator confirmed the MDS dated [DATE] was coded incorrectly. The MDS reflected the resident had no injury. The MDS Coordinator reported the MDS should be coded as Resident 33 had injury except major injury. C. Review of Resident 18's MDS dated [DATE] revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 18's PASRR (Preadmission Screening and Resident Review - a federal requirement to help ensure individuals are not inappropriately placed in nursing homes) dated 10/22/19 revealed the listed mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 4/7/21 at 11:22 AM with the DON (Director of Nursing) revealed [CONDITION(S)] is not an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 4/8/21 at 9:15 AM with the DON confirmed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 4/8/21 at 10:46 AM with the DON confirmed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON revealed Resident 18's physician had inactivated the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

LICENSURE REFERENCE NUMBER 175 NAC 12-OO6.09C3 Based on record review and interview, the facility failed to complete a discharge summary on 1 of 1 sampled residents (Resident 38). The facility had a census of 37 at the time of the survey. Findings are: Review the most current comprehensive MDS (Minimum Data Set, a federally mandated assessment tool used in care planning) for Resident 38 dated 3/11/2021 revealed an admitted [DATE]. Review of the EHR (Electronic Health Record) for Resident 38 revealed a discharge summary was available in the computer system. An interview on 4/7/21 at 1:15 PM with the DON (Director of Nursing) revealed the discharge summary was not a form the facility has used. An entry has been made in the past in the progress notes which states why the resident was admitted and what was done before the resident left. The DON also stated that there was a hospital form but it has not been initiated with the facility computer system for use unless it was requested. Review of the PN (Progress Notes) for Resident 38 revealed a discharge note had been made by two separate persons and neither of those progress notes were a recapitulation of the residents stay. PN dated 3/17/21 at 1:35 PM revealed the resident was discharged to a nursing facility at 12:45. An employee for the nursing facility was here to pick the resident up via the van and a wheel chair. Family member was here earlier and packed resident's things. Meds and pacer machine were sent over with driver as well. PN dated 3/22/21 at 9:12 AM revealed the resident was DC'd (discharged ) today. SW (Social Work) received a call from the other facility asking for the resident's information and stating the facility would be admitting the resident today (3/17). When speaking with family SW asked if the family wished to fill out a bed hold; they did not. SW also asked if they wished to remain on the list. Family stated that at this time the family wished to see how things go at the facility and to not be on the list. Family stated that the move was due to the single room at the other facility and that family believed the resident would do really well with a single room and this would help the resident's mental health and happiness overall. An interview on 4/7/21 at 2:24 PM with DON revealed and confirmed the two progress notes were the discharge summary. DON stated the facility did not know this resident was leaving until the family arrived at 10:00 AM the morning of 3/17/21 and wanted to discharge.

Licensure Reference Number NAC 175 12-006.09D7b Based on observation, record review and interview; the facility failed to investigate the occurrence of a fall, identify the causal factors for the fall and develop interventions to prevent further falls for 1 Resident (Resident 3) and the facility failed to implement toileting interventions to prevent falls for 1 resident (Resident 8) of 3 residents reviewed. The facility census was 37. Findings are: A. An observation on 04/05/21 at 10:34 AM of a sign on the table next to the chair to call for staff assistance for Resident 3 or their spouse if needed. An observation on 04/05/21 at 10:34 AM of Resident 3 up in the bathroom unattended by staff. Record review of Resident 3's MDS (a federally mandated assessment used for care planning) dated 4/23/20 revealed a BIMS (Brief Interview for Mental Status- an assessment used for elderly to monitor cognitive levels) score of 4 (indicating severe impairment). Record review of Resident 3's MDS Quarterly review dated 1/14/21 revealed Resident 3 had a BIMS score of 2 (indicating severe impairment). Record review of Resident 3's care plan revealed the signage to call for assistance was not care planned. An observation of Resident 3 on 04/06/21 at 01:30 PM revealed the resident was up in room standing in front of the recliner. Record review of a Post Fall Investigation dated 8/25/20 at 03:45 PM for Resident 3 revealed; 1. The fall was from a sitting position recliner tipped. 2. Resident 3's usual ambulatory status required 1 assist. 3. Resident 3 had a medical change. Resident 3's Mental/Cognitive state was confused. 4. Resident 3 had gotten up and down all night. 5. Neuro checks were not completed. 6. Plans to prevent reoccurrence and care plan updated were not documented. 7. Outcome no injury. Summary: Resident was sitting on the foot rest of the recliner. Recliner tipped forward. 8. If no changes to the care plan explain: This was answered with Re-educate Resident 3 to call for assistance. 9. When asked what happened Resident 3 was unable to explain. Objective: Observed Resident 3 sitting on the foot rest of recliner. The recliner tipped forward. INCIDENT INVESTIGATION: Memory: Resident 3 was confused. Activity: Resident 3 was sitting in a recliner. Vision: Resident 3 had poor vision. Transfers: Resident 3 doesn't call for assist- assist of 1 gait belt. Ambulation: Resident 3 doesn't remember to call for assistance. Elimination: Resident 3 was continent. Predisposing Disease- Resident 3 had Dementia, BPH Benign Prostatic Hypertension, and [CONDITION(S)]. Medications: Resident 3's medication: ASA (Aspirin), Diuretics (Medication used to treat edema), and Hypoglycemic (medication used to treat diabetes). Pain: Resident 3 denied pain. The changes made to care plan as a result of education were: Re-educated to call for assistance. Follow up by IDT (Interdisciplinary Team- a team that works with residents and families to form care plan that is managed on a daily basis): Anticipate residents needs work with staff on a toileting schedule for night shift. Record review of Resident 3's Care Plan dated 8/01/2021 revealed; Resident 3 on 08/25/20 sat on the recliner foot rest and tipped forward. Resident 3 was re-educated to call for assistance. Communication/Memory: Resident 3's BIMS decreased from 5 to 2/15 continue to indicate severe impairment. Resident 3 was able to complete 2/3 words during repetition but had difficulty with orientation as well as word recall. Resident 3 had a signed statement from my physician stating Resident 3 is unable to make medical decisions due to dementia. Mobility: Ambulation: Resident 3 is independent with ambulation. Transfers: Resident 3 is independent with transfers. Toileting: Resident 3 was independent with toileting. Record review of Fall Prevention Policy revealed; Purpose: to ensure residents are assessed utilizing risk factor criteria and necessary precautionary measures are taken to ensure resident safety. Policy: Risk assessment criteria is utilized to identify the residents risk for falls and to take precautionary methods to prevent falls related to injury. Procedure: Definition of a fall - unintentional change in position coming to rest on the ground, floor, or on to the next lower surface. The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. A. Fall prevention 1. Fall Risk Assessment completed, on admission, with a COC (Change in Condition), quarterly with every MDS evaluation. 2. PT (Physical Therapy) will screen resident for possible services on admission. 3. OT (Occupational Therapy) will screen resident for possible services on admission. 4. Individualized Restorative Program for residents not on a formal Therapy Program unless ordered by therapy -to ensure resident remains at maximum level of independence. 5. Develop and initiate a Fall Risk Care Plan based on resident individual risk factor to prevent/decrease falls by focusing on underlying causes 6. Consultant Pharmacist to review medications monthly for unnecessary medications. 7. It is the responsibility of every employee to prevent falls. If you notice any of the precaution that are not in place at any time, remedy what you can immediately. Inform the appropriate person for the things you cannot fix, charge nurse, maintenance, etc. It is also your responsibility to know which residents are at high risk for falls and which resident have recently fallen. This information should be conveyed at report for whenever possible and can be found in the resident care plan. B. Post Fall 1. Notify the Physician. 2. Assess and document in the resident medical record at the time of the fall: a. date, b. describe the scene, c. resident behavior at the time of the fall, d. objective statement, e. document a head to toe check and ROM (range of motion), f. describe resident injury if any, g. absence or presence of pain, h. document any first aid given or treatment by the physician, i. document how and where the resident was moved to after a fall, j. document VS, k. document initiation of Neurological checks on all witnessed and unwitnessed falls, l. document POA(Power of Attorney)/family Notification, m. document physician notification, 3. Complete post fall and incident investigation. 4. Update care plan - include details of the fall, treatment received, and new interventions to prevent future falls. 5. Place on 24 hour board, 72 hour monitoring, and share in shift report. a. body check, b. monitor VS (Vital Signs), c. objective statement, d. absence of pain, 6. Therapy to screen for possible therapy service need. 7. It is the responsibility of every employee to prevent falls. An interview on 4/7/21 at 8:45 AM with the DON (Director of Nurses) confirmed Resident 3 by nature was restless and confused and was attempting to exit the chair while the foot rest was elevated. The DON confirmed an intervention such as Re-educate to call for assistance for Resident 3 would not be a proper intervention for this resident due to severe impairment of cognition. The DON reported they are working with staff nurses related to root cause analysis. The fall investigation for Resident 3 had a missing page for root cause. The DON reported with a fall, it should be investigated and root cause should be determined to implement interventions to prevent further falls. B. Observation on 4/7/21 at 2:35 PM revealed Resident 8 was sitting in a recliner with their feet elevated in the resident's room. Resident 8 was slowly moving (gender)'s feet off of the footrest. Resident 8's right foot was on the floor to the right side of the recliner. NA-A (Nurse Aide) walked by and saw Resident 8 moving off the recliner, then went into the room and asked Resident 8 what was needed. Resident 8 told NA-A (gender) needed to use the bathroom. NA-A turned on Resident 8's call light and another NA came to the room to assist. Review of the facility Fall Incident Log dated 11/2020 - 3/2021 revealed Resident 8 had 7 falls. The following were the dates and times of the falls: 1) 11/23/20 at 4:40 PM 2) 12/3/20 at 2:15 AM 3) 12/13/20 at 3:50 PM 4) 12/21/20 at 5:55 AM 5) 12/21/20 at 9:55 AM 6) 1/2/21 at 3:40 PM 7) 2/19/21 at 11:20 PM Review of Resident 8's Post Fall Investigations dated 11/2020 - 4/5/2020 revealed: - On 12/3/20 at 2:15 AM, Resident 8 fell to the floor on the way to the bathroom. - On 12/21/20 at 5:55 AM, Resident 8 fell to the floor on the way to the bathroom. - On 2/19/21 at 11:20 PM, Resident 8 was found on the floor next to the resident's bed. Review of Resident 8's Comprehensive Care Plan revealed the following entries related to a toileting program: - Under the Safety Entry, on 2/19/21: Resident 8 was found on the floor at 11:20 PM. Staff were to continue scheduled toileting and frequent checks at night. No detail related to the frequency or times Resident 8 should be assisted to the bathroom was included. - Under the Bladder Management Entry, on 4/5/21: Resident 8 was on a toileting schedule, and to follow the schedule as the resident allows. No detail related to the frequency or times Resident 8 should be assisted to the bathroom was included. Interview on 4/7/21 at 2:50 PM with NA-A revealed interventions in place to prevent Resident 8 from falling include anticipating the residents needs and following a toileting schedule. NA-A revealed staff frequently offer to take Resident 8 to the bathroom. NA-A also revealed the resident rarely called for assistance, so staff tried to respond quickly when Resident 8's call light goes on. Interview on 4/8/21 at 8:24 AM with LPN-B revealed Resident 8 was at risk for falling due to Resident 8 (gender)'s abilities. LPN-B revealed Resident 8 would very rarely use the call light to call for assistance, but would tell staff if (gender) wanted to use the bathroom if asked. LPN-B revealed Resident 8's toileting program included toileting the resident at least 4 times on day shift, usually before and after meals and before shift change. Review of the Toileting Logs dated 3/31/21 - 4/5/21 revealed Resident 8 was on the Day Toileting Schedule for Morning Cares, at 10:00 AM, and at 12:00 PM. Resident 8 was on the Evening Toileting Schedule for every 2-3 hours, and on the Night Shift Toileting Schedule for 1st rounds, 2:00 AM, and last rounds. Documentation on the Toileting Logs revealed: - On the 4/3/21 Day Shift Log, there is no documentation that Resident 8 was assisted to the bathroom. The last documentation of toileting was at 4/2/21 at 4:30 AM, and the next documentation was 4/2/21 at 12:45 PM. 8 hours and 15 minutes had elapsed. - On the 4/3/21 Evening Shift Log, Resident 8 was toileted at 12:45 PM, then was not toileted until 8:30 PM. 7 hours and 45 minutes had elapsed. - On the 4/3/21 Night Shift Log, Resident 8 was toileted at 12:30 AM. The last documentation was on 4/2/21 at 8:30 PM. 4 hours had elapsed. - On the 4/3/21 Night Shift Log, Resident 8 was toileted at 4:35 AM. The next documentation was on 4/4/21 at 9:50 AM. 5 hours and 15 minutes had elapsed. - On the 4/4/21 Day Shift Log, Resident 8 was toileted at 12:40 PM. The next documentation was on 4/4/21 at 4:30 PM. 3 hours and 50 minutes had elapsed. - On the 4/4/21 Evening Shift Log, Resident 8 was toileted at 4:30 PM. The next documentation was on 4/5/21 at 12:37 AM. 8 hours and 7 minutes had elapsed. Interview on 4/8/21 at 9:30 AM with the DON (Director of Nursing) revealed Resident 8 was supposed to be toileted 3 times on day shift, every 2-3 hours on evening shift, and every round on night shift. The DON confirmed Resident 8's care plan does not specify times or frequency the resident should be assisted to the bathroom. The DON confirmed the Toileting Log sheets show Resident 8 was not toileted by the day shift staff on 4/3/21, from 4:35 AM - 9:50 AM on 4/4/21, and from 4:30 PM - 12:37 AM on 4/4/21. The DON confirmed the Toileting Log documentation was incomplete.

LICENSURE REFERENCE NUMBER 175 NAC 12.006.10D Based on observation, record review and interview; the facility failed to ensure residents received insulin as ordered. This had the potential to affect 1 of 1 sampled residents (Resident 24). The facility census was 37 at the time of the survey. Findings are: Review of Resident 24's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Novolog order was: -Novolog Injectable 100/ml Inject SQ per sliding scale three times daily: 60-110=0 Units; 111-150=2 Units; 151-200=4 Units; 201-250 =6 units; 251-300=8 units; 301-350-=10 units; >350= Call MD *If resident doesn't eat. Don't give Novolog, If <50% of Food=50% Dose. Don't give within 2 hours of previous dose. Glucerna =1 meal DX. Diabetes Mellitus: Schedule: Daily 0800 to 10:30 (8:00 AM-10:30 AM); Daily 11:30-13:30 (11:30 AM-1:30 PM); Daily 1730-19:30 (5:30 PM-7:30 PM) Review of the order written above revealed Resident 24 was to receive Novolog insulin according to the sliding scale for example if Resident 24's glucose reading per glucometer was in the 111-150 range Resident 24 was to receive 2 units of insulin. If Resident 24 did not eat than Resident 24 was to receive no insulin but the Glucerna was equal to one meal. If Resident 24 ate less than 50% of the meal served then Resident 24 was to receive 50% or ½ of the ordered dose. Using the example of 111-150 range being 2 units, if Resident 24 ate less than 50% then Resident 24 would receive 1 unit of insulin. Review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 4/7/21 at 2:56 PM with LPN-C (Licensed Practical Nurse) when asked to explain the Novolog Sliding Scale Insulin order revealed when the nurses initial are circled on the TAR (Treatment Administration Record) the resident did not eat enough to get any insulin or was asleep. If the resident takes only a few bites which would be less than 25% the resident would not get any insulin and if the resident eats 50% or more the resident would get the full amount. The resident had sliding scale insulin and that is the only choice the resident had left which was what to eat and when. The resident's doctor set up so Glucerna equals a meal as long as the resident drinks it all or a sandwich then the resident gets the full amount according to the residents' blood sugar. 100% eaten was 100% of the ordered insulin. 50% or less eaten would be half of insulin and according to blood sugar. If less than 25% was eaten, by the resident, which can be at nurse discretion, the insulin can be held. The Ensure was schedule 4 times a day and usually takes it at least 2 times a day. The resident can take breakfast, at times, as late at 10:00 AM. The resident has been offered alternate meal intake and has refused. The resident's blood sugar was checked by day shift and was 260. LPN-C revealed that LPN-C did not feel comfortable giving the resident the insulin which would have been 8 units for 100% or 4 units for 50%. Review of Medication Incident Log revealed on 1/29/2020 at 1458 (2:58 PM) Resident 24 had a medication error regarding Novolog Insulin per sliding scale. The Investigation of the BS (Blood Sugar) done by another nurse entered the Blood Sugar reading into the computer system incorrectly. The nurse on duty did not check correct place in red book and gave sliding scale according to incorrect BS result. Gave 2 units, then 2 more after realized mistake. Actually needed 2 more units, Doctor contacted and stated not to give additional insulin. Follow up of the investigation: Reeducated on importance of checking red book as well as in computer and pay attention to sliding scale so that the proper amount of insulin was given. Will try to have the nurse that checks the BS be the one to administer the insulin. An interview on 4/8/21 at 8:40 AM with the DON (Director of Nursing) revealed the information on the Medication Incident Log was obtained from reports submitted by the MA (Medication Aide) and the nurse. The errors are reviewed at the QA (Quality Assurance) Meetings. It was revealed no one reviews the MAR/TAR (Medication Administration Record/Treatment Administration Record) to ensure medications are given correctly or that the order was entered correctly. Perhaps the pharmacy does this during the monthly reviews. Also there were peer reviews being done, where the nurse giving insulin may do a check to see if the insulin was given correctly from the previous shift or day. An interview on 4/8/21 at 8:15 AM with LPN-B (Licensed Practical Nurse) revealed that resident 24's order for insulin was per sliding scale. Insulin was given according to the blood sugar check and the amount the resident eats. If less than 50% Resident 24 would get 50% of the dose. If Resident 24 doesn't eat Resident 24 gets no insulin. For example the sliding scale states if blood sugar is 129 the order states for 111-150 to give 2 units and if Resident 24 eats less than 50% the resident would get 1 unit. It is the practice to check Resident 24's blood sugar before the residents gets the food tray. If the day shift takes Resident 24's blood sugar and gives Resident 24 the lunch tray the evening shift nurse would give Resident 24 insulin according to how much the resident ate and the blood sugar. When asked how would the evening nurse determine how much the resident ate, if they did not see what was on the tray? The reply was the menu would be looked at which was placed on the residents tray. Review of the TAR (Treatment Administration Record) for Resident 24 for March and April revealed the Novolog Insulin and the Ensure High Protein were being documented by the nurse on duty. The following documentations were noted when comparing it to the Glucose Check log in the red binder for Resident 24 which was indicated by given name. The March TAR (Treatment Administration Record) revealed: On 3/2/21 from 11:30 AM to 1:30 PM there was no information placed on the TAR and in the red binder Resident 24 had a Glucose check of 191 recorded. No Novolog Sliding Scale insulin was documented. On 3/2/21 at 6:00 PM a Glucose check was noted in the red binder of 232 there was no documentation that the physician was notified or sign and symptoms to indicate why the Glucose check was completed. On 3/6/21 at 11:40 AM a Glucose check was noted on the TAR as 105 with no other information documented. On 3/6/21 at 2:00 PM Glucose check was noted in the red binder of 195 with nothing noted on the TAR or in the progress notes about why the test was conducted. On 3/7/21 for the time 5:30 PM to 7:30 PM there was no Glucose check listed on the TAR or the Glucose check sheet in the red binder. Resident had no documentation of insulin being given. On 3/8/21 at 2:40 PM the Glucose check was 169 with 0% for intake and 4 units of Novolog insulin was given. The TAR revealed no Ensure High Protein was taken. The order stated if resident does not eat do not give insulin. On 3/13/21 at 11:30 AM-1:30 PM the Glucose check documented was 198 with 4 units of Novolog given. The documentation in the red binder revealed 2 different Glucose check entries on for 2:30 PM an hour after the insulin was given. The other one dated 3/13/21 at 1:30 PM revealed a Glucose check of 278. On 3/14/21 at 11:30 AM to 1:30 PM revealed no documentation of a Glucose check for this date and time in the red binder on the Glucose check sheet. On 3/16/21 at 11:30 AM to 1:30 PM there was no documentation of the Glucose check being completed on the TAR. On 3/21/21 8:00 AM to 10:30 AM and 11:30 AM to 1:30 PM there were no Glucose checks documented on the TAR and no Glucose checks documented in the red binder for the Glucose Check sheet. On 3/24/21 at 5:30 PM to 7:30 PM the TAR had a Glucose check of 253 documented and in the red binder the time was not identifiable the Glucose check was 235. On 3/26/21 at 11:30 AM to 1:30 PM the Glucose check was not documented, if insulin was given or what resident ate. The red binder Glucose Check Sheet revealed a Glucose check of 148. Review of the TAR revealed Ensure High Protein consumed at 12:00 PM was 100% which would have required 2 units of Novolog Insulin. Resident 24 had no insulin documented as given. On 4/5/21 at 5:30 PM to 7:30 PM the TAR revealed a Glucose check of 202 with Resident 24 taking 50% and 6 units Novolog Insulin was given. On 4/6/21 at 5:30 PM to 7:30 PM the TAR revealed a Glucose check of 346 with Resident 24 taking 50% and 10 units Novolog Insulin was given. Review of the progress notes dated 1/6/21 to 4/3/21 revealed one documentation of the physician being notified of Glucose Check readings being out of Novolog Sliding Scale insulin range. An interview on 4/8/21 at 9:08 AM with LPN-B revealed LPN-B stating LPN-B does not have time to check on medication orders and LPN-B had not been instructed to do checks on the medications for accuracy. The only time LPN-B stated LPN-B looked at what was documented prior to LPN-B being on duty was when the physician ask how Resident 24's Glucose checks are doing. Review of the red binder labeled Glucose Check log which was located in the medication room revealed a document labeled PREVENTATIVE MAINTENANCE AND QUALITY CONTROL RECORD that listed the date, time, resident name, value and operator of glucose checks. An interview on 4/08/21 at 11:57 AM with LPN-B (Licensed Practical Nurse) revealed that the Medication Aides are the ones that give supplements and unless it is someone like Resident 24 who was being monitored closely the charge nurse does not get a report on the supplements unless the resident was not taking what was ordered. Review of the Article in ICP (Institutional Care Pharmacy) Quality Service for Quality Care revealed a significant medication error means one which causes the resident discomfort or jeopardizes client health and safety. Several types of errors may occur and often can be avoided with preparation and diligence. * Timing errors-before meals, after meals and with food, when administrating out of the proper timeframe are considered as medication errors. *Omitting medication was never acceptable Review of the Lippincott Nursing Center 8 rights of medication administration dated May 27, 2011 revealed chances are that some persons may not have known that in addition to the well-known 5 rights of medication administration, some experts have added 3 more to the list. When it comes to patient safety, the review of the basics and increasing awareness of new recommendations was never a bad idea. The rights of medication administration were: 1. Right patient 2. Right medication 3. Right Dose 4. Right route 5. Right Time 6. Right documentation (Chart the time, route, and any other specific information) 7. Right reason (Confirm the rationale for the ordered medication) 8. Right response (Make sure the drug led to the desired effect)

Licensure Reference Number 175 NAC 12-006.0917B and 12-006.09D Based on observation, interview and record review; the facility failed to ensure hand hygiene was completed when indicated during wound care and wound care was completed to prevent cross contamination for 1 resident (Resident 33). The facility also failed to ensure a catheter was stored in a manner to prevent cross contamination for 1 Resident (Resident 4) of 3 residents reviewed. The facility census was 37. Findings are: A) An observation on 04/07/21 at 01:14 PM for Resident 33 of diabetic wound care to the left bunion and great toe by RN (Registered Nurse) D revelaed RN D was in the room prior to the start of care and had gloves on. RN-D took the dressing off of the Left Great toe and the left bunion and discarded the dressings in the trash. Without hand hygience RN-D took the wash cloth and cleansed the wound. Without hand hygiene RN-D applied to a Q-tip TAO (Triple Antibiotic ointment) and then applied the TAO to the outer edges of the wound of the great toe and used the same Q-tip and applied more TAO from the tube of ointment and applied this to the outer edges of the bunion wound. Santyl ointment was applied to a new Q-tip and the ointment was applied to the tip of the great toe center of the wound, with the same Q-tip RN-D applied more Santyl. from the tube to the Q-tip and applied to the center of the bunion. Dressing was applied. Gloves were removed. No hand hygiene was performed during the wound care. Record review of Hand Hygiene Policy revealed; Procedure A. Hand Hygiene must be performed before entering and leaving patient/resident room, before and after touching a patient/resident, before a clean/aseptic procedure, after body fluids exposure risk and after touching the patient/resident environment. Below are some examples of specific opportunities when hand hygiene must be performed. 1. When coming on duty, 2. When hands are visibly soiled (hand washing with soap and water) before and after direct patient contact (for which hand hygiene is indicated by acceptable professional practice, 3. before and after performing any invasive procedure, 4. before and after entering isolation precautions setting 5. before and after eating or handling food, 6. before and after assisting resident with meals, 7. before and after assisting a resident with personal care, 8. before peripheral vascular catheter and other invasive devices, 9. before and after inserting indwelling catheters, 10. before and after dressing change, 11. upon coming into contact with a resident intact skin, 12. after personal use of toilet, 13. before and after assisting resident with toileting, 14. after contact with a resident with infectious diarrhea including but not limited to infections caused by norovirus etc., 15. after blowing nose, 16. after contact with resident's mucous membranes or body fluids or excretions, 17. after handling soiled or used linens, dressing, bed pans, catheters, and urinals. 18. after handling soiled equipment or utensil, 19. after performing your personal hygiene, 20 after removing gloves/apron, 21. after completing day. An interview on 04/08/21 at 10:47 AM with the DON (Director of Nurses) confirmed the expectation for wound care would be the Nurse would change gloves and perform hand hygiene after removal of the soiled dressing before applying ointment. The DON confirmed there should have been 4 Q-TIPS used for the application of the ointment to the 2 wounds to prevent cross contamination. B) An observation on 04/06/21 at 9:28 AM revealed Resident 4 had catheter tubing protruding from a pant leg and had large amount of sediment in tubing. Record review of the Care Plan revealed Resident 4 had a Foley catheter. Record review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 04/06/21 at 3:12 PM of Resident 4's Catheter bag hanging on the front of the recliner touching the floor with no cover. An observation on 4/8/21 at 1:11 PM with RN (Registered Nurse) E of Resident 4's catheter bag hanging in the trash bin with a liner and trash in the bin. An interview on 4/8/21 at 1:11 PM with RN E confirmed the catheter was in the trash can with trash and this was an infection control issue. RN E reported that the staff is supposed to place the catheter in a black cover and place them inside the trash bin without a plastic bag.