Every finding on record at Midwest Covenant Home

Based on record review, observation, and interviews, the facility failed to discard outdated foods. This had the potential to affect all residents who consumed food from the kitchen. The census was 38. Findings are: Record review of the facility policy and procedure Food Storage dated the year 2021 stated that policy will be that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Record review of the BakerSource company's product data sheet dated [DATE] revealed that the shelf life of Cinnamon Streusel Coffee Cake Mix is 546 days from the date of manufacturer in ambient conditions as was the shelf life of the Carrot Cake Mix. Observation on [DATE] at 9:35 AM in the facility kitchen; One (1) box of Cinnamon Streusel with a manufactured date of 09.28.2023. Three (3) boxes of Cinnamon Streusel with a manufactured date of 11.28.2023. Five (5) boxes of Carrot Cake mix with a manufactured date of 07.08.2023. Four (4) Angel Food Cake mixes from the grocery store had best if used by dates of 4.28.2024. Two (2) Frozen packages of bologna in upright freezer had a use by date of 03.04.2024. One (1) Frozen packages of bologna in upright freezer had a use by date of 01.06.2024. Interview on [DATE] at 9:30 AM with the Food Service Manager (FSM) confirmed to not knowing how long the cake mixes and bologna were good for after the manufacturing date. The angel food cake mixes had best if used by dates on them. The frozen lunch meat (bologna) had a date but was unsure how long it could be in the freezer without need of being discarded or used. Interview on [DATE] at 2:50 PM with the FSM conducted. FSM reported that once manufactured, the cinnamon streusel and carrot cake mixes had a shelf life of 546 days at room temperatures. FSM confirmed that the 5 boxes of the Carrot Cake mixes were outdated (expired) and that the FSM destroyed them. Interview on [DATE] at 1:45 PM with the FSM conducted. FSM stated that the local grocery store was unable to state how long the angel food cake mixes could be used past the used by date, so these were destroyed (thrown away) by the food service manager. Interview on [DATE] at 9:20 AM with the FSM revealed that the manufacturer would not stand by any foods that had gone past the outdate even if the bologna had been kept in the freezer, so these were destroyed (thrown away). Interview on [DATE] at 11:40 AM with the FSM confirmed that all outdated food identified on [DATE](listed above) were destroyed (thrown away).

Licensure Reference Number 175NAC 12-006.02(H) Based on record review and interview the facility failed to submit a written investigation for alleged abuse to the state agency within 5 working days as required for 2 of 3 residents (Residents 12 and 19). The facility census was 38. Findings are: A. Record review of the undated facility policy titled Abuse Neglect and Misappropriation of Property Policy revealed that the facility supports a zero tolerance for resident abuse, neglect, and/or misappropriation of property. The definition of physical abuse includes hitting, slapping, pinching, and kicking. The section titled Resident to Resident Abuse revealed that staff must intervene to protect the residents and separate the individuals immediately. In all cases of alleged abuse, neglect, or misappropriation/exploitation of resident property the role of the facility is to intervene in the situation; report the situation to the proper authorities; investigate the allegation; prevent abuse while the investigation is in process; and have documented evidence that the facility intervened, reported, prevented, and investigated. The facility must ensure that all alleged violations are reported immediately to the administrator of the facility and to other officials in accordance with State Law. A facility investigation report form will be filled out and sent/faxed within 5 working days to: Health Facility Investigations (the State Agency). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 12 dated 1/29/25 revealed that Resident 12 admitted into the facility on [DATE]. Resident 12 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 3 indicating severely impaired cognition. Resident 12 requires maximal assistance (the staff does more than half the effort) for personal hygiene, toileting and transferring. Resident 12 is frequently incontinent of bladder (urine) and occasionally incontinent of bowel (stool). Record review of the progress note dated 9/4/24 at 8:31 AM for Resident 12 revealed that Resident 12 was in the dining room. The tablemate of Resident 12 spilled their eggs and Resident 12 attempted to assist the tablemate with cleaning up the eggs. The tablemate balled their fist and hit Resident 12 on the forearm. The Director of Nursing, Facility Administrator, and Social Services Director were informed of the resident to resident incident. Record review of the progress note dated 9/4/24 at 12:41 PM for Resident 12 revealed that the facility contacted Adult Protective Services (APS) (the State of Nebraska agency designated for receiving reports of abuse, neglect, or exploitation) to file the report of the resident to resident incident. Record review of the medical record of Resident 12 revealed no documentation that a written investigation of the 9/4/24 resident to resident incident was completed and submitted to the state agency. Interview on 3/26/25 at 2:27 PM with the Facility Administrator (FA) confirmed that the 9/4/24 resident to resident incident had been reported to APS as alleged resident to resident abuse. Interview on 3/26/25 at 2:39 PM with the facility Director of Nursing (DON) confirmed that the resident to resident incident directed towards Resident 12 occurred on 9/4/24 and was reported to APS. The DON revealed that the resident that hit Resident 12 was moved to a different table. The DON confirmed that the facility did not submit the written investigation to the state agency as required. B. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 19 dated 2/12/25 revealed that Resident 19 admitted into the facility on [DATE]. Resident 19 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 3 indicating severely impaired cognition. Resident 19 is dependent on staff for personal hygiene and bathing. Resident 19 requires maximal assistance (the staff does more than half the effort) for toileting and transferring. Resident 19 is frequently incontinent of bowel (stool) and bladder (urine). Record review of the progress note dated 12/18/24 at 3:26 PM revealed that a nurse aide went to help Resident 19 with cares last evening (12/17/24). Resident 19 became agitated and combative. The nurse aide grabbed the arms of Resident 19 and held them near the resident's chest. The licensed nurse intervened and the Director of Nursing (DON) was called. Record review of the Adult Protective Services Intake Worksheet dated 12/19/24 revealed that APS was notified of the physical abuse on 12/18/24 at 5:14 PM. The worksheet revealed that on 12/17/24 the nurse aide went to provide care for Resident 19. Resident 19 declined and requested to continue watching television in the gathering area. The nurse aide tried to forcibly move Resident 19 from the gathering area by grasping the resident's arms and putting them across the resident's chest while Resident 19 was in the wheelchair. Another staff saw this and immediately intervened. Record review of the medical record of Resident 19 revealed no documentation that a written investigation of the 12/17/24 staff to resident incident was completed and submitted to the state agency. Interview on 3/26/25 at 2:27 PM with the Facility Administrator (FA) confirmed that the 12/17/24 staff to resident incident had been reported to APS. Interview on 3/26/25 at 2:39 PM with the facility Director of Nursing (DON) confirmed that the DON was notified of the staff to resident incident on 12/17/24 and came to the facility. The DON revealed that the staff member involved was agency staff and the DON escorted the staff member out of the building. The DON revealed that that staff member was not allowed to return to work in the facility. Interview on 3/26/25 at 4:22 PM with the DON confirmed that the facility completed an Incident Investigation Report (a written investigation) dated 12/18/24. The DON confirmed that the investigation report was not submitted to the state agency as required.

Licensure Reference Number 175 NAC 12-006.09 Based on record reviews and interviews the facility failed to follow orders to notify the physician when blood glucose levels were outside of set parameters. This affected two residents, Resident 24, and Resident 38. The facility census was 38. Findings are: A. A review of an Admission Record dated 03/24/2025 showed Resident 24 admitted on [DATE] with primary and admitting diagnoses of: -Parkinson's Disease (a brain disorder causing uncontrollable movements) -Calculus of Kidney (formed stones in the kidneys caused by preexisting conditions) -Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a condition is which the body does not use insulin properly and nerve damage caused by high blood sugars) A review of Resident 24's Care Plan Report dated 03/18/2025 revealed: -Focus: Patient Medical History of Diabetes Mellitus with insulin -Intervention: Diabetic medications as ordered; blood sugars as ordered A review of Resident 24's Medication Review Report for the month of 03/2025 signed and dated by the physician on 03/12/2025 revealed orders: -Notify MD (medical doctor) when blood sugar is < (less than) 60 or >(greater than) 400, order dated 08/28/2024 -Insulin Lispro Injection Solution 100 Unit/ML(milliliter) (Insulin Lispro) Inject as per sliding scale: if 0-70 = 0 CALL PCP(Primary Care Provider); 71-149= 0; 150-199= 1; 200-249= 2; 250-299= 3; 300-349= 4; 350-399=5; 400-999= 5 CALL PCP, subcutaneously four times a day related to Type 2 Diabetes Mellitus with Diabetic Polyneuropathy A review of Resident 24's blood sugars (BS) from 01/01/2025 through 03/21/2025 revealed BS's outside of parameters: -03/21/2025 12:02 534.0 mg (milligram)/dL(deciliter) -02/16/2025 16:38 425.0 mg/dL -01/17/2025 21:18 425.0 mg/dL A review of Resident 24's Progress Notes dated 12/23/2024 through 01/22/2025 revealed that on 01/17/2025, notification to the physician on the BS reading had not occurred. A review of Resident 24's Progress Notes dated 01/23/2025 through 02/22/2025 revealed that on 02/16/2025, notification to the physician on the BS reading had not occurred. A review of Resident 24's Progress Notes dated 02/23/2024 through 03/25/2025 revealed that on 03/21/2025, notification to the physician on the BS reading had not been documented as occurred. A review of policy titled Midwest Covenant Home Clinical Policy-Routine Medication Monitoring System dated 07/2023 revealed: -Medication-Diabetic Medication oral or insulin-BG checked per accu-check (a blood glucose monitoring device)-scheduled ordered by doctor-Call PCP if BG (blood glucose/blood sugar) is greater than 450 or lower than 50, unless otherwise directed. An interview with the Director of Nursing (DON) on 03/26/2025 at 12:57 PM revealed that the nurse was confused on when to notify the physician on parameters, therefore did not notify when Resident 24's BS reading was between 400 and 450. A review of facility policy/procedure titled Standards of Care with a revision date of 01/01/2024 revealed Professional Nursing Standards: -Staff will notify each resident's physician when needed. -Medications will be administered as ordered by the physician or designee. -Staff will follow all orders given by the physician or designee. 41938 B. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/31/25 for Resident 38 revealed that Resident 38 admitted into the facility on [DATE]. Diagnoses included Diabetes. Medications included insulin injections (a medication that regulates the amount of glucose (sugar) in the blood). Record review of the Order Summary dated 3/25/25 for Resident 38 revealed a physician's order for Insulin injection per sliding scale (An insulin order that varies the dose of insulin based on the blood sugar level. The higher your blood sugar the more insulin you take) dated 1/27/25. The order directed that staff are to call the physician for blood sugar results over 450. Record review of the Care Plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 3/24/25 for Resident 38 revealed the potential for adverse drug reactions related to low blood sugar. Interventions included blood glucose monitoring and medications as ordered by the physician and report as warranted. Record review of the Blood Sugar Summary dated 3/26/25 for Resident 38 revealed the blood sugar results for Resident 38 from 1/27/25 through 3/26/25. Blood sugar results over 450 were obtained on 2/21/25 (461); 2/24/25 (461); and 3/2/25 (460). Record review of the progress note dated 2/24/25 at 2:10 PM revealed that Resident 38's blood sugar at 11 AM was 461. The nurse gave the sliding scale insulin and called Resident 38's physician and informed the physician of the blood sugar. Record review of the resident record revealed no documentation that the physician was notified of the blood sugar results over 450 as required for the blood sugar result of 461 on 2/21/25 or the blood sugar result of 460 on 3/2/25. Interview on 3/26/25 at 12:57 PM with the facility Director of Nursing (DON) confirmed that staff are expected to follow physician orders including notification of blood sugars as ordered by the physician.

Licensure Reference Number 175NAC 12-006.11E Based on observations, record reviews and interviews, the facility failed to monitor the required temperature for sanitization of facility dishware that had the potential to affect all facility residents; failed to ensure sanitary procedures between raw and cooked foods to prevent the potential for foodborne illness that had the potential to affect all facility residents; and the facility failed to monitor food temperatures for the prevention of foodborne illnesses for 12 of the 43 residents that ate from the kitchen. The facility census was 43. Findings are: A. On 04/01/2024 at 1:14 PM Dietary Aide (DA)-J was observed processing dishware in the soiled dish area. Dietary Aide (DA)-K was observed assisting in the soiled dish area assisting DA-J with dishwashing. The temperature gauge markings for the dish machine were not readable due to either internal steam or scaling of the glass covering the temperature markings. DA-J was interviewed on the dishware process and stated that the dishes get rinsed off, placed on the rack, sometimes covered when needed. DA-J included that the lever is pulled to open the machine, the rack enters the machine, the lever is switched to be closed and the button is pushed. DA-K was interviewed on the sanitization process and stated that the water is checked with a small strip and checked for amount of proper sanitization parts per million (ppm). The ppm is then annotated on a form that is hanging behind a cabinet door a few steps away from the dish machine. When inquired about the gauge on the dish machine, DA-K revealed that the temperatures were not observed or recorded as part of their process. The facility Dietary Manager (DM) was interviewed on 04/01/2024 at 1:45 PM about the dishwashing process. The facility DM revealed that the dish machine is a low temperature machine and uses chemical sanitization as part of their dish sanitization process. The facility DM stated that temperatures for the low temperature machine have not been monitored as part of their process. A review of the dish machine Manufacturers Specification information dated 5/9/2005 revealed that the wash minimum Fahrenheit (F) for the machine they are using is for 120 degrees F. During an interview on 04/02/2024 at 2:55 PM the facility DM confirmed that all facility residents eat out of the kitchen. B. On 04/01/2024 at 10:19 AM Dietary Aide (DA)-M was observed washing raw chicken in the prep sink, a tray with parchment paper was in place over the sink overlapping the sink compartment as DA-M washed the raw chicken in the prep sink, during the process, splashing was occurring on the top and bottom of the tray that held the chicken being prepped. DA-M placed the washed raw chicken on the parchment paper on the tray. The tray of chicken was then placed on the prep table across from the prep sink and Dietary Cook (DC)-B began to put marinade on the chicken. This chicken was then placed in oven #2 for cooking at 425 degrees F. The prep table was observed to not be sanitized after preparation of the chicken. DC-B then brought out a pan of chicken from oven #2, placed the tray on the same prep table, checked the chicken temperature which revealed to be at 170 degrees F. The chicken was placed back into oven #2. On 04/01/2024 at 10:24 AM DC-B was observed grabbing a large stock pot from the stove, placing it on the prep table. The prep table had not been sanitized. The rice was temped and found to be at 199.9 degrees F. DC-B began scooping out rice from the stock pot into a larger pan covered in a food grade liner. DC-B was then observed lifting the large stock pot and dropping the bottom of the pot into the rice, then placing the pot back down on the prep counter, scooping the rice out until almost completed, once again lifting the stock pot, scraping the rice out. DC-B then placed the pan of rice on a small cart and placed into the steam table and covered with a lid. C. On 04/01/2024 at 10:33 AM DC-B was observed pulling a tray of chicken from oven #2 and placed on the prep counter. This chicken was temped and found to be at 165.5 degrees F. The large pan was pulled from oven #1 that contained more chicken. This chicken was placed on the counter and the tray of chicken was added to the larger pan, one piece of chicken remained on the tray. The large pan of chicken was placed on a wheeled cart and added to the steam table. The one piece of chicken was not temped and was placed into a blender for later use. On 04/01/2024 at 11:15 AM this surveyor observed the one piece of chicken to still be in the blender. The chicken had not been temped. On 04/01/2024 at 11:40AM DC-B is observed to be adding tap water and pureeing the chicken that has been sitting in the blender since 10:33 AM. Thickener is added to the puree and a powder of gravy mix is added then blended. This was poured and scraped into a small pan with a liner covering. The pan was taken to the steam tray then covered. DC-B did not obtain a temp of the gravy. DC-B was then interviewed about the reason for the blended chicken. DC-B stated that the gravy is used for ground, chopped and preferred use. Meal service was observed on 04/01/2024 starting at 12:04 PM, no temperatures were recorded at the start of service or during service. The third plate observed to be dished was a chopped/ground meat, gravy was added to this meat. Meal was delivered to the resident. An interview on 04/02/2024 at 2:55 PM with the facility DM revealed that 12 residents; 23, 21, 42, 35, 14, 17, 6, 7, 32, 3, 18, 10 eat chopped and or ground meats out of the kitchen. Interview with the facility DM also revealed that DC-B was personally trained and will be undergoing ServSafe training (a program that provides food safety training) in the future. The DM further confirmed that tempertures should be checked prior to service. A review of the facility policy and procedure manual on food temperatures indicated that: The temperatures of all food items will be taken and properly recorded prior to service of each meal. Procedure: 1. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees. a. cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. b. Hot food items may not fall below 135 degrees after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees and reheated to at least 165 degrees prior to serving. Caution should be taken to avoid serving food and liquids at temperatures that are too hot to avoid the risk of burns. 3. Temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area.

Licensure Reference Number 175NAC 12-006.10D Based on observation, record review, and interview the facility failed to ensure the medication error rate was under 5% with an observed medication error rate of 21.21%. This affected 7 of 15 residents observed (Residents 10, 32, 13, 9, 8, 22, and 21). The facility census was 43. Findings are: A. Record review of the [NAME] Lilly manufacturer's directions on both the drug insert and information located on [NAME] Lilly company website, the Insulin injection pen for Lispro Injection Solution, specifies Insulin needles must be primed prior to use. To prime the Insulin pen needle (priming means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly and assures that the needle is filled) one must first observe for any discoloration and/or air bubbles that may in the medication chamber, then dial the device to 2 units, and finally remove the top of the needle and click the pen to push out the two units while holding the pen vertically to observe a small amount of insulin at the top of the needle prior to use. It is at this point that one will then dial the pen to the prescribed insulin dose. The pen is now ready for giving the medication. Inform the patient there will be a small stick and insert the needle, click the pen to administer, then count to 5 slowly prior to removing the insulin needle to allow for complete injection of the insulin from the pen. LISKP-0006-IFU-20230721 https://uspl.lilly.com/lispro/lispro.html#ug1 Revised date 9/2023 Record review of the annual nursing competencies for insulin which had the revision date of 6/6/2011 revealed that the Insulin Competencies did not include information or checkoffs related to Insulin injection pens including the requirement to prime the needle. Record Review on 4/1/24 of the Electronic Medical Record revealed Resident 10 had a physician order for Insulin Lispro Injection Solution (Insulin Lispro) Inject 5 unit subcutaneously two times a day with breakfast and noon meal. There was a second physician order for Resident 10 for sliding scale insulin. This order stated Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if blood sugar level 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units; 451 - 500 = 6 units and recheck blood sugar in 15 minutes. subcutaneously three times a day for diabetes. An observation on 3/27/24 at 12:00 PM Licensed Practical Nurse (LPN)-E checked blood sugar of Resident 10 which was 182. This indicated a need for one additional unit of insulin per the sliding scale insulin order. LPN-E attached the needle, dialed the pen to 6 units and administered the insulin. The needle was not primed prior to the administration. The observation further revealed that the needle was not held in place for a total of 5 seconds or a slow count to 5 during the administration of insulin to the resident. Interview on 4/2/24 at 10:35 AM with Licensed Practical Nurse (LPN)-D revealed how Insulin pens are used and the procedural steps to follow when administering an insulin injection that needed both a regular order and sliding scale insulin based upon an elevated blood sugar. LPN-D followed through with all the correct steps of priming the needle with 2 Units prior to dialing the correct dose of the insulin on the insulin pen to be given to the resident. LPN-D reveal that they had worked in other facilities in which insulin pens were used and was taught to prime the insulin pen needles by dialing in 2 units. When questioned about the annual competencies, LPN-D revealed the staff either demonstrate how to do procedures or use table discussion procedure discuss the correct steps to follow. LPN-D did not know that the annual training competencies do not include training for the insulin pens or the need to prime the insulin pen needles. LPN-D has been employed at this facility for 2 years. Interview on 4/2/24 at 11:05 AM with LPN-E. Discussed how insulin pens are used and the procedure that must be followed when giving insulin with an insulin pen. LPN-E followed nearly all the correct steps but missed the step of priming the needle, which was not included. LPN-E did state that the needle needs to be left in the skin for a few seconds before removing the needle. LPN-E revealed employment at the facility for the past ten years and that the insulin pens have been used in the facility for a few years. B. Record Review on 4/1/24 of the Electronic medical record revealed Resident 32 had a physician order for Insulin Lispro Solution 100 UNIT/ML (milliliter) Inject 6 units subcutaneously three times a day There was a second physician order for Resident 32 for sliding scale insulin. This order stated Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale: if blood sugar 0 - 149 = 0 If less than 70, call PCP: 150 - 199 = 1 units; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400 -450 = 6 units If greater than 400, give 6 units and call PCP., subcutaneously before meals and at bedtime. Observation on 4/1/24 at 4:24 PM. Medication Aide (MA)-F checked the blood sugar of Resident 32 (the blood sugar was 177) then waited to do the prescribed Insulin injection until just prior to going to meal. MA-F revealed that Resident 32 must have something to eat within 15 minutes of the insulin injection. Just prior to sending Resident 32 to the dining room for the noon meal, the insulin was given. The resident required the regular dose as well as one additional unit of insulin per the dosing instructions for the sliding scale insulin based on blood sugar parameters. MA-F attached the needle, dialed the pen to 7 units and administered the insulin. MA-F did not prime the needle. The injection needle was not left in place for a slow count to five or for 5 seconds. Interview on 4/2/24 at 1:30 PM with the facility Director of Nursing (DON), confirmed the facility did not have a policy and procedure for the use of the insulin pens. At that point, the DON did present a copy of a Policy and Procedure that they were thinking of implementing in the facility. After review, the DON revealed that there was a step missing in that the policy did not include the need to prime the needle of the insulin pen. C. Record review of the Voltaren instructions for use dated 2024 revealed the need to use the dosing card to measure the correct dose each time the medication is administered. Gently rub Voltaren Arthritis Pain Gel into the skin using your hand. One should apply it 4 times a day for best results. Only apply to clean, dry skin that doesn't have any cuts, open wounds, infections, or rashes. Do not apply in the same area as any other medicine or products applied to the skin. The dosing card should always be used to measure a dose. For each upper body area (hand, wrist, or elbow) squeeze out 2.25 inches (2 grams). For each lower body area (foot, ankle, or knee) squeeze out 4.5 inches (4 grams). https://www.voltarengel.com/arthritis-pain-gel Updated 2024 Record Review on 4/1/24 of the Electronic Medical Record revealed that Resident 13 had a physician's order for Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) (A topical medication for pain) Apply to knees topically four times a day; apply 4 grams to knees. Observed on 4/1/24 at 4:00 PM Voltaren cream was administered to Resident 13 by Licensed Practical Nurse-G (LPN-G). The measuring tool was not used to measure the correct dosage of Voltaren gel for each knee. LPN-G simply placed the Voltaren gel to the resident's knee and squeezed the tube until she had enough. This was approximately 1 to 1 1/2 of medication on each knee of Resident 13. (A 4-gram dose of Voltaren is 4.5 inches of gel.) In an interview on 4/1/24 at 4:00 PM while LPN-G was squeezing the Voltaren cream, LPN-G revealed [gender] would squeeze the tube until [gender] had enough. D. Record review of the online article entitled How to Put In Eye Drops updated on July 23, 2021 from the National Eye Institute and the National Institute of Health revealed if your doctor prescribes eye drops to treat glaucoma or another eye condition, it's important to use eye drops correctly so that all the medicine gets into your eye. If you don't use them correctly, you could lose your vision. Follow these steps to put in your eye drops: Tilt your head back and look up. With 1 hand, pull your lower eyelid down and away from your eyeball - this makes a pocket for the drops. With the other hand, hold the eye drop bottle upside down with the tip just above the pocket. Squeeze the prescribed number of eye drops into the pocket created when pulling the eye lid down and away from eyeball. For at least 1 minute, ask the patient or resident to their close eye and press a finger lightly on the tear duct (small hole in the inner corner of your eye next to the nose) - this keeps the eye drop from draining into your nose. If you need to use more than 1 type of eye drop, like different drops for different eye conditions, wait at least 5 minutes between each type. To prevent infections when you use eye drops, follow these tips to protect your eyes: Wash your hands with soap and water (or apply gloves) before you use eye drops. Don't touch the tip of the eye drop bottle with your hands. Don't let the tip of the eye drop bottle touch your eye or eyelid https://www.[NAME].nih.gov/Glaucoma/glaucoma-medicines/how-put-eye-drops Last updated: July 23, 2021 Record review on 4/1/24 of the Electronic Medical Record for Resident 9 revealed orders for Artificial Tears Ophthalmic Solution 1.4 % (Polyvinyl Alcohol) Instill 1 drop in both eyes every 2 hours for eye comfort until 04/02/2024. Observed on 4/1/24 at 4:10 PM MA-F entered the room of Resident 9 to give an eye drop in the right eye. Resident 9 informed MA-F that the medication order had been changed as Resident 9 had just returned from the eye doctor and the new orders were hanging on the closet door. MA-F told the resident MA-F had to return to the medication cart to review the new orders. This was a potential for error had Resident 9 not intervened to tell MA-F of the new orders. Both eyes of Resident 9 needed one eye drop every two hours. The eye drops were given in the middle of the lower lid instead in the outer area. E. Record review on 4/1/24 revealed a physician order for Resident 8 for Artificial Tears Solution 0.4 % (Hypromellose) (an eye drop solution); Instill 1 drop in both eyes four times a day related to macular degeneration (a degenerative disease-causing loss of vision). Observation on 4/1/24 at 4:30 MA-F instilled eye drops in the eyes of Resident 8. Both of Resident 8's eyes remained closed when giving the eye drops. MA-F (Medication Aid) did give one drop in each eye, did not open the eye or attempt to create a pocket in which to instill the drops. F. Record review on 4/1/24 of the Electronic Medical Record for Resident 22 revealed an order for Systane Complete Ophthalmic Solution 0.6 % (Propylene Glycol (Ophth) eye drop solution). Instill 1 drop in both eyes four times a day for dry eyes and history of cataracts. Observed on 4/1/24 at 4:37 LPN-G performed Hand Hygiene (cleansed hands) with alcohol-based hand sanitizer then donned clean gloves while standing at the medication cart. LPN-G removed the cap of the eye drops to show this surveyor that the drops had a different type of top and the drops were more difficult to administer. Upon entering the room, LPN-G explained that it was time for Resident 22's eye drop administration then gave the resident the eye drops. LPN-G contaminated the bottle of eye drops as the bottle of eye drops were rubbed in a back-and-forth motion on the eye lashes of both closed eyes when giving the drops. At no point did LPN-G try to open either eye or try to create a pocket for the administration of the eye drops. Resident 22 did not open either eye for the procedure. Unknown how much and if the drops were put into the eyes as LPN-G simply squeezed the bottle while rubbing both eyes and no drop was actually observed coming from the bottle. G. Record Review of the Electronic Medical Record on 4/1/24 for Resident 21 revealed a physician order for Dry Eye Relief Drops Solution 0.2-0.2-1 % (Glycerin-Hypromellose-PEG 400) eye drop solution. Instill 1 drop in both eyes three times a day for dry eyes. Observed on 4/1/24 at 4:42 LPN-G touched the bottom of the right eye lid of Resident 21 with the tip of the bottle of solution when instilling the eye drops thus contaminating the bottle. LPN-G did not create a pocket in which to instill the eye drops.

License reference number 175 NAC 12-006.10D Based on observation, record review, and interview the facility failed to ensure facility staff primed insulin pen needles as required to ensure the correct dosage administration for 2 residents of 2 residents observed (Residents 10, and 32). The facility census was 43. Findings are: A. Record review of the [NAME] Lilly manufacturer's directions on both the drug insert and information located on [NAME] Lilly company website, the Insulin injection pen for Lispro Injection Solution, specifies Insulin needles must be primed prior to use. To prime the Insulin pen needle (priming means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly and assures that the needle is filled) one must first observe for any discoloration and/or air bubbles that may in the medication chamber, then dial the device to 2 units, and finally remove the top of the needle and click the pen to push out the two units while holding the pen vertically to observe a small amount of insulin at the top of the needle prior to use. It is at this point that one will then dial the pen to the prescribed insulin dose. The pen is now ready for giving the medication. Inform the patient there will be a small stick and insert the needle, click the pen to administer, then count to 5 slowly prior to removing the insulin needle to allow for complete injection of the insulin from the pen. LISKP-0006-IFU-20230721 https://uspl.lilly.com/lispro/lispro.html#ug1 Revised date 9/2023 Record review of the annual nursing competencies for insulin which had the revision date of 6/6/2011 revealed that the Insulin Competencies did not include information or checkoffs related to Insulin injection pens including the requirement to prime the needle. Record Review on 4/1/24 of the Electronic medical record revealed Resident 10 had a physician order for Insulin Lispro Injection Solution (Insulin Lispro) Inject 5 unit subcutaneously two times a day with breakfast and noon meal. There was a second physician order for Resident 10 for sliding scale insulin. This order stated Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if blood sugar level 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units; 451 - 500 = 6 units and recheck blood sugar in 15 minutes. subcutaneously three times a day for diabetes. An observation on 3/27/24 at 12:00 PM Licensed Practical Nurse (LPN)-E checked blood sugar of Resident 10 which was 182. This indicated the need for one additional unit of insulin per the sliding scale insulin order. Licensed Practical Nurse-E (LPN-E) attached the needle, dialed the pen to 6 units and administered the insulin. The needle was not primed. The needle was not held in place for a total of 5 seconds or a slow count to 5. Interview on 4/2/24 at 11:05 AM with LPN-E revealed how insulin pens are used and the procedure steps to follow in giving insulin with an insulin pen. LPN-E followed all the correct steps however the step of priming the needle was not included. LPN-E did state that the needle needs to be left in the skin for a few seconds before removing the needle. LPN-E revealed employment at the facility for the past ten years and that the insulin pens have been used in the facility for a few years. Interview on 4/2/24 at 10:35 AM with LPN-D revealed how Insulin pens are used and the procedure steps to follow in giving an insulin that had both a regular order as the need for Sliding scale insulin based upon an elevated blood sugar. LPN-D followed through with all the correct steps including priming the needle with 2 Units prior to dialing the correct dose of the insulin on the insulin pen to be given. LPN-D reveal that they had worked in other facilities in which insulin pens were used. They always had to prime the insulin pen needles by dialing in 2 units. LPN-D also revealed that the Insulin pens are more accurate than using a multi-dose vial as the insulin pen eliminates the possible error in drawing up insulin into a syringe. When questioned about the annual competencies, LPN-D stated the staff either demonstrate how to do procedures or use table discussion procedure discuss the correct steps to follow. LPN-D did not know that the annual training competencies do not include training for the insulin pens or the need to prime the insulin pen needles. LPN-D has been employed at this facility for 2 years. Interview on 4/2/24 at 1:30 PM with the facility Director of Nursing (DON) confirmed the facility did not have a policy and procedure for the use of the insulin pens. At that point, the DON did present a copy of a Policy and Procedure that they were thinking of implementing in the facility. After review, the DON revealed that there was a step missing in that policy that did not include the need to prime the needle of the insulin pen. B. Record Review on 4/1/24 of the Electronic medical record revealed Resident 32 had a physician order for Insulin Lispro Solution 100 UNIT/ML (milliliter) Inject 6 units subcutaneously three times a day. There was a second physician order for Resident 32 to receive sliding scale insulin if needed based on blood sugar parameters. This order stated Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale: if blood sugar 0 - 149 = 0 If less than 70, call PCP: 150 - 199 = 1 units; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400 -450 = 6 units If greater than 400, give 6 units and call PCP., subcutaneously before meals and at bedtime. Observation on 4/1/24 at 4:24 PM. Medication Aide (MA)-F checked blood sugar of Resident 32 (the blood sugar was 177) then waited to do the prescribed Insulin injection until just prior to going to meal. MA-F voiced awareness that Resident 32 must have something to eat within 15 minutes of the insulin injection. Just prior to sending Resident 32 to the dining room for the noon meal, the insulin was given. The resident required the regular dose as well as one additional unit of insulin per the dosing instructions for the sliding scale insulin based on blood sugar parameters. MA-F attached the needle, dialed the pen to 7 units and administered the insulin. MA-F did not prime the needle. The injection needle was not left in place for a slow count to five or for 5 seconds.

Licensure Reference Number 175NAC 12-006.02(8) Based on interview and record review the facility failed to submit an investigation for alleged abuse to the state agency within 5 days as required for 1 (Resident 10) of 3 sampled residents. The facility census was 43. Findings are: Record review of the undated facility policy titled Abuse, Neglect and Misappropriation of Property revealed that the facility supports a zero tolerance for resident abuse, neglect, and/or misappropriation of property. In all cases of alleged abuse, neglect, or misappropriation/exploitation of resident property the facility is to intervene in the situation, report the situation to the proper authorities, investigate the allegation, prevent abuse and neglect while the investigation is in process. The facility is to have documented evidence that the facility intervened, reported, prevented abuse/neglect/misappropriation, and investigated. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the administrator of the facility and to other officials in accordance with state law. The aggressor will be removed from the situation. If the aggressor is an employee, they will be suspended without pay until the investigation is completed. The section titled Reporting revealed that all alleged cases of resident abuse, neglect, and misappropriation will be reported to the administrator or his/her designee. The Administrator or his/her designee will immediately contact the proper authorities. Local law enforcement will be contacted as determined necessary. The Administrator or his/her designee should report the following to Adult Protective Services (APS): Any allegation of abuse/neglect/misappropriation that results in a resident being physically injured; unreasonably confined. A Facility Investigation Report Form will be filled out and sent/faxed within 5 working days to: Health Facility Investigations (the state agency). Record review of the Admission Record dated 4/1/24 for Resident 10 revealed that Resident 10 admitted into the facility on [DATE]. Diagnoses included dementia, anxiety, and major depressive disorder. Record review of the letter dated 8/10/23 addressed to the facility Director of Nursing (DON) revealed that Licensed Practical Nurse-A (LPN-A) strapped the right foot of Resident 10 to the wheelchair foot pedal with a gait belt. The letter reported that this was a restraint affecting Resident 10. Record review of the Investigation Form dated 8/10/23 provided by the DON revealed that the DON completed the form. The form documented that the DON was notified of LPN-A using a gait belt improperly. The other Licensed Practical Nurse (unidentified) on duty was told to check it out. The unidentified LPN in charge on duty removed the gait belt from Resident 10's wheelchair and no injury was noted to Resident 10. Verbal education was done with LPN-A on proper use of gait belts. The form revealed in the section titled Next Investigative Steps - Visit with staff, LPN-A, and take further steps if required. Interview on 4/01/24 at 2:52 PM with Nurse Aide-C (NA-C) revealed that the facility provided NA-C with abuse and neglect training. NA-C revealed that a resident tied to their wheelchair would be considered abuse and NA-C would report that to the charge nurse. Interview on 4/02/24 at 8:17 AM with the facility Director of Nursing (DON) confirmed that the letter dated 8/10/23 for the 8/10/23 incident involving Resident 10 was received from an agency staff and would be considered potential abuse. The DON confirmed that the facility should follow the facility Abuse, Neglect, and Misappropriation of Property policy for alleged abuse. The DON revealed that the DON was out of state at the time of the incident involving Resident 10. The DON revealed that the previous facility Administrator determined the occurrence did not need to be reported. The DON confirmed that the facility had no documentation of the investigation by the previous facility Administrator. The DON confirmed that a facility investigation report had not been submitted to the state agency.

Licensure Reference Number 175NAC 12-006.09 Based on record review, observation, and interviews, the facility failed to implement resident care consistent with the resident's physician orders for 1, (Resident 4) of 5 sampled residents. Facility stated census of 43. Findings are: A. Review of an Admission Record dated 03/28/2024 indicated that the facility admitted Resident 4 on 04/04/2023 with diagnoses of: Type 2 Diabetes (which is a condition in which the body has trouble controlling blood sugar and using it for energy), Neuromuscular dysfunction of the bladder, (which is a condition where there is a lack of bladder control due to a brain, spinal cord, or nerve problem), and Pressure ulcer of the right heel (which is a area of skin damage due to prolonged pressure on the skin and or lack of blood flow to the area). The Quarterly Minimum Data Set (MDS which is a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), with and Assessment Reference Date (ARD) of 01/02/2024, revealed Resident 4 had a Brief Interview for Mental Status (BIMS is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 10, indicating the resident was moderately cognitively impaired. The resident required supervision and touching assistance with eating, partial to moderate assistance with bed mobility and was totally dependent on staff assistance with transfers and toilet use. The resident had an indwelling catheter, which is a tube placed in the bladder, and had a stage 2 pressure ulcer. Review of Resident 4's Care Plan dated 03/28/2024, revealed the resident had a pressure ulcer to the right heel that was present on admission with interventions that included to elevate heels off of the bed with a pillow under the legs, heel protector to the left heel and prafo (Multi-Podus boots are often prescribed for patients who must spend extended periods of time in bed. These devices are worn on the calf and foot. They suspend or float the heel and hold the ankle in a neutral (90 degree) position.) boot to the right heel at all times, Nurses to perform wound care as recommended by the medical provider, and to see the medication and treatment record for current intervention for pressure relief, protections, and treatment. All interventions date of initiation was 10/04/2023. The resident had a supra-pubic catheter (which is a tube that goes through the abdomen and into the bladder to drain the bladder), with an intervention of supra pubic catheter cares with morning and bedtime care with and initiation date of 01/06/2023. Review of Resident 4's electronic physician orders revealed the following orders: -An order start date of 08/24/2023, to clean the supra pubic catheter and site with warm water and change the gauze sponge every shift. -An order start date of 03/23/2024Wash Resident 4's wound daily with Hibiclens, (which is an antimicrobial cleanser), and water or soap and water. Wash in an outward circular fashion. Apply Thera Bond dressing, (which is a thin cloth like material infused with silver used in wound care), to wound bed only and secure. On 04/01/2024 at 2:51 PM the following was observed in the room of Resident 4: Resident 4 was lying in bed flat on the [gender] back. Medication Aide (MA)-L obtained 2 disposable wipes from a package located on the bedside table located near the head of the resident's bed. MA-L then dispensed 4 pumps of a thick white solution from a container labeled Tena Cleansing Cream onto the center of the disposable wipes. MA-L then rubbed the wipes together dispensing the thick white solution over a larger area of the wipes. MA-L then placed their left hand to Resident 4's abdomen just below the resident's belly button and used the hand to hold on to the resident's supra catheter that was located there. MA-L used the disposable wipes with the cream on them to wipe the resident's supra catheter from where MA-L's left hand was at the resident's abdomen to approximately 3 inches down the supra catheter tubing. MA-L then threw the wipes away in a trash can. MA-L then obtained 2 additional wipes from the package on the overbed table and repeated the supra catheter cleansing actions as listed above. In an interview conducted on 04/01/2024 at 3:15 PM with MA-L, revealed that the Medication Aides or the Nurse Aides (NA) complete supra catheter cares twice a day in the morning and evening. MA-L further revealed that they use the disposable washcloths and the Tena Cream or soap and water for supra catheter cares. MA-L denied knowing if the resident had orders for an alternate form of supra catheter cares to be provided. In an interview conducted on 04/02/2024 at 10:45 AM with Licensed Practical Nurse (LPN)-D, confirmed that Medication Aides or Nurse Aides complete supra catheter cares on residents twice a day following facility policy for supra catheters. LPN-D further confirmed that Resident 4's physician ordered supra supra catheter cares dated 08/24/2023, which gave directions to clean supra pubic catheter and site with warm water and change the sponge every shift, day, evening, and night. Record review of facility supplied Policy labeled Perineal Care Using Tena Wipes dated 01/2024 revealed under procedure #9 if a resident has a supra catheter wipe around catheter insertion site with the wipe and down 3 to 5 inches of the catheter tubing. In an interview on 04/02/2024 at 8:19 AM with the Director of Nursing (DON), revealed the facility was in the process of re-writing the facilities policy for care of supra catheters. DON further revealed MA-L performed the care using the new process and not the physicians' ordered directions or the facilities current policy. B. Review of Resident 4's electronic physician orders revealed, an order start date of 08/24/2023, to clean supra pubic catheter and site with warm water and change the gauze sponge every shift and to wash Resident 4 wound daily with Hibiclens, (which is an antimicrobial cleanser), and water or soap and water. Wash in an outward circular fashion. Apply Thera Bond dressing, (which is a thin cloth like material infused with silver used in wound care), to wound bed only and secure with and order start date of 03/23/2024. Review of Resident 4's medical chart revealed a document labeled Physician Orders dated 03/23/2024 with documentation stating to start Thera Bond, daily, wash wound with soap and water, signed by the provider, and noted by a nurse. Observation on 04/01/2024 at 10:17 AM LPN-D in the room of Resident 4 completed wound care for Resident 4's pressure ulcer in the following manner: LPN-D used a light teal bottle with a white cap labeled Hibiclens. LPN-D then took a crumpled piece of white gauze and depressed it into the bed of the wound. LPN-D moved the gauze in the wound bed in multiple half circular motions. LPN-D disposed of the used piece of gauze and obtained a clean piece of gauze. LPN-D placed the gauze to the wound bed and rotated it in half circular motions. LPN-D took a thin silver-gray colored piece of mater out of a package labeled TherBond. LPN-D cut the material in a circle shape and placed the material in a cup of tap water located on the resident's bedside table. With a gloved hand LPN-D removed the material from the cup and then using their gloved finger pressed the material into the wound bed. The material was observed to be overlapping the wound edges and setting on the skin surrounding the wound. LPN-D continued to press the silver-gray material into the wound bed until the material only was located over the wound bed. In an interview conducted on 04/01/2024 at 11:15 with LPN-D, [gender] confirmed that the physicians ordered wound care for Resident 4's wound care stated to wash the resident's heel with Hibiclense and water or soap and water, wash outward in circular fashion, apply Thera Bond dressing to wound bed only and secure. LPN-D confirmed [gender] should not have put the Hibiclense directly on the wound bed and not rinsed it off. LPN-D also confirmed the Thera Bond dressing should have been cut smaller size and there was not direction from the physician to soak the material in the tap water. LPN-D further confirmed that the wound should have been cleansed using a circular motion starting in the center and working outward to the skin surrounding the wound. Record review of a document labeled Hibiclense dated 2024 revealed under how to use Hibiclense to rinse the skin before applying. Apply only enough to cover the area you are treating. Do not apply this medicine to deep cuts, scrapes, or open skin wounds. Record review of a facility supplied document labeled Wound Cleaning undated revealed for an open wound to gently clean the wound in a full or half circle beginning in the center and working toward the outside clean at least 1 inch beyond the end of the new dressing or 2 inches beyond the wound margins. Record review of a document labeled Open Wound Cleansing dated June 30, 2017 by The Wound Care Education Institute revealed for cleansing of open wounds, gently clean the wound in a full or half circle beginning in the center and working toward the outside and to clean at least one inch beyond the end of the new dressing or two inches beyond the wound margins. In an interview on 04/02/2024 at 8:19 AM the DON confirmed that LPN-D did not follow the physician prescribed directions for wound care for Resident 4 and did not use the proper technique when cleansing the residents wound. DON further confirmed the providers directions for wound care were not transcribed into the electronic medical health record correctly.

Licensure Reference Number 175NAC 12-006.09D7b Based on record review and interviews, the facility failed to identify causal factors and implement interventions to prevent incidents and accidents. This affected 1 (Resident 7) of 5 sampled residents. Facility stated census of 43. Findings are: Review of an Admission Record dated 03/28/2024 indicated that the facility admitted Resident 7 on 04/05/2021 with diagnoses of: Cerebral Infarction (which is a stroke where blood supply to part of the brain is deprived and brain cells die), Hypertension (which is high blood pressure), Osteoarthritis (which is a degenerative disease of the joints often resulting in pain and stiffness in the joint), and Muscle Weakness. The Comprehensive Minimum Data Set (MDS which is a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), with and Assessment Reference Date (ARD) of 02/27/2024, revealed Resident 7 had a Brief Interview for Mental Status (BIMS is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) Score of 15 indicating the resident was cognitively intact. The resident required set up or clean up assistance with eating and supervision or touching assistance with bed mobility, transfers, and toilet use. The resident was indicated as taking an antiplatelet medication which is a medication that prevents blood clots from forming. Review of Resident 7's Care Plan dated 03/28/2024, revealed a focus of the resident had a potential for adverse drug reactions related to taking aspirin, which is a blood thinning medication, dated 03/03/2024 with an intervention of staff to monitor the resident for signs and symptoms of excessive bruising and bleeding and to report this dated 03/03/2024. A focus of standard basic care plan information dated 02/29/2024 with an intervention of staff to monitor skin for bruising and report to the nurse. The nurse is to notify the provider as needed and to refer to the medication and treatment record and skin condition report for current interventions, monitors and protections dated 03/03/2024. A focus stating the resident is alert and oriented and able to tell staff what they want or need dated 02/28/2024. With a intervention of the resident being able to tell the staff what they want or need if staff have trouble hearing the resident to eliminate background noise or come closer dated 02/28/2024. A focus of the resident needing assistance with bed mobility dated 02/29/2024 with a focus of the resident needing more assistance with activities of daily living and staff to aid of one with transfers and bed mobility dated 03/05/2024 and for staff to provide skin care and reposition assistance as needed. Staff to apply lotion to the residents' extremities dated 03/03/2024. Review of the resident's care plan revealed no focus, goal, or intervention for prevention of bruising to skin during transfers or guidance to staff on how to assist resident with transfers to prevent injury or bruising. In an interview on 03/27/2027 at 3:39 PM with Resident 7, revealed that when staff assist the resident with getting out of bed the staff pull on the residents left arm and hand, and this causes bruising to the residents' hand. Resident further revealed that now [gender] tells staff not to pull on [gender] arm or left hand when they assist the resident out of bed or with transfers. A record review of Resident 7's Progress Notes revealed on 06/13/2023 a bruise was noted to the residents left hand measuring 4 centimeters by 4 centimeters and the resident stated it was from staff grasping the residents' hands when assisting up. On 01/12/2024 a Progress Note was entered that the resident reported to staff of having a quarter sized bruise to the residents left hand and the resident stated the bruise came from staff while being assisted with the morning cares. A record review of facility supplied Incident and Accident Report dated 06/13/2024 revealed documentation of a bruise to Resident 7's left hand due to staff grasping the residents' hands when assisting the resident. There were no interventions for prevention or investigation of causative factor listed on the report. In an interview on 04/01/2024 at 9:01 AM with Nurse Aide (NA)-C, revealed staff aide Resident 7 with transfers and bed mobility. NA-C stated the resident tells the staff how to provide the assistance to the resident and is specific for staff not to pull on the resident's arms or hands, so the staff just help as the resident directs. NA-C denies being educated or directed to aide Resident 7 with any special equipment or in a specific special manner. Stated if found a bruise on a resident would report it to the nurse. In an interview on 04/01/2024 at 4:03 PM with Licensed Practical Nurse (LPN)-D, revealed staff are to report skin issues including bruises to the nurses. The Nurse it was reported to would then investigate to see if the area was new or old if new would ask the resident how it happened if the resident does not know or could not answer then the nurse would ask the staff. LPN-D further revealed the nurse would assess the area including measurements, notify the provider and the family, and complete and incident accident report and document everything in a progress note. In an interview on 04/01/2024 at 4:30 PM with the Director of Nursing (DON), confirmed that resident had received bruises to the resident's hand while being assisted by staff. DON confirmed no incident report was completed for the bruise occurring on 01/12/2024. DON confirmed no interventions were placed to prevent this from continuing to occur. DON stated the facility did not have a policy directly to address incidents or accidents occurring to the skin. Stated staff would follow the New Skin Issue Checklist form and follow those instructions. A record review of facility supplied document labeled New Skin Issue Checklist not dated revealed directions for staff to fill out an incident report making sure to fill out the form completely with an explanation of what happened and what the staff did as a treatment or intervention.

Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility failed to provide assistance with oral care for 1 (Resident 17) of 3 sampled residents. The facility census was 39. Findings are: An observation on 3/6/23 at 10:30AM revealed Resident 17 with white debris build up on the base of Resident 17's lower teeth. The observation further revealed Resident 17 missing multiple upper teeth. In an interview on 3/6/23 at 10:30AM Resident 17's responsible party and Resident 17 confirmed that Resident 17's teeth had not been brushed and do not get brushed. An observation on 3/7/23 at 10:49AM revealed Resident 17 with white debris build up on the base of Resident 17's lower teeth. In an interview on 3/7/23 at 10:49AM Resident 17's responsible party and Resident 17 confirmed that Resident 17's teeth had not been brushed. A record review of Resident 17's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 12/6/22, 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) Summary Score of 5, which indicated severe impairment. -Had no rejection of care -Required extensive assistance for personal hygiene A record review of Resident 17's comprehensive care plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 12/7/22, revealed that Resident 17 needed extensive assist with all of Resident 17's cares. In an interview on 3/7/23 at 1:00PM, NA-B (Nurse Aide) confirmed that Resident 17 had white debris build up on the base of Resident 17's lower teeth and that Resident 17's teeth had not been brushed. A record review of the facilities: Midwest Covenant Home Standards of Care, revised 4/4/19, revealed: -Caregiving Standards: teeth/dentures are cleaned at least daily as resident will allow

Based on record review and interview, the facility failed to provide Resident 43 with Written Notice of Transfer on transfer to the hospital. This affected 1 of 1 resident sampled for hospitalization . The facility's census was 39. Findings are: A review of Resident 43's Progress Notes revealed that on 1/19/23 the resident fell at the facility and was sent to the hospital. The facility was unable to provide a copy of the Written Notice of Transfer upon request. In an interview conducted on 3/8/23 at 11:53 AM, the Administrator confirmed that the facility had not been providing residents or their representatives with Written Notices of Transfer upon discharge or transfer to the hospital.

175 NAC 12-006. 17D and 175 NAC 12-006.18B Based on observations, record reviews and interviews, the facility failed to ensure Hand Hygiene (cleaning the hands with soap and water or the use of an alcohol based hand rub (ABHR) to help prevent the spread of infection) was completed during wound care for 1 Resident (40) out of 2 sampled for Pressure Injury, and the facility failed to maintain clean Respiratory equipment for 1 Resident 2 sampled for Respiratory Care. The facility census was 39. A. On 3/8/23 at 10:24 AM an observation was made of a dressing change for Resident 40's right heel wound completed by Licensed Practical Nurse (LPN) A. -LPN A washed their hands with soap and water and put on clean gloves. -LPN A then removed the resident's shoe, sock, and old dressing, then cleaned the open area with gauze and wound cleanser. -LPN A then discarded the old dressing and the gauze used for cleaning, removed the soiled gloves, and without performing Hand Hygiene put on new gloves and put on a clean dressing. A review of the undated facility policy for Wound Care revealed that after removing the old dressing, it should be discarded, and the nurse should remove their gloves and wash their hands again. In an interview on 03/08/23 at 10:39 AM, LPN A confirmed that they should have performed Hand Hygiene between removing soiled gloves and putting on clean gloves. 47312 B. A review of Resident 2's admission record revealed that Resident 2 admitted to the facility on [DATE] with the diagnoses of: Influenza, Pneumonia, Respiratory failure, and Chronic Obstructive Pulmonary Disease. An observation on 3/6/23 at 10:22AM revealed Resident 2's Positive Airway Pressure (PAP-a machine used to deliver pressure to the airway to keep it open during sleep) mask on a bedside table with a residual amount of water in the chamber and dust particles on the machine. An observation on 3/7/23 at 10:47AM revealed Resident 2's PAP mask on a bedside table with a residual amount of water in the chamber and dust particles on the machine. A review of Resident 2's Treatment Administration Record (TAR), dated 3/7/23, revealed the following: -Continuous PAP (CPAP) orders: on at bedtime (HS) and off in AM. Wipe down daily -Wipe CPAP mask or pillow, tubing and humidity basin if used with warm soapy water daily and dry In an observation and interview on 3/7/23 at 12:32PM, the Director of Nursing (DON) confirmed the presence of residual water in the chamber and dust particles on the machine. The DON further confirmed that the PAP mask and machine had not been wiped down. A record review of Northwest Respiratory Services CPAP/BiPAP Safety Precautions, undated, revealed: -Clean and disinfect mask, tubing, and humidifier regularly -Wipe off machine with a clean damp cloth as needed

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interview, and record review; the facility staff failed to serve resident meals in a manner to preserve nutritive value and were maintained at a temperature to preserve safety and palatability. This had the potential to affect all of the facility residents who received food from the facility kitchen. The facility identified a census of 39 at the time of survey. Findings are: Interview with Resident 1 on 10/18/21 at 3:19 PM revealed when inquired how the facility food was they replied they had not received a bun for the cheeseburger they had ordered. They had received a hamburger patty and 2 slices of bread. Resident 1 revealed they had requested the hamburger for lunch today 2 days ago so the facility had time to get buns. Resident 1 revealed they had received a baked potato that was not done. Resident 1 revealed they could not put a fork in it. Resident 1 revealed they had requested an English muffin for breakfast and received a bagel instead. Resident 1 revealed a bagel for breakfast was okay, just not every day. Interview with Resident 19 on 10/18/21 at 4:56 PM revealed when inquired how the facility food was they replied the potatoes were not cooked today. Resident 19 revealed everything was hamburger, even the chicken fried steak and they had gotten burned out on hamburger. Temperature check and taste test of a test tray received covered from the kitchen on 10/20/2021 at 12:39 PM revealed the following: Glazed Chicken breast: 120.2 F (Fahrenheit); hash brown casserole 185 F; sliced carrots 129.2 F. Taste test of the chicken revealed it was cool and not hot; the hash brown potato casserole was not seasoned and tasted undercooked as the hash browns were crunchy and gritty. A breadstick was also received with the meal and it tasted cold and tough as it was difficult to chew. Interview with the DON (Director of Nursing) on 10/21/21 at 9:57 AM revealed there were no residents who were NPO (nothing by mouth) and the DON confirmed all of the residents received food from the facility kitchen. Review of the undated facility policy Food Borne Illness Control Safe Food Preparation revealed the following: Food will be prepared using safe food handling techniques. All potentially hazardous food must be held outside the temperature Danger Zone with an internal temperature of below 41 F or above 135 F. Review of the undated facility policy Food Borne Illness Control Tray Line, Food Delivery Safety revealed the following: Food handlers will practice safe food handling techniques during meal service. Hot food will be held at 135 F or above. Interview with the RD (Registered Dietician) on 10/21/21 at 3:02 PM revealed it was their expectation for the hot foods to be served above 140 F and it was expected for the food to be cooked. Review of the 2017 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees C (135 degrees F) or above.

Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure that staff followed hand washing and safe food handling practices during food preparation to prevent the potential for cross contamination and food borne illness. This had the potential to affect 37 of 37 residents that received the meal from the facility kitchen (Residents 2, 17, 10, 23, 30, 22, 19, 1, 18, 141, 7, 4, 38, 20, 32, 12, 6, 37, 5, 9, 26, 33, 3, 29, 21, 27, 142, 25, 34, 31, 140, 8, 11, 24, 35, 16, and 14). The facility census was 39. Findings are: Record review of the undated facility policy titled Disposable Gloves revealed the purpose is to reduce the risk of food borne illness. Step 2. Food handlers will wash hands before putting on gloves. Step 3. Gloves will be changed when soiled, torn, or the task is changed. Used gloves are to be discarded. Food handlers will wash their hands after removing soiled gloves. Record review of the undated facility policy titled Safe Food Preparation revealed Step 8. Wash hands before handling food, after handling raw food, and after any interruption that may contaminate hands. Record review of the facility document titled Drown a Germ .Wash Your Hands dated 2000 revealed the procedure for washing hands with soap and water. The procedure contained the step to lather hands with soap and rub the hands together for 20 seconds. Rinse hands under warm running water. Dry hands with a paper towel. Observation on 10/18/21 at 9:38 AM in the facility kitchen revealed that the facility document Drown a Germ .Wash Your Hands was posted on the paper towel dispenser above the handwashing sink. Observation on 10/20/21 at 9:59 AM in the facility kitchen revealed that Dietary Cook-A (DC-A) put on gloves and scooped sour cream mix onto hash browns in a large steam table pan. DC-A did not wash the hands before putting on the gloves. DC-A used the gloved hands to mix the sour cream into the hash browns. DC-A removed the gloves and went to the sink. DC-A applied soap and scrubbed the hands for 16 seconds. DC-A rinsed and dried the hands. DC-A picked up scissors and opened packages of hash browns. DC-A poured the hash browns into a second steam pan. DC-A scooped the sour cream mix onto the hash browns. DC-A put on gloves and used the gloved hands to mix the sour cream into the hash browns. DC-A did not wash the hands before putting on the gloves. DC-A removed and discarded the gloves. DC-A did not wash the hands. DC-A removed a pan of baked chicken breasts from the oven and used a set of tongs to place the chicken breasts into a small steam pan. Observation on 10/20/21 at 10:31 AM in the facility kitchen revealed that DC-A used a washcloth from the sanitizer bucket and wiped off the prep table. DC-A opened a package of raw chicken breasts and used the bare hands to remove the raw chicken breasts and place them onto a baking sheet. DC-A did not wash the hands prior to using the bare hands to remove the raw chicken breasts. DC-A opened additional packages of raw chicken breasts and used the bare hands to place the raw chicken breasts onto another baking sheet. DC-A grabbed the can of non-stick spray and sprayed a third baking sheet. DC-A did not wash the hands. DC-A used the bare hands to place raw chicken breasts onto the third baking sheet. DC-A went to the sink and applied soap and scrubbed the hands for 15 seconds. DC-A dried the hands. DC-A returned to the prep table and moved an oven mitt sitting next to a baking sheet containing raw chicken breasts. The oven mitt fell on to one of the baking sheets containing the raw chicken breasts. The oven mitt rested on top of several of the raw chicken breasts. DC-A picked up a package of shredded cheese from the prep table and sat it on top of the oven mitt. DC-A removed the package of shredded cheese and put on the oven mitt. DC-A used the oven mitt and removed a steam pan from the oven. DC-A used the oven mitt and placed the baking sheets of raw chicken breasts into the oven. Observation on 10/20/21 at 11:53 AM in the facility kitchen revealed that DC-A went to the sink and applied soap. DC-A scrubbed the hands for 6 seconds underneath running water and then dried the hands. DC-A touched the hairnet and scratched their head with the right hand while walking to the microwave oven. DC-A put on gloves. DC-A removed hamburger buns from a package and placed them on a plate using the gloved hands. DC-A placed the plate into the microwave oven. DC-A put on an oven mitt. DC-A removed a small steam pan of pureed hash brown casserole from the oven by grabbing the pan with the thumb of the oven mitt on the inside of the steam pan. DC-A used a thermometer and checked the temperature of the pureed hash browns. DC-A picked up the pan with the oven mitt. DC-A carried the pan to the steam table with the thumb of the oven mitt inside of the pan touching the pureed hash brown casserole. DC-A removed a small pan of hamburger patties from the oven using the oven mitt. DC-A used a thermometer and obtained the temperature of the hamburger patties at 182 degrees Fahrenheit. DC-A carried the small pan of hamburger patties to the steam table with the thumb of the oven mitt inside of the pan . DC-A placed the pan in the steam table. DC-A performed hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) with ABHR. DC-A plated the first resident meal from the steam table. DC-A continued to plate meals to be served to the facility residents. Interview on 10/21/21 at 2:49 PM with the facility Registered Dietitian (RD) confirmed that dietary staff are required to wash the hands before putting on gloves. The RD confirmed that staff are required to scrub the hands with soap for at least 20 seconds to be effective. The RD confirmed that the procedure for washing the hands is posted at the sink. The RD confirmed that the dietary staff are required to wash the hands after handling raw chicken breasts before proceeding to a different task. The RD confirmed that the oven mitt that came into contact with the raw chicken breasts would be considered contaminated and should not be used. The RD confirmed that pans of food are to be handled by the outside of the pan and not with the hand or oven mitt touching the inside surface of the pans to prevent potential contamination. Record review of the resident list provided by the Facility Administrator (FA) on 10/20/21 at 2:04 PM revealed that 30 Residents in the facility dining room (Residents 2, 17, 10, 23, 30, 22, 19, 1, 18, 141, 7, 4, 38, 20, 32, 12, 6, 37, 5, 9, 26, 33, 3, 29, 21, 27, 142, 25, 34, and 31) were served the noon meal on 10/20/21 that the facility kitchen prepared. The list revealed that 7 residents (Residents 140, 8, 11, 24, 35, 16, and 14) received room trays for the noon meal on 10/20/21 that the facility kitchen prepared. Interview on 10/20/21 at 2:49 PM the FA confirmed the accuracy of the list of residents that received the noon meal from the facility kitchen on 10/20/21.

Licensure Reference Number 175NAC 12-006.05(21) Based on observation and interview, the facility failed to serve the meal to all residents at the same table before serving other residents to maintain resident dignity for 3 residents (Residents 7, 22, and 31). The facility census was 39. Findings are: Observation on 10/18/21 at 11:47 AM in the facility dining room revealed that Dietary Aide-C (DA-C) delivered the meal to Resident 33. Resident 33 and Resident 7 sat at the same table. Medication Assistant-D (MA-D) began to assist Resident 33 with eating. Resident 7 had not been served. Observation on 10/18/21 at 11:52 AM in the facility dining room revealed that Dietary Aide-B (DA-B) delivered the meal to Resident 8. Resident 8 and Resident 22 sat at the same table. Resident 22 had not been served. Resident 22 watched as Resident 8 began to eat the meal. Observation on 10/18/21 at 11:53 AM in the facility dining room revealed that DA-B delivered the meal to Resident 7. Resident 7 received the meal 6 minutes after their tablemate (Resident 33) had been served. Observation on 10/18/21 at 11:55 AM in the facility dining room revealed that DA-B delivered the meal to Resident 21. Observation on 10/18/21 at 11:55 AM in the facility dining room revealed that DA-B delivered the meal to Resident 4. Resident 4 and Resident 31 sat at the same table. Resident 31 had not been served. An unidentified nursing assistant sat at the table with Residents 4 and 31. Observation on 10/18/21 at 11:58 AM in the facility dining room revealed that DA-B delivered the meal to Resident 27. Observation on 10/18/21 at 11:58 AM in the facility dining room revealed that DA-B delivered the meal to Resident 22. Resident 22 received the meal 6 minutes after their tablemate (Resident 8) had been served. Observation on 10/18/21 at 11:58 AM in the facility dining room revealed that DA-B delivered the meal to Resident 31. Resident 31 received the meal 3 minutes after their tablemate (Resident 4) had been served. Interview on 10/21/21 at 3:34 PM with the Facility Administrator (FA) confirmed that the expectation is to serve the meal to all residents at the same table before moving to the next table.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to ensure that staff performed hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) between residents during meal service to prevent the potential for cross contamination for 16 residents of 30 residents observed eating in the facility dining room (Residents 19, 18, 20, 14, 32, 9, 141, 5, 7, 21, 4, 27, 22, 8, 1, and 31). The facility census was 39. Findings are: A. Observation of the facility dining room on 10/18/21 at 11:35 AM revealed meal service began. Food was taken one tray at a time to the residents from the steam table in the dining room. Trays were placed on the counter in front of the steam table and the cook plated the food and placed it on the tray which was then taken to the residents with their drinks which were poured from a table behind the tray line. The tray was placed on the table and the food was placed on the table in front of the resident and the dietary aides then took the tray away. The dietary aides handled all of the items including the plates, dessert cups, drink glasses, and the tray after it was placed on the table in front of the resident then they put the tray on the soiled tray cart. DA-B (Dietary Aide) was observed taking trays of food to residents including handling the trays that had been placed on the table in front of the residents and touching plates, dessert cups, and pouring drinks without doing hand hygiene between residents. After taking the trays to residents, DA-B was observed setting up other trays by placing them on the tray line and putting the diet cards on the trays and sliding the trays down the tray line toward the food service portion of the steam table. DA-B took food to Resident 19 without performing hand hygiene before or after taking the tray. DA-B placed the tray on the table in front of Resident 19 then put all items from the tray down in front of Resident 19 at the table including a plate of food, a dessert cup, and glasses of fluids. DA-B then took the tray which they had placed in front of Resident 19 on the table and handled with their bare hands, placed it on the soiled tray cart, then, without doing hand hygiene, took food to Resident 18 by picking up a tray and placing the tray on the table in front of Resident 18 and placing the food in front of them by handling the plate, dessert cup and glasses of fluids. DA-B then picked up the tray, handled it with their bare hands, and then placed it on the soiled tray cart. DA-B then took food and drinks to Resident 20 without doing any hand hygiene. DA-B placed the cups of fluids and plate of food in front of Resident 20 from the tray DA-B placed in front of Resident 20. DA-B then picked up the tray, handled it with their bare hands, and then placed it on the soiled tray cart. At 11:41 AM, without doing hand hygiene, DA-B then picked up a tray of food and drinks and placed the tray on the table in front of Resident 14 then put all items from the tray down in front of Resident 14 at the table including a plate of food, a dessert cup, and glasses of fluids. DA-B then took the tray which they had placed in front of Resident 14 on the table and handled with their bare hands, placed it on the soiled tray cart, then, without doing hand hygiene, took food to Resident 32 by picking up a tray and placing the tray on the table in front of Resident 32 and placing the food in front of them by handling the plate, dessert cup and glasses of fluids. DA-B then picked up the tray, handled it with their bare hands, and then placed it on the soiled tray cart. Without doing hand hygiene, DA-B then picked up a tray of food and drinks and placed the tray on the table in front of Resident 9 then put all items from the tray down in front of Resident 9 at the table including a plate of food, a dessert cup, and glasses of fluids. DA-B then took the tray which they had placed in front of Resident 9 on the table and handled with their bare hands, and placed it on the soiled tray cart. Without doing hand hygiene, DA-B then picked up a tray of food and drinks and placed the tray on the table in front of DA-B then picked up a tray of food and drinks and placed the tray on the table in front of Resident 141 then put all items from the tray down in front of Resident 141 at the table including a plate of food, a dessert cup, and glasses of fluids. DA-B then took the tray which they had placed in front of Resident 141 on the table and handled with their bare hands, placed it on the soiled tray cart, then, with no hand hygiene, took the wrappers off of the straws and placed them into the drinks. DA-B then picked up the tray of food and drinks and placed the tray on the table in front of Resident 5 then put all items from the tray down in front of Resident 5 at the table including a plate of food, a dessert cup, and glasses of fluids with the straws. DA-B then took the tray which they had placed in front of Resident 5 on the table and handled with their bare hands, placed it on the soiled tray cart then, without doing hand hygiene, started setting up the other trays by sliding them down the tray line after handling and placing the diet cards on the trays. DA-C then touched the trays to move them down the tray line. The diet cards on the trays were labeled for Resident 4, 21, 7, 8 and 1. At 11:49 AM DA-B took food to Resident 1 by placing the tray on the table in front of Resident 1 and placing the food and drink items in front of Resident 1 then handling the tray, placed it on the soiled tray cart. Without doing any hand hygiene, at 11:51 AM DA-B poured drinks for Resident 8 and placed them on a tray then DA-C handled one of the cups after DA-B handled it after not doing any hand hygiene. DA-B then gave the food and drinks to Resident 8 without doing hand hygiene. At 11:53 AM DA-B poured drinks by handling the glasses and then took food and the drinks to Resident 7. Without doing hand hygiene, DA-B then took food and drinks to Resident 21 including handling straws by removing the wrappers and placing them into the drinks. At 11:56 AM DA-B took food and drinks to Resident 4 and handled the straws by removing the wrappers and placing them into the drinks. DA-B did not do any hand hygiene. DA-B was in close proximity to the residents when they placed their food and drinks in front of the residents and none of the residents had face masks on. All of the residents were observed eating from the plates of food, cups of desserts, and drinking from the glasses of fluids. Interview with the DON (Director of Nursing) on 10/21/21 at 9:57 AM revealed there were no residents who were NPO (nothing by mouth) and the DON confirmed all of the residents received food from the facility kitchen. B. Record review of the undated facility policy titled Safe Food Preparation revealed Step 8. Wash hands before handling food, after handling raw food, and after any interruption that may contaminate hands. Observation on 10/18/21 at 11:52 AM in the facility dining room revealed that Dietary Aide-B (DA-B) delivered the meal to Resident 8. Resident 8 did not have a face mask on. DA-B sat the meal tray on the table in front of the resident. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on a 3 shelf cart near the meal service counter. DA-B did not perform hand hygiene. DA-B picked up a tray of food from the meal service counter. DA-B delivered the meal to Resident 7. Resident 7 did not have a face mask on. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on the 3 shelf cart near the meal service counter. DA-B did not perform hand hygiene. DA-B picked up a tray of food from the meal service counter. DA-B delivered the meal to Resident 21. Resident 21 did not have a face mask on. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on the 3 shelf cart near the meal service counter. DA-B did not perform hand hygiene. DA-B picked up a tray of food from the meal service counter. DA-B delivered the meal to Resident 4. Resident 4 did not have a face mask on. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on the 3 shelf cart near the meal service counter. DA-B did not perform hand hygiene. DA-B picked up a tray of food from the meal service counter. DA-B delivered the meal to Resident 27. Resident 27 did not have a face mask on. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on the 3 shelf cart near the meal service counter. DA-B did not perform hand hygiene. DA-B picked up a tray of food from the meal service counter. DA-B delivered the meal to Resident 22. Resident 22 did not have a face mask on. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on the 3 shelf cart near the meal service counter. DA-B did not perform hand hygiene. DA-B picked up a tray of food from the meal service counter. DA-B delivered the meal to Resident 31. Resident 31 did not have a face mask on. DA-B removed the food items from the tray and placed them on the table. DA-B picked up the empty tray from the table and placed it on the 3 shelf cart near the meal service counter. Interview on 10/21/21 at 2:49 PM with the facility Registered Dietitian (RD) confirmed that staff are to perform hand hygiene after delivering food to a resident when they touch the resident area. Interview on 10/21/21 at 3:28 PM with the facility Infection Preventionist (IP) confirmed that the expectation for all staff is to sanitize the hands (perform hand hygiene) between residents during meal service.

Based on interview and record review, the facility failed to ensure the Advance Directive (a legal document (such as a living will) signed by a competent person to provide guidance for medical and health-care decisions (such as the termination of life support or organ donation) in the event the person becomes incompetent to make such decisions) for code status (code is called when a patient goes into cardiac or respiratory arrest. Code status refers to the level of medical interventions a patient wishes to have started if their heart or breathing stops) was updated for Resident 40 prior to death. This affected 1 of 1 sampled residents. The facility identified a census of 39 at the time of survey. Findings are: Review of Resident 40's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated [DATE] revealed an admitted [DATE]. Resident 40 had a BIMS (Brief Interview for Mental Status) score of 9 which indicated moderate cognitive impairment. No terminal prognosis or hospice care was indicated. Review of Resident 40's Code Status document dated [DATE] revealed the following: I want everything done to keep me alive. I want CPR (CPR stands for cardiopulmonary resuscitation. It is an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) done. The document was signed by Resident 40, the MD (Medical Doctor), and a witness. It was documented on the form we will automatically do CPR unless your doctor specifically orders a DNR order at your request. Review of Resident 40's Baseline Care Plan dated [DATE] revealed the following: Code Status: Code. Review of Resident 40's Admission Record dated [DATE] revealed the following: Advance Directive: Resuscitation (the procedure of restoring to life, as in cardiopulmonary resuscitation (CPR)). Review of Resident 40's medical record chart revealed it was flagged resuscitate (revive (someone) from unconsciousness or apparent death). Review of Resident 40's Medication Review Report dated [DATE] revealed the following: Resuscitation was listed as an order with an order date of [DATE]. The form was signed by the MD. Review of Resident 40's Physician Orders Skilled admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The form was signed by the MD. Review of Resident 40's Progress Notes dated [DATE] at 6:18 PM revealed Resident 40 was admitted to the facility from the hospital. Resident 40 was alert and oriented and was able to do admission paperwork and their spouse was also present. It was documented that Advance Directive information was reviewed with Resident 40. It was documented Resident 40 wishes to be a resuscitate for CODE status at this time. On [DATE] at 9:43 AM, [DATE] at 11:53 AM, it was documented Resident 40 was confused and had a general decline. On [DATE] at 10:19 AM it was documented that Resident 40 had increased confusion and that Resident 40's spouse was notified of this. On [DATE] at 3:07 PM it was documented Resident 40 was seen by the MD. It was documented MD recommended to family to have a hospice consult and they will think about this. There was no documentation the family was inquired to review Resident 40's code status. On [DATE], at 9:10 PM, it was documented Resident 40 was found not breathing and without a pulse. There was no documentation CPR was initiated. On [DATE] it was documented the funeral home staff left the facility with Resident 40's body at 12:16 AM. Review of Resident 40's Physician's Orders dated [DATE] to [DATE] revealed no documentation Resident 40's Code Status was changed from CPR to DNR (a do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating). Review of Resident 40's untitled document dated [DATE] signed by the MD revealed the following: I have recommended hospice (hospice care is a special kind of care that focuses on the quality of life for people and their caregivers who are experiencing an advanced, life-limiting illness. Hospice care provides compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible care) and the family is going to think about that. We will continue (Resident 40's) care otherwise as needed. There was no documentation to change Resident 40's code status to DNR. Interview with the DON (Director of Nursing) on [DATE] at 3:16 PM revealed it was their understanding the MD had written hospice and DNR orders for Resident 40 before Resident 40 died , but they had died before hospice care could be initiated. When inquired for the documentation of the change in code status from CPR to DNR for Resident 40, the DON revealed they would look for the documentation. Interview with the DON on [DATE] at 3:57 PM revealed the MD had been in the facility the day Resident 40 died and the MD had discussed hospice with the family. The DON revealed they had heard Resident 40 tell the MD they did not want CPR. The DON confirmed there was no documentation Resident 40, the MD, or Resident 40's family had requested Resident 40's code status be changed from CPR to DNR. The DON confirmed Resident 40's code status should have been checked and a request placed to the MD and family to update Resident 40's code status from CPR to DNR when Resident 40's condition continued to decline. Review of the facility policy Advance Directives dated [DATE] revealed the following: Advance directives will be respected in accordance with state law and facility policy. Changes or revocations of a directive must be submitted in writing to the Facility. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident chart. Review of the facility policy Procedure of Resuscitation dated ,d+[DATE] revealed the following: Determine unresponsiveness, breathlessness, and pulselessness. Call for help. Remain with resident. Determine DNR or Code status. If resident is to be resuscitate(d) have O2 (oxygen) tank, ambu bag (a device used to provide respiratory resuscitation) and tubing, back board brought to resident's room; place back board under resident; connect tube to O2 tank and turn flow meter to 10 L. Begin CPR. Call 911 for transport to ER and inform that CPR is in progress. Notify Physician of resident status and transfer to hospital. Notify family. Continue CPR until ambulance arrives and they can take over CPR and transport to ER.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review; the facility failed to administer medications below a 5% medication error rate with 2 errors out of 27 opportunities which resulted in a medication error rate of 7.41 %. This affected 1 of 6 residents observed during medication administration, Resident 19. The facility identified a census of 39 at the time of survey. Findings are: A. Observation of MA-D (Medication Aide) on 10/20/21 at 11:19 AM revealed MA-D drew up 5 units of Novolog insulin (a type of medication used to control blood sugar levels) from a multi-dose vial and had a nurse check the dose. At 11:20 AM, MA-D took the insulin down the hall into Resident 19's room and injected the Novolog insulin into Resident 19's right arm. Resident 19 had snacks in their room that were out of Resident 19's reach. MA-d did not give Resident 19 any food, snack, or drink with nutritional value. Observation of Resident 19 on 10/20/21 at 11:34 AM revealed they did not have any food or drink of nutritional value. Interview with Resident 19 at this time revealed Resident 19 was planning to head to the dining room in a little bit. Observation of Resident 19 on 10/20/21 at 11:37 AM revealed Resident 19 did not have any food or drink of nutritional value. Resident 19 then wheeled themselves to the dining room. Observation of Resident 19 on 10/20/21 at 11:43 AM and 11:52 AM revealed they were sitting in the dining room. Resident 19 did not have any food or drink of nutritional value. Observation of Resident 19 10/20/21 at 12:13 PM revealed they received their meal in the dining room, 53 minutes after the Novolog insulin was administered to Resident 19. B. Observation of LPN-E (Licensed Practical Nurse) on 10/20/21 at 4:27 PM revealed LPN-E drew up 10 units of Novolog insulin from a multi-dose vial. At 4:29 PM, LPN-E injected the Novolog insulin into Resident 19's left arm. LPN-E did not offer Resident 19 any food, snack, or drink of nutritional value. Resident 19 was observed sipping a sugar free flavored water beverage. Resident 19 then left the room and wheeled themselves to the dining room. At 4:52 PM Resident 19 was observed sitting in the dining room with no food or drink of nutritional value, 23 minutes after the Novolog insulin was administered to Resident 19. Review of Resident 19's Order Summary Report dated 10/20/2021 revealed the following: Insulin [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (milliliter) Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes. OK to use Novolog via vial in replace of [MEDICATION(S)]. Administer 15 mins (minutes) before or immediately after a meal. Active 08/23/2021. Insulin [MEDICATION(S)] Solution Inject 4 units subcutaneously one time a day related to diabetes. Give 4 units at suppertime routine with sliding scale; Ok to use Novolog instead of [MEDICATION(S)]. Administer 15 mins before or immediately after a meal. Active 08/23/2021. Insulin [MEDICATION(S)] Solution Inject 3 units subcutaneously three times a day related to diabetes mellitus. Active 09/18/2021. Review of Resident 19's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for October 2021 revealed documentation the Novolog insulin was administered. Interview with the DON (Director of Nursing) on 10/21/21 at 8:58 AM revealed the nurses and medications aides usually followed the AC (before meals) guideline of 30 minutes to an hour before meals for insulin. The DON revealed they did not expect the nurses and medications aides to check the manufacturer's directions for administering the insulin with regards to mealtimes. The DON revealed it should have been checked when the order was entered into the computer. The DON revealed if the insulin was to be given within 5-10 minutes of a meal then that's what the medications aides/nurses should have followed. The DON revealed if it doesn't specify that on the policy they already provided then they probably didn't have a policy for the administration of insulin according to the manufacturer's specifications with regard to meals. Review of the facility policy Medication Administration Schedule dated 6/1/2019 revealed no documentation of the administration of insulin with regard to meals and manufacturer's specifications. Review of the Novolog manufacturer's directions for use How should I take NovoLog®? dated June 2021 revealed the following: NovoLog® starts acting fast. Eat a meal within 5 to 10 minutes after taking it.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility failed to ensure the bed was maintained to prevent a potential entrapment accident hazard for 1 of 16 residents observed, Resident 4. The facility identified a census of 39 at the time of survey. Findings are: Review of Resident 4's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/27/2021 revealed an admitted [DATE]. Resident 4 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 4 required extensive assistance from staff for bed mobility, dressing, personal hygiene, bathing, transfer, walk in room and corridor, locomotion on and off the unit, and toilet use. Observation of Resident 4's bed on 10/19/21 at 9:35 AM and 10/20/2021 at 2:20 PM revealed the mattress was not secured to the bed and could be slid off the bed frame and away from the wall creating a potential entrapment hazard as the bed was locked against the wall and there was a gap between the wall and the mattress. Interview with the FA (Facility Administrator) on 10/20/ at 9:54 AM revealed there had been no entrapment incidents in the facility. Requested documentation of monitoring the beds for entrapment and a policy from the administrator. Review of the untitled bed check documents received from the FA revealed the following: Bed Inspected was marked for Resident 4 on March 2021, May 2021, August 2021, and September 2021. There was no documentation of what specifically was inspected on the bed. Observation of Resident 4's bed on 10/21/21 at 10:14 AM with the FA, MS (Maintenance Supervisor), and EVS (Environmental Services) revealed Resident 4's bed was against the wall; the mattress was not secured to the bed frame and could be slid off the bed frame which created a gap between the wall and the mattress. Interview with the FA at this time revealed the expectation was for the mattresses to be secured to the beds. The FA revealed MA-F did the bed checks. Interview with MA-F (Medication Aide) on 10/21/21 at 12:29 PM revealed when they checked the beds they checked to make sure the brakes worked, the pump worked, the HOB (Head of Bed) and FOB (Foot of Bed) would raise and lower, made sure no cords were frayed, and made sure the remote worked. When inquired if they checked the beds for entrapment MA-F said they checked to make sure the side rails were secure and if there were gaps between the mattress and the side rails. When inquired if MA-F checked for other entrapment hazards such as mattresses not being secured to the bed creating gaps between the wall or side rails, MA-F said they didn't have a way to secure mattresses to the beds. Review of the facility policy Facility Inspection and Preventative Maintenance Protocol dated 3/23/2018 revealed the following: Bed frames/cords/bed canes are inspected routinely, encouraged to be monthly but at least quarterly, by maintenance/safety staff. Review of the facility document Guidance for Industry and FDA staff dated March 10, 2006 requested to be reviewed by the administrator revealed the following: We suggest that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment. As a result, healthcare facilities may use this guidance as part of a bed safety program to help identify entrapments risks that may exist with current hospital beds systems. Other educational documents are available to assist health care facilities in making decisions towards the goal of achieving a safe and comfortable sleeping environment for their patients.

LICENSURE REFERENCE NUMBER 175 NAC 12-007.04G Based on observation, interview, and record review; the facility failed to ensure the call system was functioning for 1 of 16 residents, Resident 142. The facility identified a census of 39 at the time of survey. Findings are: Interview with Resident 19 on 10/18/21 at 4:52 PM revealed the facility staff never answered their roommates call for assistance, Resident 142. Observation of Resident 142's room on 10/19/21 at 9:44 AM revealed Resident 142 had a pneumatic (containing or operated by air under pressure) call cord that was hanging on the wall clipped to itself. It was not kinked or obstructed. Test of the call cord when pressed revealed the call cord was not functioning; it did not light up outside the door or chime over the pagers after it was activated by pressing on it several times. On 10/19/2021 at 9:54 AM requested documentation from the FA (Facility Administrator) of the procedure for checking the call cords to ensure they were working and documentation the call cords were checked to make sure the call cords were working. Interview with the FA on 10/19/2021 at 10:44 AM revealed the facility had no documentation they were checking the call cords to ensure they were working. The FA revealed if the call cords were not working the staff were to let maintenance staff know so they could fix it. The FA revealed they could run a report to determine if Resident 142's call cord was working. Requested a copy of the report. Interview with the FA on 10/19/2021 at 11:18 AM revealed they and the MS (Maintenance Supervisor) checked Resident 142's call cord which was a pneumatic call cord and it worked the first time they pushed it then it didn't work the next time they pushed it so they changed it out. The FA revealed the test call made at 9:44 AM and the second test call the MS made with the call cord did not come out on the report which the FA confirmed indicated Resident 142's call cord wasn't working. The FA revealed they ran a report when they tested Resident 142's roommates call cord to see if it was working and it was which the FA indicated Resident 142's call cord not working was isolated to Resident 142 and not the entire room. Review of Resident 142's Alarm Event Report dated for 10/11/21 to 10/19/2021 revealed the following: Call cord alarm documented on 10/11/21, 10/13/21, and 10/15/2021. No alarms were documented since 10/15/2021 through 10/19/2021 then so there was no documentation the call cord had worked since 10/15/21. The alert from the test check of Resident 142's call cord on 10/19/2021 at 9:44 AM was not logged. Review of the facility policy Call Light Protocol dated 6/14/2018 revealed the following: All call lights are checked for function after a resident is discharged from the room, and before a resident is admitted in a room. Maintenance is notified of any issues in call light function on an as needed basis. Quality Checks: Call light compliance is randomly checked at least quarterly and reported at QA. Review of the facility policy Facility Inspection and Preventative Maintenance Protocol dated 3/23/2018 revealed the following: Call Lights-Call light function is checked upon deep clean of room and on an as needed basis for issues. Call light response time is monitored randomly at least quarterly.

Based on observation, interview and record review, the facility failed to protect all residents in the facility by not following acceptable infection control practice recommendations for COVID-19 from the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid (CMS) Services. The facility failed to have a screening system in place to ensure all staff and visitors were screened for signs and symptoms of COVID-19 prior to having contact or providing care to the residents. The facility allowed staff to enter the facility and pass multiple resident rooms prior to being screened for signs and symptoms of COVID-19. The facility failed to follow up on employee documented signs and symptoms of COVID-19 and allowed staff to care for the residents after reporting signs and symptoms of COVID-19. The facility failed to screen visitors for signs and symptoms of COVID-19 when entering the facility and having contact with residents. This deficient practice placed all 30 residents at risk for contracting COVID-19 and resulted in Immediate Jeopardy (IJ). As a result of the identified non-compliance, the Administrator was notified on 6/25/20 at 4:05pm of the Immediate Jeopardy. Review of CMS, Center for Clinical Standards and Quality, Safety and Oversight (QSO) Memo 20-14-NH, dated 3/13/20, provided guidance to long term care facilities which included screening all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough and sore throat. If ill, have them self-isolate at home. Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 3/13/20, showed the following: -Screen all healthcare professionals (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. If they are ill, have them keep their facemask on and leave the workplace. -Fever is either measured temperature >100.0 degrees Fahrenheit or subjective fever. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath and sore throat. Findings include: Review of the COVID-19 employee symptom evaluation log forms on 6/25/20 revealed on: -4/27/20: Agency Staff/Nurse Aide (AS/NA1) entered the facility, no temperature assessed. Review of information provided by the administrator on 7/7/20 showed AS/NA1 was in orientation from 1:30pm to 2:25pm. -4/30/20: facility Administrator entered facility, no screening completed for signs and symptoms of COVID-19. -5/4/20: AS/NA2 entered the facility and documented intermittent cough and shortness of breath. Sore throat. Review of information provided by the administrator on 7/7/20 showed AS/NA2 worked and provided care to the residents from 2pm until 11pm on 5/4/20. -5/16/20: Dietary Aide (DA1) entered facility, no screening completed for signs and symptoms of COVID-19. Review of information provided by the administrator on 7/7/20 showed DA1 worked from 5:28am to 2:14pm on 5/16/20. -5/12/20: AS/NA2 entered facility and documented having a sore throat. Review of information provided by the administrator on 7/7/20 showed AS/NA2 worked and provided care to the residents on from 2pm until 11pm on 5/12/20. -5/11/20: Registered Nurse (RN1) entered facility and documented having a sore throat. Review of information provided by the administrator on 7/7/20 showed RN1 worked and provided care to residents from 6:27am until 2:45pm on 5/11/20. -5/11/20: Social Services Director (SSD) entered facility and documented slight cough and sore throat. Review of information provided by the administrator on 7/7/20 shows the SSD worked from 8:06am until 5:00pm on 5/11/20. During an interview on 6/25/20 at 2:30pm, the Infection Control Nurse stated that she tried to look over the employee screening logs to see if any staff had documented any signs or symptoms of COVID-19. She stated that staff had been educated to talk to herself, the DON or the Administrator if they documented any signs or symptoms of COVID-19 in the employee screening log forms. She stated she would expect any staff who reported any signs or symptoms of COVID-19 on the employee screening form to contact her. Review of the facility's document titled COVID-19 Timeline on 6/25/20 showed the following: -3/13/20: Non-essential personnel restricted from entering building. -3/15/20: Calls made to families to ask them to limit visitors. -3/16/20: Started no visitors except for those people on hospice or palliative care. Review of the facility's visitor COVID-19 symptom evaluation form on 6/25/20 revealed the following: -3/29/20: Visitor (V14) entered facility, err documented under temperature. -4/10/20: V2 entered the facility, no temperature documented. -4/17/20: V3 entered the facility, no screening completed for signs and symptoms of COVID-19. -4/28/20: V4 entered facility, no temperature assessed. -5/12, 5/14, 5/19, 5/26, 6/12/20: V5 entered the facility, no temperature assessed. -6/9/20: V6 entered facility, no screening completed for signs and symptoms of COVID-19. -6/19/20: V7 entered facility, no screening completed for signs and symptoms of COVID-19. -6/12/20: V8 entered facility, no screening completed for signs and symptoms of COVID-19. -6/12/20: V9 entered facility, no screening completed for signs and symptoms of COVID-19. -6/12/20: V10 entered facility, no screening completed for signs and symptoms of COVID-19. -6/12/20: V11 entered facility, no screening completed for signs and symptoms of COVID-19. -undated: V12 entered facility, no screening completed for signs and symptoms of COVID-19. -undated: V13 entered facility, no screening completed for signs and symptoms of COVID-19. During an interview on 6/25/20 at 12:05pm, the DON stated a screening station was set up at the front entrance of the building and the receptionist who worked Monday through Friday 8am to 4:30pm was responsible to ensure that anyone that entered the facility was screened for signs and symptoms of COVID-19. She stated anyone who entered the front door beyond the time that the receptionist was working, was responsible to screen themselves before proceeding to resident care areas. She stated about a week ago, the facility realized visitors were entering the facility through the front door and not conducting the screening for signs and symptoms of COVID-19 on themselves. She said the facility was not able to lock the front door related to fire codes but there was a sign at the front entrance letting anyone who entered the facility know that they were not allowing any visitors into the facility. She stated at that time (about a week ago), the facility initiated a new procedure that required anyone who entered the facility through the front door to interact with a staff member via telephone prior to entering resident care areas and to ensure the individual did not have a temperature or any signs or symptoms of COVID-19 before proceeding into the resident care areas of the facility. Review of the facility's COVID-19 visitor symptom evaluation form on 6/25/20 revealed on: -6/24/20: Dietician (D1) entered the facility and was not screened for signs and symptoms of COVID-19. -6/24/20: Visitor (V1) entered the facility and documented having shortness of breath. During an interview on 6/25/20 at 2:30pm, the Infection Control Nurse stated she would have expected all family and visitors who entered the facility to complete the COVID-19 screening log form prior to having any contact with any residents in the facility. She stated the facility had made a change to the screening process about a week ago for anyone who entered through the front door. She stated they had to communicate with staff via telephone and staff would ensure that they were screened prior to entering resident care areas. She stated prior to making the change that anyone who entered through the front entrance of the facility were kind of screening themselves. The facility submitted an acceptable plan and the IJ was removed and deficient practice corrected on 6/26/20 after verification of implementation of the removal plan.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility staff failed to prevent potential cross contamination by failing to follow contact precautions, failing to perform hand hygiene when indicated, failing to clean equipment used by multiple residents, and failing to ensure the facility policies for infection control, immunizations, and antibiotic stewardship were reviewed annually. The facility staff also failed to ensure that staff followed isolation precautions (the use of gloves, gowns, and hand washing to help stop the spread of germs from one person with a known infection to another) and to ensure that hand hygiene (hand washing) was performed when exiting the room of a resident under isolation precautions before entering the room of another resident. This had the potential to affect all of the facility residents. The facility identified a census of 30 at the time of survey. Findings are: [NAME] Interview with the ICC (Infection Control Coordinator) on 2/27/20 at 1:36 PM revealed the facility had 8 residents who had tested positive for CP-CRE (Carbapenem-resistant [MEDICATION NAME] (CRE) are [MEDICAL CONDITION] that that can cause serious infections and require interventions in healthcare settings to prevent spread according to the CDC (Centers for Disease Control)) and required contact precautions and 2 other residents who were discharged from the facility had also tested positive. Observation of the rooms belonging to Residents 29, 6, 14, 1, 30, 22, 31 and 29 on 2/24/20 at 4:05 PM revealed they had Contact Precautions signs and PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) on their doors. Review of the undated facility document Contact Precautions received from the DON (Director of Nursing) revealed the following: Perform hand hygiene before entering and before leaving room, wear gloves when entering room or cubicle, and when touching patient's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces, use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment between patients. Observation of ES-H (Environmental Services) on 2/25/20 at 11:58 AM revealed they were distributing personal clothing to Resident 14 and Resident 1 who shared a room. Contact Precautions were posted on the door. A sign posted on the door read must wear gloves and gown before entering room. ES-H donned gloves and took the clothes into the room, opened a drawer, and placed the clothing into the drawer before closing the drawer. Resident 14 and Resident 1 were present in the room. ES-H did not put a gown on. ES-H then took the gloves off, came out of the room and scrubbed hands with hand sanitizer. ES-H then took clothes to Resident 20, Resident 26, and Resident 7 who did not have contact precautions. ES-H then took clothes to Resident 28 at 02/25/20 at 12:02 PM who had contact precautions and PPE posted on their door. ES-H put gloves on, entered the room, opened the drawer and put the clothes in. ES-H did not have a gown on. ES-H then took the gloves off and used hand sanitizer that was in the dispenser outside the door. Resident 28 was present in the room. ES-H then took clothes to Resident 3, Resident 17, Resident 16, and Resident 21. They did not have contact precautions. On 2/25/20 at 12:06 PM, NA-F (Nurse Aide) took a Styrofoam container of food into Resident 28's room and put it on the wheeled walker platform in front of Resident 28 who was sitting in the recliner then did hand sanitizer and took food to Resident 16 who did not have contact precautions. NA-F was in close proximity to Resident 28 and their belongings and did not have a gown on. On 2/25/20 at 12:09 PM, ES-G brought plastic hangers out of the room belonging to Resident 14 and Resident 1. There was a sign on the door Contact Precautions and PPE. ES-G was wearing gloves and did not have on a gown. ES-G handled the outside of a large white plastic bag marked for CRE hangers with the gloved hands, placed the hangers in the bag, then went back into the room and discarded the gloves. The bag was hanging on the end of a rolling clothes rack that had personal clothing on it that was out in the hall. Resident 14 and Resident 1 were present in the room. At 2/25/20 at 12:10 PM, ES-G had gloved hands and brought hangers from Resident 29's room and placed them in the bag marked for CRE hangers by handling the outside of the bag with the gloved hands. Resident 29 also had a sign on the door Contact Precautions and PPE. ES-G had gloves on and no gown. Resident 29 was present in the room. ES-G then proceeded to push the cart down the hall. The clothes were touching ES-G's smock. ES-G then took clothes into Resident 4's room on 2/25/20 at 12:15 PM then into Resident 2's room. Resident 4 and Resident 2 did not have Contact Precautions on their door. ES-G brought the hangers out of Resident 2's room and hung them on the rack. On 2/25/20 at 12:16 PM ES-G then took clothes in to Resident 5 and Resident 25. Their clothes had also been touching ES-G's smock. On 2/25/20 at 12:17 PM the bag marked for CRE hangers was touching the clothing belonging to Resident 27 and Resident 24 who did not have contact precautions. ES-G was also observed using bare hands when putting the clothes into the closets. On 2/25/20 at 12:19 PM ES-G hung a T shirt on the handrail outside Resident 6's door and it was touching the floor. On 2/25/20 at 12:20 PM ES-G donned gloves and took the T-shirt into Resident 6's room then brought hangers out and put them in the bag marked for CRE hangers by handling the bag with the same gloves. On 2/26/20 at 8:15 AM NA-F was observed carrying a pile of linens (sheets, pillowcases) down the hall up against their uniform. NA-F took the pile of linens into Resident 5's room and put some of the linen on the bed which was stripped. NA-F then took the remainder of the linens still carrying them up against their uniform into Resident 4's room. Interview with LHS (Laundry Housekeeping Supervisor) on 02/27/20 at 11:37 AM revealed the facility staff were supposed to be leaving the hangers in the rooms of residents who have contact precautions until they found a proper procedure for sanitizing them before they brought them out of the room. LHS confirmed they were looking for a disinfectant they could use the clean the hangers. The LHS revealed the facility staff should not be touching the resident clothing to their own clothing when they are passing clothing. If a clothing item fell on the floor or touched the floor the staff should have taken it back to the laundry to wash it. The LHS confirmed that the observations with laundry deviated from their expectations. Review of the undated Policy for Passing linens revealed no documentation of clothing not touching the staff clothing or items should be re-laundered if dropped on the floor or touch the floor. No documentation that staff should not be taking the hangers out of the rooms who had residents in isolation/contact precautions. There was also no documentation that staff should not be taking the same linens from room to room. Review of the facility policy Hallway Policy dated 3/7/2017 revealed the following: Linen carts-load your cart, pass linen and put cart away. B. Observation of the facility bath house on 02/26/20 at 1:52 PM revealed a Penner Cascade jetted tub with a lift chair. NA-E with the DON (Director of Nursing) present proceeded to clean the tub. The DON said they were done with baths for the day so they used a different cleaning procedure as all of the residents used the tub and the residents with CRE received the last baths of the day. NA-E set a timer for 10:45 seconds, dispensed the disinfectant in about 1 1/2 gallons of water into the bottom of the tub, then started wetting the surfaces. Everything was finally wet with 8:47 left on the clock. NA-E then proceeded to use a brush to scrub the tub with Penner disinfectant on the inside of the tub. NA-E said they cleaned the inside of the tub with the Penner disinfectant that was dispensed into the bottom of the tub and NA-E used a spray bottle of the Penner disinfectant the keep the surfaces wet. NA-E said the tub surface had to stay wet with the Penner disinfectant for 10 minutes. NA-E said they would use MicroKill wipes to clean the outside of the tub. NA-E did not put the sprayer or the spray hose into the tub and clean it. NA-E focused on the left side of the tub and did not consistently keep the right side of the tub wet. NA-E only scrubbed the underside of the lift seat that was in the tub 3 times. NA-E did not run the jets on the tub. NA-E said they did the procedure twice so after the 10 minute timer went off, NA-E started over again. This time NA-E put the sprayer into the tub and put the disinfectant on it with the scrub brush but NA-E did not spray the hose on the outside of the tub with the disinfectant. NA-E did not have the sprayer hose wet with disinfectant and the surfaces of the tub were not wet the full 10 minutes. NA-E demonstrated where the disinfectant came out of the floor of the tub, not the jets. NA-E said they did not run the jets when cleaning the tub. At 2:15 PM the DON said they don't have to run the disinfectant through the jets. After NA-E cleaned the tub NA-E wiped the outside of the tub and the sprayer hose with a MicroKill wipe. Observation of the tub of MicroKill wipes read it had a 1 minute wet set time. The surface did not stay wet for the full 1 minute. It was dry in 10 seconds. NA-E also wiped from the floor to the top of the tub when NA-E cleaned the outside of the tub. NA-E then wiped the cabinets which did not stay wet and the paper towel holder. NA-E then sprayed the shower chair with the Penner disinfectant 2 times but it did not stay wet 10 minutes. There was also a commode tub sitting on the shower chair which was not sprayed at all. NA-E then took their gloves off, took another pair of gloves out of the box, laid them on the sink, did hand hygiene with hand sanitizer and then put the gloves on. This was at 2:17 PM. Review of the undated The System Cleaning for whirlpool tubs revealed the following: press and hold the disinfect button #1 located on the left side of the tube. As the button is held down, the properly mixed cleaning solution is running through and disinfecting the pump and motor. Release the button after you see solution coming out of both jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. For aqua-air tubs: press and hold the disinfect button #1 located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. Use a long-handled brush to thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Disinfect the seat by reattaching it to the lift and positioning it over the tub. Use the brush to scrub its surfaces with the remaining solution. Allow for proper disinfectant contact time (Usually 10 minutes or as recommended by the disinfectant manufacturer) and rinse the seat. Replace the seat on the Penner Transfer. Repeat the disinfecting procedure on the wet portions of the lift's upper arm and latching mechanism. Remove the plug from the drain. For Whirlpool tubs, spray water from the shower sprayer into the back outlet until clear water appears from the inlet. Repeat this procedure with the front outlet. Rinse the tub's interior surfaces thoroughly with the shower sprayer. For Aqua-Air tubs spray water from the shower sprayer to rinse out most of the disinfectant solution. Then press and hold the rinse button (32) until you see clear water (not soapy) coming out of the air jets. Release the rinse button. Finish rinsing the interior surfaces of the tub with the shower sprayer. Start the air blower by pushing the Aqua-air button #7. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. Stop the air blower by again pushing the Aqua-Air button #7. There was a picture of the tub on the document. Observation of the facility tub on 2/26/20 at 4:40 PM with the ICC revealed the tub not have any outlets and had a button for the air jets. The ICC confirmed the tub in the tub room looked similar to the tub on the document indicated as an Aqua air jet tub. Observation of the facility tub on 2/26/20 at 4:43 PM with the DON revealed the DON said it was a Cascade side entry tub and thought it looked like an Aqua air tub as there were not outlets. Review of the untitled facility documents identified by the DON as the bathing records for (MONTH) 2019 through (MONTH) 2020 revealed documentation all of the facility residents received a bath during the timeframe of the outbreak of CP-CRE, (MONTH) 2019 to the present. Review of the Penner Disinfectant Cleaner dated 7/7/2011 revealed the following: To disinfect inanimate, hard, non-porous surfaces add 2 ounces of per gallon of water. Apply solution. Allow to remain wet for 10 minutes. Review of the undated Medline Micro-Kill One Germicidal Wipes revealed the following: Exposure time for Escherichia coli and [DIAGNOSES REDACTED] pneumoniae is 1 minute at room temperature. Requested documentation of the first case of CP-CRE from the DON. On 2/27/20 at 9:17 AM Resident 31 tested positive for CRE on 12/9/2019 when they were hospitalized . Resident 31 returned to the facility on [DATE] and had been in strict contact isolation since then. The DON also provided a list of residents who tested positive for CP-CRE (Carbapenemase Producing Carbapenem-Resistant [MEDICATION NAME]-an antibiotic resistant bacteria) and the dates: Resident 29 on 12/27/2019 [DIAGNOSES REDACTED] pneumoniae; Resident 6 on 12/27/2019 eschericia coli; Resident 14 on 1/9/2020; Resident 1 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 30 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 22 on 2/12/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 28 on 2/12/2020. Interview with the DON on 2/27/20 on 11:07 AM revealed Resident 31 took a shower and had their own shower chair in their room as Resident 31 was CRE positive. Resident 21 took a shower and Resident 21's was the shower chair that was in the bath house that NA-E had sprayed twice and it had not remained wet for the full 10 minutes. The DON revealed that if a resident wanted a shower, the staff just put them in the tub and used the shower attachment. Otherwise all of the other residents received a tub bath. The DON revealed they did not know if the staff were allowed to hold resident clothing and linens up against their uniforms or smocks. The DON revealed the expectation was that the staff were supposed to take linens and fill their cart. If they were going to leave it in the hallway they had to cover it. When they were going into the room they were supposed to grab everything for that resident depending on the resident and they were supposed to take 2-4 towels and washcloths. If they took linen into one room they could take it out of that room and take it into another resident's room. If they took linen into one resident's room and didn't need it had to be laundered and not used for another resident. The DON revealed the staff could not take the linen into another resident's room. The staff were allowed to keep the laundry hampers in the hall during am and pm cares so they were not dragging soiled linens down the hall. The DON confirmed that NA-F should not have entered resident rooms with the linen after they had taken the linen into another resident's room; when NA-F crossed the plane of the resident's room with the linen it should not have been taken into another residents room. That is why the facility had carts. Based on contact precautions, as long as they are not going to touch the residents (at first they were strict but they were running out of PPE) so they looked at the standard of care for contact precautions as long as they weren't going to do any direct resident contact for dropping off meals they did not have to wear a gown. Review of the undated untitled modified contact precautions provided by the DON: Contact isolation-any time you are going to come into contact with the resident or the residents belongings you must wear a (sic) isolation gown. The only time that you do not need to wear isolation gowns is: if you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in to do any of these things you must: Do hand hygiene: wash your hands or use hand sanitizer. Apply gloves. Make sure that you or your clothing does not touch the resident or the residents belongings. Deliver what you need to or do what you need to do. Remove gloves. Hand hygiene: wash with soap and water or use hand sanitizer. Interview with the DON on 2/27/20 at 12:55 PM revealed they did not have documentation of communication with ICAP/ASAP (state agencies responsible for infection surveillance when outbreaks of communicable diseases occur in facilities) when they modified the contact precautions. The DON revealed the Administrator made the decision to do the modified (no gown) contact precautions based on the contact precautions information they had. The DON pointed out the statement on the contact precautions document: Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. The DON revealed the facility did not have a procedure in place if the staff did not wear a gown, entered a CP-CRE room and got coughed on or inadvertently contaminated their uniform. The DON revealed that the equipment and surfaces needed to be wet for the amount of time per the recommendations for the Penner Disinfectant and the Micro-Kill wipes. The DON confirmed NA-E should have performed hand hygiene before touching the gloves and the wet times were not long enough on the tub, shower chair, sprayer and sprayer hose, and the cabinets. Interview with the DON on 2/27/2020 at 1:37 PM revealed they didn't know how or when the first resident had CP-CRE or how long it could have been spread. The DON confirmed they had residents who initially were negative for CP-CRE and then were positive at a later time while they were residing in the facility. On 2/27/20 at 2:27 PM the ICC provided the list of residents who were initially negative and then had positive CP-CRE tests while they were in the facility: Resident 14 tested negative 12/27/2020 then tested positive 1/9/2020. Resident 1 tested negative 1/15/2020 then tested positive 1/29/20. Resident 30 tested negative on 1/15/2020 then tested positive 1/29/20. Resident 22 tested negative on 1/29/20 then tested positive 2/12/20. Resident 28 tested negative on 1/29/20 then tested positive 2/12/20. There was no documentation any of these residents were out of the facility in the time frames which indicated the residents were in the facility when they contracted the CP-CRE. C. Review of the facility policy Influenza, Prevention and Control of Seasonal dated 8/11/2015 revealed no documentation it had been reviewed annually. Review of the undated facility policy Infection Prevention and Control Policy and Procedures revealed no documentation it had been reviewed annually. Review of the facility policy Antimicrobial Stewardship Program dated 11/16/2017 revealed no documentation it had been reviewed annually. Interview with the DON on 2/27/20 at 2:28 PM confirmed there was no documentation the facility policies had been reviewed annually. D. An observation of the contact isolation precautions for Resident 6 revealed that a sign on gold paper and placed on Resident 6's door stated anyone entering the room must wear a gown and gloves at all times. Also on a pink sign were instruction for putting on PPE (Personal Protective Equipment) which was complete hand hygiene, apply gown, mask, goggles, or face shield and gloves. An observation on 2/24/2020 at 12:46 PM of ES-H (Environmental Services) delivering laundry into the isolation room for Resident 6 revealed that ES-H cleansed hands with hand sanitizer and walked into the room without applying a gown. An interview on 2/24/20 at 1:00 PM with ES-H revealed that the laundry staff because those staff don't come into contact with the residents only have to wear gloves into the room. An interview on 2/24/20 at 1:07 PM with ES-J revealed the type of PPE worn depends on the job you're doing at the time. Laundry staff only have to wear a pair of gloves into the room since there was no contact with the resident. Housekeeping need to wear a gown, gloves and booties into the isolation rooms. ES-J stated the staff have been doing this forever and are frazzled. Working with the Health Department and getting all kinds of instruction was overwhelming. D. Observation on 2/25/20 at 8:21 AM of NA-E who was taking a breakfast meal to Resident 6 revealed that NA-E was wearing only gloves into the room. NA-E after doing unobserved hand hygiene in the restroom because this surveyor could not get on the PPE (Personal Protective Equipment) in time, went into Resident 23's room and informed Resident 23 that the bath for this resident was ready. NA-E did not complete hand hygiene before going into Resident 23's room. NA-E then went around the room touching the closet door and dresser drawers gathering clothing for Resident 23 to put on after the bath. Review of a Sign at nurses' station that states: Midwest Covenant Home- * Contact Isolation-Any time you are going to come into contact with the resident or the residents belongings you must wear a isolation gown. *The only time that you do not need to wear isolation gowns is: 1. If you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in for these few things you must: a. Do hand hygiene wash your hands or use hand sanitizer b. apply gloves c. Make sure that you or your clothing does not touch the resident or the residents' belongings d. Deliver what you need to or do what you need to do. e. Remove gloves f. Hand hygiene wash with soap and water or use hand sanitizer. There was no documentation or education on the posting or anywhere in the facility to instruct staff what the process was or what to do if the staff not wearing a gown were touched by a resident or the residents personal items came into contact with the staff or the staff 's clothing. Observation on 2/27/20 at 11:39 AM of ES-H (Environmental Services) entering the isolation room for Resident 6 revealed ES-H reached into the pocket of ES-H uniform and removed a pair of gloves and applied them without doing hand hygiene. ES-H then entered the room without putting on an isolation gown. An interview on 2/27/20 at 1:24 PM with the DON (Director of Nursing) revealed the DON did not know what the precautions were if the staff touched items in the room without gloves on or if the resident touched the staff who did not have a gown on. The staff person then would be contaminated and if leaving the room would potentially contaminate everyone the staff person came into contact with. DON stated the staff are being instructed if the staff find out the resident needs something more than just answering the call light. The staff need to remove the gloves. Sanitize the hands and put a gown on then help the resident. Observation on 2/27/20 at 1: 42 PM of the sign outside Resident 22's room a yellow sign on the door that states When entering this room please wear a gown, gloves and mask at all times. Resident 22 had just returned from the hospital around 5:00 PM on 2/26/20 with a [DIAGNOSES REDACTED]. Observation on 2/27/20 at 1:50 PM of RN-K (Registered Nurse) entering the room for Resident 22 revealed RN-K did hand hygiene and applied gloves, gown was applied and a face mask. RN-K then turned off the nebulizer machine (machine used to administer aerosol medication) for Resident 22. Observation on 2/27/20 at 1:57 PM NA-C (Nurse Aide) getting Resident 22 ready to take to the bath revealed NA-C completed hand hygiene with hand sanitizer before applied gloves and a gown before entering the room. NA-C went about the room touching the closet door, the residents' bedside table, and the recliner that the resident was sitting in. Touching the items in the room contaminated the gloves worn by NA-C. NA-C was not wearing a face mask while in the residents' room and NA-C was within 2 feet of Resident 22. Resident 22 stated Resident 22 had to go to the restroom. NA-C got the isolation lift from the hallway by the door to Resident 22's Room and touched the lift without removing the gloves and doing hand hygiene after touching items in the room. This contaminated the handles of the lift. NA-C shut the door to take Resident 22 to the restroom. After 5 minutes NA-C opened the door and placed the contaminated lift in the hallway. NA-C then proceeded to assist Resident 22 out of the room in Resident 22's contaminated wheelchair down the hallway. NA-C was wearing the same gloves that were worn to push the lift into the hallway to push the wheelchair down the hallway. NA-C was pushing the wheelchair and pulling the lift contaminated lift that hadn't been cleaned from the hallway behind them. Resident 22 was brought down the hallway, by other residents, in the contaminated wheelchair that was in residents' room. Wheelchair was not wiped down and resident was not wearing a mask or gown. Resident 22 was wearing the same clothes Resident 22 had been wearing this morning. The door to the bath house was open and NA-C went inside with Resident 22, the contaminated wheelchair and contaminated lift which contaminated the bath house. Review of the undated CRE positive procedure for going to designated activity the process was to: cleaning the resident wheelchair (including wheels and high-touch surfaces like handles), putting on clean clothes; clean resident hands; use reasonable distance from others when positioning the residents'; paper copies of supplies (thrown away after use, i.e. song book); push to activity and push back when done. An interview on 2/27/20 at 2:15 PM with MA-L (Medication Aide) revealed that it is staff preference as to what you want to wear for mask, gown or gloves when entering Resident 22's room. Observation on 2/27/20 at 3:04 PM of Resident 22 sitting at the nurses' station within 3 to 4 feet of the other residents at the activity. Resident 22 was sitting in the same wheelchair that Resident 22 had been taken to the bath house in. Resident 22 was not wearing a mask. When other residents or staff wanted to go down the South hallway they would have to walk within 2 feet of the residents from contact isolation rooms. An interview on 2/27/20 at 3:34 PM with RN-K (Registered Nurse) revealed that Resident 22 was not coughing much at this time and Resident 22 was receiving nebulizer breathing treatments and hopefully would start to cough up some of the secretions from the lungs. Review of the CDC (Centers for Disease Control and Prevention) article Healthcare-associated Infections revealed that the Healthcare Facilities should- Ensure precautions are implemented for CRE (Carbapenem-resistant [MEDICATION NAME] ) colonized or infected patients. These include: *Whenever possible, place patients currently or previously colonized (Some people have germs on or in their body, but those germs do not cause an infection (when germs enter the body, often through medical devices like ventilators, intravenous catheters, urinary catheters, or wounds caused by injury or surgery) or infected with CRE in a private room with a bathroom and dedicate noncritical equipment (e.g., stethoscope, blood pressure cuff) to CRE patients. *Have and enforce a policy for using gown and gloves when caring for patients with CRE. *Have and enforce policies for healthcare personnel hand hygiene before and after contact with patient or their environment, and increase emphasis on hand hygiene on a unit caring for a patient or resident with CRE. *Healthcare personnel should follow standard hand hygiene practices, which include use of alcohol-based hand sanitizer or, if hands are visibly soiled, washing with soap and water. *When a patient with an unusual type of carbapenemase-producing CRE is identified in your facility, work with public health to prevent spread, including following guidance to assess for ongoing transmission. F. Record review of the history and physical documentation by the physician for Resident 31 dated 2/9/20 revealed that the resident had a urine lab test confirming that the resident's urine contained Carbapenem-resistant [MEDICATION NAME] (CRE) [DIAGNOSES REDACTED] (a type of bacteria that has become resistant to carbapenem, a class of antibiotic used to kill bacteria). Observation on 2/25/20 at 2:45 PM revealed that Nursing Assistant C (NA-C) entered the room of Resident 31 without putting on personal protective equipment (PPE) (protective clothing such as gown, gloves, or mask used to protect the wearer's body from infection). Resident 31 was in isolation precautions (requiring the use of gloves, gowns, and hand washing when in the resident room to help stop the spread of germs from one person with a known infection to another) and disposable PPE was available in a holder hanging on the resident's door for staff use. NA-C exited the room of Resident 31 carrying linens and did not perform hand hygiene. NA-C then carried linens into the room of Resident 3. Interview on 2/27/20 at 12:57 PM with the facility Director of Nursing (DON) confirmed that staff are required to wash the hands with soap and water or with alcohol based hand rub when exiting a resident room.

Licensure Reference Number: 175 NAC 12-006.04 Based on record review and interview, the faciltiy failed to ensure that staff were competent to care for residents in order to prevent accidents with injuries from occurring for one Resident (Resident 1). The facility census was 50 and three residents were on sample. Findings are: A. Review of Resident 1's MDS (Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated 4/25/12 revealed Resident 1 had no impairment in range of motion (the extent to one can move one's joints) in the lower extremities, had no behaviors, had occasional moderate pain that did not limit day to day activities. Review of a facility investigation report dated 6/26/12 revealed that "on (6/5/12) Nursing Assistant (NA A) was assisting (Resident 1) to the commode. (NA A) attached harness (used with a mechanical lift) around waist but failed to utilize shin pad strap (an additional strap that positions behind the resident's legs), resulting in resident slipping out of belt and falling on platform of EZ stand (a mechanical lift) and landing on both knees. .....Results of X-ray showed fracture of left femur (leg).....(and) right femur." B. After the fall on 6/5/12, the resident exhibited ongoing issues with pain despite treatment as evidenced by: Review of Resident 1's MDS dated [DATE] revealed Resident 1 had impairment in Range of Motion in the lower extremities on both sides, had behaviors not directed towards others (such as screaming) 4 to 6 days out of the prior 7 days, and exhibited non verbal and verbal indicators of pain 3 to 4 days out of the prior 7 days. Review of Resident 1's PRN (as needed) Results Report from June 5th to July 11th revealed Resident 1 was administered [MEDICATION NAME] and/or [MEDICATION NAME] for pain in bilateral legs or knees 52 times. Further review of the same form revealed Resident 1 was yelling and screaming out in relation to pain as evidenced but the following documented reasons for administering the pain medication:-6/5/12 Resident screamed "yes" when asked if in pain -6/5/12 yelling c/o (complaints of) severe pain in both knees -6/8/12 Bilateral knee pain -6/8/12 yelling "my legs and knees are killing me" -6/13/12 c/o pain all over - yelling out loudly -6/14/12 yelling states pain #8 (on a scale of 1 {least} to 10 {most}) -6/16/12 res (resident) yelling out c/o knees hurting "terrible" -6/17/12 Res grunts - says hurts a lot - 80% pain -6/21/12 Resident yelling out in pain and unable to settle down -7/2/12 saying hurts #8 C/o legs hurting C. The fall and resulting injury and pain were attributable to staff competency as evidenced by: Review of NA A's employment file revealed the following incidents: -May 18, 2011 written warning given by LPN (Licensed Practical Nurse) B after 2 to 4 verbal warnings about proper use of sit to stand (a mechanical lift used to assist residents with transferring from one surface to another). No leg strap applied. Resident shifted and could have been on the floor. -June 5, 2012 improper use of EZ stand (sit to stand lift) by NA A resulting in resident falling, two weeks after fall, resident was found to have bilateral femur (leg) fractures. Was instructed to watch watch video on EZ stand use..then instructed to have second staff member who is qualified to use the EZ stand with (NA A). Review of an untitled and undated typed statement by LPN D revealed, "I observed NA A on June 5th 2012 on how (NA A) used the ez-stand. (NA A) hooked all the straps up properly at that time. (NA A) also was not to use the ex stand by self needed another person with (NA A). Further review of NA A's employee file revealed the following incidents: -June 8, 2012 noncompliance and discipline ..was transferring resident on EZ stand without another qualified staff member present, another incident occurred where the resident sustained [REDACTED]. -June 23rd unsatisfactory work -July 2nd Mandatory in-service on the EZ stand and EZ lift with qualifying demonstration by (representative of EZ stand company) with return demonstrations and checklist of adequate use by each staff member. NA A was NOT present for the mandatory inservice and return demonstration. Interview with NA C on 7/10/12 at 10:15 AM revealed that the facility had performed competency checks of use of the mechanical lifts with NA C annually and that training on proper use of the mechanical lifts was provided annually. Review of an In-service attendance sheet for the EZ Way stand on 4/19/2011 revealed NA A did not attend. Review of the competencies evaluated on NA A for mechanical lifts revealed that NA A had not been evaluated for competency since 10/1/10.