Every finding on record at Mitchell Care Center

Licensure reference number 175 NAC 12-006.11(E) Based on observation, record review, and interviews, the facility failed to ensure cold foods were maintained at a temperature below 41 degrees Fahrenheit, and hot foods were maintained at a temperature above 135 degrees Fahrenheit to prevent the potential for foodborne illness. This had the potential to affect all residents. The facility showed a census of 46.Findings are:During an interview at 11:01 AM on 7/15/26 Dietary [NAME] (DC)-B confirmed that all lunch foods had already been prepared and were in the steam table, and they would begin serving foods at 11:45 AM.An observation made at 11:01 AM on 7/15/26 revealed a large silver bowl filled with salad sitting on a cart next to the steam table.Continuous observations made between 11:35 AM and 12:24 PM revealed the following:At 11:35 AM DC-B began measure temperatures of different foods.-Lasagna 175 Fahrenheit (F)-Garlic Bread 153F-Salad 52F-Pureed lasagna 154F-Pureed garlic bread 160F-Pureed salad 61F-DC-B did not measure the temperature of the hamburger patties from the steam table.-The salad bowls were placed on top of large bowls filled with ice to keep them cold, on top of a cart near the steam table.-DC-B began plating food for residents at 11:45 AM-At 11:55 AM DC-B prepared a hamburger for one resident without measuring the temperature.-At 12:01 PM DC-B prepared 2 more hamburger patties for residents without measuring their temperatures.-At 1:10 PM, DC-B brought a sample tray to this surveyor and revealed the following food temperatures: -Lasagna 173F -Salad 65F -Burger 130F Record review of a facility policy with a last revision date of 11/2022 labeled 'Food preparation and Service' revealed the danger zone means food temperatures above 41F and below 135F allows for the rapid growth of pathogenic microorganisms that can cause foodborne illness. The policy also revealed that the longer food remains in the danger zone the greater the risk for growth of harmful pathogens, therefore potentially hazardous foods must be maintained at or below 41F and at or above 135F.An interview at 2:00 PM on 7/15/26 with the Certified Dietary Manager (CDM) confirmed that if hot food does not measure at the minimum required holding temperature of 135F, it needs to be reheated and should hold that required temperature for a minimum of 15 seconds. CDM also confirmed that if chilled food is out and has not been maintained at 41F or below for 2 hours it needs to be discarded. The CDM confirmed that the DC-B should have discarded the salad that had been out and was above 41F since 11:01 AM.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure 2 of 5 sampled nurse aides (NA) completed the required 12 hours of ongoing training annually and failed to ensure 5 of 5 sampled NAs had completed 4 hours of Alzheimer's care and dementia care training annually. This had the potential to affect all residents who reside within the facility. The facility census was 42. Findings Are: A record review of a facility document [NAME] Care Center Employee Hire and Release Dates dated 9/7/2025 revealed the following:-NA-C was hired on 6/25/2024,-NA-D was hired on 5/9/2024,-NA-E was hired on 8/10/2023,-NA-F was hired on 7/17/2023, and -NA-G was hired on 7/10/2019. A.A record review of a facility provided document Employee Training Tracker for NA-F for the timeframe of 7/10/2024-7/10/2025 revealed NA-F had completed 8 hours of ongoing training. A record review of a facility provided document Employee Training Tracker for NA-G for the timeframe of 7/17/2024-7/17/2025 revealed NA-G had completed 1 hour of ongoing training. An interview on 9/9/2025 at 9:55 AM with the Director of Nursing (DON) confirmed NA-F and NA-G had not completed the required 12 hours of ongoing training annually. B.A record review of a facility provided document Employee Training Tracker for NA-C for the timeframe of 6/25/2024 through 6/25/2025 revealed NA-C had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-D for the timeframe of 5/9/2024 through 5/9/2025 revealed NA-D had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-E for the timeframe of 8/10/2024 through 8/10/2025 revealed NA-E had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-F for the timeframe of 7/17/2024 through 7/17/2025 revealed NA-F had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-G for the timeframe of 7/10/2024 through 7/10/2025 revealed NA-G had not completed any Alzheimer's care or dementia care training. An interview on 9/9/2025 at 9:55 AM with the Director of Nursing (DON) confirmed NA-C, NA-D, NA-E, NA-F, and NA-G had not completed the required 4 hours of Alzheimer's care and dementia care training annually.

Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review and interview, the facility failed to implement an effective bowel management program to prevent constipation for 2 (Residents 4 and 9) of 5 sampled residents. The facility census was 42. Findings Are: A record review of the facility's undated Policy and Procedure for Bowel Care Program revealed in the Steps section: 1) If no BM (Bowel Movement) for 3 days, perform full GI (gastrointestinal) assessment and document in progress note. Administer Milk of Magnesia 30 milliliters (ML) by mouth. Document effectiveness. 2) If no BM for 4 days, perform full GI assessment and document in progress note. Administer Dulcolax suppository rectally. Document effectiveness. 3) If no BM for 5 days, perform full GI assessment, contact provider for recommendations, and document in progress note. A. A record review of Resident 9's Significant Change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 6/10/2025 revealed the resident was always incontinent of bowels A record review of Resident 9's undated care plan revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit, was to be checked/changed per protocol, and was dependent on staff for proper toileting hygiene. The Care Plan also revealed the resident was taking antidepressant, antipsychotic, and opioid pain medications and staff was to monitor the resident for side effects of each medication, which included constipation. A record review of Resident 9's Medication Administration Record (MAR) for August 2025 revealed the resident had an order for Magnesium Hydroxide Suspension 400 milligrams (MG)/5 milliliters (ML), give 30 ML by mouth for constipation. The order was in place for one day, 8/6/2025, and was administered that day. There were no other medications for bowel movements on the MAR. A record review conducted on 9/9/2025 of Resident 9's MAR for September 2025 revealed there were no medications for bowel movements on the MAR. A record review of Resident 9's Task: B&B- Bowel Elimination documentation from 8/10/2025 through 9/8/2025 revealed the resident had no bowel movements on the following dates: -From 8/10/2025 through 8/13/2025, which was 4 days, -From 8/15/2025 through 8/18/2025, which was 4 days, -From 8/21/2025 through 8/25/2025, which was 5 days, and -From 9/1/2025 through 9/3/2025, which was 3 days. A record review of Resident 9's Progress Notes from 8/5/2025 through 9/9/2025 revealed there were no progress notes related to assessing Resident 9's bowels or interventions related to the resident's bowels. A record review of the Assessments section of Resident 9's electronic medical records from 8/5/2025 through 9/9/2025 revealed there were no assessments related to the resident's bowels. An interview on 9/9/2025 at 2:08 PM with the Director of Nursing (DON) confirmed Resident 9 had not had any bowel movements during the referenced timeframes. The DON also confirmed the facility had not followed their bowel protocol when Resident 9 had gone 3 or more days without a bowel movement. B A record review of Resident 4's Bowel and Bladder Elimination Record from 8/11/2025 through 9/9/2025 revealed documentation Resident 4 had No Bowel Movement for the following dates: -From 8/12/2025 through 8/15/2025, which was 4 days, and -From 9/7/2025 through 9/9/2025, which was 3 days A record review conducted on 9/8/2025 of Resident 4's active physicians' orders revealed the following order: -Senna-Docusate Sodium Oral Tablet 8.6-50 MG (give 1 tablet by mouth every 12 hours as needed for constipation, dated 5/31/2025 A record review of Resident 4's Progress Notes from 8/11/2025 through 9/11/2025 revealed no evidence that the resident had been assessed related to lack of bowel movements during this timeframe. A record review of a Care Plan on ADL/S/Mobility Function section revealed under interventions I am continent of bowel with supervision/touching assist of one. Care Plan entry dated 9/07/2025 revised under nutrition, resident is under fluid restriction of 2 liters in 24 hours. A record review of Progress Notes from 8/13/2025 through 8/30/2025 revealed no evidence that the resident had been assessed related to their lack of bowel movements during this timeframe. There was also no charted evidence in the progress notes of Resident 4's chart being provided with physician ordered PRN medication Senna for constipation dated 5/31/2025. A record review of the Comprehensive Minimum Data Set (MDS, a federally mandated assessment tool for nursing homes) dated 7/07/2025 Section H: Bowel Continence, revealed resident is continent of bowel and is not on a toileting program. An interview with Registered Nurse (RN)-H was conducted on 9/09/2025 at 4:00 PM. During the interview RN-H confirmed the Bowel management documentation showed Resident 4 had not had a bowel movement in 4 days, and further confirmed the Medication Administration Record did not reflect that the as needed (PRN) medication Senna had been given for constipation during this time.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(a) Based on record review and interview, the facility failed to ensure a nurse aide registry check was completed as required for two of five sampled employees. This had the potential to affect all residents who resided within the facility. The facility census was 42. Findings Are: A record review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy with a review date of 6/17/2025 revealed in the Screening Components section that board registrations and certifications will be verified regarding the prospective employee's background. A record review of the [NAME] Care Center Employee Hire and Release Dates document dated 9/7/2025 revealed Licensed Practical Nurse (LPN)-A was hired on 7/11/2025 and Maintenance (Maint)-B was hired on 8/5/2025 as a Maintenance Assistant. A record review of LPN-A's employee files revealed no evidence of a Nurse Aide Registry check being completed. A record review of Maint-B's employee files revealed no evidence of a Nurse Aide Registry Check being completed. A record review of the Nebraska License Information System Search website revealed no results for Maint-B and revealed no disciplinary action had been taken against LPN-A's Nurse Aide certification. An interview on 9/8/25 at 11:15 AM with the Administrator confirmed a Nurse Aide registry check had not been completed for LPN-A or Maint-B. The Administrator confirmed both employees did have the potential to have unsupervised access to all residents.

Licensure Reference Number 175 12-006.02(H) Based on record review and interviews, the facility failed to protect residents from further potential abuse during an investigation of alleged violations of abuse as per regulatory requirements. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of a facility undated Abuse Policy revealed the following: The facility must include the following investigative components- -Have evidence that all investigative components have been thoroghly investigated. -Prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in progress. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of an incident involving a nurse and a resident that occurred on 04/19/2025. The DON stated they were aware that LPN -E has had numerous complaints lodged against them in the past and thought perhaps it was LPN-E ' s personality. The DON confirmed that LPN-E is their sibling and stated because of that fact, all disciplinary action taken on LPN-E went through the Former Nursing Home Administrator (FNHA). The DON went on to reveal that they were made aware of the 04/19/2025 incident on 04/25/2025 by the FNHA who instructed them to investigate the allegations. The DON stated they performed several interviews and all said nothing happened. The DON stated they turned their documented finding to the FNHA for review. The DON confirmed the alleged employee had not been suspended during the investigation because nothing happened. Regarding access to residents, the DON revealed that while on shift LPN-E had the potential to provide care for all residents in the building but was formerly assigned to half the building. An interview with the Nursing Home Administrator (NHA) on 06/16/2025 at 4:30 PM revealed that at present there is no documentation for the investigation that the DON stated took place on 04/25/2025 but they would continue to look. An interview with NHA on 06/16/2025 at 5:15 PM revealed that they were able to find the investigation summary and stated they reached out to the staff who were interviewed on 04/25/2025 to re-obtain their statements. The NHA presented three statements from employees that were dated 06/16/2025 and further presented the investigation summary. The NHA stated that according to the schedule LPN-E was not scheduled to work from 04/25/2025 through 04/28/2025 and confirmed this was the facility's original schedule and that LPN-E was not placed on suspension pending the investigation.

Based on record review and interviews, the facility failed to implement policies and procedures to prevent the potential for further abuse to occur during the investigation of abuse allegations. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of an undated facility Abuse Policy revealed no documented evidence regarding procedures for how residents would be protected from further abuse while allegations of abuse were investigated, as per regulatory requirements. The policy revealed the facility was to include how the residents were protected in the report to the State Agency. A record review of an Investigative Summary dated 4/25/25 revealed no documented evidence of how residents were protected during investigative process. The summary describes the Director of Nursing's (DON) interviews with staff and effected residents regarding an incident that occurred on 4/19/2025 involving Licensed Practical Nurse (LPN-E) and Residents 3 and 4. The DON further revealed that LPN-E was called on the phone regarding the incident and was questioned. The date and times of these interviews was not observed on the summary. The summary concluded by saying that LPN-E was educated that when they are talking/yelling at residents they needed to slow down and have more patience with them and talk to them with respect. An interview with Nurse Aide (NA)-A, on 06/16/2025 at 12:30 PM revealed NA-A had concerns involving an incident they witnessed in April 2025. NA-A stated they were giving a bath down the 300 hall, with the water running when they heard their nurse, LPN-E yelling at a resident clear down the hall, NA-A stated that even the resident they were bathing heard it and asked what was going on. NA-A further revealed they heard LPN-E yelling at a resident that they needed to respect the staff. NA-A confirmed they reported their concerns to the registered nurse on shift who stated they had heard it too and would take care of it. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of a incident involving a nurse and a resident that occurred on 04/19/2025. The DON stated that on 4/25/2025 they performed several interviews and all said nothing happened. The DON stated they turned their documented findings to the Nursing Home Administrator (NHA) for review. The DON confirmed the alleged employee had not been suspended during the investigation because nothing happened. An interview with the Nursing Home Administrator (NHA) on 06/16/2025 at 4:30 PM revealed that at present there is no documentation for the investigation that the DON stated took place on 04/25/2025 but they would continue to look.The NHA stated they would look into whether or not the employee was suspended during the course of the investigation. An interview with NHA on 06/16/2025 at 5:15 PM revealed that they were able to find the investigation summary and stated they reached out to the staff who were interviewed on 04/25/2025 to re-obtain their statements. The NHA presented three statements from employees that were dated 06/16/2025 and further presented the investigation summary. The NHA states according to the schedule LPN-E was not scheduled to work from 04/25/2025 through 04/28/2025 and confirmed this was the facility's original schedule and that LPN-E was not formerly placed on suspension pending the investigation.

Licensure Reference Number 175 12-006.02(H) Based on record review and interviews, the facility failed to report an allegation of abuse as per regulatory requirements. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of the facility's undated Abuse Policy revealed the following: External Reporting: -Intitial reporting of allegations: If an incident or allegation is considered reportable the Administratior or designee will make initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. A record review of an Investigative Summary that concluded on 04/28/2025 revealed no documented evidence of abuse allegations being reported to the State Agency. The investigation revealed that the Director of Nursing (DON) was notified on 4/25/25 of an event that occurred on 4/19/25 regarding allegations of abuse from LPN-E to Resident 4 and Resident 3. The investigation revealed that LPN-E was observed speaking firmly to Resident 4 and said a curse word to Resident 3 after Resident 3 said the same curse word to LPN-E. The summary went on to detail interviews with two staff in which one recalled hearing LPN-E talking loudly to Resident 4 and it made them come out of the bath house. The other staff denied that LPN-E was verbally abusing residents and that LPN-E was educating Resident 4 to quit being rude/mean to staff. That staff member denied that LPN-E said a curse word to Resident 3 but rather told them not to say that. The DON detailed a phone call to LPN-E who denied verbally abusing Resident 3 and 4 and stated they were sternly educating them not to talk rudely/bad to the staff. The DON revealed that LPN-E was educated that if they were talking/yelling at the residents that they needed to slow down and have more patience with them and talk to them with respect. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of a incident involving a nurse and a resident that occurred on 04/19/2025. The DON stated they were aware that LPN-E has had numerous complaints lodged against them in the past and thought perhaps it was LPN-E 's personality. The DON confirmed that LPN- E is their sibling and stated because of that fact, all disciplinary action taken on LPN-E went through the administrator. The DON went on to reveal that they were made aware of the 04/19/2025 incident on 04/25/2025 by the former nursing home administrator (FNHA) who instructed them to investigate the allegations. The DON stated they performed several interviews and all said nothing happened. The DON stated they turned their documented finding to the FNHA for review. The DON confirmed the allegations of abuse were not reported to the State Agency and stated it was not reported because nothing happened. An interview with the Nursing Home Administrator (NHA) on 06/16/2025 at 4:30 PM revealed that at present there is no documentation for the investigation that the DON stated took place on 04/25/2025 but they would continue to look. The NHA confirmed that the incident had not been reported to the State Agency, and it should have been.

Licensure Reference Number 175 NAC 12-007.04D Based on record review, observation, and interview; the facility failed to ensure that the ventilation system was operational in resident's bathrooms on 100, 200, and 300 wings. This had the potential to affect all 43 residents who resided within the facility. Findings are: A record review of a policy Maintenance Service with a last revised date of December 2009 revealed function of maintenance personnel include maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. An observation on 8/8/2024 at 9:29 AM revealed a strong odor of bowel movement in the 100 wing. An observation on 8/8/2024 at 9:45 AM with the Administration and Maintenance Personnel (MP) - E revealed rooms 101,104, 111, 200, 300, and 301 were not functional and would not draw a 1-ply square of toilet paper to the surface of the ventilation cover. An interview on 8/8/2024 at 10:00 AM with the Administrator and MP-E confirmed that the ventilation system for 100, 200, and 300 wing were not functional, confirming all residents would be affected.

LICENSURE REFERENCE NUMBER NAC 175 12-006.11(E) Based on observations, interviews, and record review; the facility failed to ensure foods were date-marked or labeled with their common names and failed to dispose of or consume foods within seven days as required to prevent the potential for food-borne illness. This had the potential to affect all 43 residents who resided within the facility and were served out of the kitchen. Findings are: A. A record review of the 2017 Nebraska Food Code revealed in section 3-602.11(C)(1) and (2) that bulk foods which are available for consumer self-dispensing shall be prominently labeled with the manufacturer's or processor's label that was provided with the food or a card, sign, or other method of notification that includes the required information. An observation on 8/7/24 from 7:40 AM to 7:55 AM during the initial kitchen tour revealed the following: -In the greater kitchen area, four large plastic bins with open lids, labeled only with paper taped on each lid reading, thick-it, cornstarch, flour, and sugar. -In the dry storage room, four sealed plastic bags containing a red liquid approximately one gallon each with a handwritten date in black marker on each bag. None of the bags had a label indicating what the red liquid was. An interview on 8/7/2024 at 9:55 AM with the Certified Dietary Manager (CDM) confirmed the thick-it, cornstarch, flour, and sugar observed during the initial kitchen tour should have been dated with an open and use by date. This interview also confirmed that the four plastic bags of red sauce only had a received by date written on them and lacked any additional identification. An observation on 8/12/24 at 9:05 AM of the walk-in freezer revealed four clear plastic bags of an unidentified meat product with an illegible handwritten date in black marker, with no other identifying information. There were 5 additional plastic bags with breaded food product on the same shelf labeled in the same fashion. An interview on 8/12/24 at 9:05 AM with Cook-B revealed that dietary staff takes the bags out of the boxes when they arrive from the vendor, write the received-by date on the bags, and put the bags on the shelves in the freezer. Cook-B stated that the four clear plastic bags contained cooked diced chicken and confirmed the bags were not labeled with that information. An interview on 8/12/24 at 12:45 PM with the CDM confirmed the bags of unidentified frozen meat products were labeled only with received by dates and lacked any additional identification. B. A record review of the 2017 Nebraska Food Code revealed in section 3-501.17 that ready-to-eat, time/temperature-controlled foods should be clearly marked to indicate the date or day by which the food should be consumed or discarded, which is a maximum of 7 days. The date of preparation should be counted as day 1. An observation on 8/12/24 at 10:17 AM revealed Cook-B was preparing a salad that included lettuce and shredded cheese from a mobile salad station for a staff member. The mobile salad station held containers of lettuce, onion, and shredded cheese that were each dated 8/5/24 as well as a container of pickles that was dated 7/27/24. An interview on 8/12/24 at 10:17 AM with Cook-B confirmed the four items (lettuce, onion, shredded cheese, and pickles) were more than seven days old. An interview on 8/12/24 at 11:38 AM with the CDM confirmed that the four items (lettuce, onion, shredded cheese, and pickles) were more than seven days old and needed to be removed from the mobile salad station.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record review; the facility failed to utilize enhanced barrier precautions as required when assisting with personal cares for Residents 3 and 40, and failed to ensure staff did not continue to utilize gloves after they were contaminated during medication administration for Resident 12. The facility census was 43. The Findings Are: A. A record review of an undated facility policy Infection Control-Enhanced Barrier Precautions revealed that the facility would implement enhanced barrier precautions (EBP) during high-contact resident care activities when caring for residents that had an increased risk for acquiring a multi-drug resistant organism, such as residents with wounds. The policy stated that high contact care activities included dressing, transferring, changing briefs, and wound care. Personal protective equipment of a gown and gloves were required for all staff performing the high contact care activities. A record review of Resident 3's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 7/29/24 revealed Resident 3 had a stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer to their right buttock and was dependent on staff for toileting hygiene, dressing, bed mobility, and transfers. A record review of Resident 3's Care Plan revealed Resident 3 was on EBP due to having a suprapubic urinary catheter and a wound. The Care Plan stated to follow standard of practice for EBP and that instructions & supplies were outside of the resident's room. An observation on 8/12/24 at 3:40 PM revealed Centers for Disease Control (CDC) EBP signage outside Resident 3's room doorway and hanging above Resident 3's bed. Nurse Aide (NA)-F was standing next to Resident 3's bed wearing gloves and holding Resident 3, so the resident was positioned on their left side while RN-A performed wound care to Resident 3's pressure ulcer on their right buttock. NA-F then assisted Registered Nurse (RN)-A to apply a new incontinence brief and reposition the resident in their bed after the cares were completed. A record review of the CDC's EBP signage revealed that providers and staff must wear gloves and a gown for high-contact resident care activities. The signage included dressing, transferring, providing hygiene, changing briefs, and wound care in the list of high-contact resident care activities. An interview on 8/12/24 at 4:03 PM with NA-F confirmed that NA-F did not wear a gown while assisting with Resident 3's cares. NA-F confirmed that they were aware Resident 3 was on EBP, but NA-F stated they did not think they needed to wear a gown when assisting with Resident 3's cares. 49766 B. A record review of an undated facility policy Infection Control - Enhanced Barrier Precautions - Personal Protective Equipment (PPE) of a gown and gloves are required during urinary catheter care. A record review of a facility policy Handwashing/Hand Hygiene with a last revised date of August 2014 revealed alcohol-based hand rub should be used after removing gloves. An observation on 8/12/2024 at 2:50 PM of Nurse Aide (NA) - D provide urinary catheter cares to Resident 40. NA-D performed hand hygiene then donned (put on) a pair of gloves. NA-D then removed [gender] gloves, drew the curtain for privacy and explained the procedure to Resident 40. No hand hygiene was performed after NA-D removed their gloves. NA-D then applied a new pair of gloves and a gown. NA-D tied their gown around the back of [gender] neck, touching [gender] hair. NA-D then removed gloves without performing hand hygiene after. NA-D then removed a paper towel inside a graduate cylinder, placing the paper towel in the trash can, touching [gender] glove to the trashcan. NA-D proceeded to catheter cares, during the cares, NA-D's gown began to fall off, exposing [gender] clothes to the urinary catheter care area. NA-D removed [gender] gloves without performing hand hygiene and retied [gender] gown in the back, finishing catheter cares. An interview on 8/12/2024 at 3:01 PM with NA-D confirmed hand hygiene should be completed between changing of gloves and confirmed contamination of their clothes and urinary catheter area due to gown not being donned properly. C. An observation on 8/8/2024 at 11:15 AM of Registered Nurse (RN) - A preparing to administer insulin to Resident 12. RN-A donned gloves then touched the computer lid to close it, knocked on the door, and used the door handle to open the door, contaminating [gender] gloves. RN-A then administered insulin to Resident 12 without first changing the contaminated gloves. An interview on 8/8/2024 at 11:20 AM with RN-A confirmed touching door handles and other dirty surfaces would contaminate their gloves.

Licensure Reference 175 NAC 12-006.09(H)(vi) Based on record reviews and interview; the facility failed to ensure a PRN (as needed) psychotropic medication (a medication to treat mental illnesses) had a stop date for 1 (Resident 37) of 5 sampled residents. The facility identified a census of 43. Findings are: A record review of a facility policy Use of Psychotropic Medications with a last reviewed date of 1/1/2024 revealed the following: - PRN orders for all psychotropics drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days.) - If the attending physician believes that is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. A record review of an Admission Record indicated the facility admitted Resident 37 on 12/26/2023 with an admitting diagnosis of dementia, Alzheimer's disease, and Major Depressive Disorder. A record review of Resident 37's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) with an Assessment Reference Date of 7/28/2024 revealed Resident 37 had a Brief Interview for Mental Status score of 4/15, which indicated Resident 37 had severe cognitive impairment. A record review of Resident 37's Order Summary revealed an order for PRN Ativan with a start date of 2/7/2024 and did not have stop date. An interview on 8/12/2024 at 8:36 AM with the Director of Nursing confirmed Resident 37's PRN Ativan order did not have a stop date and confirmed it should have a duration or stop date for use.

Licensure Reference 12-006.12(A)(vi) Based on record reviews and an interview; the facility failed to ensure the pharmacist had identified irregularities during their monthly medication regimen review (MRR, a monthly review of a resident's medications by a licensed pharmacist to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary medications) for 1 (Resident 37) of 5 sampled residents. The facility identified a census of 43. Findings are: A record review of a facility policy Medication Regimen Reviews with a last revised date of April 2007, revealed no information regarding identifying irregularities regarding regulatory requirements. A record review of an Admission Record indicated the facility admitted Resident 37 on 12/26/2023 with an admitting diagnosis of dementia, Alzheimer's disease, and Major Depressive Disorder. A record review of Resident 37's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) with an Assessment Reference Date of 7/28/2024 revealed Resident 37 had a Brief Interview for Mental Status score of 4/15, which indicated Resident 37 had severe cognitive impairment. A record review of Resident 37's Order Summary revealed an order for PRN (as needed) Ativan with a start date of 2/7/2024 and did not have a stop date. A record review of Resident 37's Monthly Medication Regimen Reviews revealed the following: - 3/2024 - No irregularities identified by the pharmacist - 4/2024 - No irregularities identified by the pharmacist - 5/2024 - No irregularities identified by the pharmacist - 7/2024 - No irregularities identified by the pharmacist - 8/2024 - No irregularities identified by the pharmacist An interview on 8/12/2024 at 9:05 AM with the Pharmacist confirmed an irregularity of Resident 37's Ativan without a stop date should have been identified.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to monitor 1 (Resident 2) of 2 sampled resident's blood pressure while the resident was taking medications used to treat hypertension (elevated blood pressure). The facility census was 43. The Findings Are: A record review of a facility document provided by the Director of Nursing (DON) titled Admission Check Off List revealed that if a resident was taking a blood pressure medication, staff must put an order in for weekly vital signs and medications must have parameters. A record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 6/27/24 revealed Resident 2 had a diagnosis of hypertension. A record review of Resident 2's Physician's Orders revealed the following medications: -Amlodipine Besylate (a calcium channel blocker used to treat high blood pressure and chest pain) 5 milligrams (MG) twice a day for blood pressure management and angina symptoms. -Lisinopril (an ACE inhibitor used to treat high blood pressure and heart failure) 5 MG once a day for blood pressure management. A record review of the Vitals section of Resident 2's electronic medical records (EMR) revealed the following blood pressures: -On 2/15/2024 at 2:49 AM a blood pressure of 110/60. -On 2/15/2024 at 9:43 AM a blood pressure of 121/60. -On 2/15/2024 at 10:36 PM a blood pressure of 118/64. -On 2/16/2024 at 12:36 PM a blood pressure of 124/68. -On 2/16/2024 at 11:06 PM a blood pressure of 118/62. -On 2/17/2024 at 2:22 PM a blood pressure of 124/64. -On 2/17/2024 at 10:27 PM a blood pressure of 118/74. -On 2/18/2024 at 9:00 AM a blood pressure of 114/76. -On 2/18/2024 at 9:55 PM a blood pressure of 118/72. -On 2/19/2024 at 10:24 AM a blood pressure of 124/64. -On 2/20/2024 at 1:24 AM a blood pressure of 111/60. -On 2/20/2024 at 10:33 AM a blood pressure of 114/67. -On 2/20/2024 at 9:48 PM a blood pressure of 116/70. -On 2/24/2024 at 7:01 AM a blood pressure of 122/78. A record review of Resident 2's Progress Note dated 2/29/24 revealed a blood pressure of 47/34. The progress note also revealed the resident was admitted to the hospital on this date. A record review of Resident 2's paper Physician's Order sheet in Resident 2's hard chart (a binder containing medical records on paper) dated 3/22/24 revealed a blood pressure of 122/78. A record review of Resident 2's hard chart revealed a document faxed to Resident 2's primary care provider (PCP) dated 3/23/24 regarding the resident having a fall, revealed a blood pressure of 106/54. A record review of the Vitals section of Resident 2's EMR (electronicl medical record) dated 3/23/2024 revealed a blood pressure of 97/62. A record review of Resident 2's paper Physician's Order sheet in Resident 2's hard chart dated 5/23/24 revealed a blood pressure of 97/62. A record review of Resident 2's PCP documentation in their hard chart dated 6/18/24 revealed a blood pressure of 123/78. A record review of the Vitals section of Resident 2's EMR revealed the following blood pressures: -On 6/18/2024 at 11:48 PM a blood pressure of 92/70. -On 6/19/2024 at 8:44 AM a blood pressure of 125/81. -On 6/20/2024 at 12:59 AM a blood pressure of 92/72. -On 6/20/2024 at 9:07 AM a blood pressure of 116/78. -On 6/20/2024 at 11:57 PM a blood pressure of 120/65. -On 6/21/2024 at 10:39 AM a blood pressure of 134/66. -On 6/21/2024 at 11:50 PM a blood pressure of 118/70. -On 6/22/2024 at 9:55 AM a blood pressure of 122/67. -On 6/22/2024 at 11:41 PM a blood pressure of 126/68. -On 6/23/2024 at 2:29 PM a blood pressure of 113/65. -On 6/24/2024 at 1:00 AM a blood pressure of 112/75. -On 6/24/2024 at 12:31 PM a blood pressure of 101/70. -On 6/24/2024 at 11:27 PM a blood pressure of 83/52. -On 6/25/2024 at 7:46 AM a blood pressure of 100/55. A record review of Resident 2's Progress Notes revealed the following blood pressures: -On 7/9/24 a blood pressure of 70/42. -On 7/29/24 a blood pressure of 133/94. A record review of Resident 2's paper Physician's Order sheet in Resident 2's hard chart dated 7/30/24 revealed a blood pressure of 100/55. A record review conducted on 8/13/24 of Resident 2's EMR and hard chart revealed there were no additional blood pressure readings in the prior 6 months. An interview on 8/13/24 at 8:36 AM with the Director of Nursing (DON) confirmed that if a resident was taking a blood pressure medication, the facility obtained a blood pressure at least weekly unless the resident's provider ordered it more frequently. The DON confirmed that Resident 2 did not have an order for a weekly blood pressure and should have since Resident 2 was taking blood pressure medications. The DON also confirmed that Resident 2 had not had their blood pressure checked on a weekly basis. A follow up interview on 8/13/24 at 9:15 AM with the DON confirmed that no order had been implemented for weekly vital signs for Resident 2 per the requirements of the facility's Admission Check Off List document.

Licensure Reference Number 175 NAC 12-006.11E Based on observations, interview and record reviews, the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent the potential for foodborne illness. This had the potential to affect 46 of 47 residents who ate from the kitchen. Findings are: A. An observation on 9/21/2023 at 7:30 AM at the start of the breakfast meal service revealed Dietary Aide (DA-G) performed no hand hygiene prior to meal service. DA-G was observed grabbing plates and bowls with bare hands, placing fingers inside of the bowls and on top of the plates, sitting them down to fill with food and sending them out to the residents. DA-G then grabbed the menus and repeated the same process throughout breakfast food service. On one plate, eggs fell off onto the serving table, DA-G picked up the plate, placed thumb on the plate touching the eggs wtih bare hands and sent the plate out to a resident. When cleaning the egg off the serving table, a washcloth from the bucket containing the sanitizer was used then DA-G used a bare hand to wipe off the rest of the egg. No hand hygiene was performed throughout the breakfast meal service by DA-G. An observation on 9/21/2023 at 7:45 AM of Dietary Manager (DM) carrying a plate, that was picked up from the pass, with thumb on top of the plate and served it to the resident. B. An observation on 9/21/23 from 7:31 AM until 7:36 AM in the dining room during breakfast revealed the following concerns: The DM placed their bare thumbs on the top edge of Resident 43's and Resident 18's bowls that were filled with hot cereal and then went back to the serving window without having performed hand hygiene (HH) prior to getting another resident's plate. The DM then picked up another resident's plate and had their bare thumbs on the top edge/rim of the plate while delivering it to the resident's table, the DM then returned to the serving window and picked up a 4th resident's plate and had their bare thumbs on the top edge/rim of the plate and delivered it to the resident's table and then again returned to the serving window without the benefit of HH. Next, the DM retrieved a 5th resident's plate, placed it on the resident's table, placed their left fist on the table, touched the resident's left shoulder and then did not perform HH prior to going back to the serving window and getting a 6th resident's plate of food and placing their bare right thumb on the top rim of the resident's plate while delivering it to the resident. An observation on 9/21/23 at 8:01 AM in the dining room revealed Resident 10's plate was placed in front of them and the staff sitting beside the resident seasoned the resident's eggs per their request. The staff placed an egg on Resident 10's bread using a fork. The staff then picked up Resident 10's bread using their bare hand, folded the bread in half and handed it to the resident. Resident 10 took a bite and then handed the bread back to the staff. The staff took the bread with their bare hand, added more seasoning and then handed it back to the resident. An observation on 9/21/23 from 11:46 AM until 12:13 PM in the dining room during lunch revealed the following concerns: Residents 10 and 35 were assisted with eating by the same staff person. The staff used same the hand to feed both residents and did not perform HH between giving bites to each resident, MA-D wiped a resident's mouth with a napkin using their bare hand while the resident was coughing at the table, MA-D did not perform HH afterwards. Restorative/LPN was observed assisting two female residents with eating, used the same hand for both residents, and did not perform HH between giving bites to each resident. An observation on 9/21/23 from 12:05 PM until 12:17 PM in the dining room during lunch revealed the following concerns: The DM had placed their bare thumbs on Resident 17's bowl of dessert and another resident's plate and had not performed HH. The DM then returned to the serving window without first performing HH, retrieved a 3rd resident's plate and their bare thumb was on the top rim/edge of the plate next to the salad that was served to the resident. An interview on 9/25/2023 at 2:45 PM with Dietary Manager (DM) confirmed that staff received on the job training on how to carry plates and bowls. DM stated staff was trained to carry bowls and plates by the lip. Record review of the Nebraska Food Code taken from the 2017 recommendations of the United States Public Health Service, Food and Drug Administration with sections taken from the Pure Food Act and used as an authoritative reference for food service sanitation practices revealed the following: 1) 3-301.11 Preventing Contamination from hands. A)Food Employees shall wash their hands as specified under 2-301.12 2) 81-2,272.10 (Replaces 2017 Food Code 3-301.11 (B), (C), (D) and (E) Preventing Contamination from Hands revealed on (1) Food employees shall wash their hands as specified in the Nebraska Pure Food Act. Record review of the Assistance with Meals Policy dated 2001 and revised 10/19/2023 on Policy Interpretation and Implementation number 7) All employees who provide resident assistance with meals will be trained and shall demonstrated competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Record review of the Food Preparation and Service Policy dated 2001 and revised on 10/2018 revealed under Policy Interpretation and Implementation section Food Preparation Area number 5) food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Record review of the Handwashing/Hand Hygiene Policy dated 2001 with a revision date of 8/2015 in the section Policy Interpretation and Implementation number 2) all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors.

Licensure Reference Number 175 NAC 12-006.05(5) Based on interviews and record reviews, the facility failed to provide notice to the residents and/or their Representatives of the Facility's Bed Holding Policy before facility-initiated transfers to the hospital. This failure affected 4 of 4 sampled residents (Resident 29, Resident 36, Resident 40, and Resident 51). The facility census was 47 at the time of the survey. The Findings are: A. A record review of Resident 29's Facesheet dated 9/25/2023 revealed they were admitted to the facility on [DATE] with an admitting diagnosis of repeated falls. The Facesheet also revealed Resident 29 had a Power of Attorney (POA)-Care. A record review of Resident 29's Progress Note dated 5/29/2023 at 7:13 AM revealed that Resident 29 had been sent to the emergency room (ER) by the facility. The facility did call Resident 29's Power of Attorney (POA) and informed them of the resident's health status and transfer to the ER. There was no documentation in the progress note of the POA being made aware of the facility's Bed Holding Policy. An interview on 9/25/2023 at 3:11 PM with Social Services (SS) revealed the facility did not have a Bed Holding Policy document for Resident 29's transfer to the ER and hospitalization on [DATE]. SS revealed that if the residents are unable to sign the bed-holding policy forms, the facility staff writes a note on the form that the POA was notified of the bed-holding policy. B. A record review of Resident 36's Facesheet dated 9/25/2023 revealed Resident 36 was admitted to the facility on [DATE] with a principal diagnosis of unspecified fall, initial encounter. Resident 36's Facesheet also revealed they had a Power of Attorney-Care. A record review of Resident 36's Progress Note dated 8/4/2023 at 7:51 AM revealed Resident 36 had an episode of shaking and then fell back in bed. Upon assessment, the resident was clammy and was not responding when the nurse called the resident's name. Resident 36's blood pressure and pulse were elevated. The nurse called their POA who stated they would like the resident to be seen. The nurse called the resident's physician and was instructed to send the resident to the emergency room . A record review of Resident 36's Progress Note dated 8/4/2023 at 12:35 PM revealed the resident was going to be admitted to Regional [NAME] Medical Center. A record review of the facility's Bed Holding Policy document for Resident 36's hospitalization on [DATE] revealed x unable to sign was handwritten on the signature line of the document. 48765 C. A record review of Resident 40's Facesheet dated 9/26/23 revealed Resident 40 was admitted to the facility on [DATE] and had a principal diagnosis of Urinary Tract Infection, Unspecified. Resident 40's Facesheet also revealed the resident had a Power of Attorney-Care. An interview on 9/20/23 at 3:48 PM with Resident 40 confirmed Resident 40 was hospitalized approximately two weeks ago. A record review of Resident 40's Progress Note dated 8/30/2023 at 12:22 PM revealed Resident 40 was sent to the emergency room (ER) per family request due to severe right leg pain and neck pain. The Progress Note also revealed the POA was aware of the transfer to the ER. The Progress Note did not mention Resident 40 or their POA being notified of the facility bed holding policy. A record review of Resident 40's Progress Note dated 8/30/2023 at 4:18 PM revealed Resident 40 was admitted to the hospital with a tibia/fibula (two bones in the lower leg) fracture. A record review of Bed Holding Policy dated 8/30/23 revealed the facility did not obtain a signature from Resident 40 or their POA. There was no evidence on the document of Resident 40 or their POA being notified of the facility Bed Holding Policy at time of the resident's hospitalization . 49263 D. A record review of Resident 51's Facesheet dated 9/26/23 revealed Resident 51 was admitted to the facility on [DATE] with a principal diagnosis of Myxedema Coma. Resident 51's Facesheet also revealed the resident had a Power of Attorney (POA)-Care. A record review of Resident 51's Progress Note dated 7/22/23 at 3:30 AM revealed Resident 51's POA was contacted via telephone and notified of Resident 51's current medical condition. The POA consented to the resident being sent to the emergency room . The Progress Note did not mention Resident 51 or their POA being notified of the facility bed holding policy. A record review of a Bed Holding Policy document dated 7/22/23 revealed a signature line with Unable to sign handwritten on it. There was no evidence on the document of Resident 51 or their POA being notified of the facility Bed Holding Policy at time of the resident's hospitalization . An interview on 9/25/2023 at 3:50 PM with SS revealed the facility does not notify the resident and/or their Representatives in writing of the reason for facility-initiated transfers/discharges to the hospital. The SS also confirmed that the facility staff writes unable to sign on the signature line of the Bed Holding Policy if the resident cannot sign the form independently.

Licensure Reference Number 175 NAC 12-006.05(8) Based on observations, record review, and interviews; the facility failed to identify a body pillow secured under a fitted sheet and placed along the edge of the bed as a potential restraint for 1 resident (Resident 12). The facility staff identified a census of 47 at the time of the survey. Findings are: An observation in Resident 12's room on 09/20/2023 at 9:29 AM revealed the resident lying in bed on their right side with their eyes closed and hollering lightly, Help, help, help. The lights were off in the room, the curtains were closed, a radio was playing, the bed was in a low position, a floor mat was on the floor next to the bed, and there was a camera sitting on the dresser facing the resident's bed. There was what appeared to be a body pillow tucked under a fitted sheet on the left side of the resident's bed and the right side of the bed was against the wall. An observation in Resident 12's room on 9/20/2023 at 3:03 PM revealed the resident was lying in bed on their right side with their eyes closed. A large mound was observed along the edge of their bed, on the left side. A grey body pillow was protruding from underneath the fitted sheet that was on Resident 12's bed. An observation in Resident 12's room on 09/21/2023 at 11:23 AM revealed Resident 12 lying in bed on their left side. A body pillow was observed tucked under the fitted sheet and along the mattress on the left side. A scoop mattress and an alarm pad were also visible underneath Resident 12. An observation in Resident 12's room on 9/21/2023 at 11:40 AM revealed Resident 12 lying in bed. RN-E and NA/MA-J were preparing to reposition and change the resident. NA/MA-J had removed a grey body pillow from underneath the fitted sheet that was lying along the left side and edge of the resident's bed and placed it on a chair in the room so they could turn and provide cares to Resident 12. A record review of Resident 12's Admission Record revealed the resident admitted to the facility on [DATE]. The Adminission Record revealed Resident 12 had diagnoses of dementia in other diseases classified elsewhere, severe, with agitation, and Alzheimer's Disease with late-onset. A record review of Resident 12's Treatment Administration Record (TAR) with the dates of 9/1/2023-9/30/2023 revealed there was not a physician's order for a body pillow to be secured underneath the bed sheets to secure the resident in bed. A record review of Section P Restraints and Alarms of Resident 12's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's Care Plan) revealed Physical restraints were not being utilized. Letter C Limb restraint had a zero in the box with a code that they are not used. A record review of Resident 12's Care Plan (CP) revealed section A had a revision date of 9/12/2023 revealing the resident's cognition was severely impaired. Section D had a revision date of 12/20/2022 revealing Resident 12 was at risk for falls. There was an intervention for the use of body pillows but did not indicate the body pillow was to be tucked under the fitted sheet. An interview on 9/25/2023 at 5:25 PM with Medication Aide (MA)-K confirmed a grey body pillow was tucked under the sheet on the resident's bed and along the edge of the left side of the mattress. MA-K revealed [gender] was informed by a nurse that Resident 12 was a fall risk and to place a body pillow under the sheet to keep them from rolling out of the bed. MA-K revealed it was common practice at the facility and [gender] had seen a body pillow tucked under a fitted sheet being utilized for other residents who were at risk for falling. An Interview on 9/25/2023 at 5:36 PM with Nursing Assistant (NA)/MA-L revealed the Resident 12 had the following interventions in place to prevent them from falling: A scoop mattress; a body pillow that they tuck underneath their sheet on the bed so that the resident could not get over the bump when they roll; keep the resident's bed in low position; a lap buddy when in their wheelchair; an alarm in their bed and in their wheelchair; and a camera. An interview on 9/25/2023 at 6:05 PM with the Director of Nursing (DON) revealed they did not see a body pillow being secured under Resident 12's fitted sheet and along the edge of their bed as being considered a restraint. The DON had said Resident 12 had every intervention in place for the Resident to prevent them from falling (e.g., scoop mattress, fall matt, alarm pads, camera in the room, the use of body pillows, etc.). The DON confirmed Resident 12 was unable to move the secured body pillow if they wanted to. A record review of the facility's undated policy [NAME] Care Center Physical Restraints revealed the section titled Procedure, Number 1) Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body. Number 4) Physical restraints shall not be used to limit resident mobility for the convenience of staff. Number 5) Physician's orders must indicate the specific reason, type, and period of time for the use of restraints. Restraints must only be used as a last resort, and the medical record must indicate the events leading up to the necessity of the restraint. Number 11) The need for restraints will be re-evaluated at least quarterly to determine their continued need. Every effort will be made to eliminate their use.

Licensure Reference Number 175 NAC 12.006.17 Based on observations, interviews and record review, the facility failed to perform hand hygiene while providing direct resident care to 1(Resident 12) of 1 sampled residents. The facility census was 47. The Findings are: An observation in Resident 12's room on 9/21/2023 at 11:40 AM revealed Nursing Assistant/Medication Aide (NA/MA)-J and RN-E were preparing to reposition the resident and change their brief. Observation on 9/21/2023 at 11:40 AM revealed RN-E performed hand hygiene (HH) with soap and water for 8 seconds and had put gloves on. RN-E performed peri care (wiping the peri area with a moist disposable cloth) on Resident 12. RN-E did not change their gloves and had placed a clean brief on Resident 12. During the process of placing a clean brief on Resident 12, RN-E continued to wear soiled gloves and rolled Resident 12 from side-to-side, RN-E had touched the resident's bare legs, bare arms, bedding, and a draw sheet they were laying on as they placed the brief on them and repositioned the resident. RN-E then repositioned Resident 12's pillows. RN-E had the same soiled gloves throughout the duration of care. Observation on 9/21/2023 at 11:50 AM revealed RN-E had taken off the soiled gloves and washed their hands with soap and water for 9 seconds. An interview with RN-E on 9/21/2023 at 3:07 PM revealed hand hygiene should occur prior to donning gloves and after doffing gloves. RN-E further revealed they should wash their hands for a minimum of 20 seconds. RN-E confirmed they had not performed hand hygiene as required during care to Resident 12 on 9/21/2023 at 11:40 AM. A record review of the facility's policy, Handwashing/Hand Hygiene with a revised date of August 2015, revealed Number 7) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and waster for the following situations: Number 7) b. Before and after direct contact with residents; g. Before handling soiled dressings, gauze pads, etc.; k. After handling used dressings; and m. After removing gloves. Number 9) The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The section, Washing Hands, Number 1) Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of water.

Licensure Referene Number: 175 NAC 12-006.05 (5) Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer to the hospital for 1 (Resident 29) of 1 sampled residents. The facility identified a census of 47 residents at the time of the survey. Findings are: A record review of Resident 29's Face Sheet dated 9/25/2023 revealed Resident 29 was admitted to the facility on [DATE] with an admitting diagnosis of repeated falls. The Face Sheet also revealed Resident 29 had a Power of Attorney (POA)-Care. A record review of Resident 29's Progress Note dated 5/29/2023 at 7:13 AM revealed Resident 29 had been sent to the emergency room (ER) by the facility. A record review of Resident 29's Progress Notes did not reveal a written notifice of transfer was sent to Resident 29's representative. An interview on 9/25/2023 at 3:50 PM with SS revealed the facility does not notify the resident and/or their Representatives in writing of the reason for a facility-initiated transfers/discharges to the hospital.

Licensure Reference Number 175 NAC 12-006.06B Based on observations, interviews, and record review, the facility failed to follow up on a complaint regarding wheelchair equiptment for 1 (Resident 4) of 1 sampled residents. The facility identified a census of 48 residents at the time of the survey. Findings are: Record review of Resident 4's Face Sheet dated 5/11/2020 revealed the resident admitted on [DATE] with the diagnosis of Quadriplegia, C1- C4 Incomplete. Record review of Resident 4's Minimum Data Set (MDS) (an assessment completed to determine cares needed for the resident) dated 7/25/2023 revealed in Section C: the Brief Interview for Mental Status (BIMS) showed a score of 12 which indicates the resident was cognitively intact. In Section G: functional status showed Resident 4 needed extensive assistance and two-person physical assist in bed mobility, total dependence with a two-person physical assist for transfers and total dependence with a two-person assist for toileting. An interview on 09/20/2023 at 7:55 AM with Resident 4 revealed Resident 4's electric mobility wheelchair was broken and reported to Social Work (SS) with no resolution. Resident 4 revealed this was reported months ago. Resident 4 did not feel safe with the broken wheelchair. An observation on 9/20/2023 at 7:55 AM of Resident 4's electric mobility wheelchair revealed the right arm panel moved away from the wheelchair sideways about 4 inches, the left arm panel moved slightly sideways away from the wheelchair. The padding on Resident 4's foot pedals was secured with brown Coban that was unraveling and gray to black in color. An observation on 9/25/2023 at 1:30 PM of Resident 4's wheelchair revealed padding on foot pedals secured with brown Coban which was gray to black in color and unraveling. An observation on 9/25/2023 at 1:40 PM revealed Nurse Aid (NA-H) and Nurse Aide/Medication Aide (NA/MA-1) transferred Resident 4 from wheelchair to bed and the right arm on electric mobility wheelchair moved as Resident 4 was transferred out of the wheelchair. An interview on 9/25/2023 at 2:10 PM with the Administrator revealed Resident 4 was on a payer source that did not allow Resident 4 to get a new wheelchair at this time. The Administrator stated if the facility staff were unable to fix Resident 4's wheelchair, the storage would be checked. An interview on 9/25/2023 at 3:30 PM with Licensed Practical Nurse (LPN-A) confirmed that Coban should not be used on wheelchairs as the surface is uncleanable. LPN-A revealed that wheelchairs are fixed by maintenance in the facility if able. LPN-A further revealed that if Resident 4's chair was unable to be fixed therapy services would be involved to find a new wheelchair for the resident. An interview on 9/25/2023 at 4:00 PM with Social Serivces (SS) confirmed that Resident 4 had spoken with SS about the broken wheelchair. SS reported it to the Administrator but did not follow up with Resident 4. An interview on 9/25/2023 at 4:15 PM with DON confirmed Coban not a washable surface. Coban will unravel and should not be used to secure items on wheelchairs.

Licensure Reference Number 175 NAC 12-006.09C1c Based on observations, interviews, and record review the facility failed to review and revise 1 (Resident 23) of 1 sampled resident's care plan to meet the resident's needs. The facility census was 47. The findings are: A record review of Resident 23's Face Sheet dated 9/21/23, revealed the Resident was admitted on [DATE] with a diagnosis of Personal History of Traumatic Brain Injury. A record review of Resident 23's Minimum Data Set (MDS) dated [DATE] Section C revealed Resident 23's Brief Interview for Mental Status (BIMS) score was 11 out of 15, indicating moderately impaired cognition. Section G revealed Resident 23 required extensive assistance of one staff for transfers, walking, and toilet use. Section P revealed Resident 23 used a Chair alarm and Other alarm daily. A record review of Resident 23's current paper care plan with revision date of 8/16/23 revealed the following: -In the Focus C Section, an intervention of resident to amb with FWW & gait belt to/from bathroom per therapy. was handwritten in with no date or staff initials. There was also an intervention of 9-14-23 sit to stand per nrsg handwritten next to Transfers. A record review of the Certified Nurse's Aide (CNA) Activities of Daily Living (ADL) documentation revealed Resident 23 ambulated in their room [ROOM NUMBER] times between 9/16/23 and 9/24/23. An observation on 9/20/23 at 2:39 PM revealed Resident 23 standing in front of their recliner independently with no staff present. An observation on 9/21/23 at 11:16 AM revealed Resident 23 being assisted onto the toilet in the resident's bathroom with the Sit to Stand (STS) Lift by MA-D. An observation on 9/21/23 at 11:36 AM revealed Resident 23 being assisted off the toilet with the sit to stand lift and into their wheelchair by MA-D. An interview on 9/21/23 at 11:42 AM with MA-D confirmed staff would look at the care plan to confirm how to transfer the resident. An interview on 9/25/23 at 8:35 AM with DON confirmed Resident 23 was recently changed from a pivot transfer to using a STS lift by LPN-A due to being inconsistent and unsafe with pivot transfers. DON confirmed Resident 23 was not currently ambulating at all. The DON confirmed Resident 23's care plan was not up to date with resident's interventions.

Licensure Reference Number 175 NAC 12-006.02(8) Based on interviews and record review the facility failed to 1. thoroughly investigate allegations of potential abuse when one resident (Resident 1) received a skin tear and bruises during care, 2. thoroughly investigate possible abuse based on Grievance Forms filed on behalf of three residents (Residents 2, 3, and 5), and 3. protect residents from possible abuse while investigations were competed into allegations of potential abuse for these same four residents. The facility census was 38, and sample size was 6. Findings are: A. On 7/20/2020 at 3:51 PM, an interview with LPN (Licensed Practical Nurse)-A revealed this nurse had worked night shift in the facility for about 8 months before moving to day shift three days before this survey. LPN-A verified that on the night of 4/20/2020 Resident 1 received a skin tear while this LPN was working. LPN-A reported that a NA (Nurse Aide) who no longer worked at the facility called the nurse to Resident 1's room where NA-B had been caring for the resident. LPN-A observed a large skin tear on Resident 1's right forearm, and NA-B could not explain how the resident had received the skin tear. LPN-A reported that although Resident 1 was often confused, there were times when the resident was lucid. LPN-A stated they found the resident was quite lucid that night. LPN-A reported that the resident was very clear that NA-B was rough and had hurt them. The LPN documented the resident's comments about NA-B being rough during care in the Progress Notes. LPN-A also stated they had reported the incident to the day shift to follow up. LPN-A was unaware of any other concerns related to how NA-B cared for this resident or other residents. LPN-A also stated they were not aware of concerns with how other aides were caring for residents and did not recall being asked about this. A Progress Note made on 4/20/2020 at 8:00 PM by LPN-A verified that they had been told Resident 1 had received a skin tear and went to the room. LPN-A asked NA-B what had happened and was told NA-B was unsure how the injury happened but the resident may have received it while turning the resident in bed. The LPN also noted that while cleaning the wound the resident was asked what happened and stated that NA-B was too rough. The record indicated that this note was struck out on 4/27/2020 at 7:23 AM. A second Progress Note by the same LPN dated 4/21/2020 at 7:23 AM described the same event but omitted the last sentence which stated that when asked the resident had reported that NA-B was too rough. Review of the Injuries of Unknown Source document dated 4/21/2020 and completed by LPN-A included the same information as was documented in the Progress Notes, and the Accident/Incident Report completed by LPN-A dated 4/20/2020 also indicated that NA-B was being too rough. It was noted that the lines for additional signatures on the Accident/Incident Report had not been signed. It was also noted that the second part of the Injuries of Unknown Source document had not been completed to indicate the dates of the last in-service for caregivers on transfers/lifting, or how caregivers were evaluated and monitored and that observations requested for care of residents needing assistance and residents who are self-assist were not completed. Both the DON (Director of Nursing) and the Administrator made notes in the conclusion portion of the Injuries of Unknown Source document with the DON noting that they did not feel this was a result of abuse and the Administrator verifying that the incident occurred on 4/20/2020. There were no dates accompanying any signatures on the document. On 7/20/2020 at 5:30 PM, an interview with the facility's DON revealed that LPN-A had texted the DON about Resident 1's skin tear the night of 4/20/2020, but the DON did not see the text until the following morning. Upon arriving at the facility, the DON checked on that resident first and did observe bruising on the arm around the skin tear which was covered with a dressing. The DON notified the Administrator of the situation that morning and talked to the staff about it. The DON reported that she had asked the staff members who were working that night to write statements about what happened. Review of the facility's Abuse Prevention Policy showed that the charge nurse must obtain a written statement from the person reporting the incident and provide statements to the administrator within 24 hours of the occurrence when an immediate investigation will be made. The DON confirmed that no written statements were made until after police came to the facility on [DATE] to investigate Resident 1's skin tear. The DON verified that written statements were a part of a thorough investigation of the incident which was completed after the police had come to the facility. The DON affirmed a belief that an investigation of possible abuse was done by the facility's Administrator before the police came but could not provide documentation of that. The DON acknowledged the need to thoroughly investigate even suspected abuse. B. Review of a Grievance Form dated 4/24/ for a concern voiced by Resident 2 showed the resident complained that a tall, heavy set NA was not patient with her and was making her go to bed before she was ready. On 7/20/2020 at 4:30 PM, an interview with Resident 2 revealed that resident had a difficult time verbalizing due to [CONDITION(S)] (the loss of ability to understand or express speech due to brain injury) following a stroke. The resident reported that staff were generally kind and provided good care, but the resident was glad that they had not seen the big NA in a long time. The resident was not able to describe any specific concerns about that individual but indicated this person had not treated them well. On 7/20/2020 at 4:45 PM, an interview with the facility's Social Service Director (SSD) revealed that the SSD had heard the grievance from Resident 2 and had understood that the resident was referring to NA-B when they described the caregiver as big. The SSD stated they often received grievances from residents and after completing the top portion of the form which is the Statement of concern, they took the form to the facility's Administrator. The Administrator then either completed an investigation or assigned it to someone else like a department head. After the investigation was completed and an Action plan written down, it was the SSD's responsibility to follow up with the resident to ensure the situation had been resolved. In this case on follow up, the resident asked not to be cared for by NA-B because they were rough at times. The SSD also reported their belief that recent training and education had improved the general treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Grievance Form dated 4/16/2020 for a concern voiced by Resident 3 related to a staff member's attitude toward the resident's roommate, Resident 4, stated the staff member was not pleasant, griping about the roommate and needed more manners. Follow up stated that this staff member had been working on the medication cart rather than caring for residents, so Resident 3 felt the situation was better. On 7/20/2020 at 4:20 PM, interviews with Resident 3 and her roommate Resident 4 revealed no actual concerns with their current treatment by staff. However, Resident 3 stated that filing a grievance was a waste of time because nothing was done about it. The resident did recall filing a grievance about the roommate's treatment and said things had improved recently but did not feel this was the result of the grievance long ago. Resident 3 also reported that if you're polite to staff they're polite to you but sometimes they argue with people who are not polite. Resident 3 was not able to provide specific examples of staff members who had done this. Resident 4 did not speak clearly but was able to shake their head no when asked if they had concerns about how staff members treated them and nodded to indicate that they would be able to let someone know if anyone treated them badly. On 7/20/2020 at 5:05 PM the Grievance Forms from Resident 2, Resident 3, and one from a family member of Resident 5 were reviewed with the DON. The DON verified that there was no documentation of any investigation being completed for any of these grievances although her name was signed on the line labeled Investigating Department/Person and at the bottom on the line for the investigator's signature. The DON verified they had not personally investigated any of these concerns and stated that the Administrator completed all the investigations while it was the DON's responsibility to create an action plan. The DON verified that education had been provided to the staff member who was rude to Resident 3's roommate and stated the other concerns were addressed at a staff meeting on 5/14/2020. When asked, the DON agreed this was much more than 5 days after the complaints were filed. The DON agreed that suspected or possible abuse should be thoroughly investigated and restated that this was the responsibility of the Administrator who was away on vacation on the day of this survey. Review of a Grievance Form dated 4/24/2020 voiced by a family member of Resident 5 showed the resident had reported that the aides were rough, pulling on the resident, and not waiting for them to finish in the bathroom at night. The resident had not been able to provide the names of the aides involved. On 7/21/2020 at 10:50 AM, a phone interview with the family member of Resident 5 verified that they had filed a grievance on behalf of the resident when the resident complained that the aides had been rough with them. The family member said the resident had described younger staff members not having patience, so the family member felt they needed to let someone know about the complaint. The family member stated that the resident was very unhappy about moving to the facility after living alone for so long and would probably complain no matter how good the care was, but rough treatment was of concern. The family member revealed that no one from the facility had ever called back or contacted them to let them know what was done regarding the concern they had voiced, but since the resident had not complained again about rough treatment, they had not followed up with the facility either. The family member also reported that the resident had continued to complain that staff could be rude at times. There was no evidence that the facility had identified that rude language created the potential for verbal abuse and rough treatment created the potential for physical abuse which should be thoroughly investigated. C. On 7/20/2020 at 3:51 PM during an interview, LPN-A revealed that after the police came to the facility NA-B was suspended from work for several days but then returned to work in the facility until much later when NA-B was suspended again and was not currently working in the facility. On 7/20/2020 at 4:20 PM during an interview, Resident 3 voiced on-going concerns about staff speaking rudely to residents. On 7/20/2020 at 4:45 PM, an interview with the facility's SSD verified that NA-B continued working in the facility after Resident 1 received a skin tear during care by that NA but clarified that NA-B was no longer working there. The SSD acknowledged that a Grievance Form had been completed for Resident 2 alleging rough treatment by NA-B a few days after Resident 1 received a skin tear while being cared for by NA-B. The SSD also reported their belief that recent training and education had improved the general treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/2020 at 5:05 PM, an interview with the facility's DON revealed that no staff members had been suspended from work in relation to the concerns raised by the Grievance Forms filed on behalf of Resident 2, Resident 3, or Resident 5. However, on 7/20/2020 at 5:30 PM, the DON verified that after police officers came to the facility, NA-B was suspended for three days since NA-B told the officer they had caused Resident 1's injury. The DON also stated that after receiving notification that APS had substantiated allegations of abuse and neglect by NA-B on Resident 1, NA-B had been suspended but was not fired because the Administrator and the DON sent a letter to APS describing why they did not believe that abuse had occurred and asking to have NA-B's record expunged so they could return to work. On 7/21/2020 at 10:50 AM during a phone interview, a family member of Resident 5 revealed that the resident continued to report that staff members were rude at times. Review of the facility's Abuse Prevention Policy showed it included under Prevention that employees will identify, intervene, and correct situations in which abuse or neglect might occur. Under Identification, Reporting, and Investigation the policy further stated that any staff involved in the alleged incident would be suspended without pay until the investigation was complete.

Licensure Reference Number 175 NAC 12-006.09D8b Based on observations, interviews and record reviews the facility failed to; 1) Provide dietary supplements to two sampled residents (Residents 40 and 54) identified with weight loss, 2) identify and clarify an order for [REDACTED]. Findings are: A. Record review of Resident 54's care plan with the date initiated of 12/3/2013 revealed "D-My nutritional risk is high . . . has had a significant weight loss at this time." Interventions dated 2/24/2014 included "Offering house nourishment at meals." Record review of Dietary progress notes dated : 2/24/ 1:41 PM "Requested a reweight (sic) on this resident, . . . has a significant weight loss in 30 day's (sic), will try a house nourishment (sic) at meals..." Record review of weights for Resident 54 revealed recorded weights on the following dates: - 11/16/2013, on the date of admission, 142 pounds, - 12/14/2013; 140 pounds, - 1/14/2014; 137.4 pounds, - 2/4/2014; 131.7 pounds, - 2/18/2014; 129.6 pounds, and - 3/8/2014; most recent weight recorded, 125.7 pounds. Interview on 3/10/14 at 8:38 AM with Licensed Practical Nurse (LPN) G revealed that Resident 54 had an order for [REDACTED]." Further interview revealed that the kitchen/dietary staff would have a record of administration of Ensure for Resident 54. Observation on 3/11/2014 at 8:40 AM revealed Resident 54 eating breakfast. Further observation revealed that Resident 54 ate 80% of breakfast which consisted of 3 containers of yogurt, and a bowl of cornflakes cereal. Still further observation revealed that Resident 54 was not given house supplement or Ensure. Interview on 3/11/2014 at 8:40 AM with Nurse Aide (NA) N revealed that it was "difficult" to get Resident 54 to eat very much. Observation on 3/11/2014 from 11:30 AM - 12:10 PM revealed Resident 54 at table eating lunch. Further observation revealed that Resident 54 was not given the Ensure or the House Supplement. Interview on 3/11/2014 at 1:05 PM with Dietary Aide L revealed that the dietary staff does not pass out the Ensure to residents. Further interview revealed that Dietary Aide L had not given Resident 54 the House Supplement. Further interview revealed that Dietary Aide L recorded each resident's intake for part of the meals. Still further interview confirmed that Resident 54 consistently did not eat well. Interview on 3/11/2014 at 1:05 PM with Dietary Aide M confirmed that the dietary staff did not pass out the Ensure to residents. Further interview confirmed that the dietary staff was responsible for passing out the House Supplement to the Residents. Further interview confirmed that Dietary Aide M had not given the House Supplement to Resident 54. Interview on 3/11/2014 at 3:20 PM with LPN E revealed that the nursing staff or the Medication Aides gave out the Ensure supplements. Further interview confirmed that the Kitchen did not give out or administer the Ensure supplements to the residents. Further interview revealed that LPN E had not given Resident 54 any Ensure. Observation on 3/11/2014 at 5:50-6:00 PM revealed Resident 54 siting at the table eating supper. Further observation revealed Resident 54 was not given Ensure or the House supplement. Observation on 3/12/2014 at 8:45 AM revealed Resident 54 finished eating breakfast. Further observation revealed Resident 54 was not given the House Supplement or the Ensure. Interview on 3/12/2014 at 9:00 AM with LPN G revealed that Ensure was an order which was placed under "Dietary Supplements" and would not show up on the Medication Administration Record [REDACTED]" for Resident 54 and there was no place for the nurses to chart it. The ordered doses of Ensure were given to the residents by the nurses and charted by the nurses in the MAR. Further interview with LPN G revealed that there was no way to verify that the Ensure was given for Resident 54 because the Ensure was placed in the EHR under "dietary supplements". Continued interview revealed that the dietary staff would give out the dietary supplements. Interview confirmed that the House Supplement was on Resident 54's care plan. Further interview confirmed that Resident 54 was to have the House Supplement with meals beginning on 2/24/2014. Further interview confirmed that Resident 54 was not getting the Ensure when LPN G stated "I will fix the order for the Ensure right now so that it will show up on the MAR." Observation on 3/12/2014 at 11:30 AM revealed Registered Nurse (RN) D passing medications to residents on the 100 wing of the facility. Interview on 3/12/2014 at 11:35 AM with RN D confirmed that RN D was passing medications and had not passed any Ensure to Resident 54. Interview confirmed that Resident 54 has had weight loss. Further interview revealed that RN D was unsure if Resident 54 had any orders for Ensure and stated "let me check". Still further interview revealed that the Resident 54 had an order "dated today, for 4 ounces of Ensure BID (twice a day)." Interview on 3/12/2014 at 1:45 PM with the Dietary Supervisor/Manager confirmed that Resident 54 had significant wt. loss. Further interview confirmed that Resident 54 had an order for [REDACTED]. Interview 3/12/14 at 2:00PM with LPN G confirmed that Resident 54 has had significant wt. loss. B. Review of the "Face Sheet" for Resident 40 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Nutrition Risk Assessment" for Resident 40, dated 7/2/13 revealed a weight of 132 pounds, Height 5 foot 9 inches, Body Mass Index of 26 plus, with a diet order of Regular Geriatric with an overall score of 11 placing resident at "High Risk" as per scale guidelines of, any number over 8 is at "High Risk." Review of a " History and Physical " for Resident 40, dated 9/6/13 revealed a plan : "This is a [AGE] year old ......... who presented from ....patient has had a decreased appetite over the last few days, increasing confusion, and complaints of abdominal pain ...patient was evaluated ...with findings suggestive of [MEDICATION NAME] (inflamation of the gallbladder)..." Review of "Clinical Laboratory Services" for Resident 40 revealed an [MEDICATION NAME] levels on 9/7/13 of 2.3 and on 9/12/13 of 2.3 with the reference level for normal [MEDICATION NAME] level of 3.2 to 5.0. Review of "Progress notes" for Resident 40 dated: - 9/18/13 revealed, "a table change made per family request in the dining room and new orders for low cholesterol/fat diet" per Dietary Manager, - 9/19/13 revealed, "has new order for low cholesterol/fat diet" per Dietary Manager, - 9/23/13 revealed, "same diet order, doesn't have much appetite, is being assisted and encouraged by daughter, offering house supplement with meals, dose consume about half of it" per Dietary Manger, -10/2/13 "Annual assessment 2-cal bid (twice daily) due to low [MEDICATION NAME], recommend diet not be continued any longer than necessary" per Dietician note, -11/1/13 "faxed physician about weight loss, on house nourishment at meals, receiving 2-cal appetite improved some" per Dietary Manager, -12/17/13 "physician informed of weight loss 75% in 90 days" per the Dietitian and, -12/18/13 "talked with child about nutrition status, continue to have weight loss, continue to receive" per Dietary Manager. Review of the "Care Plan" for Resident 40 dated 10/11/13 revealed a focus of, "I am at risk for........I am considered a high risk for my nutrition due to have a [DIAGNOSES REDACTED]." Further review revealed a goal of "I want to maintain adequate nutrition and hydration ...to see improvements in resident's appetite with new diet order through target date of 4/11/14 " , with interventions of, "House nourishment at meals for added calories, will try the magic cups too...I receive 2-cal as ordered, Monitor intakes and weights, New diet or low fats/cholesterol, Offer snack three time a day, Regular geriatric diet, and will encourage fluids at meal times. " Review of a "Fax Sheet" for Resident 40, dated 11/1/13 that was sent to the physician revealed a concern that "Weight loss of 9.6% in 90 days ... may be related to meds and medical issues ...appetite is improving ...on house nourishment and 2-Cal twice a day ...do you want further intervention ...." Continued review revealed a Physician order, "No Change". Review of the MDS (Minimum Data Set - a federally mandated assessment tool used for care planning) dated 12/17/13 as a Quarterly Assessment revealed that Resident 40 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Review of Resident 40's medical record revealed; - Weight closest to survey start date:117 (pounds) lbs on 03/09/2014 - Weight 30 days ago (02/09/2014): 117 lbs (which was 0 lbs. more than on the first date or a 0.0% gain) - Weight 90 days ago (12/09/2013): 117 lbs (which was 0 lbs. more than on the first date or a 0.0% gain) - Weight 180 days ago (09/03/2013): 131 lbs (which was 14 lbs. less than on the first date or a 12.0% loss) Review of the "Intake Sheet" from dietary for Resident 40 revealed 75 opportunities of documentation for meals from 2/11 to 3/11. For 11 meals resident ate less than 0-25 (percent)% of total meal, for 38 meals resident ate 26%-50% of total meal , for 12 meals resident ate 51%- 75% of total meal and, for 14 meals resident ate 76%-100% of total meal. Review of Resident 40's medical record revealed that there was no written documentation to support the the physician was notified of the numerous meal intakes of less than 50%. Review of a "Fax Sheet" for Resident 40, dated 12/17/13 revealed a concern, "Resident consistently has 7.5 % of weight loss in 90 days.....present weight is 119 lbs is on 2- Cal twice a day.....appetite is better after health issues in October." Continued review of physician's orders [REDACTED]." Review of a "Fax Sheet" for Resident 40, dated 1/3/14 revealed a concern of, "Need clarification of 12/17/13 order for 2-Cal is it twice a day or three times a day?" Further review revealed a physician response of, " Three times a day. " Review of the "Care Plan" for Resident 40, dated as revised on 1/3/14 revealed a focus of "I am at risk for ... ...my nutrition due to having a [DIAGNOSES REDACTED]." Continued review revealed a goal of, "I want to maintain adequate nutrition and hydration ....." Further review revealed interventions of, "House nourishment at meals for added calories, will try the magic cups too ....I receive 2- Calorie (a nutritional supplement) as ordered, and a Regular Geriatric Diet for low fats and cholesterol." Interview on 3/10/14 at 8:15 AM with the Dietary Supervisor revealed that Resident 40 was not on a planned weight loss diet. Interview on 3/11/14 at 8:37 AM with (Registered Nurse) RN - D revealed that resident was on 2- Cal which was administered by the medication nurse with medications, and also received the House Supplement, one time a day with the noon meal. Observation on 3/10/14 at 8:45 AM of morning meal process revealed that Resident 40 had a glass of milk and a glass of juice that he/she had spilled. Further observation revealed that resident did drink the glass of milk which was approximately 4 ounces. The juice was not replaced for the resident to drink and there were no direct-care staff that encouraged the resident to drink fluids. Interview on 3/11/14 at 8:40 AM with LPN - E confirmed that he/she was responsible to administer the 2-Cal to Resident 40. Further interview revealed that the 2-Cal was given along with resident medications at meal times. Continued interview with LPN - E confirmed that the amount of 2-Cal consumed by resident was not measured and documented. Interview on 3/11/14 at 8:45 AM with Dietary Cook revealed that Resident 40 did receive the House Supplement once a day at lunch. Further interview confirmed that the House Supplement was prepared and administered by the kitchen staff. Interview on 3/11/14 at 5:35 PM with (Dietary Aide) DA - R revealed that Resident 40 was on House Supplement which was to be administered three times a day with meals. Further interview confirmed that the kitchen was responsible to prepare and administer the House Supplement to the resident. Interview on 3/11/14 at 9:00 AM with RN - D confirmed that Resident 40 did not have house supplement for breakfast. Further interview revealed that house supplement was only administered at the noon meal. Interview on 3/12/14 at 3:20 PM with the Administrator the DON and the MDS Coordinator confirmed that Resident 40 was at "High Risk" of losing and weight, had actually lost weight, and not regained the weight back. Further interview confirmed that meal intakes were documented, numerous meal percentages were below 50%, and the Dietary Supervisor failed to notify the physician. The Administrator, DON, and MDS Coordinator did confirm that the Direct-care staff members were not knowledgeable of orders and correct amounts of the House Supplement that Resident 40 was to receive. Further interview confirmed that the kitchen was not providing the prescribed diet of low fat/cholesterol for this resident and direct-care staff members were not knowledgeable in regards to the special diet. Further interview confirmed that the House Supplement was not administered to the resident in the appropriate amounts of three times a day and should have been. Continued interview confirmed that an order for [REDACTED].

Licensure Reference Number 175 NAC 12-006.07C Based on observations, record reviews, and staff interview; the facility failed to ensure that the QA&A (Quality Assessment and Assurance) Committee 1) identified quality of care issues and developed a plan to address the issues and 2) developed and implemented a plan of correction to ensure that quality of care deficiencies from the previous annual survey were corrected. The facility census was 48 and these failures have the potential to effect all of the residents. Findings are: Review of the facility "Quality Assurance Program Committee Agenda" revealed the following areas were reviewed at the monthly QA&A meetings: Chart audits, Abuse Reporting, Survey issues for the past 12 months, Staffing, Nursing audits including Fall rate, Incidents and Accidents, Weight Loss Report, Care Plan Audit, Medication Error Rate, Significant Medication Errors, Social Services Report including Behavior Program and Customer Satisfaction. Review of the current annual survey, dated 3/13/14, revealed quality of care deficiencies including the following which are reviewed at the monthly meetings as listed above: -F 166 - Resident Right to prompt efforts to resolve grievances; -F 225 - Investigate/Report allegations of abuse; -F 282 - Implementation of the care plan interventions to assist residents in the dining room; -F 309 - Care and Treatment to meet the resident's needs; -F 323 - Free of accident hazards; -F 325 - Maintain the nutritional status of the residents; -F 328 - Care and treatment for [REDACTED]. -F 332 - Free of Medication Error Rate of 5% or greater; -F 333 - Free from significant medication errors; -F 353 - Sufficient 24 hour nursing staff to meet the resident's needs. Review of the deficiencies cited at the previous annual survey, dated 1/10/13, revealed the following deficiencies which were not corrected: -F 253 - Housekeeping and Maintenance Services to ensure a safe and sanitary environment; -F 279 - Care plans not developed based on needs identified on the resident's comprehensive assessment; -F 280 - Care plans not updated or revised to reflect the current needs of the residents; -F 282 - Care plan interventions not implemented related to residents needs in the dining room; -F 329 - [MEDICAL CONDITION] medications administered without the required documentation of the resident's response to the medications to ensure the continued need for the medications and the therapeutic benefits of the medications. Interview on 3/13/13 at 1:30 PM with LPN (Licensed Practical Nurse) - C, QA&A Coordinator, confirmed that the QA&A Committee did not identify the quality of care issues identified in the current annual survey. Further interview confirmed that the QA&A committee did not ensure continued compliance with the previously cited deficiencies.