Every finding on record at Mother Hull Home

Licensure Reference Number 175 NAC 12-006.11(D)Based on observation, interview, and record review the facility failed to follow approved recipes when preparing resident foods and failed to ensure food temperature was maintained for hot food at or above 135 degrees Fahrenheit. This had the potential to affect all the residents receiving food items from the kitchen. The facility census was 45.Findings are:A.A record review of a facility supplied document titled Dining Manager Garlic Roasted Chicken and dated 2026 revealed instructions to arrange chicken pieces on a paper lined baking sheet and to evenly coat the chicken with 2 tablespoons and 2 teaspoons of lemon juice. To combine 1 tablespoon of dried oregano and 1 ounce of minced garlic an evenly spread the mixture on the chicken.In an observation on 02/05/2026 at 9:35 AM Dietary [NAME] A (DC-A) placed pieces of chicken into a metal bowl. The DC then added 2 tablespoons of lemon juice into the bowl and shook in a unmeasured amount of dried oregano into the bowl. The DA then added an unmeasured amount of poultry seasoning to the bowl and used gloved hands to mix the chicken and spices together in the bowl. DC-A did not add the required amount of lemon juice, did not measure the seasonings added, and did not add the garlic to the chicken.In an interview completed on 02/05/2026 at 12:35 PM with DC-A, DC-A confirmed that they did not use the required amount of lemon juice, did not measure the seasonings, and did not add garlic to the chicken mixture.In an interview completed on 02/05/2026 at 12:36 PM with the Dietary Manager (DM), the DM confirmed that recipes should be followed for food items prepared and served by the kitchen and were not.B.A record review of a facility supplied document titled Dining Manager Beef Chili and dated 2026 revealed instructions to combine 2 pounds 3 ounces of ground beef, 2 and 3/4 ounces of onions, and 1/2 ounce of minced garlic in a large stock pot and brown. Then add 2 and 2/3rds cup diced tomatoes, 1 cup tomato sauce, 1 and 3/4's cup water, 2 tablespoons and 2 teaspoons of chili powder, 1/2 teaspoon salt, 1/8th teaspoon pepper, and 1 tablespoon and 1 teaspoon of sugar then bring the mixture to a boil. To add drained beans to the mixture and return the mixture to a boil.In an observation on 02/05/2026 at 8:53 AM DC-A used a can opener to open a 6.38 pound can of diced tomatoes. The cook the emptied part of the can of diced tomatoes into a pot. The DC then opened a 6.88 pound can of red beans and emptied a portion of the can into the pot. The cook did not measure the amount of added diced tomatoes and did not rinse the beans or measure the amount of beans added. The [NAME] then added an unmeasured amount of chili powder, garlic powder, onion powder, and white pepper into the tomato and bean mixture. The cook then covered the pot.In an observation on 02/05/2026 at 9:36 AM DA-C uncovered the pot and added an unmeasured amount of taco seasoning to the pot and an unmeasured amount to barbeque sauce to the pot.In an interview completed on 02/05/2026 at 12:35 PM with DC-A, DC-A confirmed that they did not measure the seasonings, diced tomatoes, and beans when placing them in the pot. The DC confirmed that the recipe did not call for taco seasoning or barbeque sauce to be added and they did not follow the recipe when preparing the chili.In an interview completed on 02/05/2026 at 12:36 PM with the Dietary Manager (DM), the DM confirmed that recipes should be followed for food items prepared and served by the kitchen and were not.C.A record review of a facility supplied document titled Dinning Manager Grilled Cheese Sandwich and dated 2026 revealed instructions to brush both sides of sandwiches with melted margarine.In an observation on 02/05/2026 at 11:22 AM DC-A used a container labeled butter cooking spray to spray both sides of the sandwiches. The DC did not use margarine on the sandwiches as indicated in the recipe.In an interview completed on 02/05/2026 at 12:35 PM with DC-A, DC-A confirmed that they did not use margarine on both sides of the sandwiches as directed in the recipe.In an interview completed on 02/05/2026 at 12:36 PM with the Dietary Manager (DM), the DM confirmed that recipes should be followed for food items prepared and served by the kitchen and were not.D.A record review of a facility supplied document titled Dinning Manager Grilled Zucchini and dated 2026 revealed to combine oil salt pepper in a mixture then to add the sliced zucchini and toss evenly to coat the zucchini.In an observation completed on 02/05/2026 at 10:46 AM DC-A placed pieces of sliced zucchini onto a parchment lined pan in a single layer. The cook then sprinkled a layer of poultry seasoning over the zucchini and placed the pan into the oven. The cook did not coat the zucchini in an oil salt and pepper mixture then place on the parchment lined baking sheet.In an interview completed on 02/05/2026 at 12:35 PM with DC-A, DC-A confirmed that they did not follow the directions for preparation or seasoning of the zucchini.In an interview completed on 02/05/2026 at 12:36 PM with the Dietary Manager (DM), the DM confirmed that recipes should be followed for food items prepared and served by the kitchen and were not.E.A record review of a facility policy titled Maintaining Food Temperatures and not dated revealed hot food should be kept hot at or above 135 degrees Fahrenheit.In an observation completed on 02/05/2026 at 12:35 PM it was observed that the temperature of the zucchini was 120.5 degrees Fahrenheit and the temperature of the grilled cheese sandwich was 116.4 degrees Fahrenheit.In an interview completed on 02/05/2026 at 12:35 PM with DC-A, DC-A confirmed the temperature of the zucchini and grilled cheese was not 135 degrees Fahrenheit or greater and should be.In an interview completed on 02/05/2026 at 12:36 PM with the Dietary Manager (DM), the DM confirmed the temperature of the zucchini and grilled cheese was not 135 degrees Fahrenheit or greater and should be.

Licensure Refrence Number 175 NAC 12-006.11 Based on observation, record review, and interview, the facility failed to complete hand hygiene using the approved technique during meal preparation. This had the potential to affect all of the residents receiving food stuff from the kitchen. The facility census was 45.Findings are:Record review of a facility policy titled Hand Hygiene and dated 2021 revealed staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Listed under hand hygiene technique when using soap an water to dry hands thoroughly with a single use towel and use a clean towel to turn off the faucet.In an observation completed on 02/05/2026 from 8:41 AM through 12:08 AM of Dietary [NAME] A (DC-A) preparing food the following was observed:-DC-A used scissors and gloved hands to cut open plastic wrapping from raw ground beef and placed the meat into a pan. The DC-A removed their gloves from both of their hands and walked over to the sink. The cook performed hand hygiene using soap and water. DC-A shut off the water with their wet bare hands then obtained a single paper towel and dried their hands. The DC-A did not use a clean paper towel to shut off the water after drying their hands.-DC-A with gloved hands removed raw chicken from a metal bowl and placed it on a parchment lined cookie sheet. The DC-A removed their gloves from both of their hands and walked over to the sink. The cook performed hand hygiene using soap and water. DC-A shut off the water with their wet bare hands then obtained a single paper towel and dried their hands. The DC-A did not use a clean paper towel to shut off the water after drying their hands.-DC-A removed packages of frozen zucchini from the double door freezer and placed the bags in a clear square container. DC-A then placed the container with the frozen zucchini in it under cool running water. DC-A then proceeded over to the sink and performed hand hygiene using soap and water. DC-A shut off the water with their wet bare hands then obtained a single paper towel and dried their hands. The DC-A did not use a clean paper towel to shut off the water after drying their hands.-DC-A performed hand hygiene using soap and water at the sink. DC-A shut off the water with their wet bare hands then obtained a single paper towel and dried their hands. The DC-A did not use a clean paper towel to shut off the water after drying their hands. DC-A then proceeded to the prep area and applied gloves to both of their hands. DC-A then removed slices of bread and placed them on lined cookie sheets sitting on top of the prep area. The DC-A then removed their gloves from both of their hands and went to the sink. The cook performed hand hygiene using soap and water. DC-A shut off the water with their wet bare hands then obtained a single paper towel and dried their hands. The DC-A did not use a clean paper towel to shut off the water after drying their hands. In an interview completed on 02/05/2026 at 12:35 PM with DC-A, DC-A confirmed that they shut off the water with their wet hands. The DC-A confirmed that they should have dried their hands and then used a new paper towel to shut off the water and did not.In an interview completed on 02/05/2026 at 12:36 PM with the Dietary Manager (DM), the DM confirmed that DC-A did not follow the accepted procedure for performing hand hygiene and should have.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record reviews, observations and interviews, the facility failed to provide adequate indications for use consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals and a documented clinical rationale for administering an antipsychotic medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any safer treatments have been deemed clinically contraindicated for 2 of 5 sampled residents (Resident 5 and Resident 11). The facility census was 45.Findings are:A.Record review of a facility policy titled Use of Psychotropic Medications dated 2025 revealed adequate indications for use referred to the identified documented clinical rational for administering of a medication. Also, adequate indication for use means that the medication is administered in consistence with manufacturer's recommendations and or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and pharmacy journals.Record review of a document titled Highlights of Prescribing Information Olanzapine and dated 2019 revealed under indications and usage for the treatment of schizophrenia and acute and maintenance treatment of manic or mixed episodes associated with bipolar one disorder. Record review of a document titled Olanzapine and dated 02/03/2026 (https://www.drugs.com/olanzapine.html) revealed the medications is an atypical antipsychotic medication that is used to treat adults and adolescents age [AGE] and older with schizophrenia or bipolar one disorder. Record review of a Resident Face Sheet revealed the facility admitted Resident 5 on 12/18/2025 with diagnoses of depression (a common serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and physical pain), and anxiety disorder (a mental health condition characterized by persistent, excessive, and irrational fear or worry that interferes with daily life. Record review of Resident 5 Medication Administration Record (MAR) for the Month of January 2026 revealed the resident was administered the medication of Olanzapine (an antipsychotic medication) 2.5 milligrams every day at bedtime for an indication/diagnosis of anxiety disorder.Record review of a facility supplied document titled Note to attending Physician/Prescribe and dated 09/17/2025 revealed documentation that Resident 5 was receiving the medication of Olanzapine and lacked an acceptable diagnosis to support its' use. It was stated that documented clinical rational to support the other use for the medication should be supplied. The provider wrote the corelating code for the indication/diagnosis of anxiety disorder and did not document any clinical rational for this decision.In an interview completed on 02/09/2026 at 3:20 PM with the facility Director of Nursing (DON), the DON confirmed that the indication/diagnosis or anxiety was not an approved use of the medication. The DON confirmed that the provider wrote the code for the anxiety disorder and did not provide clinical rational for this decision.B.A record review of an undated policy titled, Use of Psychotropic Medication(s) reveal: It is the intent of this policy to ensure that the residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medication should only be used to treat the residents' medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.Definitions, adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate.8. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication.9. The resident and/or the resident representative has the right to accept or decline the initiation or increase of a psychotropic medication.10. The facility will document that the resident or the resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).A record review of Resident 11's undated face sheet reveals an admit date of 9/07/2016. Further review reveals current diagnoses listed:-Localization-related (focal) (partial) symptomatic epilepsy (recurrent seizures originating from a specific, identifiable brain lesion or region)-Parkinson's disease with dyskinesia (a progressive, incurable neurodegenerative disorder with involuntary, erratic, writhing, or jerky movements)-Unspecified dementia with behavioral disturbance (a cognitive decline of unknown type or severity accompanied by behavioral symptoms like agitation, aggression, or wandering)-Aphasia (loss or impairment of the power to use or comprehend words usually resulting from brain damage)-Major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies)-Anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it) A record review of Resident 11's Physician Orders revealed an order, dated 07/09/2025 for olanzapine (an atypical antipsychotic) tablet 2.5 milligram (mg) amount, 1 tablet once a day. Special instructions-Target behavior: yelling. Diagnosis: unspecified dementia with behavioral disturbance. A record review of a Medication Regimen Review (MRR, includes medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences) dated 08/06/2025 revealed a request for a Gradual Dose Reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for Resident 11 taking olanzapine tablet 2.5 mg amount, 1 tablet once a day. The facility noted, Resident 11 has recently had an increase in agitation and behaviors of wanting to leave facility (not able to verbalize where (gender) is planning to go). Staff is usually able to redirect after 30-60 minutes. A record review of Resident 11's Physician Orders revealed an order, dated 08/11/2025 for olanzapine tablet 2.5 mg amount, 1 tablet twice a day. Special instructions-Target behavior: yelling. Diagnosis: unspecified dementia with behavioral disturbance. A record review of Resident 11's Progress Notes dated 1/15/2026 showed the facility placed a call to resident's representative and left message on answering machine regarding resident being on olanzapine which started 8/11/25 with the reason for use as a behavioral impairment. Resident and resident representative informed of risk and benefits of medication and given. They understand that they can refuse or withdraw consent of medication at any time by informing staff. An interview on 2/09/26 at 2:30 PM with Licensed Practical Nurse (LPN)-B reveal monitoring for use of medications happen through daily vitals and ,just knowing the resident. A record review of an article from, American Geriatrics Society 2023 updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults provides information on safely prescribing medications for older adults, https://agsjournals.onlinelibrary.[NAME].com/doi/full/10.1111/jgs.18372. The article reveal; Antipsychotics, first (typical) and second (atypical) generation which includes olanzapine rationale for inappropriate use refers to, an increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia. It is also recommended to avoid, except in Food and Drug Administration (FDA; federal agency that regulate Food, Drugs, Medical Devices, Radiation-Emitting Products, Vaccines, Blood, and Biologics, Animal and Veterinary Cosmetics, Tobacco Product)-approved indications such as schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought, perception, emotion, and behavior, often involving hallucinations, delusions, and cognitive impairment), bipolar disease ( a chronic mental health condition characterized by intense mood swings, ranging from extreme highs (mania/hypomania) to deep lows (depression)), Parkinson disease psychosis (affects over 50% of patients, characterized by non-motor symptoms like visual hallucinations (seeing people/animals), illusions, and delusions), major depressive disorder or short term use for antiemetic (prevention of nausea/vomiting due to medication intake).

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3)Based on record review, and interview the facility failed to evaluate and monitor resident skin issues for 2 (Resident 4, and Resident 7) of 2 sampled residents. The facility census was 45.Findings are: A. Record review of a document titled Best Practices for Wound Assessment and Documentation and dated 04/17/2025 from the Wound Care Education Institute (wcei.net/best-practices-wound-assessment-documentation) revealed wound assessment and documentation serve as crucial clinical tools for effective care planning, etiology, measurements, and wound characteristics to guide treatment. High-quality documentation fosters interprofessional communication and aids in tracking healing progress while aligning with care standards. Record review of a document titled What is standard of care in wound care and dated 05/31/2022 from Wound Source (https://www.woundsource.com/blog/what-standard-care-in-wound-care) revealed to detect signs of healing progress wounds are assessed on a weekly basis and documentation of a wound assessment is a vital component of the standard of wound care and contributes to improved patient safety, outcomes, and care quality. B. Record review of a Resident Face Sheet revealed the facility admitted Resident 4 on 01/06/2026 with diagnosis of second-degree burn (which is damage to the top and second layers of skin causing intense pain redness swelling and blistering), of the right thigh and the abdominal wall. Record review of the comprehensive 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 01/12/2026 for Resident 4 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 8 indicating the resident was moderately cognitively impaired. Resident 4's MDS was coded indicating the resident required supervision or touching assistance with eating, substantial or maximal assistance with bed mobility, and partial to moderate assistance with transfers and toilet use. The MDS was also coded in the skin conditions section indicating that the resident had burns and was receiving application of nonsurgical dressings and applications of ointments and medications. Record review of Resident 4's Care Plan dated 1/06/2026 revealed a problem listed of the resident having alteration in skin integrity due to burns. A goal was listed as the alteration in the skin integrity would be resolved without signs or symptoms of infection with a target date of 04/23/2026. Approaches were listed to monitor the site for signs and symptoms of infection and to notify the physician as indicated, reposition as ordered, take nutrition supplement as ordered, and to administer treatments as ordered all dated 01/06/2026. Record review of a facility document titled admission Skin Assessment for Resident 4 dated 01/06/2026 revealed no documentation of alterations to the resident's skin integrity over the abdomen and a dressing was located to the resident's right thigh. Record review of Resident 4's Progress Notes revealed on 01/06/2026 Resident 4 was admitted to the facility and that dressings were removed from the resident's right thigh and abdomen. The documentation identified Resident 4's wounds were cleansed, a cream was applied and the wounds were covered with a dressing. Documentation was present on 01/07/2026 that the resident had a 0.3cmX0.4cm area of pink fragile tissue to their abdomen and three areas of burnt tissue present to their right upper thigh. There were no measurements to the thigh areas with description of the tissue being yellow slough with redness and traces of black dark brown tissue. The progress notes revealed documentation that the resident received dressing changes to their burns from 01/07/2026 through 01/13/2026. The documentation listed no measurements or assessments of the wounds. Record review of a facility supplied document titled Clinic Visit Sheet dated 01/13/2026 revealed Resident 4 was evaluated/seen at the wound clinic for their wounds. Record review of Resident 4's Progress Notes revealed documentation on 01/20/2026 by the facility Assistant Director of Nursing (ADON) that they reviewed the residents skin integrity during a dressing change. The areas were described to have scabbing present without open areas or drainage with slight pinkness to the surrounding skin. There were no measurements present in the documentation for the areas. There was documentation in the progress notes that dressing changes were performed to the areas from 01/13/2026 through 01/20/2026. The documentation listed no measurements or assessments of the wounds. Record review of Resident 4's Progress Notes revealed documentation on 01/26/2026 that the inner most wound of the resident's right leg/thigh was observed to have thick yellow drainage present. The progress note stated that photos were taken of the wound and the photos were sent to the wound care clinic. The response from the wound care provider was that the resident would be seen the following day. Record review of a facility supplied document titled Clinic Visit Sheet dated 01/27/2026 revealed Resident 4 was evaluated/seen at the wound clinic for their wounds. Record review of Resident r's Progress Notes revealed from 01/26/2026 through 02/10/2026 no documentation of wound measurements or assessments. In an interview completed on 02/09/2026 at 9:52 AM with Licensed Practical Nurse C (LPN-C), LPN-C stated that the dressings are changed daily to Resident 4's wounds. The LPN stated that the residents' abdominal wound was resolved at this time. The LPN denied measuring the wound with dressing changes or documenting wound assessments for the residents' wounds. In an interview completed on 02/09/2026 at 10:00 AM with LPN-B, LPN-B revealed that the ADON completed weekly wound measurements and assessments. The LPN stated that the nurses just did the dressing changes and charted the dressing changes. In an interview on 01/09/2026 at 10:48 AM with the facility ADON, the ADON stated documentation of wounds is done by exception. The ADON stated that the expectation of the facility is to only document if there is something out of the norm/baseline for wounds. The ADON confirmed that there was no routine documentation of measurements or assessments for Resident 4's wounds. In an interview completed on 01/09/2026 at 12:30 AM with the facility Director of Nursing (DON), the DON confirmed that there were no routine documentation or measurements or assessments for Resident 4's wounds. C. Record review of the Tips for Successful Wound Care Documentation dated 12/10/24 from Relias education (https://www.relias.com/blog/tips-for-wound-care-documentation) revealed that all wounds must be assessed, measured, and effectively documented every seven days. Key elements to document include location, type of wound, measurement (length x width x depth), wound bed, wound edges, drainage, odor, surrounding tissue, pain, and response to care and treatment (document whether the wound has improved and list any evidence of healing). Record review of the article Back to the Basics: Wound Assessment, Management, and Documentation dated 2022 by Wolters Kluwer Health revealed that assessment, management, and documentation are the basis of delivering evidence based wound care. Assessments should be completed at least weekly. Based on the assessment, the clinician can compare data and determine the wound's response to the treatment. Proper assessment includes location, shape, size and depth, wound base characteristics, wound edges, and the condition of the surrounding skin. Record review of the undated facility Skin Concerns Protocol revealed that skin concerns (wounds) included excoriated buttock (open wound with removal of the outer skin layers that can be caused by rubbing of the skin), moisture related skin damage (skin breakdown caused by prolonged exposure to moisture such as sweat or urine), bruising, skin tears (a traumatic wound caused by shear, friction, or blunt force that separates the top layer of skin from the underlying tissue), blisters, and pressure ulcers (a localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 7 dated 1/1/26 revealed that Resident 7 admitted into the facility on 7/2/25. The assessment revealed that Resident 7 is dependent on staff for toileting hygiene and rolling left and right on the bed. Resident 7 is always incontinent of bowel. Resident 7 has a diagnosis of Multiple Sclerosis (a disabling disease of the brain and spinal cord). The assessment revealed that Resident 7 had no pressure ulcers. The assessment revealed that Resident 7 had no other wounds or skin problems at the time of the assessment. Record review of the care plan for Resident 7 dated 2/4/26 revealed a goal for the resident's skin to remain intact. Interventions included reporting any signs of my skin breaking down (sore, tender, red, or broken areas) to the charge nurse. The care plan revealed an intervention to administer medications and treatments as ordered by the physician. Monitor me for possible side effects, adverse reactions, and effectiveness. Record review of the progress note for Resident 7 dated 1/31/26 at 11:13 AM revealed that the nurse was called into the room of Resident 7 at around 9:30 AM. Resident 7 was found to have excoriated moisture damage to an area on the buttocks measuring 8 centimeters by 10 centimeters with an open area to the right buttock. The physician was notified. Record review of the Physician Fax Communication dated 1/31/26 for Resident 7 revealed that Resident 7 has excoriated moisture damage to an area on the buttock measuring 8 centimeters by 10 centimeters with an open area to the right buttock. The area will be cleansed and zinc (a medicinal ointment) applied twice daily and as needed until resolved. The fax was signed by the provider on 2/2/26. Record review of the medical record for Resident 7 revealed no documentation of any wound assessments after initial identification of the wound on the right buttock on 1/31/26. Interview on 2/9/26 at 7:48 AM with Resident 7 confirmed that on open area on the right buttock was identified recently. Resident 7 revealed that the urinary catheter leaks sometimes and that staff try to keep the resident's buttocks dry to prevent skin problems. Resident 7 confirmed that nursing staff have been applying something to the wound a couple of times a day. Record review of the medication administration record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 7 dated 2/9/26 for administration dates of 1/10/26 through 2/9/26 revealed the order for cleanse buttocks and apply Zinc twice a day until skin damage is resolved with a start date of 1/31/26. Administrations of the order were documented twice daily on 1/31/26, 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/7/26, and 2/8/26. The administration was documented once for the AM shift on 2/9/26. Licensed Practical Nurse-B (LPN-B) documented that LPN-B administered the order on 2/4/26, 2/5/26, 2/6/26 and 2/9/26. Interview on 2/9/26 at 8:49 AM with LPN-B confirmed that LPN-B has administered the ordered treatment to the area on the right buttock of Resident 7. LPN-B revealed that LPN-B does not measure the area of the moisture excoriation wound on the right buttock of Resident 7. Interview on 2/9/26 at 10:48 AM with the Assistant Director of Nursing (ADON) revealed that bruising, skin tears, and moisture excoriation monitoring are charted by exception if there are issues or concerns. The ADON revealed that the ADON does weekly assessment and monitoring of any pressure ulcers but none for excoriation wounds. The ADON revealed that wound treatment is documented on the resident MAR. The ADON revealed that a progress note is created when an excoriation wound or skin tear is healed. Interview on 2/9/26 at 12:32 PM with the facility Director of Nursing (DON) confirmed that the facility did not have documentation of assessment and monitoring of the wound on Resident 7's buttock to determine improvement or decline in the wound size or condition.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to ensure a medication error rate of less than 5% with an observed medication error rate of 8% (25 medication administration observations and 2 errors). This affected 2 of 7 residents observed (Residents 28 and 53). The facility census was 45.Findings are: A. Record review of the facility policy titled Insulin Pen dated 2024 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of dosing. Insulin pens contain multiple doses of insulin but are used for a single resident only. A new needle will be used for each injection. Always review physician orders prior to administering any medication. The procedure revealed that staff will gather supplies needed: correctly labeled insulin pen, alcohol preps, and sterile insulin pen needle. Perform hand hygiene. Put on gloves. Verify resident identification. Check the expiration date on the pen and discard if expired. Remove the pen cap from the insulin pen. Wipe the rubber seal with an alcohol pad. Screw the pen needle onto the insulin pen. Twist open and remove the outer cover from the pen needle. Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Set the insulin Dose: Turn the dose selector to the ordered dose. A click will be heard for each unit dialed. Check the dose a second time. Injecting the insulin: Cleanse the skin with an alcohol pad. Inject the needle straight at a 90-degree angle to the skin. Fully depress the plunger until the dosing numbers count back to zero. Keep the needle in the skin for up to 6-10 seconds while still pressing the plunger and then remove the needle from the skin. Record review of the Instructions for Use Humalog KwikPen (an insulin pen containing rapid-acting prescription insulin used to treat high blood sugar for residents with diabetes) dated 7/2023 revealed that priming the pen means removing the air from the needle and cartridge. You may get too much or too little insulin if you do not prime before each injection. The section titled giving the injection revealed the steps to insert the needle into the skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 28 dated [DATE] revealed that Resident 28 admitted into the facility on [DATE]. Resident 28 had an active diagnosis of diabetes. Resident 28 received insulin injections on all 7 days of the assessment lookback period. Observation on [DATE] at 11:12 AM at the room of Resident 28 revealed that Licensed Practical Nurse-B (LPN-B) entered the resident room and performed hand sanitization. LPN-B placed a paper towel on the over bed table and organized supplies to check the resident's blood sugar. LPN-B wiped the pad of the left middle finger of Resident 28 with an alcohol prep pad. LPN-B punctured the pad of Resident 28's left middle finger and wiped the first drop of blood off with a cotton ball. LPN-B applied a drop of blood to the glucometer test strip and announced the blood sugar result of 242. LPN-B went to the medication cart located across from the front desk and reviewed the insulin orders for Resident 28. LPN-B revealed that Resident 28 has the routine order for 10 units of Humalog insulin (a rapid-acting prescription insulin used to treat high blood sugar for residents with diabetes) and also for Humalog insulin sliding scale (an insulin order that varies the dose of insulin based on the blood sugar level. The higher your blood sugar level the more insulin you take). LPN-B confirmed that Resident 28 is to receive 14 units of Humalog insulin for the blood sugar result of 242. LPN-B revealed that a total of 24 units of Humalog insulin is ordered to be given to Resident 28. LPN-B removed the Humalog insulin pen from the drawer of the medication cart. The Humalog insulin pen label had an open date of [DATE]. LPN-B removed the cap from the insulin pen and applied a needle to the pen. (LPN-B did not wipe the rubber seal on the top of the insulin pen with an alcohol prep pad prior to putting the needle on the pen). LPN-B dialed the dose selector on the insulin pen to 24 units. (LPN-B did not dial the selector to 2 units and prime the needle prior to selecting the ordered dose of insulin as required). LPN-B took the pen into the room of Resident 28. LPN-B asked Resident 28 what area they would like the insulin injected in. Resident 28 wanted to use their left upper arm. LPN-B wiped an area on the left upper arm of Resident 28 with an alcohol prep pad. LPN-B injected the Humalog insulin into the upper left arm of Resident 28 and immediately removed the needle from the skin (LPN-B did not keep the needle in the skin for the 6-10 seconds as required) (a medication error). Record review of the medication administration record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 28 dated [DATE] revealed the order for Humalog Insulin 10 units once a day. The administration of the 10 units of insulin on [DATE] was documented by LPN-B. The MAR revealed the order for the sliding scale Humalog Insulin for a blood sugar between 201 and 250 was to give 14 units. The administration of the 14 units of insulin on [DATE] was documented by LPN-B.Interview on [DATE] at 12:06 PM with LPN-B confirmed that LPN-B did not prime the insulin pen and was unaware of what priming the insulin pen was. LPN-B confirmed that LPN-B did not hold the needle in the skin for 6-10 seconds as required during administration.Interview on [DATE] at 12:39 PM with the facility Director of Nursing (DON) confirmed that staff are required to prime the insulin pen prior to selecting the ordered dose of insulin to ensure that the correct dose is administered. The DON confirmed that the insulin pen needle is required to be left in the skin for 6-10 seconds during administration to ensure proper administration of the ordered insulin dose. B.Record review of the MDS assessment for Resident 53 dated [DATE] revealed that Resident 53 admitted into the facility on [DATE]. Resident 53 had an active diagnosis of diabetes. Resident 53 received insulin injections on all 7 days of the assessment lookback period. Observation on [DATE] at 11:32 AM at the medication cart outside the room of Resident 53 revealed that Licensed Practical Nurse-C (LPN-C) reviewed the insulin order for Resident 53. LPN-C entered the blood sugar result of 388 into the medical record and revealed that Resident 53 is to receive 12 units of Humalog insulin per the sliding scale order. LPN-C removed the Humalog insulin pen from the medication cart. The insulin pen label showed the open expiration date of [DATE]. LPN-C removed the cap from the insulin pen and wiped the top seal of the pen with an alcohol pad. LPN-C attached a needle to the pen and dialed the selector to 2 units. LPN-C pressed the plunger while holding the pen with the needle upward. Insulin was observed dripping from the needle. LPN-C dialed the selector on the insulin pen to 12 units and took the pen into the room of Resident 53. LPN-C performed hand washing and put on gloves. LPN-C asked Resident 53 what site the resident wanted the insulin administered in. Resident 53 replied arm. LPN-C wiped the skin of the back of the right upper arm with an alcohol pad. LPN-C administered the insulin into the back of the right upper arm and pressed the plunger and immediately removed the needle from the skin. Clear liquid came out of the needle insertion site. (LPN-C did not keep the needle in the skin for the 6-10 seconds as required) (a medication error). Record review of the MAR for Resident 53 dated [DATE] revealed the order for Humalog Insulin sliding scale before meals and at bedtime. The order revealed Humalog insulin 12 units to be administered for a blood sugar between 351 and 400. The administration of the 12 units of insulin on [DATE] was documented by LPN-C.Interview on [DATE] at 3:22 PM with LPN-C confirmed that the insulin pen needle is to be left in the skin for 6-10 seconds during administration. LPN-C confirmed that LPN-C did not keep the needle in the skin for the required 6-10 seconds during insulin administration to Resident 53. Interview on [DATE] at 12:39 PM with the facility Director of Nursing (DON) confirmed that the insulin pen needle is required to be left in the skin for 6-10 seconds during administration to ensure proper administration of the ordered insulin dose.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to ensure that residents were free of significant medication errors for 2 of 7 residents observed (Residents 28 and 53). The facility census was 45.Findings are: A. Record review of the facility policy titled Insulin Pen dated 2024 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of dosing. Insulin pens contain multiple doses of insulin but are used for a single resident only. A new needle will be used for each injection. Always review physician orders prior to administering any medication. The procedure revealed that staff will gather supplies needed: correctly labeled insulin pen, alcohol preps, and sterile insulin pen needle. Perform hand hygiene. Put on gloves. Verify resident identification. Check the expiration date on the pen and discard if expired. Remove the pen cap from the insulin pen. Wipe the rubber seal with an alcohol pad. Screw the pen needle onto the insulin pen. Twist open and remove the outer cover from the pen needle. Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Set the insulin Dose: Turn the dose selector to the ordered dose. A click will be heard for each unit dialed. Check the dose a second time. Injecting the insulin: Cleanse the skin with an alcohol pad. Inject the needle straight at a 90-degree angle to the skin. Fully depress the plunger until the dosing numbers count back to zero. Keep the needle in the skin for up to 6-10 seconds while still pressing the plunger and then remove the needle from the skin. Record review of the Instructions for Use Humalog KwikPen (an insulin pen containing rapid-acting prescription insulin used to treat high blood sugar for residents with diabetes) dated 7/2023 revealed that priming the pen means removing the air from the needle and cartridge. You may get too much or too little insulin if you do not prime before each injection. The section titled giving the injection revealed the steps to insert the needle into the skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle. Record review of the manufacturer package insert for the Humalog Insulin pen dated 1/2026 revealed that Humalog is a rapid acting insulin. Hypoglycemia (low blood sugar) is the most common adverse reaction to insulin and can cause seizures, may be life-threatening, or cause death. The section titled Administration Instructions revealed that the dose of insulin is to be administered within fifteen minutes before a meal or immediately after a meal. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 28 dated [DATE] revealed that Resident 28 admitted into the facility on [DATE]. Resident 28 had an active diagnosis of diabetes. Resident 28 received insulin injections on all 7 days of the assessment lookback period. The MDS revealed that Resident 28 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15 indicating that Resident 28 is cognitively intact.Observation on [DATE] at 11:12 AM at the room of Resident 28 revealed that Licensed Practical Nurse-B (LPN-B) entered the resident room and performed hand sanitization. LPN-B placed a paper towel on the over bed table and organized supplies to check the resident's blood sugar. LPN-B wiped the pad of the left middle finger of Resident 28 with an alcohol prep pad. LPN-B punctured the pad of Resident 28's left middle finger and wiped the first drop of blood off with a cotton ball. LPN-B applied a drop of blood to the glucometer test strip and announced the blood sugar result of 242. LPN-B went to the medication cart located across from the front desk and reviewed the insulin orders for Resident 28. LPN-B revealed that Resident 28 has the routine order for 10 units of Humalog insulin (a rapid-acting prescription insulin used to treat high blood sugar for residents with diabetes) and also for Humalog insulin sliding scale (an insulin order that varies the dose of insulin based on the blood sugar level. The higher your blood sugar level the more insulin you take). LPN-B confirmed that Resident 28 is to receive 14 units of Humalog insulin for the blood sugar result of 242. LPN-B revealed that a total of 24 units of Humalog insulin is ordered to be given to Resident 28. LPN-B removed the Humalog insulin pen from the drawer of the medication cart. The Humalog insulin pen label had an open date of [DATE]. LPN-B removed the cap from the insulin pen and applied a needle to the pen. (LPN-B did not wipe the rubber seal on the top of the insulin pen with an alcohol prep pad prior to putting the needle on the pen). LPN-B dialed the dose selector on the insulin pen to 24 units. (LPN-B did not dial the selector to 2 units and prime the needle prior to selecting the ordered dose of insulin as required). LPN-B took the pen into the room of Resident 28. LPN-B asked Resident 28 what area they would like the insulin injected in. Resident 28 wanted to use their left upper arm. LPN-B wiped an area on the left upper arm of Resident 28 with an alcohol prep pad. LPN-B injected the Humalog insulin into the upper left arm of Resident 28 and immediately removed the needle from the skin (LPN-B did not keep the needle in the skin for the 6-10 seconds as required) (a medication error). The time was 11:17:36 AM. LPN-B did not offer anything to eat or drink to Resident 28. LPN-B exited the room and went to the medication cart. Resident 28 remained seated in the wheelchair in the middle of the room. Resident 28 did not eat or drink anything. Nuse Aide-D (NA-D) entered the room of Resident 28 at 11:35 AM with the sit to stand mechanical lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own from a seated position). NA-D transferred Resident 28 from the wheelchair into the bathroom and then left the resident room. Resident 28 remained in the bathroom. Nurse Aide-E (NA-E) went into the room of Resident 28 at 11:46 AM. NA-E transferred Resident 28 from the bathroom into the wheelchair in the room. NA-E exited the resident room at 11:50 AM. Resident 28 remained seated in the wheelchair in the room. (Resident 28 had not had anything to eat or drink since the administration of the insulin). Resident 28 began to propel themself in the wheelchair and exited the room to go to the dining room. Resident 28 arrived at their table in the dining room at 11:55 AM. A glass of water, a glass of tea, and a small bowl of diced peaches with whipped cream sat on the table. Resident 28 picked up the salad bar menu from the table. Resident 28 did not drink or eat anything. Dietary Aide-F (DA-F) took a Styrofoam cup with lid and straw filled with Diet Dr. Pepper along with the open can with the remaining Diet Dr. Pepper to Resident 28. Resident 28 took a sip of the Diet Dr. Pepper at 11:59:46 AM. Resident 28 took the lid off of the diced peaches and took a bite of the peaches at 12:01:24 PM (this was 43 minutes after the Humalog insulin was administered to Resident 28). (The Humalog insulin was not administered within 15 minutes of a meal creating the risk of hypoglycemia). Interview on [DATE] at 12:01 PM with Resident 28 confirmed that staff do not give the resident anything to eat or drink after they administer the insulin. Resident 28 confirmed that Resident 28 had not had anything to eat or drink after the insulin was administered until now.Record review of the medication administration record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 28 dated [DATE] revealed the order for Humalog Insulin 10 units once a day. The administration of the 10 units of insulin on [DATE] was documented by LPN-B. The MAR revealed the order for the sliding scale Humalog Insulin for a blood sugar between 201 and 250 was to give 14 units. The administration of the 14 units of insulin on [DATE] was documented by LPN-B.Interview on [DATE] at 12:06 PM with LPN-B confirmed that LPN-B did not prime the insulin pen and was unaware of what priming the insulin pen was. LPN-B confirmed that LPN-B did not hold the needle in the skin for 6-10 seconds as required during administration. LPN-B confirmed that LPN-B did not provide Resident 28 with anything to drink or eat after administering the insulin. Interview on [DATE] at 12:39 PM with the facility Director of Nursing (DON) confirmed that staff are required to prime the insulin pen prior to selecting the ordered dose of insulin to ensure that the correct dose is administered. The DON confirmed that the insulin pen needle is required to be left in the skin for 6-10 seconds during administration to ensure proper administration of the ordered insulin dose. The DON confirmed that Humalog insulin is a fast acting insulin and nurses are required to ensure that the resident receives nourishment within 15 minutes after administration of the insulin. B.Record review of the MDS assessment for Resident 53 dated [DATE] revealed that Resident 53 admitted into the facility on [DATE]. Resident 53 had an active diagnosis of diabetes. Resident 53 received insulin injections on all 7 days of the assessment lookback period. The MDS revealed that Resident 53 had a BIMS score of 15 indicating that Resident 53 is cognitively intact.Observation on [DATE] at 11:32 AM at the medication cart outside the room of Resident 53 revealed that Licensed Practical Nurse-C (LPN-C) reviewed the insulin order for Resident 53. LPN-C entered the blood sugar result of 388 into the medical record and revealed that Resident 53 is to receive 12 units of Humalog insulin per the sliding scale order. LPN-C removed the Humalog insulin pen from the medication cart. The insulin pen label showed the open expiration date of [DATE]. LPN-C removed the cap from the insulin pen and wiped the top seal of the pen with an alcohol pad. LPN-C attached a needle to the pen and dialed the selector to 2 units. LPN-C pressed the plunger while holding the pen with the needle upward. Insulin was observed dripping from the needle. LPN-C dialed the selector on the insulin pen to 12 units and took the pen into the room of Resident 53. LPN-C performed hand washing and put on gloves. Resident 53 was in the bed in the room. LPN-C asked Resident 53 what site the resident wanted the insulin administered in. Resident 53 replied arm. LPN-C wiped the skin of the back of the right upper arm with an alcohol pad. LPN-C administered the insulin into the back of the right upper arm and pressed the plunger and immediately removed the needle from the skin. Clear liquid came out of the needle insertion site. (LPN-C did not keep the needle in the skin for the 6-10 seconds as required) (a medication error). The time was 11:35:05 AM. LPN-C did not offer anything to eat or drink to Resident 53. LPN-C exited the resident room. No over bed table or any drink or snack were in reach of the resident. The unidentified Physical Therapist (PT) entered the room of Resident 53 at 11:39 AM. The unidentified PT told Resident 53 that they were there to work with Resident 53. PT provided exercise to the resident as Resident 53 remained in the bed. PT instructed and assisted Resident 53 to perform active exercises of the legs. PT recruited Nurse Aide-G (NA-G) to assist in transferring Resident 53 up in the bed at 11:53 AM. PT and NA-G transferred Resident 53 up in the bed and NA-G exited the resident room at 11:55 AM. PT continued with active exercises with the resident. PT exited the resident room after ensuring the resident call light was activated at 12:00 PM. Resident 53 had not received any nourishment since the insulin administration at 11:35:05 AM. NA-G and Nurse Aide-H (NA-H) entered the room of Resident 53 at 12:03 PM with the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own). Resident 53 was transferred from the bed and into the wheelchair. NA-H transported Resident 53 out of the resident room to a table in the dining room at 12:13 PM. A container of pudding sat on the table in front of the resident. Resident 53 picked up the pudding cup and removed the sealed top. Resident 53 licked the removed top at 12:16:31 PM. Resident 53 picked up a spoon and began to take bites of pudding (this was 41 minutes after the Humalog insulin was administered to Resident 53). (The Humalog insulin was not administered within 15 minutes of a meal creating the risk of hypoglycemia). Record review of the MAR for Resident 53 dated [DATE] revealed the order for Humalog Insulin sliding scale before meals and at bedtime. The order revealed Humalog insulin 12 units to be administered for a blood sugar between 351 and 400. The administration of the 12 units of insulin on [DATE] was documented by LPN-C.Interview on [DATE] at 3:22 PM with LPN-C confirmed that the insulin pen needle is to be left in the skin for 6-10 seconds during administration. LPN-C confirmed that LPN-C did not keep the needle in the skin for the required 6-10 seconds during insulin administration to Resident 53. LPN-C confirmed that LPN-C did not provide nourishment to Resident 53 within 15 minutes after insulin administration. Interview on [DATE] at 12:39 PM with the facility Director of Nursing (DON) confirmed that the insulin pen needle is required to be left in the skin for 6-10 seconds during administration to ensure proper administration of the ordered insulin dose. The DON confirmed that Humalog insulin is a fast acting insulin and nurses are required to ensure that the resident receives nourishment within 15 minutes after administration of the insulin.

Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 1-005.06(F)Based on observation, record review, and interview the facility failed to ensure that staff disinfected medication administration equipment as required for 1 of 2 residents observed (Resident 28); and the facility failed to ensure that hand hygiene was performed between glove changes during wound care for 1 resident (Resident 6) to prevent the potential for cross contamination. The facility census was 45.Findings are: A. Record review of the facility policy titled Insulin Pen dated 2024 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of dosing. A new needle will be used for each injection. Always review physician orders prior to administering any medication. The procedure revealed that staff will gather supplies needed: correctly labeled insulin pen, alcohol preps, and sterile insulin pen needle. Perform hand hygiene. Put on gloves. Verify resident identification. Check the expiration date on the pen and discard if expired. Remove the pen cap from the insulin pen. Wipe the rubber seal with an alcohol pad. Screw the pen needle onto the insulin pen. Record review of the Instructions for Use Humalog KwikPen (an insulin pen containing rapid-acting prescription insulin used to treat high blood sugar for residents with diabetes) dated 7/2023 section titled Preparing your Pen revealed the instruction to pull the pen cap straight off. Wipe the rubber seal with an alcohol swab. Select a new needle and push the capped needle straight onto the pen and twist the needle until it is tight. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 28 dated [DATE] revealed that Resident 28 admitted into the facility on [DATE]. Resident 28 had an active diagnosis of diabetes. Resident 28 received insulin injections on all 7 days of the assessment lookback period. Observation on [DATE] at 11:12 AM at the room of Resident 28 revealed that Licensed Practical Nurse-B (LPN-B) entered the resident room and performed hand sanitization. LPN-B placed a paper towel on the over bed table and organized supplies to check the resident's blood sugar. LPN-B wiped the pad of the left middle finger of Resident 28 with an alcohol prep pad. LPN-B punctured the pad of Resident 28's left middle finger with the lancet (a small sterile blade used to obtain a small amount of blood for testing) and wiped the first drop of blood off with a cotton ball. LPN-B applied a drop of blood to the glucometer test strip and announced the blood sugar result of 242. LPN-B disposed of the lancet and test strip. LPN-B stored the glucometer and removed the gloves. LPN-B performed hand washing for a total of 9 seconds. LPN-B went to the medication cart located across from the front desk and reviewed the insulin orders for Resident 28. LPN-B revealed that Resident 28 has the routine order for 10 units of Humalog insulin (a rapid-acting prescription insulin used to treat high blood sugar for residents with diabetes) and also for Humalog insulin sliding scale (an insulin order that varies the dose of insulin based on the blood sugar level. The higher your blood sugar level the more insulin you take). LPN-B confirmed that Resident 28 is to receive 14 units of Humalog insulin for the blood sugar result of 242. LPN-B revealed that a total of 24 units of Humalog insulin is ordered to be given to Resident 28. LPN-B removed the Humalog insulin pen from the drawer of the medication cart. The Humalog insulin pen label had an open date of [DATE]. LPN-B removed the cap from the insulin pen and applied a needle to the pen. (LPN-B did not wipe the rubber seal on the top of the insulin pen with an alcohol prep pad to disinfect it as required prior to putting the needle on the pen). LPN-B dialed the dose selector on the insulin pen to 24 units. (LPN-B did not dial the selector to 2 units and prime the needle prior to selecting the ordered dose of insulin as required). LPN-B took the pen into the room of Resident 28. LPN-B asked Resident 28 what area they would like the insulin injected in. Resident 28 wanted to use their left upper arm. LPN-B wiped an area on the left upper arm of Resident 28 with an alcohol prep pad. LPN-B injected the Humalog insulin into the upper left arm of Resident 28 and immediately removed the needle from the skin. Record review of the medication administration record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 28 dated [DATE] revealed the order for Humalog Insulin 10 units once a day. The administration of the 10 units of insulin on [DATE] was documented by LPN-B. The MAR revealed the order for the sliding scale Humalog Insulin for a blood sugar between 201 and 250 was to give 14 units. The administration of the 14 units of insulin on [DATE] was documented by LPN-B. Interview on [DATE] at 12:06 PM with LPN-B confirmed that LPN-B did not wipe the top of the insulin pen to disinfect it prior to applying the needle. Interview on [DATE] at 12:39 PM with the facility Director of Nursing (DON) confirmed that staff are expected to disinfect the top of the insulin pen before putting on the needle. B. Record review of a facility policy titled Hand Hygiene and dated 2021 revealed the use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Record review of a facility policy titled Clean Dressing Change and dated 2023 revealed 10. Remove gloves and discard into appropriate receptacle. 11. Perform hand hygiene and put on clean gloves 14. perform hand hygiene and put on clean gloves 17. discard disposable items and gloves into appropriate trash receptacle and perform hand hygiene. In an interview completed on [DATE] at 1:35 PM with Resident 6, Resident 6 stated that they had a soar on their bottom and nursing staff provided treatment to the area daily. Record review of a Resident Face Sheet revealed the facility admitted Resident 6 on [DATE] with diagnosis right stage 2 pressure ulcer (a partial thickness skin loss appearing as a shallow pink or red moist open ulcer or rupture blister that is often painful), of the right buttock and stage 1 pressure ulcer (an early stage localized injury to intact skin that presents as redness that does not turn white when pressed) of the left buttock. Record review of Resident 6's Physician Orders revealed the resident had order stating mepilex dressing on buttocks with directions to change daily and apply barrier cream before the dressing. In an observation completed on [DATE] at 9:30 AM of wound care being provided to Resident 6 by Licensed Practical Nurse C (LPN-C) the following was observed. With gloved hands the LPN removed the old dressing covering the resident's buttock. The LPN then removed their gloves from both of their hands and placed new gloves onto their hands without performing hand hygiene. With gloved hands the LPN used normal saline and a piece of folded gauze to clean the residents wound. The LPN removed their gloves from both of their hands and placed new gloves onto their hands without performing hand hygiene. The LPN then squeezed out a cherry sized amount of a white cream from a tube onto their finder and using the gloved finger applied the cream to the wound on the resident's buttock. The LPN removed their gloves from both of their hands and placed new gloves onto their hands without performing hand hygiene. The LPN then removed the backing from a bordered foam dressing and placed the dressing over the cream covered wound on the resident's buttock. The LPN removed their gloves from both of their hands and placed new gloves onto their hands without performing hand hygiene. The LPN then assisted the residents to pull up their pants and sit back in their chair. The LPN then removed their gloves an went into the resident's bathroom and completed hand hygiene using soap and water. In an interview completed on [DATE] with LPN-C, LPN-C confirmed that hand hygiene should be performed between each glove change and they did not do this. In an interview completed on [DATE] at 12:30 PM with the facility Director of Nursing (DON), the DON confirmed that hand hygiene should be performed between each glove change and LPN-C did not do this.

Licensure Reference Number 175 NAC 12-006.09 (H)(iii)(1) and (2)Based on observation, record review, and interview the facility failed to assess and monitor pressure related skin issues to ensure documentation of wound healing or decline for 2 residents (Resident 1 and Resident 6) of 2 sampled residents, failed to ensure the settings for a specialty low air loss mattress were at the correct setting to promote healing of a pressure related wound for 1 resident (Resident 6) of 2 sampled residents and failed to cleanse pressure related wounds per professional standards of practice to promote healing for 1 resident (Resident 6) of 2 sampled residents. The facility census was 45.Findings are:Record review of a document titled Pressure Injury Prevention Guidelines dated 2018 revealed to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries it is the policy of this facility to implement evidence-based interventions for all residents assessed at risk or who have pressure injury present. The Assistant Director of Nursing or designee will review all relevant documentation regarding skin assessments, pressure injury risks, and progression towards healing at least weekly and document a summary of findings in the medical record.Record review of a document titled Best Practices for Wound Assessment and Documentation and dated 04/17/2025 from the Wound Care Education Institute (wcei.net/best-practices-wound-assessment-documentation) revealed wound assessment and documentation serve as crucial clinical tools for effective care planning, etiology, measurements, and wound characteristics to guide treatment. High-quality documentation fosters interprofessional communication and aids in tracking healing progress while aligning with care standards.Record review of a document titled What is standard of care in wound care and dated 05/31/2022 from Wound Source (https://www.woundsource.com/blog/what-standard-care-in-wound-care) revealed to detect signs of healing progress wounds are assessed on a weekly basis and documentation of a wound assessment is a vital component of the standard of wound care and contributes to improved patient safety, outcomes, and care quality.A.Record review of a Resident Face Sheet revealed the facility admitted Resident 1 on 12/22/2025 with diagnosis pneumonia (a serious lung infection), and pulmonary hypertension (high blood pressure in the lung arteries). Record review of the comprehensive 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 12/26/2025 for Resident 1 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11 indicating the resident was cognitively intact. The MDS was coded to reflect the resident required partial to moderate assistance with eating, and substantial or maximal assistance with bed mobility, transfers, and toilet use. The resident was frequently incontinent of bowel and bladder. The resident was at risk for pressure related skin alterations and had a pressure-reducing device for their chair and bed.In an interview completed on 02/04/2026 at 10:20 AM with Resident 1, Resident 1 stated that during their stay in the facility the developed a sore on their bottom and to both of their heels.Record review of Resident 1's Progress Notes revealed the following documentation:-12/22/2025 an admission note with documentation that the resident's buttock was slightly pink.-01/05/2026 documentation stating the resident returned from provider appointment with orders to apply zinc oxide (a protective barrier cream) twice daily and as needed to the buttocks.-01/07/2026 documentation stating the resident was noted to have skin breakdown to the coccyx and right buttock. There was no documentation present of measurements or description of the skin breakdown.-01/11/2026 documentation that the resident complained to the nurse that their feet were on fire and hurt and subsequent documentation that the resident frequently requested Tylenol due to the pain. There was no documentation present that the nurse assessed or observed the residents' feet.-01/12/2026 the residents responsible party was notified of the residents' complaints of pain and that nursing staff were applying the barrier cream to a moisture related skin concern to the residents' bottom. An area measuring 6.5 centimeters X 4.5 centimeters described as moisture damage to the right buttock was documented. There was no documentation present of further assessment or description of the moisture damage to the skin.-01/14/2026 the resident called their provider and requested a cream for their buttock. The providers nurse phoned the facility and was updated on the moisture related area to the residents buttock and the barrier cream that was being applied. Orders were received for the resident to be seen by the wound clinic.-01/20/2026 the resident was seen by wound clinic and received a diagnosis of stage 3 pressure related skin injury (which is a full thickness wound extending into the fat tissue appearing as a deep crater). Orders were received for treatment of the area and for residents to be on bed rest with ok to be up for one hour for meal and therapy.-01/23/2026 the Assistant Director of Nursing (ADON) was notified of skin concerns to the residents' heels. It was documented that the resident had a stage 1 pressure injury to the left heel and a deep tissue injury to the right heel. It was documented to see wound management for further details and that the provider was notified and orders for no sting barrier to be applied to the areas twice daily and zero g heel lift boots to be applied to both feet while at rest along with the air exchange mattress. Resident was also to be seen by wound care on 02/04/2026.-01/29/2026 documentation that wound data collection was completed and due to the changes in appearance in the wound to the left heel the provider was notified. No new orders were received.-02/04/2026 the resident was seen and evaluated by wound clinic. New treatment orders were received for the residents' heels and buttock.Record review of a Wound Management Detail Report for resident revealed documentation of a complete assessment of the residents right sacral/buttock wound on 01/23/2026, 01/29/2026, and 02/04/2026. Documentation was present of complete wound assessments for Resident 1's pressure related wounds to their heels on 01/23/2026, 01/29/2026, and 02/04/2026. In an interview completed on 02/09/2026 at 09:52 AM with Licensed Practical Nurse C (LPN-C), LPN-C stated that Resident 1 received wound care at the local wound clinic. The LPN stated that facility staff changed dressings daily. The LPN denied measuring the wounds with dressing changes or documenting wound assessments for the residents' wounds. In an interview completed on 02/09/2026 at 10:00 AM with LPN-B, LPN-B states that the ADON completed weekly wound measurements and assessments. The LPN stated that when an area of skin alteration if first found or observed it should be measured assessed and the ADON who does the wound care is notified. The LPN confirmed that this should be entered as a progress note in the resident's health record.In an interview on 01/09/2026 at 10:48 AM with the facility ADON, the ADON stated routine wound assessment documentation is only completed on pressure-related skin concerns. The ADON stated that there was no routine documentation present for Resident 1's wound to the sacrum/buttock due to it being deemed a moisture related skin concern until seen by the wound clinic on 01/20/2026 when the wound clinic identified the area as a pressure related skin concern.In an interview completed on 01/09/2026 at 12:30 PM with the facility Director of Nursing (DON), the DON confirmed that there were no routine documentation or measurements or assessments for Resident 1's wounds prior to 01/20/2026. The DON confirmed there was no weekly summary of findings from skin assessments made by the ADON in Resident 1's medical record as outlined in the facility policy prior to 01/20/2026. B.Record review of a Resident Face Sheet revealed the facility admitted Resident 6 on 11/11/2025 with diagnosis right stage 2 pressure ulcer (a partial thickness skin loss appearing as a shallow pink or red moist open ulcer or rupture blister that is often painful), of the right buttock and stage 1 pressure ulcer (an early stage localized injury to intact skin that presents as redness that does not turn white when pressed) of the left buttock. Record review of the comprehensive 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 11/17/2025 for Resident 1 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14 indicating the resident was cognitively intact. The MDS was coded to reflect the resident required substantial or maximal assistance with transfers, toilet use, and bed mobility, and was dependent on staff assistance with eating. The resident had an indwelling foley catheter (a tube inserted into the bladder to drain the bladder of urine) and continent of bowel. Under the skin conditions portion of the MDS the resident was identified to be at risk and to have unhealed stage 1 and stage 2 pressure injuries. The resident had pressure reducing device to their chair and bed and was receiving pressure injury care and application of non-surgical dressings.Record review of Resident 6's Care Plan on 02/04/2026 revealed a problem of the resident had impaired skin integrity due to impaired mobility and had a pressure sore present on admission dated 11/12/2025. A goal was listed of the ulcers would heal without complications by the next care plan review dated 02/26/2026. Interventions listed were nursing to assess and record the condition of the residents skin surrounding the pressure ulcer weekly, to follow the sound care orders for treatments, to reposition the resident and off load every 2-3 hours, and a RoHo (pressure relieving cushion) to the residents wheel chair and recliner and a low air loss mattress to the residents bed all dated 11/12/2025. In an interview completed on 02/04/2026 at 1:35 PM with Resident 6, Resident 6 stated that they had a soar on their bottom and nursing staff provided treatment to the area daily.Record review of a facility supplied document titled admission Skin Assessment dated 11/11/2025 revealed documentation of a stage 2 pressure injury to the right buttock with measurements of 2.5 centimeters by 1.5 centimeters and a stage 1 pressure injury to the left buttock with measurements of 0.5 centimeters by 0.5 centimeters. Record review of facility supplied document titled Wound Management Detail Report revealed documentation of complete wound assessment of the residents right and left buttock dated 12/02/2025 and 12/16/2025. Record review or Resident 6's Progress Notes revealed the following documentation:-11/11/2025 the resident admitted to the facility with a stage 2 pressure ulcer and a stage 1 pressure ulcer to their right and left buttock.-11/17/2025 the resident was seen by wound care provider and received order for sitting position for only one hour to eat.-11/24/2025 the resident was seen by wound care provider and received order to continue with strict bed rest except for meals and must lie on sides when in bed.-12/08/2025 the resident was seen by wound care provider and received order for ok to take shower, may resume physical and occupational therapy, and ok to take the resident off bed rest and continue with treatment.-12/22/2025 The resident was seen by wound care provider with no new orders.-01/02/2026 the residents dressing was changed the wound was documented to be intact and dry with blanchable redness present. There were no measurements present in the documentation.-01/21/2026 the residents dressing was changed and the documentation stated that during the dressing change the prior day the resident's sacral area was noted to be intact. During the change of dressing this shift the residents were identified to have open areas to the left side of their buttock measuring 1.5 centimeters by 2 centimeters, and to the right side of their buttock measuring 2.5 centimeters by 2 centimeters. The residents wound care provider was notified of this with an appointment scheduled for 01/26/2026.-01/26/2026 the resident was seen by wound care provider with orders to continue with the dressing and barrier cream and to avoid scooting to stand and off loading of the pressure injury.Record review of a facility supplied document titled Clinic Visit Sheet dated 01/05/2026 revealed documentation that the residents pressure injuries had healed and to continue preventive measures.In an interview completed on 02/09/2026 at 10:00 AM with LPN-B, LPN-B states that the ADON completed weekly wound measurements and assessments. The LPN stated that when an area of skin alteration if first found or observed it should be measured assessed and the ADON who does the wound care is notified. The LPN confirmed that this should be entered as a progress note in the resident's health record.In an interview on 01/09/2026 at 10:48 AM with the facility ADON, the ADON confirmed that Resident 6 was admitted to the facility with pressure related skin injuries. The ADON stated that there was no routine documentation present for Resident 6's pressure related injury by facility staff from 11/11/2025 through 12/02/2025 as outlined in the facility policy. The ADON confirmed that the residents pressure injuries had resolved and then reopened. In an interview completed on 01/09/2026 at 12:30 PM with the facility Director of Nursing (DON), the DON confirmed that there were no routine documentation or measurements or assessments for Resident 6's wounds prior to 12/02/2026. The DON confirmed there was no weekly summary of findings from skin assessments made by the ADON in Resident 6's medical record as outlined in the facility policy prior to 12/02/2025. C.Record review of a document titled Alternating pressure and low air loss mattress operators Manual dated 03/15/2016 revealed the pressure of the mattress is adjusted by choosing the patients corresponding weight setting using the weight setting dial.Record review of a Resident Face Sheet revealed the facility admitted Resident 6 on 11/11/2025 with diagnosis right stage 2 pressure ulcer (a partial thickness skin loss appearing as a shallow pink or red moist open ulcer or rupture blister that is often painful), of the right buttock and stage 1 pressure ulcer (an early stage localized injury to intact skin that presents as redness that does not turn white when pressed) of the left buttock. Record review of the comprehensive 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 11/17/2025 for Resident 1 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14 indicating the resident was cognitively intact. The MDS was coded to reflect the resident required substantial or maximal assistance with transfers, toilet use, and bed mobility, and was dependent on staff assistance with eating. The resident had an indwelling foley catheter (a tube inserted into the bladder to drain the bladder of urine) and continent of bowel. Under the skin conditions portion of the MDS the resident was identified to be at risk and to have unhealed stage 1 and stage 2 pressure injuries. The resident had pressure reducing device to their chair and bed and was receiving pressure injury care and application of non-surgical dressings.Record review of Resident 6's Care Plan on 02/04/2026 revealed a problem of the resident had impaired skin integrity due to impaired mobility and had a pressure sore present on admission dated 11/12/2025. A goal was listed of the ulcers would heal without complications by the next care plan review dated 02/26/2026. Interventions listed were nursing to assess and record the condition of the residents skin surrounding the pressure ulcer weekly, to follow the sound care orders for treatments, to reposition the resident and off load every 2-3 hours, and a RoHo (pressure relieving cushion) to the residents wheel chair and recliner and a low air loss mattress to the residents bed all dated 11/12/2025. In an observation completed on 02/04/2026 at 1:35 PM Resident 6 was observed to be lying in their bed with the head of the bed elevated greater then 45 degrees in a supine (flat on back) position. The control box of the resident's low air loss mattress was observed to be sitting on the floor at the foot of the resident's bed. The pressure adjustment knob was observed to be in the firm position.In an observation completed on 02/05/2026 at 8:32 AM Resident 6 low air loss mattress control box was observed to be sitting on the floor at the foot of the resident's bed. The pressure adjustment knob was observed to be in the firm position.In an observation completed on 02/09/2026 at 9:45 AM Resident 6 low air loss mattress control box was observed to be sitting on the floor at the foot of the resident's bed. The pressure adjustment knob was observed to be in the firm position.In an interview completed on 02/09/2026 at 9:50 AM with Licensed Practical Nurse C (LPN-C) LPN-C stated that the air exchange mattresses are set per the resident's weight. The LPN stated they are not sure who monitors the control boxes to ensure that the setting is correct for the resident.In an interview completed on 02/09/2026 at 10:00 AM with the Maintenance Supervisor (MS), the MS stated that when a resident needs a low air loss mattress, they are notified by nursing staff. The MS stated that they install the mattress and adjust the settings as directed by the nursing staff or ADON. The MS was not aware of who monitored the control box ensuring the setting remained at the correct setting for the resident.In an interview completed on 02/09/2026 at 10:10 AM with the facility ADON, the ADON confirmed that the low loss air exchange mattresses are set by the resident's weight. In an observation completed on 02/09/2026 at 10:02 AM of Resident 6's control box of their low air loss mattress control box set in the firm position the ADON confirmed that this was not the correct setting for the resident. The ADON confirmed that there was not a procedure in place in the facility to ensure that the settings on the control boxes of the low air loss mattress remained at the correct setting for the resident. D.Record review of a facility policy titled Clean Dressing Change and dated 2023 revealed to cleanse the wound as ordered taking care not to contaminate other skin surfaces or other surfaced of the wound i.e. clean outward from the center of the wound.In an observation completed on 02/09/2026 at 9:30 of wound care being provided to Resident 6 by LPN-C the following was observed. LPN-C opened a small pink disposable plastic vial containing normal saline and a white and blue package containing a 4X4 white piece of gauze. With the resident in a standing position the LPN held the folded piece of gauze at the bottom of the cleft of the resident's buttock. The LPN used their other hand to squeeze the vial of normal saline onto the wounds covering the right and left sides of the resident's buttock and cleft allowing the fluid to drip/flow onto the piece of gauze. The LPN then folded the gauze in half and used the gauze to pat the residents wound multiple times. The LPN then folded the piece of gauze again in half and used it to continue to dab at the residents wound multiple times.In an interview completed on 02/09/2026 with LPN-C, LPN-C confirmed that the wound should have been cleansed using a circular motion from inside working to the outside of the wound and did not cleanse the wound in this manner.In an interview completed on 01/09/2026 at 12:30 PM with the facility Director of Nursing (DON), the DON confirmed that wounds should be cleansed in a circular motion working from inside to the outside of the wound and the LPN did not cleanse the wound correctly.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the 5 rights of medicaiton administration for 4 residents, (Resident 14, 199, 26, and 34) of 8 sampled residents. This made an error rate of 16.13 %. The facility census was 49. A. Record review of Resident 14's Physician Orders dated 12/16/24 revealed Resident 14 had a physician order to apply Diclofenac Sodium which is a topical pain relief or analgesic cream. Directions to apply 2 grams to both resident's knees and lower back three times a day. In an observation on 12/17/24 at 11:30 AM with Registered Nurse-B(RN-B) revealed RN-B with a gloved hand used their fingers to scrape a clear thick gel like substance from a clear medication cup that was sitting on Resident 14's bed side table. RN-B stated to the resident this was their pain cream and would apply it to the resident's knees. Resident 14 pulled up the pant legs of their pants above both knees and RN-B applied the ointment to the left knee and rubbed it in then obtained more of the gel from the medication cup and applied it to the right knee and rubbed it in. In an interview on 11/17/24 at 11:45 AM with RN-B, revealed that the clear medication cup contained the residents ordered Diclofenac Sodium. RN-B confirmed they did not use the measuring guide to ensure was applying the prescribed 2 grams of the Diclofenac Sodium. RN-B further confirmed that they did not follow the physician prescribed orders for the Diclofenac Sodium. B. Review of a document labeled National Library of Medicine Stat Pearls dated August 28, 2023, revealed that Levothyroxine tablets and capsules should be taken on and empty stomach at least thirty to sixty minutes prior to breakfast with a full glass of water. In an observation completed on 12/16/27 at 8:50 AM with Licensed Practical Nurse A (LPN-A) revealed LPN-A obtained a cardboard bubble pack of medications labeled Levothyroxine tablet 75 micrograms (MCG), give on tablet by mouth one time a day with Resident 199's name. LPN-A popped the tablet into a clear plastic medication cup with Resident 199's other medications and walked to where Resident 199 was sitting in the dinning area at a table. On the table in front of Resident 199 was a white plate with crumbs on it, a white bowl with visible crumbs in it, and 3 glasses of different fluids all missing different amounts of fluid. The nurse handed Resident 199 the cup containing the medications, the resident lifted the cup to their mouth and ingested the medications. The nurse thanked the resident and asked if the resident wanted more to eat or if had enough to eat already. The resident stated that they had eaten all their breakfast and would finish their drinks and was full. The nurse returned to the medication cart and documented the administration of the medications in the resident's electronic medical health record. In an interview on 12/16/24 at 9:05 AM with LPN-A confirmed that the levothyroxine medication should be taken on an empty stomach prior to eating a meal. The LPN stated they did not know if the provider had given permission for the levothyroxine to be administered in an alternative manner. In an interview on 12/16/24 at 2:45 PM with the Director of Nursing (DON) confirmed that the levothyroxine medication is normally given on an empty stomach. The DON was not sure if the provider had ok'd the administration of the medication outside of recommended standards and the medication should be taken per these standards unless otherwise directed by the provider. The DON confirmed this was a medication error. 50253 C. Record review of the medication insert for Diclofenac gel (Voltaren, a nonsteroidal, anti-inflammatory medication for pain) revised July 2009 revealed the following. -Total dose should not exceed 32 grams per day, overall affected joints. -Voltaren Gel should be measured onto the enclosed dosing card to the appropriate 2 grams or 4 grams designation. -Lower extremities: Apply the gel (4 grams) to the affected area 4 times daily. Do not apply more than 16 grams daily to any one affected joint of the lower extremities. -Upper extremities: Apply the gel (2 grams) to the affected area 4 times daily. Do not apply more than 8 grams daily to any one affected joint of the upper extremities. Record review of the Care Plan (a detailed document outlining the specific healthcare needs and services a person requires to manage their chronic illness or disability) for Resident 26 revealed this resident has an alteration in comfort related to the diagnoses of musculoskeletal decline, impaired mobility, and osteoarthritis with signs and symptoms of pain. Medications were to be administered as ordered and Resident 26 had to be encouraged to request pain medications before the pain became unbearable. Record review of the Physician Orders for Resident 26 revealed an order for the use of Diclofenac Sodium gel a small amount to the left shoulder and arm with a start date of 12/09/24. Interview on 12/16/2024 at 1:15 PM with Licensed Practical Nurse (LPN-A) revealed when asked how much is used on the resident's shoulder for pain relief, LPN-A chose to look at the physician orders and stated immediately, Oh, I think we need to contact the physician to find out how much we are supposed to actually use. LPN-A revealed that there was a plastic measuring tool to measure the desired grams of medication applied each time which LPN-A had difficulty finding in the drawer. Once found, LPN-A revealed the use of approximately one inch of gel when applying onto the shoulder of Resident 26. LPN-A repeated that the order needed to be updated to let the nursing staff know exactly how much Diclofenac gel was supposed to be applied. Interview on 12/16/24 at 1:25 PM with the DON when asked how much Diclofenac gel is applied to Resident 26's shoulder, DON replied I guess enough to cover the area. DON confirmed the medication order needed to be more detailed and would reach out to the ordering physician and get confirmation of the dose. D. Record Review of the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes, allowing healthcare providers to create individualized care plans based on their specific needs) dated 10/17/24 for Resident 34 revealed this resident had chronic pain. Record review of the Care Plan for Resident 34 revealed this resident had an alteration in self-care and comfort related to musculoskeletal decline caused by impaired mobility, history of bursitis in the left hip, pain, weakness and deconditioning, would attempt non-pharmacological interventions for pain, and was encouraged to request pain medication before pain became unbearable. Record review of Resident 34's Physician Orders dated 12/16/24 revealed an order for Voltaren Arthritis Pain (Diclofenac Sodium) gel 1% a small amount. Apply to both wrists. May apply to lower back as needed. Interview on 12/16/2024 at 1:25 PM with the DON confirmed the medication order needed to be more detailed and would reach out to the ordering physician and get confirmation of the dose.

Licensure Reference Number 12-006.09(H)(iii) Based on record reviews, interviews, and observations, the facility failed to ensure interventions for constipation were put into place to promote bowel movements for 2 (Residents 6, and Resident 12) of 5 sampled residents, and the facility failed to provide wound care that prevented cross contamination for 1 (Resident 14) of 1 sampled residents. The facility census was 49. Findings are: A. Record review of the undated Bowel Movement Assessment/Monitoring policy and protocol stated the purpose is to monitor bowel regularity while taking into consideration any knowledge of bowel habit history on an individual basis. The procedure included reviewing bowel and bladder records nightly and making a note as to those who had not had a Bowel Movement (BM) for 2 days. This is forwarded to the day shift nurses who would then assess for needs of a laxative. If there had been no BM by the following morning, the day shift nurse was to assess for further laxative needs. Further laxatives may be administered. Record review of the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes to create individualized care plans based on their specific needs) dated 11/24/2024 for Resident 6 revealed the resident had a BIMS (Brief Interview for Mental Status -used to assess a person's cognitive function by evaluating their orientation and short-term memory) score of 10 which indicated moderate cognitive impairment. Resident 6 had diagnoses of cancer, hypertension, anemia, heart failure, and diabetes. Record review of the Care Plan (a detailed document outlining the specific healthcare needs and services a person requires to manage their chronic illness or disability) dated 12/4/2024 for Resident 6 revealed this resident was independent with a 4 wheeled walker in the resident room and in the facility. Resident 6 was continent of bowel. Record review of the Bowel Movement output charting found that Resident 6 did not have a bowel movement during the period of 11/20/2024 and 12/16/2024. Record review of the Medication Administration Record for Resident 6 during the time period of November 17, 2024 through December 17, 2024 revealed that Resident 6 was administered Miralax (a medication for bowel regularity) on a daily basis and received Milk of Magnesia (a medication for the relief of constipation) on 11/17/2024 and 11/18/2024. Laxatives had not been administered on 11/31/2024, 12/3/2024, 12/4/2024, or 12/5/2024. Interview on 12/17/2024 at 10:30 AM with Registered Nurse (RN-B) revealed that the nurses are given a sheet every morning at report. On this sheet we (we?- is this supposed to be a quote? ) see who hasn't had a bowel movement and who may need to have Milk of Magnesia or a suppository. If the resident is more than 4 days without a bowel movement, the physician may be called for further orders. Interview on 12/17/2024 at 11:00 AM with the Director of Nursing confirmed that the bowel program for constipation had not been followed by the nursing staff for Resident 6. 49382 B. A review of a Resident Face Sheet dated 12/16/2024 revealed that the facility admitted Resident 12 on 08/26/2024 with diagnoses of lung cancer (which is development of a cancerous lesion in the lung), and constipation ( which is the difficulty or inability to have frequent bowel movements). The comprehensive MDS dated [DATE] revealed Resident 12 had a BIMS score of 10 indicating the resident was moderately cognitively impaired. The resident was coded to be dependent on staff assistance with toilet use and transfers and the resident was always continent of bowel. Constipation being present was not coded on the MDS. Review of Resident 12's Care Plan revealed a problem of the resident requiring assistance by staff with activities of daily living including transfers and toilet use dated 08/26/24. Review of Resident 12's electronic medical health record revealed the following: -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 10/10/2024, 10/11/2024, 10/12/2024, and 10/13/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 10/26/2024, 10/27/2024, and 10/28/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 11/04/2024, 11/05/2024, and 11/06/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 11/25/2024, 11/26/2024, 11/27/2024, and 11/28/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 12/01/2024, 12/02/2024, and 12/03/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 12/05/2024, 12/06/2024, and 12/07/2024. In an interview conducted on 12/06/2024 at 3:57 PM with Licensed Practical Nurse A (LPN-A) revealed that the night shift nurse gives a list of residents that have not had a bowel movement in 48 hours or more to the day shift nurse. The day shift nurse then provides an as needed intervention to help promote a bowel movement for the resident. If that intervention is unsuccessful by 6 AM the following morning a bowel assessment is completed including listening for bowel sounds at the abdomen and a suppository is given to promote a bowel movement. LPN-A further revealed that if the resident had still not had a bowel movement by the next morning the nurse would notify the provider and director of nursing for further interventions. In an interview conducted on 12/17/2024 at 10:08 AM with the facility DON confirmed that Resident 12 had gone periods of time as listed greater than 48 hours without a documented bowel movement, intervention to promote a bowel movement, or an assessment of the resident due to not having a bowel movement. The DON confirmed it is the facility policy to provide interventions and or assessment to the resident after 48 hours of not having a bowel movement and for these to be documented in the resident's electronic medical health record. D. Review of a facility supplied policy titled Clean Dressing Change and dated 2023 revealed to cleanse the wound outward from the center of the wound. Review of a document titled Collagenase Santyl Ointment, How to Apply dated 2024 revealed to apply Santyl Ointment directly to the wound in a 2 mm (millimeter) or about the thickness of a nickel layer. A review of a Resident Face Sheet dated 12/16/2024 revealed that the facility admitted Resident 14 on 09/27/23 with diagnoses of atherosclerotic heart disease (which is when fats, cholesterol, and other substance build up on the walls of arteries), varicose veins of the lower extremity (when the veins in the legs are bulging and enlarged), and hypertension (which is high blood pressure). The comprehensive MDS dated [DATE] revealed Resident 14 had a BIMS score of 10 indicating the resident was moderately cognitively impaired. The resident was coded to have 4 venous or arterial ulcers present (which are ulcers or wounds that are caused by irregularities in blood flow and circulation). Review of Resident 14's Physician Orders dated 12/16/24 revealed an order to apply Santyl to wound on the LLE, place a non-bordered foam over top of wound and cover with edema wear once daily. In an observation completed on 12/17/24 at 10:43 AM with Registered Nurse B (RN-B) revealed RN-B with gloved hands opened a vial of normal saline solution and squirted the solution on to the wounds located to Resident 14 left inner lower calf. RN-B held white gauze material to the lower portion of the wound. It was observed that the normal saline solution flowed off the wound and onto the pieces of gauze. RN-B then used the pieced of gauze to dab at the wound bed directly. The RN obtained more gauze pieces and again dabbed directly on the wound bed with the pieces of gauze. The RN then threw away the gauze and discarded their gloves. RN-B performed hand sanitization using an alcohol-based hand gel and applied another pair of gloves. RN-B obtained a clear medicine cup and a long-handled Q-Tip from on top of the over bed table. RN-B placed the cotton portion of the Q-Tip into the medicine cup and rolled the Q-Tip in the light cream-colored thick substance contained in the cup. RN-B applied the substance to the residents wound bed using the Q-Tip. There was no visible thickness to the layer of substance applied to the wound bed from the clear plastic medicine cup. In an interview conducted with RN-B on 12/17/24 at 11:20 AM, RN-B confirmed that the clear medicine cup contained Santyl Ointment. RN-B confirmed that they did not ensure the ointment was applied in a layer with thickness approximately of a nickel. RN-B also confirmed that they did not cleanse the wound from the inside working to the edges or outside of the wound. In an interview conducted on 12/17/2024 at 11:50 PM with the DON confirmed that the residents wound should have been cleansed from the inside and working to the outer edges. Confirmed the nurse should have checked to ensure they are applying the correct amount of ointment to the wound and should not have used the soiled gauze pads to dab at the wound after spraying the normal saline on the wound bed. The DON confirmed wound care, and topical application was not completed in compliance with facility policy.

Licensure Reference Number 175 NAC 12-006.19 Based on observation and interview, the facility failed to ensure a clean and sanitary environment in resident's bathrooms for 5 (rooms 9, 11, 16, 18, and 23 ) of 12 sampled rooms and failed to ensure hand sanitizer dispenser was working for 1 (Resident 23) of 49 sampled residents with a facility census of 49. Findings are: In an observation completed on 12/18/2024 at 8:05 AM the following was noted: -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that the resident would use to activate the call light was yellow brown from the middle of the cord to the end of the cord. On the faucet of the sink beneath the hot and cold-water knobs there is a buildup of porous white material that has both green and black areas on top of the white material. There is yellow white flaky build up material to the bottom portion of the faucet where it is connected to the sink. -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that resident would use to activate the call light was yellow brown in color to approximately 2 inches of the cord. The light located above the sink in the bathroom had 2 light bulbs in it only one light bulb was on and functioning. On the faucet of the sink beneath the hot water knob there is a white porous buildup with green areas on top of the buildup visible. -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that resident would use to activate the call light is dark yellow in color approximately 1 inch of the cord towards the top of the cord. -In the bathroom of room [ROOM NUMBER] the call light box is secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that resident would use to activate the call light is brown fading to yellow in color for more than 1/2 of the cord in its entirety. On the faucet of the sink beneath the hot and cold-water knobs there is a buildup of porous white material that has green areas on top of the white material. -Just inside the doorway to room [ROOM NUMBER] on the right side is a hand sanitizer dispenser attached to the wall. It was observed that on 12/16/2024, 12/17/2024 and 12/18/2024 to be not functioning. When hand is placed where indicated for product to be dispensed no product is dispensed. In the bathroom the call light box was secured to the wall to the left of the toilet. The porous cord hanging from the call light that the resident would use to activate the call light is yellow brown in color in an approximate 1-inch section towards the bottom of the cord. On the faucet of the sink beneath the hot and cold-water knobs and to the right side of the faucet opening is a white porous buildup of material. On top of this build up beneath the hot water know is green in color also. In an interview completed on 12/18/2024 at 8:30 AM with the Maintenance Supervisor, Housekeeping Supervisor, and Facility Administrator it was confirmed that the call light cords in bathrooms of rooms 9, 11, 16, 18, and 23 were discolored, that the faucets in the bathrooms of rooms 9, 11, 18, and 23 had build up on them and the buildup was a non-cleanable surface, and room [ROOM NUMBER] bathroom light bulb was out and room [ROOM NUMBER] hand sanitizer was not working.

Based on record reviews and interviews, the facility failed to ensure that resident assessments were coded incorrectly for hypoglycemic and antiplatelet on the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes to create individualized care plans based on their specific needs) . This affected 2 residents (Residents 6 and 12) of 3 sampled residents. The facility census was 49. Findings are: A. Record review of the Physician Orders reviewed on 12/16/2024 for Resident 6 revealed an order for Humalog insulin subcutaneous three times daily before meals and once at bedtime given on a sliding scale based on Resident 6's blood sugar. The physician orders also revealed an order for Levemir 12 units subcutaneous at bedtime. Record review of the MDS dated [DATE] for Resident 6 revealed the resident had a diagnosis of diabetes. Section N (Medications) subsection N0300 this resident received injections 7 days a week and in subsection N0350 that this resident received insulin injections 7 days a week. In subsection N0415 the use of hypoglycemic was not checked and indication was not noted. This information is required to provide resident specific information for payment and quality measure purposes. Interview on 12/17/2024 at 11:45 AM with the Minimum Data Set Coordinator (MDS) revealed this information is reviewed quarterly for each resident and then the resident care plan is updated. There is a specific look back period of time to review medications when creating the MDS. Interview on 12/17/2024 at 11:50 AM with MDS who (delete who) confirmed that this information for hypoglycemic was encoded incorrectly in Section N subsection N0415. B. Record Review of the Physician Orders printed on 12/12/2024 for Resident 12 revealed an order for Aspirin delayed release 81 milligram tablet once daily. (Aspirin is a medication with antiplatelet properties). Record review of the MDS data report dated 9/26/2024 for Resident 12 revealed that the resident had diagnoses of anemia, atrial fibrillation, and coronary heart disease. The MDS also revealed in Section N subsection N0415 that the resident was taking an antipsychotic, an antidepressant, and an anticoagulant. Interview on 12/17/2024 at 11:50 with MDS who confirmed that aspirin is an antiplatelet and not an anticoagulant and the MDS subsection N0415 was coded incorrectly.

Licensure Reference Number 175 NAC 1-005.06(E) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review, and interview, the facility failed to ensure that staff wore both a gown and gloves during resident care as required for Enhanced Barrier Precautions (An infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Precautions involve gown and glove use during high-contact resident care activities (Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or Assisting with toileting) for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices) for 1 (Resident 201) of 3 residents sampled to prevent the potential for cross-contamination and multidrug-resistant organisms. The facility census was 49. Findings are: Record review of the facility policy titled Enhanced Barrier Precautions dated 9/18/24 revealed that it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The section titled Prompt recognition of need revealed that all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. Residents with any of the following will be placed on enhanced barrier precautions-wounds including surgical wounds; indwelling medical devices including urinary catheters. Make gowns and gloves available inside the resident room. Note: face protection may also be needed if performing activity with risk of splash or spray such as wound irrigation. High-contact resident care activities include: dressing, bathing, transferring, device care including urinary catheters, and wound care of any skin opening requiring a dressing. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 12/16/24 for Resident 201 revealed that Resident 201 admitted into the facility on [DATE]. The MDS revealed that Resident 201 had an indwelling urinary catheter (A flexible plastic hollow tube inserted into the bladder to continuously drain urine. An indwelling medical device.). Interview on 12/16/24 at 2:59 PM with the spouse of Resident 201 confirmed that Resident 201 has had the indwelling urinary catheter due to prostate problems and difficulty with urination. Record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 12/16/24 for Resident 201 revealed that staff are to use enhanced barrier precautions. Observation on 12/17/24 at 1:14 PM in the room of Resident 201 revealed that Resident 201 sat in the wheelchair in the middle of the room. A sign titled Enhanced Barrier Precautions was present on the wall just outside the resident room door. A second Enhanced Barrier Precautions sign hung on the wall just inside the room door next to the hanging container with gloves and gowns. The Enhanced Barrier Precautions signs directed that providers and staff must wear gloves and a gown for the following high-contact care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting, and device care or use. Nurse Aide-C (NA-C) and Nurse Aide-D (NA-D) entered the resident room with the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own). NA-C and NA-D put on yellow protective gowns. NA-C positioned the lift in front of the resident. The lift sling was underneath the resident's back and thighs. NA-C and NA-D used the bare hands to connect the lift sling loops onto the lift bar of the total body lift. NA-C put on gloves. NA-C removed the catheter urine collection bag from the privacy cover under the wheelchair and hung it on the lift. NA-C removed and discarded the gloves and performed hand sanitization. NA-C operated the lift and Resident 201 was lifted out of the wheelchair. NA-D prevented Resident 201 from hitting objects and grabbed the resident's lift sling from behind the resident. NA-D moved behind the recliner and held onto the lift sling using the bare hands to help guide Resident 201 to the back of the recliner. Resident 201 was lowered into place in the recliner. NA-C put on gloves and moved the catheter urine collection bag from the lift and hung it on the trash can. NA-D obtained a pillow. NA-C and NA-D used the bare hands to lean Resident 201 forward in the recliner. NA-C and NA-D placed the pillow behind the back of Resident 201. NA-D removed the gown and exited the resident room. Interview on 12/18/24 at 8:39 AM with the facility Director of Nursing (DON) confirmed that staff are to wear both gown and gloves during high contact care activities for residents on Enhanced Barrier Precautions.

Licensure Reference Number 175 NAC 12-006.09D6(7) The facility failed to ensure respiratory equipment was cleaned and stored in a manner to prevent the potential for cross contamination related to oxygen tubing when not in use for 3 residents (Residents 2, 6, and 22) of 4 sampled residents and related to the CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask for 1 resident (Resident 36) of 1 sampled residents. The facility identified a census of 46. Findings Are: A record review of the undated facility policy titled Oxygen Safety read as follows: 7. Oxygen tubing shall be monitored for cleanliness, monitored to assure tubing is not kinked, that it does not touch the floor, and is properly stored when not in use. Tubing is change weekly by nursing staff. A. A record review of the demographic information revealed Resident 2 had been accepted into the facility on [DATE] with diagnoses of: included Chronic Kidney Disease (CKD) (a condition where your kidneys are losing their ability to filter waste products from your blood), Congestive Heart Failure (CHF)( a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Edema (swelling caused by too much fluid trapped in the body's tissues), and acute respiratory failure (a sudden and often reversible reduction in respiratory function). A record review of Resident 2's MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 11/30/23, Section C, revealed Resident 2 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 out of 15 which indicated the resident was cognitively intact. An observation on 12/20/23 at 10:06 AM revealed Resident 2 had a portable oxygen tank on the back of the wheelchair. The oxygen tubing connected to the portable tank was noted to have the nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) touching the wall. An observation on 12/21/23 at 09:45 AM revealed Resident 2's oxygen tubing, which was not in use, to be coiled up and hanging on the oxygen concentrator with the nasal cannula touching the machine in Resident 2's room. An interview on 12/21/23 at 10:13 AM with Registered Nurse (RN)-M confirmed that oxygen tubing should be stored in a bag when not in use. An interview on 12/21/23 at 10:15 AM with Nurse Aide (NA)-N who was also a MA (Medication Aide)) revealed that the MA's in the facility were able to transfer oxygen source from the concentrator to the portable tanks and back. NA-N voiced that the facility expectation was to hang the oxygen tubing on the concentrator when not in use and not on the ground yet made no mention of storing the tubing in a bag. B. A record review of the demographic information revealed Resident 6 had been accepted into the facility on [DATE] with diagnoses of: a fall resulting in a pelvic fracture and a history of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). A record review of Resident 6's MDS dated [DATE], Section C, revealed Resident 6 had a BIMS score of 09 which indicated the resident was cognitively impaired. An observation on 12/20/23 at 2:31 PM, revealed Resident 6 to have a portable oxygen tank on the wheelchair with the nasal cannula touching the wheel of the wheelchair. An observation on 12/21/23 at 9:54 AM revealed Resident 6's oxygen tubing to be draped over the nightstand with part of the tubing shut in the 2nd drawer and the cannula to be draped across the nightstand with the cannula touching the top of the nightstand. An interview on 12/21/23 at 10:13 AM with RN-M confirmed that oxygen tubing should be stored in a bag when not in use. An interview on 12/21/23 at 10:15 AM with NA (Nurse Aide)-N (who was also a MA (Medication Aide)) revealed that the MA's in the facility were able to transfer oxygen source from the concentrator to the portable tanks and back. NA-N voiced that the facility expectation was to hang the oxygen tubing on the concentrator when not in use and not on the ground yet made no mention of storing the tubing in a bag. C. A record review of the demographic information revealed Resident 22 had been re-accepted into the facility on [DATE] after being sent to the emergency room (ER) due to an unresponsive episode and low oxygen saturation rates. A record review of Resident 22's MDS dated [DATE], Section C, revealed Resident 22 had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. An observation on 12/20/23 at 1:48 PM revealed Resident 22 had an oxygen concentrator and portable tank in room with the tubing still connected and the cannula resting on the floor between the concentrator and the wall. An observation on 12/21/23 at 9:57 AM revealed Resident 22's oxygen tubing which was attached to the concentrator had the cannula end resting on the floor. An interview on 12/21/23 at 10:13 AM with RN-M confirmed that oxygen tubing should be stored in a bag when not in use. An interview on 12/21/23 at 10:15 AM with NA (Nurse Aide)-N (who was also a MA (Medication Aide)) revealed that the MA's in the facility were able to transfer oxygen source from the concentrator to the portable tanks and back. NA-N voiced that the facility expectation was to hang the oxygen tubing on the concentrator when not in use and not on the ground yet made no mention of storing the tubing in a bag. An observation on 12/27/23 at 7:58 AM revealed Resident 22's oxygen tubing had been draped across the bed with nasal cannula touching the bedspread. An interview on 12/27/23 at 7:46 AM with LPN (Licensed Practical Nurse)-O confirmed that the oxygen tubing was to be stored in a bag when not in use. D. A record review of the demographic information revealed Resident 36 had been accepted into the facility on [DATE] with diagnoses of: Chronic Respiratory Failure with Hypoxia and Heart Failure. A record review of Resident 36's MDS dated [DATE], Section C, revealed Resident 36 had a BIMS score of 15 out of 15 which indiciated the resident was cognitlvey intact. An observation on 12/20/23 10:54 AM revealed Resident 36's CPAP mask to be connected to the tubing and lying with the mask face down on the dresser and the tubing which connects the machine to the concentrator was draped across the bed. An observation on 12/21/23 at 9:59 AM revealed Resident 36's CPAP mask to be draped over the nightstand with the mask to be resting face down on the nightstand. An observation on 12/27/23 at 7:41 AM revealed Resident 36's CPAP mask to be draped over the dresser with the mask resting face down on the dresser. The observation also revealed that Resident 36's oxygen tubing was coiled and tucked under the handle of the concentrator. An interview on 12/27/23 at 7:46 AM with LPN-O revealed that the CPAP mask and oxygen tubing are to be stored in a bag when not in use. A record review of the facility's undated policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) revealed it did not contain any instruction or guidance regarding cleaning and storage of a CPAP mask when not in use.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure that dietary sanitizer solution (a substance or preparation for killing germs on food-processing surfaces and equipment) was at the required concentration (The amount of the sanitizer (chemical) in the water. Too high of a concentration is toxic, and too little will not ensure sanitation) to prevent the potential for foodborne illness. This affected all 46 residents that ate food prepared by the facility kitchen. The facility census was 46. Findings are: Record review of the Nebraska Food Code, Effective date 7/21/16 section 4-501.116 revealed that the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Record review of the Sink and Surface Cleaner Sanitizer dated 2020 revealed that test strips should be changed out every time solution in the bucket is changed out. The food code requires a new solution to be prepared every 4 hours, so it is recommended to change the strip at the same time. The strips are replaced every time the solution is changed. Customers need to use the Sink and Surface Cleaner Sanitizer test strips to ensure their use dilution falls within the acceptable concentration range. Observation on 12/21/23 at 9:40 AM in the facility kitchen revealed that Dietary Cook-A (DC-A) performed hand washing and put on gloves. DC-A placed bone in chicken pieces onto a baking sheet on the prep table. DC-A put the baking sheet into the oven. DC-A removed the yellow cloth rag from the sanitizer bucket and wiped the top of the prep table. DC-A obtained the ingredients for the sauce to be put on the baked chicken. DC-A mixed the ingredients in a bowl on the prep table. Observation on 12/21/23 at 11:15 AM in the facility kitchen revealed a sanitizer dispenser at the 3-compartment sink. DC-A confirmed that the sanitizer solution in the sanitizer bucket comes from the sanitizer dispenser. DC-A was asked about testing the sanitizer concentration level. DC-A revealed that test strips are used to test the sanitizer concentration. DC-A was unable to find any test strips. DC-A revealed that facility maintenance staff does the testing along with checking of the hot water temperature. DC-A was unsure where testing results of the sanitizer solution were documented. Interview on 12/22/23 at 2:42 PM with the facility Maintenance Director (MD) revealed that the MD does not check the sanitizer solution concentration and thinks the Dietary Manager and dietary staff check the concentration. Interview on 12/27/23 at 8:25 AM with the facility Dietary Manager (DM) revealed that the sanitizer solution concentration is checked by using test strips. The DM revealed that the concentration should be checked every time the sanitizer solution is dispensed. The DM revealed that when the sanitizer solution in the sanitizer bucket becomes cool it is to be dumped and hot solution put into the sanitizer bucket. The DM revealed that the testing of the sanitizer solution concentration was to be documented. Interview on 12/27/23 at 8:31 AM with Dietary Aide-C (DA-C) revealed that DA-C uses a bucket with sanitizer solution to wipe down the dining room tables. DA-C revealed that DA-C gets a new bucket, solution, and rag to wipe the tables. DA-C revealed that the sanitizer solution is to be tested but that DA-C had not been testing the solution concentration and does not know how to do it. Observation on 12/27/23 at 8:33 AM in the facility kitchen revealed that Dietary Cook-B (DC-B) grabbed the yellow cloth out of the red sanitizer bucket and wiped the prep table. DC-B put the yellow cloth rag back into the bucket. The bucket was cold to the touch. Observation on 12/27/23 at 8:37 AM in the facility kitchen revealed that the DM was unable to find any test strips for the sanitizer solution. The DM revealed that no one had notified the DM that they were out of test strips and that the DM would order some. The DM confirmed that the sanitizer in the sanitizer bucket was cold and should not be used. DC-B revealed that DC-B was just about to change out the solution. Observation on 12/27/23 at 9:38 AM in the facility dining room revealed that Dietary Aide-D (DA-D) and Dietary Aide-E (DA-E) cleaned breakfast dishes and refuse from the tables. A green bucket of sanitizer solution was warm to the touch. DA-D used the yellow cloth rag from the sanitizer bucket to wipe each table after the dishes and refuse were removed. DA-D confirmed that the sanitizer solution concentration could not be checked as the facility had no test strips. Interview on 12/27/23 at 11:37 AM with the facility DM confirmed that the sanitizer solution concentration was to be checked (tested ) each time the sanitizer bucket solution is changed out. The DM confirmed that the facility had no test strips to ensure that the sanitizer solution was at the required concentration.

Licensure Reference Number 175 NAC 12-006.17 Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview, the facility failed to perform hand hygiene to prevent the potential for food borne illness during meal service, which had the potential to affect 46 residents; and failed to ensure a resident had a cleanable sleeping surface for infection prevention for 1 resident (Resident 6). Facility stated census of 46. Findings are: A record review of facility supplied document labeled Hand Washing Guidelines Dietary Employees revealed frequency of hand washing should be after hands have touched anything unsanitary, after hands have touched bare human body parts, and after engaging in any activity that may contaminate the hands. A. During a meal service observation on 12/24/2023 at 12:10 PM Dietary Aide (DA)-D obtained a used coffee cup from a resident and took it over to the coffee pot to refill the cup and then returned it to the resident. DA-D did not complete any form of hand hygiene prior to serving a plate of food to another resident. During a meal service observation on 12/26/2023 at 12:45 PM it was revealed DA-E obtained a used coffee cup from a resident and took it to the coffee pot and refilled the cup and returned it to the resident. DA-E did not complete any form of hand hygiene prior to serving a plate of food to another resident. The observation further revealed DA-H entered the kitchen area obtained a gallon of milk poured a glass of milk and delivered it to a resident. DA-H did not complete any form of hand hygiene prior to serving a plate of food to another resident. The observation further revealed DA-D was standing at the kitchen window and utilized their hand to adjust their hair net on their head, scratch/rub their face, and wiped their hands on their clothing. DA-H did not complete any form of hand hygiene prior to serving a plate of food to another resident. Interview on 12/26/2023 at 1:05 PM with DA-H revealed hand hygiene should have been completed after touching clothing or any other non-sanitary surface prior to serving food to residents. Interview on 12/27/2023 at 11:21 AM with the Dietary Manager (DM), revealed hand hygiene should have been performed after taking a used cup and refilling it for a resident, touching hair or face and clothing. The DM stated dietary staff should complete hand hygiene after touching any non-sanitary surface. 42861 B. A record review of the demographic information revealed Resident 6 had been accepted into the facility on [DATE] with diagnoses of: a fall resulting in a pelvic fracture and a history of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 10/19/23, Section C, revealed Resident 6 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 09 which indicated the resident is cognitively impaired. The MDS revealed Resident 6 was frequently incontinent. During an interview on 12/20/23 at 2:31 PM Resident 6 revealed they have pain when getting out of bed and therefore Resident 6's family member had bought a cover for their bed. An observation on 12/20/23 at 2:31 PM, revealed Resident 6 had a foam egg-crate on the bed to help decrease (gender) back pain. During the interview on 12/20/23 at 2:31 PM Resident 6 voiced being incontinent of bladder all of the time. An observation on 12/27/23 at 7:55 AM revealed Resident 6 had a foam mattress pad on the bed. An interview on 12/27/23 at 8:00 AM with Nurse Assistant (NA)-P revealed Resident 6 was incontinent of bladder most of the time. An interview on 12/27/23 at 9:42 AM with the facility Administrator revealed the facility was unaware of the foam egg crate mattress cover for Resident 6. The Administrator confirmed the facility should not utilize these as they were a foam mattress and not a cleanable surface.

Licensure Reference Number 175 NAC 12-006.09D3(1) Based on observation, record review, and interview, the facility failed to provide perineal care (which is cleansing of the genatalia of a resident) in a manner to prevent cross contamination of 2 sampled residents (Resident #5 and Resident #14). The facility census was 46. Findings are: A. A record review of Resident #14's Face Sheet dated 12/20/2023 revealed, that the facility admitted Resident #14 on 09/07/2016, with diagnoses of: Epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), Parkinson's disease (a progressive disease of the nervous system causing tremors and muscular rigidity), myocardial infarction (which is blockage of blood flow to the heart), and Benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). A record review of Resident #14's Quarterly Minimum Data Set (MDS), (which is an resident assessment and care screening tool that is used by nursing homes), dated 08/17/2023 revealed, that Resident #14 required extensive assistance by one staff member with bed mobility, transfers, and toilet use and was occasionally incontinent of urine and frequently incontinent of bowel. Resident #14 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicaited the resident had severe cognitive impairment. A record review of Resident #14 Care Plan dated 11/22/2023 revealed, the resident had an inability to care for self and staff provided one assistance with personal hygiene. In an observation completed on 12/27/2023 at 8:56 AM Nurse Aide (NA)-G used a disposable wipe to cleanse Resident #14 left buttock folded the wipe, wiped the right buttock, folded the wipe, then used the soiled wipe to wipe the middle of the buttock and threw the wipe away. NA G obtained another disposable wipe and used it to wipe Resident #14 inner right groin area, folded the wipe, wiped inner left groin area folded the wipe, and then used the soiled wipe to wipe Resident #14 penis using a downward motion wiping towards the residents urethral opening. In an interview completed on 12/27/2023 at 9:15 AM with NA-G revealed, perineal care should be completed by cleansing the male penis cleansing should occur from the urethral opening outward and down the penis. Review of a facility policy titled, Perineal Care revealed Females: cleanse perineum wiping in the direction from the front to the back, repeat this on the opposite side using a new disposable wipe, clean urethral meatus and vaginal orifice using a new disposable wipe with each stroke. Males: Cleanse the tip of the penis at the urethral meatus using a circular motion and working outward, use a new disposable wipe with each stroke. In an interview conducted on 12/27/2023 with the Director of Nursing (DNS) it was revealed, that when using a disposable wipe, a new wipe should be used for each stroke. B. A review of a Face Sheet dated 12/20/2023 revealed the facility admitted Resident #5 on 03/31/2014 with diagnoses of: Congestive Heart Failure (a condition in which your heart can not pump blood well enough to meet your body's needs), Chronic obstructive pulmonary disease(a condition that causes air flow blockage and breathing related problems in the lungs), and Neurocognitive disorder with Lewy bodies(which progressive disease that leads to a decline in thinking, reasoning, and independent function). A review of Resident #5 Annual MDS, dated [DATE] revealed, that Resident #5 was totally dependent on two staff members for transfers, extensive assistance by one staff member with toilet use, limited assistance by one staff member with personal hygiene, and always incontinent of bowel and bladder. Resident #5 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicaited the resident had severe cognitive impairment. A review of Resident #5's Care Plan dated 10/04/2023 revealed, that Resident #5 had an inability to care for self and was dependent on staff assistance for personal hygiene. In an observation completed on 12/27/2023 at 8:23 AM NA-F used a disposable wipe to cleanse Resident #5 perineal area. NA-F used a disposable wipe to cleanse Resident #5's inner right groin, folded the wipe, then used the soiled wipe to cleanse Resident #5 inner left groin then discarded the wipe in the trash can. NA-F obtained another disposable wipe and used wipe to cleanse Resident #5 outer labia (the skin folds that surround the outer opening of the vagina), wiping from front to back (pelvic bone to anus), folded the wipe and repeated this process with the soiled wipe, then discarded the wipe in the trash can. In an interview conducted on 12/27/2023 at 9:26, NA-F revealed, that during female perineal care you should wipe from front to back and use a new wipe for each stroke and during male perineal care you should wipe from urethra outwards and use a new wipe for each stroke.

Licensure Reference Number 174 NAC 12-006.09D Based on record review and interviews, the facility staff failed to perform pain assessments for scheduled pain medications for Resident 37 and 38 who said they experienced pain. This affected 2 out of 3 residents sampled. The facility census was 40 at the time of survey. Findings are: A. During an interview on 11/28/22 at 11:55 AM Resident 37 complained of pain all the time to the right leg due to a history of a stroke. A record review of Resident 37's demographic information revealed an admitted [DATE]. A record review of the Medication Administration History dated 11/01/22-11/29/22 revealed Resident 37 had an order for Tylenol (used to treat minor aches and pains, and reduces fever) 325 milligrams (mg) three times a day. A record review of the PRN (as needed) Medication Administration History dated 11/01/22-11/29/22 revealed Resident 37 had an order for Acetaminophen (used to treat minor aches and pains, and reduces fever) 325 mg give 2 tablets as needed for pain and the record showed it had been used 7 times from 11/01/22-11/29/22. A record review of Resident 37's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 10/13/2022 revealed in Section J, question J0400 Pain Frequency which asked how much of the time have you experienced pain or hurting? with an answer of almost constantly. A record review of Resident 37's MDS, dated [DATE] Section C revealed a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of a 9 for Resident 37. A record review of Medication Administration History and the Treatment Administration History dated 11/01/22-11/29/22 for Resident 37 revealed no nursing assessment to monitor pain level for routine pain medication. A record review of the electronic medical records revealed no nonpharmacological interventions had been documented before giving medications used for pain control. An interview on 11/30/22 at 12:26 PM with the Director of Nursing (DON) revealed the nurses should chart in the progress notes if an intervention was provided. A record review of the Pain Management Policy, with copyright 2022 #6 revealed: Nonpharmacological interventions will include but are not limited to: a. Environmental comfort measures b. loosening any constrictive bandage, clothing or device c. applying splinting d. physical modalities e. exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility f. cognitive/behavioral interventions. An interview on 12/01/22 at 10:17 AM with the DON confirmed the policy does not state to do nonpharmacological interventions prior to giving a pain med as needed, stating staff are to look at the careplan to know which interventions are supposed to be used. The DON confirmed it is not documented as to which specific intervention is used before the pain med is given. B. During an interview on 11/28/22 at 11:25 AM Resident 38 verbalized constant pain due to cancer and it was difficult to get into a comfortable position. A record review of Resident 38's demographic information revealed an admitted [DATE]. A record review of Physician Order Report dated 11/01/22- 12/1/22 revealed orders for 1. Morphine (a controlled substance used to treat severe pain) solution 100 milligrams (mg) per 5 milliliters (ml) and to give 0.25 ml every 3 hours as needed with a start date of 11/16/22 and for 2. Hydrocodone-acetaminophen tablet (an opioid used to treat pain) 5-325 mg three times a day. A record review of Resident 38's MDS dated [DATE] revealed in Section J the answer to question J0400, how much of the time have you experienced pain or hurting? with an answer of almost constantly. A record review of Medication Administration History dated 11/01/22-11/29/22 for Resident 37 revealed no nursing assessment to monitor pain level for routine pain medication. A record review of Resident 38's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 11/14/22 revealed Potential for alteration in comfort related to deconditioning, malignant melanoma, diabetes, protein/calorie malnutrition, weakness resident requesting pain medication, resident showing signs/symptoms of pain. Interventions included: -Administer medications as ordered. Evaluate and record effectiveness and any adverse side effects. -Observe for any non-verbal signs of pain (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal) and report to charge nurse. -Position for comfort using pillows for support as necessary. An interview on 11/30/22 at 04:39 PM with Registered Nurse (RN) - D confirmed that hospice was to manage wound care and infection prevention. The hospice nurse also confirmed that the resident does report pain and doesn't always ask for pain meds even when in pain. A record review of the Pain Management Policy, with copyright 2022 #6 revealed: Nonpharmacological interventions will include but are not limited to: a. Environmental comfort measures b. loosening any constrictive bandage, clothing or device c. applying splinting d. physical modalities e. exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility f. cognitive/behavioral interventions. An interview on 11/30/22 at 12:26 PM with the DON revealed that the nurses should chart in the progress notes if an intervention was provided. An interview on 12/01/22 at 10:17 AM with the DON confirmed the policy does not state to do nonpharmacological interventions prior to giving a pain med as needed, stating staff are to look at the careplan to know which interventions are supposed to be used. The DON confirmed it is not documented as to which specific intervention is used before the pain med is given.

175 NAC 12-006.09D7 Based on record reviews and interview, the facility failed to identify and implement interventions to prevent injury for Resident 4. This affected 1 of 1 residents sampled for accidents. The facility census was 40. Findings are: A review of the Event History for Resident 4 revealed the following Event Reports (a document describing an injury the resident sustained): -On 2/25/22 the resident received a skin tear to the right hand. The immediate measures taken were first aid and applying a transparent dressing. -On 3/1/22 the resident received a bruise to the left lower leg. There were no immediate measures listed. -On 3/3/22 the resident received a bruise to the right upper inner thigh. There were no immediate interventions listed. -On 3/13/22 the resident received a skin tear to the left forearm, and a bruise to the left elbow. The immediate intervention taken was to apply a transparent dressing. -On 6/6/22 the resident received a bruise to the right lower extremity (leg) with a skin tear at the top of the bruise. The immediate measure taken was to apply a transparent dressing. -On 6/16/22 the resident received 2 bruises to the left lower extremity. There were no immediate measures listed. -On 7/25/22 the resident received a skin tear to the left lower leg. The immediate intervention was to clean and cover the area. -On 7/27/22 the resident received a bruise to the lower left cheek by the jaw, and a bruise under the left eye. There were no immediate interventions listed. -On 9/6/22 the resident received a skin tear to the right hand. This was described as an old skin tear that was scabbed over reopened. The only skin tear the resident had previously listed was the one received on 2/25/22. The immediate intervention was to clean and cover the area. -On 9/7/22 the resident received a skin tear to the left lower leg. The immediate intervention was to clean and cover the area. -On 9/9/22 the resident received a bruise to the right hand. There were no immediate interventions listed. -On 11/15/22 the resident received a skin tear to the upper right forearm. The immediate intervention was to clean and cover the area. -Further review of the Event Reports and the resident's Progress Notes revealed that all immediate interventions were basic first aid, and that no further investigation was done for root cause analysis of injuries. Review further revealed that no other interventions were put in place after each injury to prevent further injury. A review of Resident 4's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care) revealed a Pressure ulcer problem with a start date of 7/24/14. This problem stated that the resident had the potential for alteration in skin integrity due to a history of skin tears. There were no current skin tears listed. The most recent intervention for this care plan was dated 11/22/19. An intervention dated 8/9/19 stated [NAME] sleeves (a type of protective wrap) to bilateral (both sides) arms on in AM (morning) off at HS (bedtime) as resident will allow. There were no new interventions put in place after any of the injuries in 2022. An interview on 12/01/22 at 10:02 AM with Nurse Aide (CNA) B revealed that CNA B tries to watch carefully when going through doors. The CNA B also revealed that they try to put long sleeves on the resident. CNA B also revealed that Resident 4 does not wear geri-sleeves, and is unsure if that has been discussed with the resident's family. An observation on 12/1/22 at 12:50 PM during a transfer revealed the resident did not have any geri-sleeves present on arms or legs. An interview with the Director of Nursing (DON) on 12/01/22 at 11:25 AM revealed that on 10/20/22 the facility had discussed discontinuing the resident's order for a blood thinner with the family after the resident was admitted to hospice services and the family wanted to continue the medication. The DON also revealed that the restorative nurse had talked with Resident 4's family on 10/5/22 about using a full lift instead of the sit-to-stand lift to reduce the chance for injury during transfer as the resident had been having unresponsive episodes during transfers. The resident had refused this intervention and the family wanted to respect her wishes. An interview with the DON on 12/1/22 at 1:11 PM revealed that they review things like falls and injuries at least quarterly for trends. The DON revealed that if a root cause analysis had been done, it would be in the Event Report or Progress Note. The DON further confirmed that the facility had not addressed this resident's injuries. The DON also confirmed the resident does not have protective wraps on either her arms or legs today.

Based on record review and interview, the facility failed to ensure written notice of transfer was provided to the resident or resident representative for Resident 11. This affected 1 of 3 residents sampled for hospitalization . The facility census was 40. Findings are: A review of Resident 11's Census listing revealed that the resident had been transferred to the hospital on 9/30/22 and returned to the facility on [DATE]. A review of Resident 11's Progress notes between 9/28/22 and 10/7/22 revealed that the resident had gone to a physician's office visit 9/30/22 and had been admitted to the hospital from that appointment. A review of the facility's policy Transfer and Discharge (Including AMA) reviewed/revised 8/1/22 revealed the following under Section 7 Emergency Transfers/Discharges: j. Provide transfer notice as soon as practicable to resident and representative. An interview on 11/30/22 at 10:00 AM with the Social Services Worker (SS) confirmed that the facility had not provided the resident and/or resident representative with written notice of transfer/discharge upon hospitalization .