Every finding on record at Mt Carmel Home - Keens Memorial

Licensure Reference Number 175 NAC 12-006.12 (D)The facility filed to ensure medications were labeled in compliance with professional standards of practice and or manufacturer instructions for 2 of 5 sampled Residents (Resident 51 and 57). The facility census was 58.Findings are:Record review of a facility supplied document titled Medication storage and labeling and dated 01/2023 revealed drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principals including the expiration date when applicable. A.Record review of a document titled Carboxymethylcellulose sodium solution (a lubricating eye drop) dated 06/2022 revealed to discard the multiuse vial 90 days after opening of the vial.In an observation completed on [DATE] at 8:13 AM Licensed Practical Nurse C (LPN-C) removed a multi dose clear vial with a white lid from the medication cart. The vial was labeled with a pharmacy label including Resident 51 name, medication name, dose, and frequency to administer the medication on the label. There was no date written on the multi dose bottle indicating the date the bottle was opened or when the bottle should be discarded 90 days from being opened. The LPN proceeded to administer the prescribed eye drop medication to Resident 51 and then return to the medication cart.In an interview completed on [DATE] at 9:09 AM with LPN-C, LPN-C confirmed there was no open date or date indicating 90 days after opening for the bottle to be discarded. The LPN confirmed that this should be written on the bottle so staff knew when the medication was no longer good and should be discarded.B.Record review of a document titled Humalog highlights of prescribing information and dated 03/2013 revealed multi dose vials stored at room temperature should be discarded after 28 days.In an observation completed on [DATE] at 8:45 AM LPN-C removed a white box containing a multi dose insulin vial from the medication cart and placed it on top of the medication cart. The LPN then checked Resident 57 orders. The LPN stated that due to the resident's blood sugar level the resident would not receive the insulin at this time. The vial of insulin was labeled with a pharmacy label including Resident 57 name, medication name, dose, and frequency to administer the medication on the label. A yellow sticker was located on the vial with an Open date written as 12/13 and an EXP (expiration date) of 01/10.In an interview completed on [DATE] at 9:09 AM with LPN-C, LPN-C confirmed that Resident 57 insulin expired 5 days ago on [DATE] and should have been discarded and a new vial obtained. The LPN confirmed that the vial of insulin should not be on the medication cart and was.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2)Based on observation, record review, and interview the facility failed to monitor resident pressure ulcers (a localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) per professional standards for 1 of 1 resident reviewed (Resident 4). The facility census was 58.Findings are: A.Record review of the facility policy titled General Wound Care dated 1/2023 revealed that the guidelines are designed to assist the nursing staff in deciding how to care for skin problems. Measure the wound size (length, width, depth). If the wound fails to show signs of healing, re-evaluate the treatment plan and consult the physician. Record review of the facility policy titled Wound Documentation dated 1/2024 revealed that the guidelines are to assist nursing staff in deciding how to care for skin problems as well as where to record their findings and treatments. Document the size, location, drainage, color, stage, and dressing used. The facility wound nurse documents weekly wound assessments of pressure ulcers and significant wounds.Record review of the facility policy titled Pressure Sore Treatment dated 1/2025 revealed that staff are to document the location, stage, length, width, and depth, color, treatment, progress, and the condition of the wound. Perform treatment on the wound as ordered. Inform the physician of changes and treatments. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 5/15/25 for Resident 4 revealed Resident 4 admitted into the facility on 3/25/22. The assessment revealed that Resident 4 did not have any pressure ulcers.Record review of the care plan for Resident 4 dated 1/13/26 revealed Resident 4 was at risk for impaired skin integrity. Record review of the progress note for Resident 4 dated 10/19/25 at 9:04 PM revealed Resident 4 had a large water blister to the right heel and a left heel blister has opened. Record review of the progress note for Resident 4 dated 10/20/25 at 3:25 PM revealed Resident 4 was seen in wound clinic related to the heel blisters. A treatment for silicone bordered foam dressings to both heels was ordered for the resident. A Iodosorb (a sterile antimicrobial wound dressing that absorbs drainage, dead tissue, and debris while releasing iodine to kill bacteria) was ordered for the left heel and to have a padded cushions while in bed or chair. Record review of the care plan for Resident 4 dated 1/13/26 revealed Resident 4 had an intervention to change the dressing to the bilateral heels as ordered initiated on 10/24/25. The care plan revealed Resident 4 required Enhanced Barrier Precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism and residents at increased risk due to wounds or indwelling medical devices) due to pressure ulcers to both heels. Record review of the MDS assessment for Resident 4 dated 11/13/25 revealed Resident 4 had three stage 2 pressure ulcers (a stage 2 pressure ulcer involves damage to the skin that results in the loss of the outermost skin layer and exposure of the inner layer of skin) that were not present on admission to the facility.Observation on 1/14/26 at 10:01 AM in the room of Resident 4 revealed that Nurse Aide-A (NA-A) was in the room to change the resident's clothing. Resident 4 was barefoot and no wound was observed on the left heel. The red wound bed on the right heel was approximately 1.3 centimeters (cm) in length and 2.5 cm in width per visual measurement and did not have drainage. NA-A applied the compression stockings to the right foot/leg and then to the left foot/leg. Interview on 1/15/26 at 11:38 AM with the facility Director of Nursing (DON) revealed the DON was the wound nurse and does the weekly assessments of resident wounds for the facility. Record review of the Weekly Wound Assessment (the facility record of the wound assessment performed by the facility wound nurse) for Resident 4 dated 10/24/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The date acquired was documented as 10/20/25. The documentation revealed that this was the first observation of the wound by the wound nurse. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 10/31/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 11/7/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 11/14/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 11/21/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound.Record review of the Weekly Wound Assessment for Resident 4 dated 11/24/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/4/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 20 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/12/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 20 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/19/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 20 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/22/25 revealedthe assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 20 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/31/25 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 20 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 1/9/26 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 15 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 1/16/26 revealed the assessment was for the stage 2 pressure ulcer on the right heel. The section titled Wound Measurements revealed a length of 15 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Interview on 1/20/26 at 12:52 PM with Licensed Practical Nurse-B (LPN-B) revealed the wound dressing on the right heel of Resident 4 was changed by LPN-B on 1/20/26. LPN-B revealed the right heel wound was open and had clear drainage. LPN-B reported the wound was oval shaped and approximately 1.5 cm in length and 2.5 cm in width. LPN-B revealed that there is no measurable depth of the wound.Record review of the resident record for Resident 4 revealed no measurements of the length and width of the pressure ulcer on the right heel. Interview on 1/20/26 at 11:36 AM with the facility Director of Nursing (DON) confirmed that Resident 4 had pressure ulcers on the right heel and the left heel. The DON confirmed that the DON performs weekly wound assessments. The DON revealed that weekly the DON completes assessment of each pressure ulcer and puts the assessment findings into the Weekly Wound Assessment in the electronic health record for the resident. The DON confirmed that the weekly assessment includes measurements, any changes with drainage, change in pain with dressing changes, and any signs or symptoms of infection. The DON confirmed that the length and width of the wounds were not measured as required.B.Record review of the progress note for Resident 4 dated 10/19/25 at 9:04 PM revealed that Resident 4 had a large water blister to the right heel and a left heel blister has opened. Record review of the progress note for Resident 4 dated 10/20/25 at 3:25 PM revealed Resident 4 was seen in wound clinic related to the heel blisters. A treatment for silicone bordered foam dressings to both heels was ordered for the resident. A Iodosorb (a sterile antimicrobial wound dressing that absorbs drainage, dead tissue, and debris while releasing iodine to kill bacteria) was ordered for the left heel and to have a padded cushions while in bed or chair. Record review of the Weekly Wound Assessment (the facility record of the wound assessment performed by the facility wound nurse) for Resident 4 dated 10/24/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel with a acquired date documented as 10/20/25. The documentation revealed this was the first observation of the wound by the wound nurse. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 10/31/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 11/7/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 11/14/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 11/21/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound.Record review of the Weekly Wound Assessment for Resident 4 dated 11/24/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 30 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/4/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 25 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/12/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 25 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/19/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 25 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/22/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 25 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 12/31/25 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Wound Measurements revealed a length of 25 millimeters (mm). The section contained no measurement of the width or any depth of the wound. Record review of the Weekly Wound Assessment for Resident 4 dated 1/9/26 revealed the assessment was for the stage 2 pressure ulcer on the left heel. The section titled Overall Impression revealed that the wound was healed. Record review of the resident record for Resident 4 revealed no measurements of the length and width of the pressure ulcer on the left heel. Interview on 1/20/26 at 11:36 AM with the facility Director of Nursing (DON) confirmed that Resident 4 had pressure ulcers on the right heel and the left heel. The DON confirmed that the DON performs weekly wound assessments. The DON revealed that weekly the DON completes assessment of each pressure ulcer and puts the assessment findings into the Weekly Wound Assessment in the electronic health record for the resident. The DON confirmed that the weekly assessment includes measurements, any changes with drainage, change in pain with dressing changes, and any signs or symptoms of infection. The DON confirmed that any change of treatment order and any special interventions is documented on the Weekly Wound Assessment. The DON confirmed that the DON uses a paper or see through ruler to measure the vertical (length) and horizontal (width) at the largest parts of the wound. The DON revealed that the DON measures a diameter measurement for regular shaped wounds. The DON revealed that irregular shaped wound measurements are the length and width. The DON confirmed that the measurements of the pressure ulcers on Resident 4's right and left heels were a diameter. The DON confirmed that the length and width of the wounds were not measured as required.

Licensure Reference Number 175 NAC 12-006.09(G)(i)Based on record review and interview the facility failed to complete a recapitulation of stay (a concise summary of the resident's stay and course of treatment in the facility) for 2 of 2 sampled discharged residents (Resident 67 and 63) as required. The facility census was 58.Findings are: Record review of the facility policy titled Discharge of a Resident and dated 01/2025 revealed that the purpose was to ensure accurate documentation upon discharge of a living resident to another location. Nursing will print off the Transfer/Discharge Record that includes medical diagnoses, Advance Directives, and other pertinent information. Medications are also listed and last dose and time given needs to be documented. A. Record review of an admission Record revealed that the facility admitted Resident 67 on 06/21/2025 an discharged from the facility on 07/05/2025. Record review of Resident 67's Progress Notes revealed documentation that on 07/05/2025 at 1:47 AM Resident 67's body was released to their mortuary of choice. There was no further documentation in the progress notes for Resident 67. Record review of a facility supplied document titled Discharge Plan and dated 06/21/2025 revealed that Resident 67 was admitted to the facility for dementia and planned to stay in the facility long term. The residents responsible party and provider agreed with this plan. The resident's choice of pharmacy, that the resident would only like to be asked about discharge on their comprehensive assessment, that the resident passed away at the facility and that the social services designee checked in with the residents responsible party were also documented on the document. There was no recapitulation of the residents stay present in Resident 67 medical health record. In an interview completed on 01/20/2025 with the facility Director of Nursing (DON), the DON confirmed that the facility did not complete a recapitulation of stay or discharge summary for Resident 67. B. Record review of the facility policy titled Discharge of a Resident dated 1/2025 revealed that the purpose was to ensure accurate documentation upon discharge of a living resident to another location. Nursing will print off the Transfer/Discharge Record that includes medical diagnoses, Advance Directives, and other pertinent information. Medications are also listed and last dose and time given needs to be documented. Record review of the admission Record dated 1/14/26 for Resident 63 revealed Resident 63 admitted into the facility on [DATE]. The admission Record revealed that Resident 63 discharged from the facility on 11/26/25. Record review of the progress note for Resident 63 dated 11/26/25 at 9:00 AM revealed that Resident 63 discharged to home against medical advice. Record review of the Discharge Instructions to Resident and/or Family dated 1/20/26 at 9:17 AM in the electronic medical record for Resident 63 revealed the date of discharge as 11/26/25. The form revealed that Resident 63 discharged to home by car accompanied by family. The section titled Therapy Needs revealed that no information was documented in the section. The section titled Nursing contained no information documented in the box for special instructions and no information documented in the box for Explanation of medications and treatments provided to. Record review of the facility provided Discharge Instructions to Resident and/or Family dated 1/20/26 for Resident 63 revealed that Resident 63 discharged home by car accompanied by family. The section titled Therapy Needs contained the information that the Resident left AMA (against medical advice) The section titled Nursing contained the box for special instructions. The special instructions box contained the information Resident left AMA. The box titled Explanation of medications and treatments provided to contained the information NA (Not Applicable). Record review of the medical record for Resident 63 revealed that it contained no required recapitulation of the resident's stay. The medical record contained no required reconciliation of the resident's medications. Interview on 1/20/26 at 1:33 PM with the facility Director of Nursing (DON) confirmed that the facility did not have a recapitulation of stay for Resident 63 as required.

Licensure Reference Number 175 NAC 12-006.05 (G)Based on record review and interview, the facility failed to ensure medications were used per the manufacture approved recommendations for 2 of 5 sampled residents (Residents 16 and Resident 17). The facility census was 58.Findings are: Record review of a facility supplied document titled Use of Psychotropic Medications and dated 08/2025 revealed adequate indications for use means that the medication administered is consistent with the manufacturer's recommendations. A.Record review of a document titled Remeron (mirtazapine) (which is an antidepressant medication) and dated 2009 revealed under indications and usage the medication is indicated for the treatment of major depressive disorder.Record review of an admission Record revealed the facility admitted Resident 16 on 07/06/2022 with diagnoses of dementia (which is a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), major mood disorder (which is 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, insomnia (which is the inability to sleep), restlessness and agitation, and anxiety (which is 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). Record review of Resident 16's Electronic Medical Health Record (EMHR) revealed that Resident 16 had orders to receive Mirtazapine tablet 15 milligrams one time a day for insomnia. In an interview completed on 01/14/2026 at 4:17 PM with the facility Director of Nursing (DON), the DON confirmed that insomnia was an off-label use of the medication and not the approved indication or use of the medication. B.Record review of a document titled Risperdal (which is an antipsychotic medication) and dated 01/2020 revealed under indications and usage that the medication is indicated for the treatment of schizophrenia, acute manic or mixed episode associated with bipolar one disorder, and treatment of irritability associated with autistic disorder.Record review of an admission Record revealed the facility admitted Resident 17 on 03/29/2024 with diagnoses of dementia (which is a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), anxiety (which is 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) and Alzheimer's Disease (which is a degenerative brain disease of unknown cause that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood). Record review of Resident 17's Electronic Medical Health Record (EMHR) revealed that Resident 17 had orders to receive Risperdal 0.5 milligrams one time daily for Alzheimer's disease. In an interview completed on 01/14/2026 at 4:17 PM with the DON, the DON confirmed that Alzheimer's was not an approved indication for the use of the medication.

Licensure Reference Number 175NAC 12-006.17D Licensure Reference Number 175NAC 12-006.18C1 Based on observations, record reviews, and interviews the facility failed to ensure that staff performed hand sanitization (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) to prevent the potential for cross contamination during laundry delivery for 13 residents (Residents 39, 40, 54, 47, 51, 14, 32, 11, 7, 22, 29, 50, and 2) of 13 residents observed; failed to ensure that staff performed hand sanitization to prevent the potential for cross contamination during delivery of room meals for 4 residents (Residents 29, 15, 26, and 31) of 4 residents observed; failed to ensure that laundry was handled in a manner to prevent the potential for cross contamination for 3 residents (Residents 39, 14, and 11) of 13 residents observed; failed to ensure that staff removed soiled gloves between resident rooms to prevent the potential for cross contamination for 2 residents (Residents 34 and 311); failed to ensure that staff performed hand sanitization during medication administration to prevent the potential for cross contamination for 3 residents (Residents 8, 43, 26) of 4 residents observed; and failed to perform hand sanitization as required during resident perineal care (cleaning of the private parts of the body) for 2 residents (Residents 24 and 25) of 2 residents observed. The facility census was 59. Findings are: A. Record review of the facility policy titled Infection Prevention and Control Program dated 1/2023 revealed that the facility will implement Hand Hygiene Policies consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. The section titled Linens revealed that laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. Record review of the facility policy titled Hand Hygiene dated 1/2023 revealed that staff involved in direct resident contact will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table revealed that hand hygiene is indicated between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings and linens, and after handling items potentially contaminated. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-A (ESS-A) removed clothing on hangers from inside the laundry cart. ESS-A carried the clothes into the room of Resident 39. ESS-A exited the room of Resident 39 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 40. ESS-A exited the room of Resident 40 carrying used empty clothes hangers and returned to the laundry cart. ESS-A hung the empty hangers on the rack inside the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 54. ESS-A exited the room of Resident 54 carrying used empty clothes hangers and returned to the laundry cart. ESS-A hung the empty hangers on the rack inside the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed folded linens from inside the laundry cart. ESS-A carried the linens against the front of their uniform into the room of Resident 39. ESS-A exited the room of Resident 39 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 47. ESS-A exited the room of Resident 47 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 51. ESS-A exited the room of Resident 51 carrying used empty clothes hangers. ESS-A hung the empty hangers on the rack inside the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed folded clothing from inside the laundry cart outside the room of Resident 14 and held them against the front of their uniform. ESS-A continued to hold the clothing against the front of their uniform with their right hand and arm cradling the clothing. ESS-A removed a hanger with a shirt from inside the laundry cart with the left hand. ESS-A carried the clothing into the room of Resident 14. The folded clothing was held against the front of the uniform as it was carried into the room of Resident 14. ESS-A exited the room of Resident 14 carrying used empty clothes hangers and placed them on the rack inside the laundry cart. ESS-A did not perform hand sanitization. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-B (ESS-B) removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 32. ESS-B exited the room of Resident 32 carrying used empty clothes hangers. ESS-B returned to the laundry cart and hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart. The clothing rubbed against the right arm and uniform sleeve of ESS-B as ESS-B carried them into the room of Resident 11. ESS-B exited the room of Resident 11 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 7. ESS-B exited the room of Resident 7 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 22. ESS-B exited the room of Resident 22 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B pushed the laundry cart further towards the nurse's station. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 29. ESS-B exited the room of Resident 29 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 50. ESS-B opened the closet door and hung the clothing on the rack inside the closet. ESS-B removed used empty clothes hangers from the rack in the closet. ESS-B exited the room of Resident 50 and placed the empty hangers on the rack inside of the laundry cart. ESS-B did not perform hand sanitization. ESS-B pushed the laundry cart around the corner and stopped near the entry to the room of Resident 2. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 2. ESS-B exited the room of Resident 2 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. Interview on 11/14/23 at 1:36 PM with ESS-B confirmed that ESS-B received training on hand washing and hand sanitizer use from the facility. ESS-B confirmed that hand hygiene (hand sanitization) is to be performed after putting stuff in resident rooms and closets. Interview on 11/14/23 at 1:41 PM with ESS-A confirmed that the facility provides yearly training on hand hygiene. ESS-A revealed that hand sanitizer is located in the halls for staff to use. ESS-A confirmed that hand hygiene is to be performed after leaving a resident room before going to deliver laundry to the next resident room. Interview on 11/15/23 at 5:00 PM with the facility Director of Nursing (DON) confirmed that staff are expected to perform hand sanitization when exiting resident rooms. The DON confirmed that staff are expected to perform hand sanitization when going between resident rooms including during laundry delivery. B. Record review of the facility policy titled Hand Hygiene dated 1/2023 revealed that staff involved in direct resident contact will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table revealed that hand hygiene is indicated between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings and linens, and after handling items potentially contaminated. Observation on 11/15/23 at 8:55 AM outside the room of Resident 29 revealed that Dietary Aide-F (DA-F) lifted the blue side cover of the room meal cart over the top of the cart. DA-F picked up a covered plate and carried it into the room of Resident 29. DA-F was in the room for approximately 50 seconds. DA-F exited the room and pulled the blue side cover down. DA-F pushed the cart down the hall and stopped near the room of Resident 15. DA-F did not perform hand sanitization. DA-F lifted the blue side cover of the cart and removed a covered plate and a napkin with silverware. DA-F carried the plate into the room of Resident 15 and moved items to set the plate and silverware on the overbed table in front of the resident. DA-F exited the room and picked up a coffee cup by the handle and poured coffee from the white carafe into the cup. DA-F carried the cup into the room of Resident 15. DA-F exited the room. DA-F did not perform hand sanitization. DA-F removed a plate of food from the cart and carried it into the room of Resident 26. DA-F sat the plate on the overbed table at the resident bedside. DA-F exited the room and picked up 2 coffee cups by their handles. DA-F poured coffee into the 2 cups from the white carafe. DA-F carried the 2 cups of coffee into the room of Resident 26 and sat them on the overbed table. DA-F exited the room. DA-F did not perform hand sanitization. DA-F pulled the blue side cover on the cart down. DA-F pushed the cart to just outside the room of Resident 31. DA-F lifted the blue side cover and removed a covered plate and carried it into the room of Resident 31. DA-F sat the plate on top of items on the overbed tray, touching the items with their hands. DA-F exited the room and pulled the blue side cover back down. DA-F pushed the cart to the facility 300 hall. DA-F did not perform hand sanitization. Interview on 11/15/23 at 1:59 PM with Dietary Aide-F (DA-F) confirmed that the dietary aide was trained on proper hand washing and use of hand sanitizer. DA-F confirmed that hand hygiene is to be performed between resident rooms when going from room to room. Interview on 11/15/23 at 5:00 PM with the facility Director of Nursing (DON) confirmed that staff are expected to perform hand sanitization when exiting resident rooms. The DON confirmed that staff are expected to perform hand sanitization when going between resident rooms including during room meal delivery. C. Record review of the facility policy titled Infection Prevention and Control Program dated 1/2023 section titled Linens revealed that laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-A (ESS-A) removed folded linens from inside the laundry cart. ESS-A carried the linens against the front of their uniform into the room of Resident 39. ESS-A exited the room of Resident 39 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed folded clothing from inside the laundry cart outside the room of Resident 14 and held them against the front of their uniform. ESS-A continued to hold the clothing against the front of their uniform with their right hand and arm cradling the clothing. ESS-A removed a hanger with a shirt from inside the laundry cart with the left hand. ESS-A carried the clothing into the room of Resident 14. The folded clothing was held against the front of the uniform as it was carried into the room of Resident 14. ESS-A exited the room of Resident 14 carrying used empty clothes hangers and placed them on the rack inside the laundry cart. ESS-A did not perform hand sanitization. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-B (ESS-B) removed clothing on hangers from inside the laundry cart. The clothing rubbed against the right arm and uniform sleeve of ESS-B as ESS-B carried them into the room of Resident 11. ESS-B exited the room of Resident 11 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. Interview on 11/14/23 at 1:36 PM with ESS-B confirmed resident clothing is to be carried so it does not touch their uniform. Interview on 11/14/23 at 1:41 PM with ESS-A confirmed that resident clothing and linens are to be carried so that they do not touch their skin or uniform. Interview on 11/15/23 at 5:03 PM with the Facility Administrator (FA) confirmed that staff are expected to carry clothing and linens in a manner to prevent them from touching the staff uniform. D. Record review of the facility policy titled Hand Hygiene dated 1/2023 revealed that staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table revealed that hand hygiene is indicated between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings and linens, and after handling items potentially contaminated. Observation on 11/15/23 at 9:44 AM revealed that Dietary Aide-F (DA-F) pushed a cart from near the room of Resident 31 towards the nurse's station. DA-F wore blue disposable gloves. DA-F stopped outside the room of Resident 34. DA-F entered the room and then exited carrying a used plate and utensils. DA-F scraped remaining food debris from the plate into the trash on the end of the cart. DA-F sat the items in the bins on the cart that contained other soiled plates and utensils. DA-F did not remove the gloves or perform hand sanitization. DA-F pushed the cart using the gloved hands to outside the room of Resident 311. DA-F entered the room and then exited carrying a used plate and utensils. DA-F scraped food debris from the plate into the trash. DA-F placed the plate and silverware in a bin on the cart. DA-F did not remove the gloves or perform hand sanitization. Interview on 11/15/23 at 1:59 PM with Dietary Aide-F (DA-F) confirmed that the dietary aide was trained on proper hand washing and use of hand sanitizer. DA-F confirmed that gloves should not be worn in multiple resident rooms when going from room to room. Interview on 11/15/23 at 5:00 PM with the facility Director of Nursing (DON) confirmed that staff are expected to perform hand sanitization when exiting resident rooms. The DON confirmed that staff are not to reuse gloves between resident rooms. 49382 E: Observation on 11/14/2023 at 12:14 PM revealed Medication Aide C (MA C) obtained Resident #26 blood sugar then removed their gloves and exited the room. MA C did not perform hand hygiene. MA C placed the blood sugar equiptment within the medication cart. Observation on 11/15/2023 during medication administration from 7:21 AM to 8:35 AM by LPN G the following was observed: - LPN G administered an inhaled medication to Resident #8 by placing tip of the inhaler into the resident's nostril. LPN G did not perform hand sanitization then applied gloves to both hands. LPN G then applied a topical medication using gloved hands, removed their gloves and did not complete hand sanitization prior to applying another set of gloves to both hands. LPN G then applied another topical medication to resident and removed their gloves. LPN G did not perform hand sanitization and proceeded to return all items to the medication cart. - LPN G performed the task of obtaining Resident #26 blood sugar with gloves on their hands. LPN G then removed gloves and did not perform hand hygiene. LPN G then administered Resident #26 oral medications and fluids. LPN G returned to the medication cart and returned items used during task in medication cart then charted the medication pass. LPN G did not perform hand hygiene. Interview on 11/15/2023 at 8:35 AM with LPN G revealed hand hygiene should be performed between glove changes. F. Observation on 11/15/2023 from 8:30 AM to 8:55 AM revealed Resident #25 recieved care by Nurse Aide (NA H) and Nurse Aide I (NA I). The observation revealed: - NA H removed gloves and utilized a handheld radio within Resident #25's room then exited the resident room without performing hand sanitization. - NA H returned to Resident #25's room and applied gloves to both hands without performing hand sanitization. - NA I removed gloves from both of their hands and applied new gloves without performing hand sanitization. - NA I again removed gloves and placed a clean incontinence product on Resident #25 without performing hand sanitization. - NA I and NA H exited Resident #25 room after providing cared without performing hand sanitization. G. Observation on 11/15/2023 from 9:00 AM to 9:20 AM revealed Resident #24 recieved care by NA H and NA I. The observation revealed: - NA I removed gloves and assisted to pull up Resident #24 pants without performing hand sanitization. -NA H removed gloves and assisted to pull up Resident #24 incontinence product without performing hand sanitization. -NA H exited Resident #24's room after providing care without performing hand sanitization. Interview on 11/14/2023 at 10:10 AM NA H revealed [gender] should have used alcohol-based hand hygiene between glove changes. Interview on 11/16/2023 at 9:20 the facility Infection Preventionist (IP), revealed alcohol-based hand gel should be used between glove changes. Review of facility supplied policy labeled Hand Hygiene dated 01/23 Section 6 letter B stated, the use of gloves does not replace hand washing. Wash hands after removing gloves. Further review of the Hand Hygiene table located within the policy revealed hand hygiene with soap, water, and antimicrobial soap or alcohol-based hand gel should be performed before applying and after removing personal protective equipment, including gloves. Review of facility supplied policy labeled peri care dated 1/2023 Section 1 letter B perform the beginning four steps, wash your hands, Section 16, after providing cares, remove gloves complete hand hygiene, Section 20 after removing soiled items and trash from room, complete hand hygiene, Section 21 perform ending four steps, letter C hand hygiene.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident is cognitively intact and dependent on staff for transfers, toileting, and personal hygiene.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility staff failed to provide a written summary of the baseline care plan to the resident and/or PR (Personal Representative) which affected 3 of 8 sampled residents, Residents 35,46, and 39. The facility identified a census of 50 at the time of survey. Findings are: A. Review of Resident 35's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/16/2021 revealed an admitted [DATE]. Staff assessment for mental status indicated short term memory problems and modified independence with decision making. Review of Resident 35's Baseline Care Plan dated 3/10/2021 revealed no documentation a written summary had been provided to Resident 35 and/or their PR. Review of Resident 35's Progress Notes revealed no documentation a written summary of Resident 35's Baseline Care Plan had been provided to Resident 35 and/or their PR. Interview with the DON (Director of Nursing) on 05/11/21 at 9:45 AM confirmed there was no documentation a written summary of the baseline care plan had been provided to Resident 35 and/or their PR. B. Review of Resident 46's quarterly MDS dated [DATE] revealed an admitted [DATE]. Resident 46 had a BIMS score of 2 which indicated severe cognitive impairment. Review of Resident 46's Baseline Care Plan dated 7/3/2020 revealed no documentation a written summary was provided to Resident 46 and/or their PR. Review of Resident 46's Progress Notes revealed no documentation Resident 46 and/or their PR was provided a written summary of Resident 46's baseline care plan. Interview with the DON on 5/11/21 at 9:45 AM confirmed there was no documentation a written summary of the baseline care plan had been provided to Resident 46 and/or their PR. C. Review of Resident 39's Quarterly MDS dated [DATE] revealed an admitted [DATE]. Resident 39 had a BIMS (Brief Interview for Mental Status) score of 2 which indicated severe cognitive impairment. Review of Resident 39's Baseline Care Plan dated 9/22/2020 revealed no documentation a written summary of Resident 39's Baseline Care Plan had been provided to Resident 39 and/or their PR. Review of Resident 39's Progress Notes revealed no documentation a written summary of Resident 39's Baseline Care Plan had been provided to Resident 39 and/or their PR. Interview with the DON on 5/10/21 at 4:55 PM confirmed there was no documentation the written summary of the baseline care plan was provided to Resident 39 or their PR. The DON revealed a written summary was supposed to be provided to the resident and/or PR. Review of the facility policy Care Plans dated 11/19 revealed the following: Upon admission the charge nurse will complete the necessary admission assessments .within 24 hours. This includes the ICP or Interim Care Plan and a copy will be provided to the resident/POA (Power of Attorney).

Licensure Reference Number 12-006.11C Based on observation, interview, and record review; the facility staff failed to ensure that meals were not served from reused food trays to prevent the potential for cross contamination in the main dining room which affected 36 of 36 residents who received food in the main dining room (Residents 13, 6, 2, 29, 20, 34, 40, 43, 19, 46, 41, 21, 17, 42, 48, 3, 1, 35, 32, 7, 9, 11, 39, 31, 33, 12, 45, 23, 28, 50, 5, 38, 52, 25, 51, and 10) and the facility failed to ensure that staff handled ready to eat foods in a manner to prevent hands from contacting the food to prevent the potential for cross contamination for 1 of 11 residents who ate their meal in the special care unit dining room (Resident 36). The facility identified a census of 50 at the time of survey. Findings are: A. Observation of the main facility dining room on 5/06/21 from 11:34 AM to 12:25 PM revealed DC-A (Dietary Cook) plated the food which consisted of bowls of chili and plates with a cinnamon roll, fruit, lettuce, and cheese cubes, and placed it on trays on the shelf above the steam table in the meal service line. AA-B (Activity Assistant), AA-E, DA-C (Dietary Aide), DA-D, and DA-G then each took a tray with the plates of food out to the residents who were seated in the dining room, placed the items in front of the residents, then brought the trays back and placed them on the shelf above the steam table. DC-A would then place plates and bowls of food on the trays and AA-B, AA-E, DA-C, DA-D, and DA-G would then take the items to other residents. AA-B, AA-E, DA-C, DA-D, and DA-G were observed reusing the trays after returning them to the meal service line without cleaning them. The staff were observed placing the trays on the tables in front of the residents. None of the residents were wearing masks and were in close proximity to AA-B, AA-E, DA-C, DA-D, and DA-G who brought the trays. The residents were observed eating the food that had been brought to them on the trays by the staff. The staff continued to bring the trays back to the meal service line which DC-A then placed food items on which were then served to the residents repeatedly by AA-B, AA-E, DA-C, DA-D, and DA-G until all of the residents were served. Residents 13, 6, 2, 29, 20, 34, 40, 43, 19, 46, 41, 21, 17, 42, 48, 3, 1, 35, 32, 7, 9, 11, 39, 31, 33, 12, 45, 23, 28, 50, 5, 38, 52, 25, 51, and 10 were observed receiving food from the trays that were reused without being cleaned. Interview with the FSS (Food Service Supervisor) on 5/06/21 at 2:13 PM verified Residents 13, 6, 2, 29, 20, 34, 40, 43, 19, 46, 41, 21, 17, 42, 48, 3, 1, 35, 32, 7, 9, 11, 39, 31, 33, 12, 45, 23, 28, 50, 5, 38, 52, 25, 51, and 10 were present in the dining room for lunch on 5/6/2021. B. Observation of the main facility dining room on 5/10/2021 from 11:30 AM-12:30 PM revealed AA-B, AA-E, DA-C, DA-D and DC-F were observed serving food to the residents in the dining room by reusing the trays without cleaning them. Interview with the FSS on 5/10/21 at 3:10 PM revealed their expectation was the trays would not be brought back to the service line if they were sat on the table or if the resident touched the tray. Interview with the facility Administrator on 5/10/2021 at 3:10 PM revealed the meal trays should not be re-used and they will update the policy. Review of the facility policy Food Preparation and Service dated 12/19 revealed the following: Employees will perform hand hygiene between tray passes. There was no documentation of how the service trays were to be handled. C. Observation on 5/6/21 at 12:00 PM in the facility main dining room revealed that Dietary Assistant-C (DA-C) carried a tray with food for Resident 39 to the dining table and placed the plates of food in front of the resident. DA-C returned to the steam table and sat the used tray on the shelf on the top of the steam table. Dietary Cook-A (DC-A) plated food and sat the plates on the used tray that had been returned to the shelf. DA-G carried the tray of food to Resident 38. Resident 38 grabbed at the tray with the left hand and grabbed a plate of food off the tray and sat it on the table. DA-G began to remove the plate with the cinnamon roll from the tray. Resident 38 grabbed the bowl of chili off of the plate and refused the cinnamon roll. DA-G returned to the steam table and sat the used tray on the shelf on the top of the steam table. DC-A used the gloved hand and repositioned the used tray on the top shelf of the steam table. DC-A plated food and placed it on the used tray. Activity Assistant-B (AA-B) picked up the tray and delivered the plates of food to Resident 32. AA-B returned the used tray to the shelf on the top of the steam table. DC-A plated food and sat the plates on the used tray. AA-B picked up the tray and delivered the plates of food to Resident 48. AA-B returned the used tray to the shelf on the top of the steam table. DC-A plated food and sat the plates on the used tray. AA-E picked up the tray and delivered the plates of food to Resident 45. AA-E returned to the steam table and sat the used tray on the shelf on the top of the steam table. D. Record review of the facility policy titled Handling of Food and Drinks dated 12/19 revealed the policy that food is handled appropriately by staff in such a manner that limits the opportunity for cross contamination. Procedure step 1. Ready-to-eat food is not handled with bare hands. Observation on 5/5/21 at 12:32 PM in the facility secured unit dining room revealed that LPN-I picked up a cup of food from the 3 shelf cart of food. A cupcake was on the table in front of Resident 36. LPN-I asked Resident 36 if the resident needed help with the cupcake. LPN-I held the cup of food in the left hand. LPN-I peeled the cupcake liner away from the cupcake by placing the fingers of the bare right hand inside the cupcake liner and pulling it away from the cupcake. LPN-I peeled the liner from all sides of the cupcake with the bare right hand. White frosting was visible on the fingers of LPN-I's right hand. LPN-I carried the cup of food to Resident 4. LPN-I went to the sink in the dining room and performed hand washing. Interview on 5/11/21 at 11:03 outside the facility chapel with the Food Services Supervisor (FSS) confirmed that ready to eat foods are to be handled using utensils or gloves. The FSS confirmed that foods should not be touched with the bare hands.

Licensure Reference Number 175NAC 12-006.17D Based on observation, interview, and record review the facility failed to ensure that staff followed the facility procedure for washing hands during food service and resident care to prevent the potential for cross contamination (the transfer of harmful microorganisms, usually bacteria and viruses from one person, object or place to another). This had the potential to affect 5 of 11 residents observed (Residents 44, 15, 22, 24, and 8). The facility census was 50. Findings are: Record review of the facility policy titled Hand Washing dated 12/19 revealed the policy that handwashing is regarded by the facility as the single-most important means of preventing the spread of infections and food borne illnesses. The purpose of the policy is to provide guidelines to employees for proper and appropriate handwashing techniques that aid in the prevention of the transmission of infections. To prevent the spread of infectious diseases or food borne illnesses. The procedure steps: 1. Turn on water to desirable temperature and wet hands. 2. Apply soap and vigorously lather hands by rubbing them together, creating friction to all surfaces, for at least 15-20 seconds. 3. Rinse hands thoroughly under running water with the water starting above the wrists and with hands and finger tips pointed down, so that the water runs downward. 4. Leave the water running and dry hands thoroughly with paper towels. When drying is completed, turn the water off with fresh, dry towel. 5. The entire process of handwashing must take at least 20 seconds. 6. Handwashing is appropriate and mandatory: -After physical contact with the residents and their wheelchairs or walkers. -After handling dirty dishes utensils, soiled rags, mops, and garbage. -Before handling clean dishes. -Before serving trays, plates, or beverages. -Before putting gloves on. -After taking gloves off. Observation on 5/5/21 at 11:48 AM revealed that Dietary Cook-A (DC-A) pushed a 3 shelf cart of meal plates into the facility secured unit dining room. Nursing Assistant-H (NA-H) exited the room of Resident 44 and dropped a tied bag of trash on the floor just outside of the room. NA-H was wearing disposable gloves. NA-H went to Resident 44 at the dining room table and provided the dentures to Resident 44. NA-H assisted the resident to put the dentures in the resident's mouth. NA-H removed the gloves and performed hand washing with soap at the dining room sink. NA-H scrubbed the hands with soap for 10 seconds and then rinsed and dried the hands. NA-H picked up the trash bag from the floor outside the room of Resident 44 and carried it into the utility room. Observation on 5/5/21 at 11:54 AM in the facility secured unit dining room revealed that Licensed Practical Nurse-I (LPN-I) picked up a plate of food from the 3 shelf cart and delivered the plate to Resident 36. LPN-I sat the plate on the dining room table in front of Resident 36. LPN-I went to the dining room sink and performed hand washing. LPN-I scrubbed the hands with soap for 11 seconds and then rinsed and dried the hands. LPN-I picked up silverware and napkins from the dish cart and placed a napkin and a set of silverware on the dining room table in front of Residents 15, 22, and 44. LPN-I placed a napkin and a set of silverware on the dining room table for Resident 8. LPN-I picked up a plate of food from the 3 shelf cart and sat the plate on the table in front of Resident 22. Observation on 5/5/21 at 12:08 PM in the facility secured unit dining room revealed that NA-H exited the room of Resident 24 and carried a bag of trash into the utility room. NA-H went to the dining room sink and performed hand washing. NA-H scrubbed the hands with soap for 14 seconds and then grabbed and touched the paper towel hanging from the dispenser with the left hand. NA-H resumed scrubbing the hands with soap for 3 seconds and then rinsed and dried the hands. NA-H picked up a plate of food from the 3 shelf cart and delivered the plate of food into the room of Resident 24. NA-H exited the room of Resident 24 and performed hand washing with alcohol based hand sanitizer (ABHR). NA-H assisted Resident 8 from a recliner to Resident 8's chair at the dining room table. Observation on 5/5/21 at 12:18 PM in the facility secured unit dining room revealed that LPN-I put on disposable gloves and sat down next to Resident 15 at the dining room table. LPN-I obtained a blood sample from a finger of Resident 15. LPN-I placed a drop of blood from the resident on the test strip in the glucometer (a medical device used to measure and display the amount of sugar in the blood for residents with diabetes). LPN-I went to the medication cart and removed the gloves. LPN-I recorded the blood sugar result and then went to the dining room sink. LPN-I performed hand washing and scrubbed the hands with soap for 5 seconds underneath running water and then dried the hands. LPN-I picked up a plate of food from the 3 shelf cart and delivered the plate to Resident 15. LPN-I sat the plate on the table in front of Resident 15 and then performed ABHR. Observation on 5/5/21 at 12:32 PM in the facility secured unit dining room revealed that Resident 4 was seated in a recliner. LPN-I carried a cup of food to Resident 4 and sat the cup on the over bed table in front of Resident 4. LPN-I assisted Resident 4 with the clothing protector (an adult bib). LPN-I went to the sink in the dining room and performed hand washing. LPN-I scrubbed the hands with soap for 11 seconds and placed the hands underneath the running water and scrubbed the hands for 6 seconds underneath the running water. LPN-I dried the hands. LPN-I sat down at the dining room table beside Resident 15 and assisted the resident with eating the meal. Observation on 5/6/21 at 11:40 AM in the facility secured unit dining room revealed that Licensed Practical Nurse-J (LPN-J) exited the room of Resident 24. LPN-J went to the dining room sink and performed hand washing. LPN-J scrubbed the hands with soap for 12 seconds and then rinsed and dried the hands. Observation on 5/6/21 at 11:47 AM in the facility secured unit dining room revealed that Nursing Assistant-K (NA-K) exited the room of Resident 24 and went to the dining room sink. NA-K performed hand washing and scrubbed the hands with soap for 12 seconds and then rinsed and dried the hands. Nursing Assistant-L (NA-L) performed hand washing at the dining room sink and scrubbed the hands with soap for 14 seconds and then rinsed and dried the hands. LPN-J prepared medications at the medication cart next to the dining room sink. LPN-J went to the sink and performed hand washing and scrubbed the hands with soap for 13 seconds and then rinsed and dried the hands. Interview on 5/11/21 at 11:03 AM outside the facility chapel with the Food Services Supervisor (FSS) confirmed that during hand washing staff are required to wet the hands and then apply soap. Staff are expected to scrub the hands with soap for 15 to 20 seconds before placing the hands underneath running water to rinse and dry the hands. FSS confirmed that if the hands touch any object during hand washing the staff should rewash the hands.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility failed to prevent the potential spread of Covid-19 and other infectious diseases by failing to doff PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) at the point of contact (staff exited residents' rooms with gown and gloves and walked down the hall with them on) which had the potential to affect all of the residents who resided on units 1, 2 and 3 who had not tested positive for Covid-19 or had tested positive over 90 days ago and were at risk for re-infection: Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26); failing to ensure the sit to stand lift sling was not used for multiple residents which affected 2 residents who had either not tested positive for Covid-19 or had Covid-19 more than 90 days ago and were at risk for re-infection (Residents 2 and 13) and placed 6 other residents at risk for cross contamination (Residents 27, 28, 29, 30, 31, and 32); and failing to ensure gloves were removed and hand hygiene performed after the gloves were contaminated before handling resident personal items which affected Resident 27. The facility identified a census of 55 at the time of survey. Findings are: Interview with the facility Administrator on 1/6/2021 at 9:45 AM revealed the entire facility was designated as a yellow zone (Quarantine zone for asymptomatic residents who may have been exposed to COVID-19) due to the residents potentiallly having been exposed to a Covid-19 positive contracted staff person on 12/28/2020. Staff were expected to wear N95 and eye protection at all times in the facility. Gown and gloves were to be worn in addition to the N95 and eye protection when staff went into the residents' rooms. Staff were required to wear an N95 and eye protection while they were in the hall but the gown and gloves were not required in the hall. Staff were expected to change their gown and gloves between resident rooms. Review of the facility Historical Positive Resident List received 1/6/2021 revealed 48 staff members and 43 residents had tested positive for Covid-19. 28 of those residents currently resided in the facility. 12 residents were positive for Covid-19 at the time of their death. Resident 2, Resident 25, and Resident 26 had tested positive for Covid-19 on 5/30/2020, which was beyond the 90 day window and were at risk for re-infection. Review of the facility Never tested Positive list received from the facility administrator on 1/7/2021 revealed the following residents had not tested positive for Covid-19 and were at risk for becoming infected: Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24. A. Observation of the facility on 1/6/2021 at 10:27 AM revealed NA-G (Nurse Aide) walked out of Resident 12's room wearing a washable gown and gloves and walked across and down the hall to a laundry and trash bins sitting in the hall. NA-G then doffed the gown and gloves and put them in the bins when NA-G got to them. NA-G placed the washable gown into the laundry bin and the gloves into the trash. There were staff in the hall that did not have a gown and gloves on and there were resident room doors open on the unit. Residents were observed in the rooms with the open doors. B. Observation of the facility on 1/6/2021 at 10:30 AM revealed NA-A and NA-B donned a gown and gloves and entered Resident 27's room. NA-A and NA-B assisted Resident 27 to the resident's chair with the STS lift (Sit to stand-a type of lift that utilizes a strap or belt placed around the person's back which is then connected to a mechanical lift which assists the person to a standing position). After Resident 27 was assisted into the chair in their room, NA-A removed the sling from around Resident 27's back and placed it over the bars of the lift. The sling was fabric. NA-B sprayed the lift with disinfectant spray and took it out of the room with the sling on the lift and left it on the lift in the hall. NA-B sprayed part of the back side of the sling as it was draped over the top of the lift. NA-B did not spray the straps or the underside of the sling which was touching the resident during the transfer. While they were assisting Resident 27, NA-A touched their face shield and face mask with their gloved hands then touched Resident 27's blanket, alarm box, and call cord which NA-A put in reach of Resident 27 on the blanket that was covering Resident 27. NA-A did not change their gloves or perform hand hygiene after touching their face shield and face mask before handling Resident 27's personal items. NA-A and NA-B then left Resident 27's room with their PPE on and went into the hall and removed the gown and gloves when they got to the bins that were sitting in the hall that was across and down the hall from Resident 27's room. There were other staff in the hall with no gown and gloves on and resident room doors were open. Residents were observed in the rooms with the open doors. C. Observation of Unit 2 on 1/6/2021 at 10:44 AM revealed MA-F (Medication Aide) walked out of the bath house with a green washable gown on, took the gown off as they walked down the hall past several open resident room doors then placed the gown in the bin. There were other staff in the hall without a gown and gloves on and MA-F walked by resident room doors that were open. Residents were observed in the rooms with the open doors. D. Observation of Unit 2 on 1/6/2021 at 10:45 AM revealed PTA (Physical Therapy Assistant) walked out of Resident 15's room with PPE on including a gown, gloves, mask, and face shield. PTA walked across and down the hall and discarded their PPE in containers in the hall. There were other staff in the hall without a gown and gloves on and PTA walked by resident room doors that were open. Residents were observed in the rooms with the open doors. E. Observation of Unit 1 on 1/6/2021 at 11:15 AM revealed NA-E came out of Resident 4's room wearing a gown and walked halfway down the hall then took it off and discarded it in a bin that was sitting in the hall. There were other staff in the hall without a gown and gloves and NA-E walked by resident room doors that were open. Residents were observed in the rooms with the open doors. F. Observation of Unit 2 on 1/6/2021 at 11:34 AM revealed NA-B came out of Resident 15's room with a gown on and walked down and across the hall to discard the gown. NA-B wore the gown in the hall and didn't remove it until they got to the bin to place the gown in it. NA-B walked past several open resident room doors and there were other staff observed in the hall who were not wearing a gown or gloves. Residents were observed in the rooms with the open doors. G. Observation of Unit 1 on 1/6/2021 at 11:37 AM revealed a STS lift in the hall with a fabric sling draped over it. H. Observation of Unit 2 on 1/6/2021 at 12:03 PM revealed NA-A took the STS lift with the same sling that had been used to transfer Resident 27 in to Resident 28's room. Observation of Unit 2 on 1/6/2021 at 12:37 PM revealed the STS lift and sling was sitting in the hall by Resident 28's room. Interview with NA-A at this time revealed the lift in the hall by the door was the lift they had used to assist Resident 28. The sling was laying over the lift out in the hall. I. Observation of Unit 2 on 1/6/2021 at 12:05 PM revealed NA-A and NA-H donned a gown and gloves and went into the room shared with Resident 18 and Resident 19 and assisted both residents with transfers and cares. NA-A and NA-H then left the room with their PPE on and walked across the hall, removed the gown and gloves, and placed them in bins in the hall. There were other staff in the hall with no gown and gloves on and resident room doors were open. Residents were observed in the rooms with the open doors. Interview with LPN-D (Licensed Practical Nurse) on 1/6/2021 at 11:20 AM revealed the staff wore the same face shield from room to room. LPN-D also confirmed the lifts were used for multiple residents. Interview with the facility Administrator on 1/7/2021 at 10:52 AM revealed the facility staff were not to leave the rooms with gown and gloves on unless all resident room doors were closed or if their hands were full and setting down the items prior to doffing would result in higher risk of transmission. The Administrator revealed the facility staff were expected to perform hand hygiene anytime they touched their facemask or face shield or when their hands were contaminated. The administrator revealed the staff were expected to use a separate lift sling for each resident. Review of the facility policy Hand Hygiene dated 4/2020 revealed the following: PURPOSE: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 4. Condition Antimicrobial Soap and Water: Hands are visibly dirty Hands are visibly soiled with blood or other body fluids Before and after eating After using a restroom Exposure to Bacillus anthracis is suspected or proven Exposure to [MEDICAL CONDITION] is suspected or likely (i.e. isolation room for [DIAGNOSES REDACTED]) Either Antimicrobial Soap and Water or Alcohol Based Hand Rub: When coming on duty Between resident contacts* After handling contaminated objects* Before performing invasive procedures Before applying and after removing personal protective equipment (PPE), including gloves Before preparing or handling medications Before and after handling clean or soiled dressings, linens, etc.* Before performing resident care procedures Before and after providing care to residents in isolation* After handling items potentially contaminated with blood, body fluids, secretions, or excretions* When, during resident care, moving from a contaminated body site to a clean body site* After assistance with personal body functions (e.g., elimination, hair grooming, smoking) After sneezing, coughing, and/or blowing or wiping nose Before going off duty When in doubt *For conditions involving a resident, or the resident's environment, who is isolated for [MEDICAL CONDITION], handwashing with antimicrobial soap and water is required. Review of the facility policy Personal Protective Equipment dated 3/20 revealed the following: POLICY: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators). PROCEDURE: 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. 3. Multiple factors determine the appropriate selection of PPE for a particular task: a. The type of exposure anticipated (e.g., splash/spray versus touch) b. The volume of fluid or tissue to which there is a potential exposure c. The likelihood of exposure d. The probable route of exposure (e.g., direct contact versus inhalation) e. The need for transmission-based precautions 4. Indications/considerations for PPE use: a. Gloves: i. Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment is anticipated. ii. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. iii. Non-sterile gloves are appropriate for most tasks. Use sterile gloves for sterile procedures. iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. v. Select gloves according to hand size. Extend the gloves to cover the wrist. vi. The outside of gloves are contaminated. Remove gloves to prevent contamination of hands by grasping outside of glove with opposite gloved hand, peel off, hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist, and turn the second glove inside out while pulling it away from your body (leaving the first glove inside the second). vii. Dispose of gloves in appropriate waste receptacle. viii. Do not reuse gloves. b. Gowns: i. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. ii. Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist. iii. Change gowns when heavily contaminated or torn. iv. The gown front and sleeves are contaminated. Remove gown inside the room at the door threshold to prevent contamination by pulling down in a peeling motion so that gown turns inside out, holding gown away from the body, and rolling the gown into a bundle. v. Dispose of gown into appropriate waste receptacle. vi. Do not reuse gowns. c. Face protection: i. Wear a mask to protect the face from contamination with blood, body fluids, and other potentially infectious materials during tasks that generate splashes or sprays. ii. Wear goggles or face shield as added face/eye protection. Personal eyeglasses are not a substitute for goggles. iii. Keep hands away from face. iv. Change when heavily contaminated or torn. v. The outside of goggles and face shields are contaminated. Remove to prevent contamination by grasping the clean headband or earpieces and pulling away from the body. vi. The outside of facemasks are contaminated. Remove to prevent contamination by grasping only the bottom, then top ties/elastics. vii. Place into appropriate waste receptacle. viii. Do not reuse. d. Respiratory protection: i. Wear a NIOSH-approved N95, KN95, or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route. ii. Select the size according to fit testing. iii. Remove according to instructions for the type of respirator. iv. Do not reuse single-use-only respirators. 5. Sequence of donning/removing PPE when using multiple types: a. Put on PPE in this order: gown, mask or respirator, goggle or face shield, then gloves. b. Remove PPE in this order: gloves, goggles or face shield, gown, then mask or respirator. Perform hand hygiene immediately after removing all PPE. 6. PPE supply management: a. The central supply clerk is responsible for ordering and maintaining adequate PPE supplies and stocking in appropriate facility locations to ensure access to staff who need them. i. During a pandemic, PPE supply areas may be altered to accommodate zoning procedures. ii. PPE should be covered or in closed containers while in storage b. Direct care staff shall check supply of gloves in each room during shift change and restock as needed. c. The charge nurse shall check isolation supply carts twice per shift (such as beginning and halfway point), and replenish as needed. d. The Infection Preventionist shall notify the supply clerk and/or Director of Nursing when more than usual supplies are needed (i.e. during periods of outbreaks, flu season, or when there are more than usual number of residents on transmission-based precautions). 7. Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed. Review of the facility policy COVID-19 (Pandemic) Zones dated 5/2020 revealed the following: PURPOSE: It the purpose of this policy to identify and cohort residents with similar illness per the recommendations of the CDC, which is subject to change based on the evolution of the disease. PROCEDURE: 1. Red Zone: Isolation Zone a. Dark Red = Residents with Positive COVID-19 test i. PPE includes: gown, gloves, eye protection and N95/KN95 mask ii. N95/KN95 is preferred, but if not available then use a surgical mask with face shield b. Light Red = Symptomatic residents suspected having COVID-19 i. PPE includes: gown, gloves, eye protection and N95/KN95 mask ii. N95/KN95 is preferred, but if not available then use a surgical mask with face shield c. If entire area is red zoned, the same gown may be used between rooms unless it becomes visibly soiled. i. Doff gloves and visibly soiled gown inside the threshold of the room and dispose of in appropriate receptacle. 2. Yellow Zone: Quarantine Zone a. Asymptomatic residents who may have been exposed to COVID-19 i. PPE includes: gown, gloves, eye protection and N95/KN95 mask ii. N95/KN95 is preferred, but if not available then use a surgical mask with face shield iii. Don gown and gloves outside of room. iv. Doff gown and gloves in room at the threshold and dispose of in appropriate receptacles to prevent contamination into other rooms/hallway 3. Green Zone: COVID-19 Free Zone a. Asymptomatic residents without any exposure to COVID-19 i. PPE includes: Surgical mask and PPE per standard precautions ii. Facility may choose to implement N95/KN95 masks for direct care givers in the green zone based on community spread 4. Gray Zone: Transitional Zone (Post-Acute Care Wing) a. Residents who are being transferred from hospital/outside facilities (but have no known exposure to COVID-19) are usually kept in this zone for 14-days b. If they remain asymptomatic at the end of the 14-days they may be moved to the Green Zone i. PPE includes: gown, gloves, eye protection and N95/KN95 mask ii. N95/KN95 is preferred, but if not available then use a surgical mask with face shield

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to prevent and/or contain COVID-19 by 1) staff failing to perform hand hygiene when leaving the red zone and after working with residents residing on the yellow zone units; 2) failing to store re-usable PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) in a manner to prevent potential cross contamination; and by 3) failing to reduce the potential for cross contamination by wearing excess jewelry while working in the yellow zone. This had the potential to affect all of the facility residents. The facility identified a census of 49 at the time of survey. Findings are: A. Observation on 10/27/2020 at 12:00 PM revealed face shields hanging on hooks on the wall outside the Angel's Way (locked Special Care Unit). The face shields were not covered. B. Observation of the wall outside the yellow zone on 10/27/2020 at 1:22 PM revealed a hooded sweatshirt hanging outside the yellow zone door on the hooks on the wall. There were also uncovered face shields hanging on the hooks. C. Observation on 10/27/2020 at 1:24 PM revealed face shields and a KN95 face mask hanging on the hooks outside the door by the Angel's Way. They were uncovered. D. Observation on 10/27/2020 at 1:25 PM observed AA-C (Activities Aide) working on and then leaving the red zone. AA-C was standing inside the double glass doors on the unit. AA-C had a clipboard with papers on it and was wearing a gown, gloves, face shield and KN95 face mask. AA-C put the clipboard down on the floor against the wall and removed the gown and gloves and discarded them in a garbage can inside the red zone unit. AA-C then picked up the clipboard and walked out the door. AA-C did not do any hand hygiene. AA-C then removed the face shield and carried it as AA-C walked across the dining room. AA-C then walked into an area off the dining room. Interview with AA-C revealed the area was the break room for Joe's way which was the Red Zone unit. AA-C also had a clipboard and pen that AA-C had with AA-C in the red zone. It was on the table as well and AA-C was writing on it. AA-C put the face shield back on and left the break room. E. Observation on 10/27/2020 at 1:54 AM revealed NA-D (Nurse Aide) came down the hall after coming out of an unidentified resident's room. NA-D had a blue absorbent cloth under pad in one hand and 2 clear plastic re-usable glasses stacked on top of each other in the other hand. NA-D put the under pad in a soiled laundry cart and the glasses on another cart that appeared to have dirty dishes on it. NA-D did not do any hand hygiene then walked into the bath house and did a verbal demonstration of the whirlpool cleaning process then left the bath house. Interview at 2:17 PM with the IP (Infection Preventionist) confirmed the cart where NA-D put the glasses and did not do hand hygiene before going into the bath house was a dirty dish cart. Interview with the DON (Director of Nursing) on 10/27/2020 at 3:10 PM revealed the staff were to clean the face shields with antimicrobial wipes after they left the zones. The zones had areas outside the zone with hooks to place the face shields so they could dry. The DON revealed the staff left the face shields on the hooks until the next shift. The DON revealed the staff were not supposed to hang the KN95's on the hooks. The DON revealed the KN95's should either be on their face or in the trash as the KN95's were not reusable. Interview with the facility Administrator on 10/30/2020 at 11:01 AM revealed staff were staff were expected to do hand hygiene when leaving the COVID unit and after handling soiled items. Review of the facility policy Hand Hygiene dated 4/2020 revealed the following: PURPOSE: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 4. Condition Antimicrobial Soap and Water: Hands are visibly dirty Hands are visibly soiled with blood or other body fluids Before and after eating After using a restroom Exposure to Bacillus anthracis is suspected or proven Exposure to [MEDICAL CONDITION] is suspected or likely (i.e. isolation room for [DIAGNOSES REDACTED]) Either Antimicrobial Soap and Water or Alcohol Based Hand Rub: When coming on duty Between resident contacts* After handling contaminated objects* Before performing invasive procedures Before applying and after removing personal protective equipment (PPE), including gloves Before preparing or handling medications Before and after handling clean or soiled dressings, linens, etc.* Before performing resident care procedures Before and after providing care to residents in isolation* After handling items potentially contaminated with blood, body fluids, secretions, or excretions* When, during resident care, moving from a contaminated body site to a clean body site* After assistance with personal body functions (e.g., elimination, hair grooming, smoking) After sneezing, coughing, and/or blowing or wiping nose Before going off duty When in doubt *For conditions involving a resident, or the resident's environment, who is isolated for [MEDICAL CONDITION], handwashing with antimicrobial soap and water is required. Review of the facility policy Personal Protective Equipment dated 3/20 revealed the following: POLICY: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators). a. Face protection: i. Wear a mask to protect the face from contamination with blood, body fluids, and other potentially infectious materials during tasks that generate splashes or sprays. ii. Wear goggles or face shield as added face/eye protection. Personal eyeglasses are not a substitute for goggles. iii. Keep hands away from face. iv. Change when heavily contaminated or torn. v. The outside of goggles and face shields are contaminated. Remove to prevent contamination by grasping the clean headband or earpieces and pulling away from the body. vi. The outside of facemasks are contaminated. Remove to prevent contamination by grasping only the bottom, then top ties/elastics. vii. Place into appropriate waste receptacle. viii. Do not reuse. b. Respiratory protection: i. Wear a NIOSH-approved N95 or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route. ii. Select the size according to fit testing. iii. Remove according to instructions for the type of respirator. iv. Do not reuse single-use-only respirators. F. Observation of EVS Aide-A (Environmental Services Aide) cleaning a Room on the 200 hallway. The EVS Aide was finishing up in the room and was mopping the floor. The EVS Aide-A cleaned the entire floor and removed the gloves and discarded them into the trash can inside the resident's room. The EVS Aide-A removed the isolation gown and placed it into the dirty laundry. The EVS Aide-A then completed hand hygiene with hand sanitizer. The EVS Aide-A used a quarter sized amount of hands sanitizer and scrubbed the tops, bottoms and between the fingers of both hands. While the EVS Aide-A was using the hand sanitizer it was observed the EVS Aide-A had a ring on the index, middle, ring and pinky fingers on both hands. When the EVS Aide-A was asked about wearing so many rings while there was an [MEDICAL CONDITION] outbreak EVS Aide-A stated, My spouse asked the same thing and I told my spouse that no one had told me that I couldn't wear them so I am going to keep wearing them. It was observed each of the 4 rings (total of 8) on both hands had sets and raised jewels in them. The EVS Aide-A did hand hygiene but extra care of making sure each ring was cleansed with hand sanitizer was not completed. On 10/27/2020 at 3:44 PM an interview with the IP (Infection Preventionist) revealed that staff are to wear simple jewelry only and not have excessive amount of jewelry on especially rings. When asked what was meant by simple the IP replied a wedding band or single ring only. ON 10/27/2020 at 3:57 PM an interview with NSM (Nutritional Services Manager) revealed the NSM's expectation was for the staff to wear a simple ring and not a lot of jewelry. The NSM also confirmed that EVS Aide-A was wear an excessive amount of jewelry. Review of the Dress Code policy revealed that, * Jewelry should not be functionally restrictive, dangerous to job performance, or excessive. The facility also reserves the right to ask any employee to change their jewelry if found to be of a safety concern.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations, interviews and record reviews the facility failed to provide privacy to residents during personal cares this involved 2 of 7 sampled residents (Resident 5 and Resident 7). The facility census at the time of the survey was 63. Findings: A. An observation on 8/10/2020 at 11:22 AM of Resident 5's room noted a video camera on bedside table. The video camera was set to view the entire length of the bed from head to foot. On 8/10/2020 at 11:25 an attempted interview with Resident 5 revealed Resident 5 was non-interviewable. When trying to speak to the Resident 5 was speech was in word salad (phrases that do not make a complete sentence). Resident 5 was sitting in commons area in a recliner with Resident 5's feet elevated talking to a baby doll. Review of Resident 5's MDS (Minimum Data Set, a federally mandated assessment tool used in care planning) dated 6/25/2020 revealed for Section G Resident 5 was extensive assistance for bed mobility, transfers, walk in room and corridor, toilet use and personal hygiene. Limited assistance for locomotion on and off unit, dressing, and eating. Review of Section C listed a BIMS (Brief Interview of Mental Status, mandatory interviewing tool used to assist with identifying a resident's cognitive function) score of 1 was obtained. This indicated a severe cognitive impairment. Review of the PN (Progress Notes) for Resident 5 revealed documentation on video monitor twice from 5/14/2020 through 8/09/2020. PN dated 6/12/2020 at 6:52 PM: Continues with fall interventions in place. Restless this evening. Able to be redirected to recliner with baby doll. Video monitoring continues at bedside. PN dated 5/17/2020 at 11:49 PM: Resident cooperative with staff and cares this evening. Does become upset temporarily due to noise around Resident 5/other residents being loud. Resident 5 was able to be redirected easily and is otherwise very pleasant with staff. Sleeps well in bed without restlessness or attempt to self-transfer. Continues with video monitoring at bedside. Review of Resident 5's Care Plan revealed the following , Added video monitor to room due to frequent self-transfers and limited cognitive ability to call for help, not knowing own limitations and inability to follow directions. The Care Plan does not state that the monitor needs to be turned off while doing person cares for Resident 5 to maintain privacy. On 8/10/2020 at 11: 35 AM an interview with NA-B (Nurse Aide) revealed that residents are checked on hourly rounding and during the checks the residents are checked to make sure fall mats are in place, the call lights are within reach, alarms are working and the resident doesn't need anything. If a resident has a bed or chair alarm they are never left in the restroom alone. On 8/10/2020 at 12:23 PM an interview with LPN-A (Licensed Practical Nurse) revealed the camera and monitor are used at night and whenever the resident was laying down in bed. Resident 5 does spend a lot of time during the day here in the recreational area. The video was not recorded. The camera was used for a fall intervention and to monitor Resident 5 at night due to falls. The staff do not carry it around with them because it needs to be plugged in. On 8/10/2020 at 12:35 PM observation of the video monitor screen for the camera that was in Resident 5''s room revealed the video monitor screen was on the desk by a computer in the commons area. The video monitor screen was plugged in and was sitting within the view of anyone who was in the area. LPN-A turned on the video monitor and a view of the entire length of the bed from the head to the foot was observed on the video monitor screen. B. On 8/10/2020 at 11:32 AM observation of Resident 7 in Resident 7's room revealed Resident 7 walking in the room with a walker. Resident 7 applied a face mask and walked into the hallway. Observation of resident's room revealed there was a note on yellow paper on the outside of the bathroom door that stated when resident was in the bathroom Resident 7 wants the bathroom door shut. An interview on 8/10/2020 at 1:42 PM with Resident 7 revealed Resident 7 felt the staff are pleasant. When asked if Resident 7 asked if Resident 7 was provided privacy Resident 7 replied, Only if I show this to the staff. Resident 7 then closed the bathroom door and presented a hand written note on a yellow piece of paper that Resident 7 removed from the bathroom door. The note stated when Resident 7 was in the bathroom the staff are to shut the bathroom door. Resident 7 further replied that when Resident 7 was in the bathroom the staff will come into the room and open the bathroom door telling Resident 7 that Resident 7 can't be left alone. Resident 7 replied that Resident 7 wants privacy and feels Resident 7 had earned it and deserves it. Review of Resident 7's MDS (Minimum Data Set, a federally mandated assessment tool used in care planning) for Resident 7 dated 7/27/2020 a Medicare 5 Day assessment under Section G for Activities of Daily Living (ADL) Assistance revealed for toilet use that resident was Independent with setup help only needed and Personal hygiene was listed as Supervision with setup help only required. Resident 7 was independent with bed mobility, transfer, locomotion on and off unit, and eating. Resident 7 was coded as Supervision with walk in room and corridor and dressing. Review of Section C listed a BIMS (Brief Interview of Mental Status, a mandatory interviewing tool used to assist with identifying a resident's cognitive function) score of 14. This score indicates an intact cognitive response. 08/11/2020 at 4:13 PM Review of Resident 7's Care Plan for toileting revealed Resident 7 was modified independent with toileting and independent with personal hygiene. Review of the policy Resident Rights dated 11/19 revealed the privacy listed with regarding to personal care of the residents and the rights of privacy with cares. Policy: The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State and Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. PROCEDURE: 8. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. b. The resident has a right to secure and confidential personal and medical records except as provided at 483.70 (i) (2) or other applicable federal or state laws. 08/11/2020 at 5:13 PM Review of the Policy for Video and Audio Room Monitoring dated 12/19 revealed: POLICY: It is the facility's purpose to provide safe monitoring for those residents that may be risk for harm or at risk for harming others. PROCEDURE: 1. Audio monitors may be used in semi -private rooms, as long as both families are made aware. 2. Video monitors may be placed in a private room only, as long as the family has been made aware. a. If significant safety concerns arise for a resident in a semi-private room, a video monitor may be used as long as both POA's have been made aware and the video monitor only monitors the resident of concern. 3. The monitors shall be kept at the nurse's station behind the desk. 4. The use of the monitors will be added to resident care plan. 5. If the monitor is no longer needed, the Risk/Behavior Committee may remove the intervention when see fit.

Licensure Reference Number: 175 NAC 12-006.11E Based on observations, record reviews, and interviews, the facility failed to: 1) ensure opened used food items were dated and labeled; and 2) prevent ice buildups in the walk-in freezer in the kitchen. This failure could potentially cause cross-contamination for all facility residents. Facility census was 68. Findings are: [NAME] Kitchen Observation on 8/19/19 at 2.15 p.m. There were open food items in the walk in freezer that were not labeled or dated. These Items were located on the top shelf on the right side as you walked into the walk in freezer and they appeared to be some kind of meat patties. Kitchen Observation on 8/21/19 at 10:54 a.m. There were open food items in the walk in freezer that were not labeled or dated. These Items were located on the top shelf on the right side as you walked into the walk in freezer and they appeared to be some kind of meat patties. Staff interview on 8/21/19 at 1:30 p.m. Administrator and Dietary Manager verified that food items located on the top right hand shelf of the walk in freezer were not labeled or dated. Dietary Manager Confirmed that any food items that were left open should have been labeled and dated. Review of the 07/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices revealed the following: 3-201.11 (C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-201.17 and 3-202.18. B. Kitchen observation on 8/19/19 at 2:15 p.m. there was ice build up on the ceiling and door of the walk in freezer located in the Kitchen. Kitchen observation on 8/21/19 at 10:51 a.m. there was ice build up on the ceiling and door of the walk in freezer located in the Kitchen. Staff interview on 8/21/19 at 1:30 p.m. Administrator and Dietary Manager verified there was ice build up on the freezer door and ceiling of the walk in freezer located in the freezer. Review of the 07/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices revealed the following: 3-303.12-(A) Packaged food may not be stored in direct contact with un-drained ice. Source: Quality Assurance & Food Safety, (MONTH) (YEAR) quotes the Food and Drug Administration and the United States Department of Agriculture/Food and Safety Inspection Service Related to Condensation in guidance documents with the most recent a draft guidance from the Food Safety Modernization Act. The preventive rule discusses condensation buildup as a hazard for listeria, salmonella, and molds that produce mycotoxins (substances produced by mold growing in food that cause illness or death when ingested by man).

Licensure Reference Number: 175 NAC 12-006.12E1 Based on observations, record reviews, and interviews, the facility failed to ensure open dating on two multi-dose vials of [MEDICATION NAME] ([MEDICATION NAME] testing solution) in one of three medication storage areas. Facility census was 68. Findings are: Observation on 8/19/19 at 2:42 p.m. revealed two multi-dose vials of [MEDICATION NAME] were stored in the St. Joe's wing medication storage refrigerator. Further observation revealed the multi-dose vials had been opened and used, but neither vial was labeled to indicate when the vials were opened for use. Observation and interview on 8/19/19 at 3:45 p.m. with RN (Registered Nurse)-A confirmed the two multi-dose vials stored in the St. Joe's wing medication storage refrigerator had been opened but undated as to when the vials were opened and used. Interview with the DON (Director of Nursing) on 8/19/19 at 4:00 p.m. verified that [MEDICATION NAME] multi-dose vials should include dating when opened to ensure vials are discarded as directed by the manufacturer. Source: Package Insert instructions for [MEDICATION NAME] multi-dose vials. Regarding Storage the insert described A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded.

Licensure Reference Number: 175 NAC 12-007.04D Based on observations and interviews, the facility failed to ensure bathroom mechanical ventilation was operational on one of three clinical areas. Facility census was 68. Findings are: Observation on 8-20-19 at 10:25 a.m. Tissue test was completed on bathroom vents for rooms 201-2, 204-2, 206-1 and 209-2 and the bathroom vents were not operational in any of these identified rooms. Observation on 8-20-19 at 3:01 a.m. Tissue test was completed on bathroom vents for rooms 201-2, 204-2, 206-1 and 209-2 and the bathroom vents were not operational in any of these identified rooms Staff interview on 8-20-19 at 3:36 p.m. Administrator and Maintenance Supervisor verified that bathroom vents in rooms 201-1, 204-2, 206-1, and 209-2 were not operational. Maintenance Supervisor reported the motor that operates the vents on this 200 hall was not operational and this would be repaired immediately.

Based on record reviews and interview, the facility failed to obtain a PASRR (Pre-Admission Screening and Review, an assessment to determine proper placement of residents with serious mental illness or developmental disabilities) screen for one sampled resident (Resident 22) with changes in mental health diagnosis. Facility census was 68. Sample size was 19 current residents. Findings are: The Admission Record for Resident 22 showed this resident was initially admitted to the facility on [DATE]. This record also included a [DIAGNOSES REDACTED]. The facility's Medical Records department provided a copy of the PASRR screening completed prior to the resident's admission. This screening indicated that Resident 22 did not have any serious mental illnesses including [MEDICAL CONDITION]. On 8/20/19 at 3:25 PM, an interview with the DON (Director of Nursing) verified that Resident 22 had returned from a brief hospitalization in (MONTH) of (YEAR) with a new [DIAGNOSES REDACTED]. The DON also verified that this new [DIAGNOSES REDACTED].

Based on record reviews and interviews, the facility failed to ensure that as needed anti-psychotic medication was reviewed by the physician in face to face evaluation for one sampled resident (Resident 27). Facility census was 68. Sample size was 5 current residents. Findings are: Record review of Resident 27's Medication Administration Record [REDACTED]. Listed among the medications ordered for the resident by the physician was an order for [REDACTED]. Review of Resident 27's electronic medical record revealed the physician had not assessed the resident's condition every two weeks throughout the duration of the as needed order for ABH Gel use. Interview with the DON (Director of Nursing) on 8/21/19 at 10:00 a. m. verified Resident 27 was ordered an as needed medication of ABH Gel in (MONTH) and re-ordered with a duration of 12 months on 8/8/19. The DON confirmed the physician had not assessed the resident's condition every two weeks to determine the need to continue with the Anti-pscyhotic as needed medication.

Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to obtain or re-evaluate the continued use of duplicate anticoagulant (medications that reduce blood clotting) medications for one sampled resident (Resident 42). Facility census was 68. Sample size was 19 current residents. Findings are: Record review of Resident 42's Medication Administration Record [REDACTED]. Further review of the record revealed the resident had physician orders [REDACTED]. - Xarelto 15 milligrams every evening for stroke prevention. The start date for the medication was 3/29/19. - [MEDICATION NAME] Bisulfate (generic name for [MEDICATION NAME]) 75 milligrams daily. Record review of an undated pharmacy Admission Medication Regimen Review for Resident 42 signed by the pharmacist recorded in the preliminary admission review of medications requested a review of Duplicate orders for therapeutically similar medications: [REDACTED] Record review of Resident 42's electronic medical record and scanned documents revealed there was no documentation by the pharmacist or physician addressing the use of duplicative anticoagulants including rationale for the continued use and need for the medications to be administered concurrently. Interview with the DON (Director of Nursing) on 8/21/19 at 10:00 a.m. confirmed Resident 42 was receiving two anticoagulant medications ([MEDICATION NAME] and Xarelto) since being admitted on [DATE]. The DON verified there was no documentation by the pharmacist or physician providing rationale or the need for continued need and use of duplicative anticoagulant medications.

Based on record reviews and interviews, the facility failed to ensure one sampled resident (Resident 34) was offered a Pneumococcal vaccination. Facility census was 68. Sample was five current residents. Findings are: The Admission Record for Resident 34 revealed an initial admission date of [DATE]. Review of records for Resident 34 did not show any Pneumococcal vaccines had been offered or given. A fax from the resident's primary physician signed 4/8/19 showed that there was no record regarding the [MEDICATION NAME] (1. pneumococcal [MEDICATION NAME] vaccine) immunization for this resident. The Quarterly MDS (Minimum Data Set, a federally mandated assessment and tracking tool) completed on 6/27/19 showed no Pneumococcal vaccine had been received by Resident 34 and indicated that the vaccine was not offered. On 8/20/19 at 5:14 PM, an interview with the DON (Director of Nursing) verified no Pneumococcal vaccine had been offered or provided to Resident 34 and that there was no apparent medical contraindication which would have prevented this immunization from being given. The facility's Operational Guideline on the subject Pneumococcal Vaccine dated 11/17 showed, Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. 1. https://www.cdc.gov/pneumococcal/vaccination.html accessed 8/26/19

LICENSURE NUMBER 175 NAC 12-006.09D1c Based on record reviews, and interviews, the facility failed to ensure 5 dependent residents requiring ADL (Activities of Daily Living) assistance had call lights answered in a timely manner. Findings are: A. Interview on 12-31-18 at 12:30 PM with Resident 200 revealed sometimes it took the staff a long while to answer the call lights. Review of Resident 200's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-6-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated a moderate impairment of cognition. Resident 200 required extensive assist of 2 staff with bed mobility, transfers, and toileting. Review of Resident 200's call light report for the month of (MONTH) (YEAR) revealed 38 call lights over 10 minutes (with 5 of those lights being in the 30 plus minutes, 1 at 48 minutes, 2 at 62 minutes, and 1 at 90 minutes). B. Observation on 12-31-18 at 3:20 PM in Resident 301's room revealed resident was in bed awake and the call light was on the floor on top of the fall mat beside the bed. Review of Resident 301's MDS dated [DATE] revealed a BIMS score of 4 which indicated severe cognitive impairment. Resident 301 was totally dependent on staff for transfers. Review of the facility Grievance Log revealed on 5-14-18 the family complained about the Resident 301's call light not being with in reach of the resident. C. Interview on 12-31-18 at 3:00 PM of Resident 208 revealed the resident often has had to wait 30 minutes or more to have the call light answered by staff. At times it even up to an hour. Review of Resident 208's MDS dated [DATE] revealed the resident required extensive assist with 2 staff for bed mobility and toileting. The resident was totally dependent on staff for transfers. The BIMS was 15 which indicated the resident had no cognitive impairment. Review of Resident 208's call light report for the month of (MONTH) (YEAR) revealed 37 call lights over 10 minutes. Of the 37 call lights, 4 of them were over 40 minutes and 6 of them in the 30 minute range. D. Observation on 12-31-18 at 2:40 PM of Resident 303 revealed the resident sitting in a leisure chair in the resident's room without the call light in reach. The call light was on the floor beside the chair. Interview on 12-31-18 at 2:50 PM with Resident 303 revealed there are times the resident has to wait a long time for someone to answer the call lights, even up to 1 hour. Review of Resident 303's MDS dated [DATE] revealed a BIMS of 15 which indicated no cognitive impairment. Resident 303 required extensive assist of staff for transfer, bed mobility, and toileting. Interview on 12-31-18 at 3:20 PM with NA-A revealed the facility expectation is to answer call lights within 15 minutes of the call light turning on. Review of the call light report provided by the ADM for (MONTH) 1-31st, (YEAR) revealed 66 call lights over 10 minutes. Of these 66 call lights 7 were in the 30 minute range, 4 in the 40 minute range, 3 in the 50 minute range, 2 in the 60 minute range, and 1 was 75 minutes long. Interview on 12-31-18 at 5:10 PM with the Administrator confirmed the residents were expected to have their call lights within reach at all times. Administrator also confirmed the long call lights were unacceptable.

LICENSURE REFERENCE 175 NAC 12-006.11D Based on observations and interview, the facility failed to ensure that opened packages of food were dated. This had the potential to affect all 67 residents that ate food from the kitchen. The facility census was 67. Findings are: Initial tour of the kitchen on 5/22/18 at 9:15 AM revealed that 2 packages of raisin bran, 1 package of cheerios, and 1 package of corn flakes, that were stored in the cabinet below the ice machine, were opened but were not dated as to when they were opened. Observation on 5/24/18 at 9:47 AM revealed that 1 package of cheerios, 1 package of corn flakes, 1 package of wheat bread, 1 package of hamburger buns, 1 package of raisin bread and 1 package of English muffins that were opened but were not dated as to when they were opened. Review of the facility policy, titled Labeling and Dating Food and Liquids, with a revised date 11/2017; stated that Obviously recognizable items do not need to be labeled as to what it is, e.g., dry, uncooked macaroni, uncooked rice, etc., but do need to be dated with the date that it was opened. Interview on 5/24/18 at 10:20 AM with the CDM (Certified Dietary Manager) confirmed that there were opened packages of cheerios, corn flakes, wheat bread, hamburger buns, raisin bread and English muffins that were opened and did were not dated as to when they were opened.

LICENSURE REFERENCE: 175 NAC ,[DATE].09D9 Based on record review and interview, the facility failed to provide adequate fluid intake to prevent dehydration for 1 (Resident 105) of 11 residents reviewed. The facility census was 72 at the time of the complaint investigation and the survey sample size was 11. Findings are: Resident 105 was admitted to the facility on [DATE] according to the ADMISSION AND DISCHARGE SUMMARY on the medical record. The following [DIAGNOSES REDACTED]. According to PUBMED HEALTH, Prerenal Azotemia is "an abnormally high level of nitrogen-type wastes in the blood" that could be caused by "prolonged vomiting or diarrhea". "Lab tests show that nitrogen-type wastes, such as creatinine and urea, build up in the body (azotemia). These waste products act as poisons when they build up. They damage tissues and reduce the ability of the organs to function". Review of Resident 105's Comprehensive Care Plan dated [DATE] revealed that a problem of "RISK FOR DEHYDRATION" had been identified with the need for fluids available in the room. The goal was for Resident 105 to have no complications from dehydration resulting in hospitalization . The approach was to monitor for signs of dehydration such as strong urine odor and changes in behavior and increased confusion. Facility staff were to make sure that fluids were within reach in room, offer fluids with cares and when in room and encourage fluids with and between meals. From [DATE] until Resident 105 was admitted to the hospital on [DATE], Resident 105 had experienced bouts of nausea and vomiting, diarrhea stools, foul, strong urine, elevated temperatures and was having poor nutritional intakes. Further review of Resident 105's medical record revealed no documentation of fluid intake to monitor for sufficient hydration. Documentation in the Nurse's Notes from [DATE] until hospitalized on [DATE] revealed that Resident 105 had taken sips of water, juice, nutritional supplements; however, there were no totals of intake versus output to ensure that adequate fluid intake was occurring to prevent dehydration. Documentation in Resident 105's Nurse's Notes dated [DATE] revealed that the facility had received a call from the physician's office that Resident 105 had been admitted to the hospital for dehydration and [MEDICAL CONDITION]. On [DATE] at 10:00 AM, documentation in the Nurse's Notes revealed that the facility had received an update that Resident 105 was receiving antibiotics for pneumonia and IV's (intravenous) fluids for hydration. The resident was in [MEDICAL CONDITION]. On [DATE], the facility received notice that Resident 105 had expired. Interview on [DATE] at 3:12 PM with the ADON (Assistant Director of Nursing) confirmed that there was no evidence of amounts of fluid intake documented other than supplements to ensure that Resident 105 was consuming sufficient fluids to prevent dehydration from occurring. Review of Resident 105's Discharge Summary from the Hospital dated [DATE] revealed that Resident 105 was admitted to the hospital with [REDACTED]. On admission to the Hospital, it was noted that Resident 105 had an elevated white blood count, was minimally responsive and had rales in lung bases.

LICENSURE REFERENCE: 175 NAC ,[DATE].09 Based on record review and interview, the facility failed to ensure services were provided and assessment performed in a timely manner when there was a change in condition for 1 (Resident 105) of 11 residents reviewed. In addition, the facility failed to perform assessments on residents who fell with a possible head injury for 1 (Resident 102) of 11 residents reviewed. The facility census was 72 at the time of the complaint investigation and the survey sample size was 11. Findings are: A. Resident 105 was admitted to the facility on [DATE] according to the ADMISSION AND DISCHARGE SUMMARY on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 105's PHYSICIANS ORDERS dated [DATE] revealed that the resident was a Full Code. Review of Resident 105's Comprehensive Care Plan dated [DATE] revealed an approach to monitor Resident 105 for any changes or decline in cognition and notify the physician if needed. In addition, a problem of "RISK FOR DEHYDRATION" had been identified with the need for fluids available in the room. The goal was for Resident 105 to have no complications from dehydration resulting in hospitalization . The approach was to monitor for signs of dehydration such as strong urine odor, changes in behavior and increased confusion. Facility staff were to make sure that fluids were within reach in room, offer fluids with cares and when in room and encourage fluids with and between meals. Review of Resident 105's Nurse's Notes dated [DATE] at 2:15 PM revealed that Resident 105 left the facility to go to an eye appointment and returned to the facility at 4:20 PM. At 10:30 PM on [DATE], documentation in the Nurse's Notes revealed that the resident's urine was "very foul" and the resident was incontinent of urine while in the wheelchair. There was no further documented follow-up or assessment in Resident 105's Nurse's Notes of the foul urine or the amount of urine output Resident 105 was experiencing. Documentation in the Nurse's Notes revealed that on [DATE] at 4:40 AM, Resident 105 had a large emesis of grape juice and undigested food. At 5:00 AM on [DATE], documentation in the Nurse's Notes revealed that Resident 105 had another large emesis and the physician was notified and orders received for [MEDICATION NAME] 12.5 mg suppository to be administered every 8 hours PRN (as necessary) for 2 days. Further review of Resident 105's Nurse's Notes revealed on [DATE] at 10:30 AM, Resident 105 continued to have nausea and vomiting with a small liquid emesis and the physician was updated on the resident's condition. On [DATE] at 12:35 PM, Resident 105 had a large diarrhea stool and the accucheck (blood sugar check) was 260 (normal range is ,[DATE]). Resident 105's physician's orders dated [DATE] were to check Accuchecks 2 times a week at 7:00 AM and 5:00 PM on Tuesdays and Fridays; however, there were no parameters documented to direct nursing staff when to notify the physician of elevated blood sugars. According to the Nurse's Notes dated [DATE] at 10:50 PM, Resident 105 was noted to have a 99.9 degree F (Fahrenheit) temperature. Documentation in the Nurse's Notes revealed that Resident 105 took sips of juice and water; however, there were no totals of fluid documented to ensure that the resident was consuming sufficient fluids to prevent dehydration. On [DATE] at 2:30 AM, documentation in the Nurse's Notes revealed that Resident 105 had a 99.7 degree F temperature and at 8:50 AM the temperature remained elevated at 99.1 degree F. At 2:20 PM on [DATE], Resident 105's temperature was noted to be 100.0 degrees F with the resident complaining of being uncomfortable and being hot. Tylenol 325 mg 2 tabs were documented as being administered to Resident 105 at that time; however, there was no further assessment documented of Resident 105's condition until 2:40 AM on [DATE], a period of 12 hours. On [DATE] at 2:40 AM, documentation in the Nurse's Notes for Resident 105 revealed a note that the resident had a 99.0 degree F temperature and sips of water were given. The resident was noted to have pale, warm and dry skin. At 10:00 PM, Resident 105 was noted to still be having loose stools with no further assessment documented of Resident 105's hydration status. On [DATE] at 1:00 AM, Nurse's Notes documented that Resident 105 had a 99.1 degree F temperature with continued diarrhea and sips of water were given frequently to prevent 'dehydration'. There was no documented assessment to ensure that the resident was taking in sufficient fluids to prevent dehydration. On [DATE] at 2:15 PM, documentation in the Nurse's Notes revealed that Resident 105 was complaining of chest discomfort, describing it as "burning". In addition, Nurse's Notes on [DATE] at 11:15 PM revealed that Resident 105 had experienced 3 diarrhea stools; however, there was no further documented assessment of the chest pain, diarrhea stools or fluid intake to ensure that Resident 105 was maintaining hydration status. On [DATE] at 8:55 AM, documentation in the Nurse's Notes revealed that Resident 105 complained of nausea with [MEDICATION NAME] administered as ordered by the physician on [DATE]. At 12:30 PM on [DATE], documentation in Resident 105's Nurse's Notes revealed that Resident 105 was assisted with taking noon fluids and then had an emesis of undigested food and a temperature of 99.0 degree F. Documentation in Resident 105's Nurse's Notes on [DATE] at 1:00 PM revealed Resident 105 was taking sips of fluids; however, there was no further assessment of Resident 105's status until Nurse's Notes on [DATE] at 12:00 AM documented a temperature of 97.8 degrees F. On [DATE] at 1:30 PM, documentation in Resident 105's Nurse's Notes revealed that the resident continued to be very weak and slow to respond. Resident 105 was also noted to have a poor appetite. On [DATE] at 1:30 PM, the physician was finally notified again, a week after the resident first experienced signs and symptoms of illness with possible dehydration noted in the Nurse's Notes. The next assessment of Resident 105 was documented in the Nurse's Notes on [DATE] at 5:50 PM that the resident took sips of juice, water, supplement and soup with no complaints of nausea or vomiting and a temperature of 97.5 degrees F. There was no assessment of stools, lung sounds or urine output documented. On [DATE] at 9:00 AM, the physician requested to see Resident 105 at the office. The next documented assessment occurred on [DATE] at 10:10 AM when Resident 105 was sent to the physician's office and revealed that Resident 105 was noted to have rhonchi throughout lung fields with O2 (oxygen) sats ranging from ,[DATE] % (normal is greater than 92%). In addition, Resident 105 was noted to be weak, slow to respond and confused with a blank stare. Resident 105 was also noted to have a moist cough, poor appetite and poor fluid intake. At 12:30 PM on [DATE], documentation in the Nurse's Notes showed that the facility had received a call from the physician's office that Resident 105 was admitted to the hospital for dehydration and [MEDICAL CONDITION]. On [DATE] at 10:00 AM, documentation in Resident 105's Nurse's Notes revealed the facility received an update that Resident 105 was receiving antibiotics for pneumonia and IV's (intravenous) fluids for hydration. The resident was in [MEDICAL CONDITION]. On [DATE], the facility received notice from a family member that Resident 105 had expired. Review of Resident 105's Discharge Summary from the Hospital dated [DATE] revealed that Resident 105 was admitted to the hospital with [REDACTED]. On admission to the Hospital, it was noted that Resident 105 had an elevated white blood count, was minimally responsive and had rales in lung bases. B. Resident 102 was admitted to the facility on [DATE] according to the ADMISSION AND DISCHARGE SUMMARY on the medical record. The following [DIAGNOSES REDACTED]. Review of the facility policy and procedure titled NEUROLOGICAL assessment dated ,[DATE] revealed the following PURPOSE: "To record and monitor data on specific neurological conditions following an injury resulting in actual or suspected head trauma. PROCEDURE: Per (name of facility) Policy any fall that occurs that the elder is unsure if he/she hit their head Neurological Checks must be done". Review of Resident 102's Nurse's Notes dated [DATE] at 9:45 PM revealed that Resident 102 had sustained a fall but denied hitting head. A 3 cm (centimeter) scratch was noted to left side of nose. Further review of Resident 102's medical record revealed there was no neurological assessment or follow-up performed to ensure that a head injury had not occurred. Review of Resident 102's Nurse's Notes dated [DATE] at 7:00 AM revealed that the resident had bruising to the left eye from the fall but the facility did not initiate a neurological assessment to ensure that Resident 102 had not sustained a head injury. Interview on [DATE] at 12:50 PM with the ADON (Assistant Director of Nursing) confirmed that there had not been neurological checks performed for Resident 102 after the fall that occurred on [DATE].