Every finding on record at Nye Pointe Health & Rehab Ctr

Licensure Reference Number 175 NAC 12-006.09(H). Based on record review and interview the facility failed to ensure daily weights were obtained for 1 (Resident 1) of 1 sampled resident and failed to implement neurological evaluations after an unwitnessed fall for 1 (Resident 3) of 4 sampled residents. The facility staff identified a census of 40. The findings are: A. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-28-2025 revealed the facility staff assessed the following about the resident:-admission date of 07-22-2025.-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-had a diagnosis of Heart Failure.-required moderate assistance with hygiene, and transfers.-required substantial assistance with upper body dressing.-required total assistance with lower body dressing, toileting and bathing. Record review of Resident 1's Medication Administration Record (MAR) for July of 2025 revealed an order for daily weights and to notify the physician if the resident gains greater than 3 pounds in a day or greater than 5 pounds in a week. Further review of Resident 1's MAR revealed there were no weight listed for 07-25-2025 or 07-28-2025. Record review of Resident 1's MAR for August of 2025 revealed an order for daily weights and to notify the physician if the resident gains greater than 3 pounds in a day or greater than 5 pounds in a week. Further review of Residents 1's MAR for August 2025 revealed no weight were listed on 08-03-2025, 08-04-2025, 08-05-2025, 08-07-2025, 08-08-2025, 08-09-2025, 08-10-2025, 08-14-2025 and 08-16-2025. An interview with the Corporate Nurse (CN) on 08-20-2025 at 10:30 AM confirmed daily weights were not conducted daily and should have been for Resident 1. B. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS was scored at a 9. According to the MDS Manual a score of 08-12 indicates moderate cognitive impairment.-required substantial assistance with bed mobility and hygiene.-required total assistance with toileting, dressing and transfers. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 08-01-2025 revealed Resident 3 had an unwitnessed fall on 08-07-2025. Record review of Resident 3's Electronic Health Record revealed no neurological evaluations (an assessment for identifying potential head trauma) following the unwitnessed fall on 08-07-2025. An interview with the CN on 08-21-2025 at 11:00 AM confirmed the neurological evaluations were not done after the unwitnessed fall on 08-07-2025 and should have been done for Resident 3.Record review of the facility's undated policy titled Falls revealed a possible head injury includes visible head trauma, unwitnessed fall where resident is unable to deny a head injury or a witnessed fall with resident hitting their head. When a head injury is noted or suspected, neurological checks will be initiated and any adverse findings will be reported to the resident's physician.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(4) Based on observation, interview and record review the facility failed to secure a catheter in a manner to prevent skin trauma for 1 (Resident 29) of 1 residents sampled. The facility census was 40. The findings are:Record review of Resident 29's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-had a life expectancy of 6 months or less.-had an indwelling urinary catheter.-had a stage 4 pressure ulcer.-required moderate assistance with upper body dressing.-required total assistance with toileting, bathing, lower body dressing, bed mobility and transfers. Record review of Resident 29's Treatment Administration Record for August 2025 revealed an order for a foley catheter for continuous drainage. Secure tubing to thigh area to avoid pulling. An observation on 08-19-2025 at 12:01 PM of Resident 29 lying in bed being repositioned by the hospice Nursing Assistant revealed the urinary catheter was not secured to Resident 29's thigh with the urinary catheter tubing was laying across the right thigh. An observation on 08-20-2025 at 10:17 AM with the Assistant Director of Nursing (ADON) revealed Resident 29 was lying in bed and the urinary catheter tubing was not secured to the resident's thigh. An interview with the ADON on 08-20-2025 at 10:25 AM confirmed Resident 29's catheter tubing was not secured to the resident's thigh and should have been.

Licensure Reference Number 175 NAC 12-006.10DBased on observation, interview and record review the facility failed to ensure a medication error rate of 5% of less, as evidenced by 3 errors out of 25 opportunities for error resulting in a 12% medication error rate. The facility census was 40. The findings are:A.Record review of Resident 10's Order Summary (OS) printed on 08-20-2025 revealed the following orders:-ondansetron 4 milligram (mg) take 1 tablet by mouth every morning before breakfast.-pantoprazole 40 mg take 1 table by mouth daily, do not crush or chew, take 30 to 60 minutes prior to eating. An observation on 08-20-2025 at 8:20 AM of Medication Aide (MA) A administering medications to Resident 10 revealed the following medications were administered while eating breakfast:-pantoprazole 20 mg tablet give 1 tablet by mouth-ondansetron 4mg tablet give 1 tablet by mouth An interview conducted on 08-20-2025 at 12:47 PM with MA A confirmed pantoprazole and ondansetron were given while Resident 10 was eating breakfast and should have been given prior to eating. B. Record review of Resident 2's Medication Administration Record (MAR) printed on 8-19-2025 revealed an order for aspirin enteric coated 81mg take 1 tablet by mouth daily take with food and do not crush. An observation on 08-20-2025 at 8:25 AM of MA A administering medications to Resident 2 revealed Aspirin 81mg chewable tablet was administered to Resident 2. An interview with MA A on 08-20-2025 at 12:19 PM confirmed Resident 2 received Aspirin 81mg chewable tablet and Aspirin 81mg enteric coated tablet should have been administered. Record review of the facility policy titled Medication Administration Guideline dated 2023 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure a sanitary environment, equipment, and food storage spaces were maintained in a manner to prevent potential food borne illness. This had the potential to affect 37 of 38 residents that consumed food from the kitchen. Findings are: A record review of the facilities policy General Sanitation of Kitchen dated 2017 revealed the following: -Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. -Cleaning and sanitation tasks will be defined and assigned to employees. The employees will also be trained on each task. An observation on 7/17/24 at 9:08 AM revealed the following: -The cupboards had small particles of a substances that was varied in color (black, brown, and white) and size. This was on the shelves and doors of the cabinets. -The drawers that were in the cabinets had varying substances with the appearance of food particles and dirt, as well as grease. - The walls in the entire kitchen along the floor edges and surrounding the equipment herein (which included dry storage room, dish room and the room the ice machine room) had a buildup approximately . 5-6 inches away from the walls and /or leg bases. looked as if there were food particles, hair, grease, and other debris stuck to it. -Food particles and debris various colors and shapes scattered across the floor and underneath all the equipment throughout the kitchen. -The stove including the top, inside and sides were heavily coated with grease and grime. The coating was a dark brownish black color and was thick in appearance. -The oven was coated with a greasy yellow substance that was slightly sticky. The inside had a heavy buildup of a dark, brownish/black color substance that also had a thick looking appearance. -The upright freezer had dirt and grime, brownish black in appearance on the sides, around the door handle and the back. Along the bottom of the doors was a white film, that ran the width of the doors. -Behind the upright freezer was a piece of mopboard that was hanging off the wall that was heavily coated with a grease/grime in brownish black substance on it. That traveled up the wall approximately . 6 inches. -Dry storage floor had a coffee type substance (in both color and texture) that ran along the south wall. -The ice machine had a build of has dirt/grime/furry appearance that is dark brownish black in color and is approximately . 1/4 inch covering the platform in the back and as well as a white colored piece of equipment. The platform had large rusty colored areas in between the legs of the ice machine and surrounding the legs. An interview and kitchen tour on 7/23/24 at 1:00 PM with the Dietary Manager (DM) confirmed all the above findings were a concern. The DM confirmed that there was no evidence of a cleaning schedule for the kitchen environment and its equipment. The DM also confirmed that the cleaning is an issue and that it is the expectation that it is completed daily per facility policy and current standards of practice.

Licensure Reference Number 175 NAC 12-006.18 Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to ensure contaminated laundry and linens were contained during transport and the laundry carts were sanitized, wear required Personal Protective Equipment (PPE) during laundry sorting, and clean laundry and linens were transported without touching staff clothing to prevent cross contamination, this had the potential to affect all residents in the facility. The facility failed to ensure hand hygiene was completed following wound care on 1 (Resident 2) of 3 sampled residents, ensure 2 (Residents 2 and 21) of 2 sampled resident's nasal cannulas (tubing that goes in the nose to deliver oxygen) were stored in a bag to prevent cross contamination and ensure 1 (Resident 2) of 2 sampled resident's concentrator and 1 (Resident 21) of 2 sampled resident's concentrator filters were clean. The facility census was 38. Findings are: A. A record review of the undated Resident personals, hang-ups, and delivery policy revealed the staff should cover the cart with a clean sheet or drapery before leaving the laundry area. An observation on 07/18/2024 at 8:34 AM revealed the facility's Environmental Services Coordinator (EEC) had the laundry cart at the 200-hall linen closet and transported the laundry cart to the 100-hall linen closet with the drape piled on top of the cart. An observation on 07/23/2024 at 6:52 AM revealed there were 2 large rectangular soiled linen carts that laundry used, 1 yellow one in the laundry room, and 1 gray one on the hallway across from the soiled laundry entrance. In an interview on 07/23/2024 at 6:52 AM, the EEC confirmed there was a large gray plastic cart in the hallway that laundry is placed in and a yellow cart in the laundry room that is used to transport laundry. The EEC confirmed the staff sprayed a sanitizer on the carts to disinfect, but it was not on a regular basis. The EEC pointed to the Cleaning Schedule for July 2024 that was on the corkboard in the laundry room. There were no entries for the carts being sanitized in July 2024. A record review of the undated Daily Cleaning Schedule revealed the large rectangular yellow soiled linen cart was to be cleaned weekly or as needed. A record review of the Cleaning Schedule logs dated May 2024, June 2024, and July 2024 revealed the large rectangular yellow soiled linen cart was only cleaned on: In an interview on 07/23/2024 at 11:09 AM, the Executive Director (ED) confirmed the large soiled linen carts in the laundry area should have been cleaned weekly and were not. B. An observation on 07/23/2024 at 6:52 AM of the laundry room did not reveal a gown or eye protection to be used when sorting laundry. In an interview on 07/23/2024 at 6:52 AM, the EEC confirmed gloves were the only PPE used when removing contaminated laundry from bags and sorting the laundry. C. A record review of the undated Resident personals, hang-ups, and delivery policy revealed to avoid cross-contamination keep clean items away from your body. An observation on 07/18/2024 at 10:46 AM revealed Nursing Assistant (NA)-L obtained linens from the linen closet and walk down the 300-hall to a resident, room [ROOM NUMBER] with linens under the arm and against NA-L's clothing. An observation on 07/18/2024 at 11:00 AM revealed the EEC delivered clothing to room [ROOM NUMBER] with the clothing between the right arm and against the clothing on the right side of EEC's body. An observation on 07/22/2024 at 8:53 AM revealed the EEC took linens out of the cart and held against EEC's clothing as it was placed in the 200-hall linen closet. An observation on 07/22/2024 at 8:54 AM revealed NA-L got linens from the linen closet and enter room [ROOM NUMBER] with linens between the left arm and NA-L's clothing. In an interview on 07/22/2024 at 11:40 AM, the ED confirmed staff should not allow linens and clothing to touch the staff's clothing. D. A record review of the facility's Hand Hygiene (disinfecting) policy dated February 2024 revealed the staff would perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Hand hygiene technique when using soap and water was to wet hands with water, apply soap, and rub hands together for at least 20 seconds, then rinse. Hand hygiene was indicated and would be performed before applying and after removing PPE including gloves. An observation on 07/18/2024 at 1:27 PM revealed APRN-K performed handwashing after completing wound care and removing PPE for 7 seconds. In an interview on 07/23/2024 at 7:11 AM, the Director of Nursing (DON) confirmed APRN-K should have washed hands with soap and water for at least 20 seconds. E. A record review of the facility's Oxygen Administration Guideline dated 2023 revealed infection control measures included keep delivery devices secured off the floor or bag when not in use. A record review of the facility's Infection Control - Nasal Cannula/ O2 (oxygen) Tubing Bags dated 06/24/2024 revealed the staff was educated to ensure that nasal cannulas/oxygen tubing were placed in bags that were attached to the oxygen concentrator (a machine that purifies oxygen). An observation on 07/17/2024 at 3:32 PM revealed Resident 21's nasal cannula was on the floor. An observation on 07/22/2024 at 7:31 AM revealed Resident 21's nasal cannula was on the floor. An observation on 07/18/2024 at 3:14 PM revealed Resident 2's nasal cannula was in between 2 blankets in the resident's room to the right of the recliner, the concentrator was on. An observation on 07/22/2024 at 8:28 AM revealed Resident 2's nasal cannula was in between 2 blankets in the resident's room to the right of the recliner and the concentrator was on. In an interview on 07/22/2024 at 11:54 AM, NA-M confirmed NA-M observed Resident 2's nasal cannula was between the blankets and should have been in the plastic bag. In an interview on 07/23/2024 at 7:11 AM, the DON confirmed nasal cannulas should not be on the floor and should be bagged when not in use per the facility's policy. F. An observation on 07/18/2024 at 3:14 PM revealed there was a thick layer of a gray and brown substance on the top of Resident 2's oxygen concentrator. An observation on 07/22/2024 at 8:28 AM revealed there was a thick layer of a gray and brown substance on the top of Resident 2's oxygen concentrator. An observation on 07/17/2024 at 3:32 PM revealed the filter on the right side of Resident 21's oxygen concentrator had a thick layer of a gray fuzzy substance on it. An observation on 07/22/2024 at 7:31 AM revealed the filter on the right side of Resident 21's oxygen concentrator had a thick layer of a gray fuzzy substance on it. An observation with the DON on 07/23/2023 at 7:24 AM revealed Resident 21's oxygen concentrator had a thick layer of a gray fuzzy substance on it. In an interview on 07/22/2024 at 11:54 AM, NA-M confirmed NA-M observed Resident 2's oxygen concentrator had a thick layer of a gray and brown substance on it and should have been cleaned as needed. In an interview on 07/23/2023 at 7:24 AM, the DON confirmed Resident 21's oxygen concentrator had a thick layer of a gray fuzzy substance on it, and it should have been cleaned, and the top of Resident 21's oxygen concentrator should have been clean.

Licensure Reference Number 175 NAC 12.006.09 Based on observation, interview, and record review, the facility failed to ensure wound care was completed as ordered for 1 (Resident 2) of 2 sampled residents. The facility census was 38. Findings are: A record review of the facility's Wound Treatment Management policy dated 2023 revealed wound treatments would be provided in accordance with physician's orders including the cleansing method, type and application of dressing, and frequency of dressing change. A record review of Resident 2's Clinical Census dated 07/22/2024 revealed the resident was admitted to the facility 08/02/2022. A record review of Resident 2's Medical Diagnosis dated 07/22/2024 revealed the resident had diagnoses of Diabetes Mellitus Due To Underlying Condition With Diabetic Neuropathy, Unspecified (uncontrolled blood sugar), Lymphedema (swelling caused by buildup of fluids), Not Elsewhere Classified, Chronic Combined Systolic (Congestive) and Diastolic (congestive) Heart Failure. Edema (excess fluid in the body), Chronic Obstructive Pulmonary Disease (COPD), and Long Term (Current) Use Of Anticoagulants (blood thinners). A record review of Resident 2's Minimum Data Set (MDS),a comprehensive assessment used to develop a resident's care plan) dated 05/09/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) 5 of 15 that indicated the resident was severely cognitively impaired (difficulty with mental function and skills). The resident was independent with personal and oral hygiene, needed partial/moderate staff assistance with upper body dressing and footwear, needed substantial/maximal assistance with bathing and lower body dressing. The resident did have a skin tear and was getting applications of ointments/medications. A record review of Resident 2's Care Plan with an admitted [DATE] revealed the resident had the potential impairment (weakened or damaged) to skin integrity and had a right great toe open area on 06/27/2024. The resident had interventions dated 06/27/2024 of treatment to right great toe and right leg edema/weeping (leaking fluid through skin) as ordered and observe changes but did not reveal an intervention for the left lower leg skin tear. A record review of Resident 2's Treatment Administration Record dated July 2024 revealed orders of: -Bilateral lower extremities (both lower legs): Wash daily with soap and water, Apply Xeroform gauze to any open areas, cover lower extremities with ABD (abdominal) and Kerlix. -Right Toe Wound: Apply Silver Alginate to wound, cover with dry dressing daily. A record review of Resident Wound note dated 07/18/2024 by facility's contracted wound care Advanced Practice Registered Nurse (APRN)-K revealed the wound care had been completed with the following information: Assessment: -Type 2 Diabetes Mellitus with foot ulcer (wound) -Venous Insufficiency (chronic)(peripheral)(poor blood flow) -Chronic venous hypertension (idiopathic)(blood pressure in legs don't fall when walking) with ulcer of right lower extremity. -Chronic venous hypertension (idiopathic) with ulcer of left lower extremity. -Laceration (cut or tear) without foreign body of right elbow. Plan: -Type 2 Diabetes Mellitus with foot ulcer -Notes: Right great toe tip wound: -Wash daily with soap and water -Apply Silver Alginate to the wound and secure with gauze and tape -Chronic venous hypertension (idiopathic) with ulcer of left lower extremity -Notes: Left lower leg wound care -Wash lower leg with soap and water daily -Apply Xeroform gauze to any open areas on the lower leg -Cover the weeping areas with ABD pads -Secure with Kerlix roll gauze An observation on 07/17/2024 at 3:07 PM revealed Resident 2's bilateral lower extremities were large and swollen. The resident had edema wear stockings on both lower legs with wound dressings underneath. An observation on 07/18/2024 at 1:27 PM revealed APRN-K had gloves and a gown on and removed Resident 2's right shoe, sock, and edema wear stocking, and measured the wound. APRN-K looked trough the bag of dressing on the floor with the contaminated gloves, removed a curette (surgical instrument) and debrided (removed the dead skin) the right great toe. APRN-K then dug through the bag of dressing with contaminated gloves opened a 4x4 (4 inch by 4 inch) dressing and wiped the blood from the resident's right great toe. APRN-K dug through the bag and pulled out a package of Silver Alginate (a wound dressing), cut a piece to size, and applied to the right great toe wound with contaminated gloves. APRN-K dug through the bag and got a 2x2 2 inch by 2 inch) bandage, opened, and it stuck to the APRN's glove, so APRN-K grabbed it touching the wound surface with the contaminated gloves and applied it to the right great toe. APRN-K put the resident's edema wear stocking on, sock on, shoe on, and pulled down the resident's pant leg. APRN-K removed gloves, used hand sanitizer, and re-gloved. APRN-K removed Resident 2's left, shoe, sock, and pulled down the edema wear stocking. APRN-K removed the Kerlix dressing from the resident's left lower leg and removed the Xeroform dressing from the wound. APRN-K dug through the bag of dressing with the contaminated gloves, removed a package of Xeroform and cut a piece to size. APRN-K opened the Xeroform with the contaminated gloves and placed the Xeroform in the resident's left lower leg wound. APRN-K then opened an ABD (abdominal) and Kerlix dressing and held the ABD dressing over the wound and wrapped the left lower leg with the Kerlix dressing. APRN-K assessed the leg and heel and pulled the edema wear back up over the dressing, applied the left sock and shoe. APRN-K got up of the floor, removed gown and gloves, and washed hands with soap and water for 7 seconds before exiting the room. The observation did not reveal that APRN-K washed either wound with soap and water prior to applying clean dressings. In an interview on 07/23/2024 at 7:11 AM, the Director of Nursing (DON) confirmed that APRN-K should have performed hand hygiene (cleaning) and glove changes when going from a contaminated body site to a clean body site during wound care and should have washed the wounds prior to applying the new dressings on both of Resident 2's wounds as ordered.

Licensure Reference Number 175 NAC 12.006.09(H) Based on record review and interview; the facility staff failed to implement non-phrampharmocological interviews prior to administering a as needs medication for 1 (Resident 18) of 5 sampled residents. The facility census was 38. A review of the facilities policy dated 2023 and named Use of Psychotropic Medication Guideline revealed that PRN medications shall be documented with a rationale in the resident medical record. Also the indications for initiating as well as the use of non-pharmacological approaches be determined by assessing the residents underlying condition current signs, symptoms, expressions, and preferences and goals for treatment. A record review of resident Clinical Resident Profile dated 7/18/24 Revealed Resident 18 was admitted on [DATE]. A record review of Medical Diagnosis list for Resident 18 dated 7/18/24 revealed the following: Parkinson's Disease with Dyskinesia, without mention of fluctuations, Major Depressive Disorder, Altered Mental Status, Depression, Generalized Anxiety Disorder, A review of the Minimum Data Set (MDS), (a tool that measures health status of residents in nursing homes) dated 6/27/24 revealed a Brief Interview of Mental Status (BIMS) of 11. According to the MDS [NAME], a score of 8 to 12 indicates a person has moderately impaired cognition. A review of physician's orders dated 7/18/24 revealed Resident 18 received Alprazolam (medication used for anxiety) tablet 0.25 milligrams (mg) take 1 tab by mouth every day as needed (related to generalized anxiety disorder. A Review of Documentation in the Medication Administration Record (MAR) for June 2024 and up until July-22-2024 revealed Resident 18 had no behaviors, hallucinations, delusions, or symptoms of anxiety documented. Further review of Resident 18's MAR for June and July 2024 revealed Resident 18 received the as needed (PRN) Alprazolam on 6/23/24 at 9:44 PM, 7/6/24 at 9:47 PM, and 7/16/24 at 9:36 PM. An interview on 04/23/24 at 1:01 PM with Director of Nursing confirmed that Res 18 was given Alaprazolam 0.25 mg tab PRN on 6/23/24 at 9:44 PM , 7/6/24 at 9:47 PM, and 7/16/24 at 9:36 PM and further confirmation no indications Resident 18 had anxiety symptoms or non-pharmacological logical interventions implemented. A review of the facilities policy dated 2023 and named Use of Psychotropic Medication Guideline revealed the following: -As needed (PRN) medications shall be documented with a rationale in the resident medical record. Also -The indications for initiating as well as the use of non-pharmacological approaches be determined by assessing the residents underlying condition current signs, symptoms, expressions, and preferences as well as goals for treatment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility staff failed to report an injury of unknown origin to the state agency within the required time frame for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 38. The findings are: Record review of the skin concern form dated 02/09/23 10:52 AM revealed Resident 1 was noted with a large bruise under the left arm down to left rib with large bump formed on front of left shoulder. Resident stated (gender) felt pain throughout the night. Record review of the Progress Note's (PN) dated 02/09/23 for Resident 1 revealed Resident 1 physician was notified regarding bruise under left arm down to rib and large bump on front of left shoulder. Resident 1's physicain ordered X-rays to rule out a fracture. Interview was conducted with the DON (Director of Nursing) per telephone on 02/16/23 at 12:13 PM revealed the bruise was noted in the am when morning staff was providing cares and Nursing Assistant staff reported to the nurse and nurse reported to DON. Review of the Abuse and Neglect Policy dated 11/21/17 revealed the following: Reporting of a serious physical injury has a 2 hour limit. Injuries of unknown origin are injuries incurred for unknown or unexplained reasons. An injury should be classified as an injury of unknown source when both of the follwoing conditions are met: -The source of the injury was not observed by any person or the source of injury could not be explained by the resident. -The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular time or the incidence of injuries over time. Injuries of Unknown Origin may include, but are not limited to:-suspicious bruising of residents -bilateral bruising on arms, which may indicate grabbing or rough handling. -Bruises resembling an object, human hand, or finger nails. -Bruises that dont resemble the explanation given. -Unexplained bruise An interview was conducted with the Corporate Nurse Consultant on 02/16/23 at 11:48 AM. During the interview the Coporate Nurse Consultant confirmed that the bruise, injury of unknown origin, was not reported to the state agency within the required time frame.

LICENSURE REFERENCE NUMBER 12-006.02(8) Based on record review and interview; the facility failed to report an injury of unknown origin to the state agency within the required time frame for 1 ( Resident 5) of 1 sampled resident. The facility staff identified a census of 37. The findings are: Record review of an Inury of Unknown Source report dated 4/19/22 for Resident 5 revealed Resident 5 complained of pain in the right wrist with bruising noted. Resident 5 stated I dont know what happened. Upon assessment it was noted that the wrist is swollen on the posterior side measuring 18cm (centimeters). Right side anterior aspect of the wrist is bruised noting a 5cm X 4cm bruise. Doctor on call updated with orders for ice to be applied and in house x-ray in the am. Record review of the facility Policy and Procedure for Abuse and Neglect revised 11/21/2017 revealed injuries of unknown origin are injuries incurred for unknown or unexplained reasons. Any injury should be classified as an injury of unknown source when both of the following conditions are met: -the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. AND -The injury is suspicious because of the extent of the injury. Injries of Unknown origin may include, but are not limited to susupicious bruising of residents. Injuries of Unknown Origin should be reported to the State Agency within 2 hours after occurence/forming suspicion. Interview conducted on 09/12/22 at 12:30 PM with the Corporate Nurse Consultant confirmed that the Injury of Unknown Origin should have been called into the State Agency within 2 hours and an investigation completed within 5 working days. Further interview with Corporate Nurse Consultant revealed no other documentation of an investigation being completed for the Injury of Unknown Origin.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure ventilation covers in the kitchen were clean. This had the potential to affect 36 residents. The facility census was 38. Findings are: Observation ON 6/29/22 at 8:45 AM the ventilation covers in the ceiling of the kitchen were coated with dirt and dust. Interview on 7/5/22 at 2:07 PM with the Maintenance Supervisor confirmed the ventilation covers in the ceiling were not clean. Record review of the Maintenance Work History Report from 4/30/22 thru 6/30/22; revealed cleaning of exhaust fans, but the location was not present on the work sheet or specific time or date.

LICENSURE REFERENCE 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure that 1) the bathroom vents were free from dirt and dust affecting rooms 104, 311 and 313. The facility also failed to ensure that the ceiling ventilation covers in the dining room were free from dirt and dust affecting 36 residents that eat in the dining room. The facility census was 38. Findings are: Observation on 6/29/22 at 11:00 AM revealed resident rooms 104, 311, and 313 were found to have dirt and dust in the ventilation covers. Observaiton on 6/29/22 at 1200 PM revealed dirt and dust on the ventilation covers in the ceiling in the dining room. Interview on 07/05/22 at 2:33 PM with the Maintenance Supervisor confirmed the ventilation covers were not clean.

175 NAC 12-006.04A3b Based on record review and interview, the facility failed to perform the required background check on an unlicensed direct care staff member. This affected 1 of 5 staff members sampled for background checks. The facility census was 38. Findings are: A review of Life Enrichment staff (LE) C's employee file revealed no documentation that a Nurse Aide Registry check was done at the time of hire. The employee's hire date was 3/8/22. A review of the facility policy titled Section 214 Abuse and Neglect (INCLUDING INJURIES OF UNKNOWN ORIGIN) revised 1/17/2017 revealed the following: (1) Employee Hiring a. All potential employees will be screened for a history of abuse, neglect or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Offers of employment are conditional upon satisfactory reports from the following registries (if applicable). Nurse Aide Registry (if applicable) An interview conducted on 7/6/22 at 2:35 PM with Administration/Human Resources (HR) B confirmed that no check of the Nurse Aide Registry was present in LE C's employee file. An interview conducted on 7/6/22 at 3:35 PM with the Executive Director (ED) A confirmed that the facility had not been checking the Nurse Aide Registry for non-nursing personnel.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review, and interview; the facility failed to ensure that it was free of medication error rates of 5% or greater. 28 medications were observed with 2 medication errors resulting in a medication error rate of 7.14%. Census was 38. Finding are: Observation on 5/5/22 at 9:10 AM revealed MA-J in the dining room passing medications to Resident 20. One of the medications being given to Resident 20 was [MEDICATION(S)] 125 mcg and the directions revealed this medication should be be given on empty stomach at 7:00 AM. Observation on 5/5/22 at 09:20 AM, MA-J was in the dining room passing medications to Resident 18. One of the medications being given to Resident 18 was [MEDICATION(S)] 50 mcg the directions revealed this medication should be be given on empty stomach and be administered at 7:30 AM. Record review revealed Medication Administration and Handling procedure: Medication administration timing parameters should include the following: The policy stated: Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. Interview with Administrator on 07/05/22 at 12:58 PM; revealed the medication was given at times not scheduled and times were late tor the medication residents received.

Based on record review and interview, the facility failed to provide pneumonia vaccinations per the Centers for Disease Control and Prevention (CDC) guidelines for Resident 3 and 27. This affected 2 of 5 residents sampled for vaccinations. The facility census was 38. Findings are: A. A review of the immunization record for Resident 3 revealed that Resident 3 was [AGE] years old and received the [MEDICATION(S)] (a 13-valent pneumococcal conjugate vaccine) on 5/21/13. There was no record of the resident receiving any other pneumococcal vaccination. B. A review of the immunization record for Resident 27 revealed that Resident 27 was [AGE] years old and received the [MEDICATION(S)] on 10/26/18. There was no record of the resident receiving any other pneumococcal vaccination. C. A review of the facility's policy titled INFLUENZA, [MEDICATION(S)], and PNEUMONIA VACCINE revised 11/21/17 revealed the following: It is the policy of the company to offer influenza, [MEDICATION(S)] and pneumonia vaccines as outlined below. Procedure 3. The campus shall offer the pneumonia vaccine as ordered by the resident's physician or the Medical Director unless the immunization is medically contraindicated or the resident has already been immunized. All residents and or resident representative have the right to refuse the vaccination. 9. Administration of these vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. D. A review of the CDC information sheet Pneumococcal Vaccine Timing for Adults dated 4/1/22 revealed that a 23-valent pneumococcal polysaccharide vaccine (PPSV23-brand name [MEDICATION(S)]) was recommended for adults aged 65 and over and should be given at least one year after the [MEDICATION(S)] was received. E. An interview conducted on 7/6/22 at 2:48 PM with the Infection Control nurse (IC) D confirmed that Resident 3 and Resident 27 only received the [MEDICATION(S)], and not the [MEDICATION(S)]. The IC D further confirmed there was no record of the vaccination being offered, education provided, or resident refusal for either Resident 3 or Resident 27.

LICENSURE REFERENCE NUMBER 12-0006.12B Based on interview, observation and record review; the facility failed to prevent the potential for adverse medication reactions related to no blood pressure parameters for Residents 18 and 27 and no blood sugar or insulin parameters for Resident 18. The facility census was 34. FINDINGS ARE: A record review of the MAR (Medication Administration Record) dated January 1-January 31, 2021 and February 1-February 28, 2021 for Resident 18 revealed no blood pressure parameters had been in place for the [MEDICATION NAME] (a medication used to treat chest pain and high blood pressure) order. The record review of the MARS revealed weekly blood pressures as follows; January 4th 96/61, January 11th 103/59, January 18th 96/64, January 25th 108/66, February 1st 104/48, and February 8th 109/50. An interview on 2/16/21 at 03:45 PM with the DON (Director of Nursing), after review of the weekly blood pressures for Resident 18, confirmed that the blood pressures had been low and the [MEDICATION NAME] should have been held. During the interview, it was revealed that the physician for Resident 18 preferred not to give parameters as this medication had also been given to strengthen the heart, written documentation of this was not provided. A review of the MAR indicated [REDACTED]. A record review of the facility document titled Nurse Admission Checklist worksheet provided by the facility Corporate Nurse revealed instructions to ensure orders such as blood sugars had parameters and to request parameters if needed. A record review of the facility document titled Unit Coordinator Admission Checklist worksheet provided by the facility Corporate Nurse revealed instructions to ensure orders such as blood sugars, insulin and blood pressure medications had parameters. An interview on 2/16/21 03:45 PM with the facility Corporate Nurse confirmed that the [MEDICATION NAME] and insulin orders for Resident 18 did not contain parameters and should have. Record review of Resident 27 MDS (The Minimum Data Set) (is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems dated 1/29/21 revealed the following information: Section I ( Diagnosis) Depression, Asthma, [MEDICAL CONDITION], non-Alzheimer's Dementia, Cardiorespiratory conditions, Acute [MEDICAL CONDITION] with [MEDICAL CONDITION], CAD, Hypertension, [MEDICAL CONDITIONS], and UTI ( in the last 30 days) Record Review of Resident 27's Medication Orders dated 02/2021 revealed Resident 27 was currently taking 2 medication for hypertension (high blood pressure): -[MEDICATION NAME] Tablet 320 MG Give 1 tablet by mouth one time a day Related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) -Start Date- 01/23/2021 0900 -[MEDICATION NAME] Tablet 25 MG Give 0.5 tablet by mouth two times a day Related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) -Start Date- 01/22/2021 1800 Record Review of Resident 27's Medication Record Revealed Resident 27 is taking 2 medications for hypertension and currently has weekly vital signs. According to physician orders [REDACTED]. Record review of Resident 27's Medication Administration Record [REDACTED] 1/13/21 101/75 1/14/21 108/63 1/15/21 112/68 1/17/21 100/50 According to Davis's Drug Guide for Nurses specific nursing administration are to take apical pulse prior to administration of blood pressure medications ([MEDICATION NAME]) if pulse is below 50 beats per minute and/ or Systolic blood pressure is below 100, The medication should be held and health care professional notified. Record of facility unit coordinator checklist specifies all orders are to be confirmed in electronic health record system and are to ensure detailed orders for blood pressure medications with parameters are included. An interview on 02/16/21 at 3:00PM with DON (Director of Nursing) confirmed Resident 27 Medication Administration Record [REDACTED].

Licensure Reference Number 175 NAC 12-006.17 B Based on observation, interviews and record reviews; the facility to ensure glucometer (A machine used to check blood sugar) surface was visibly wet for 3 minutes contact time as per the Bleach wipes manufacture's directions between resident use. This had the potential to affect Residents 22, 12, 18, 6, 21, 20, and 83 who have blood sugar checks completed with the same glucometer. The facility census was 34. Finding are: An observation on 02/11/21 at 11:43 AM revealed RN (Registered Nurse) -A applied hand sanitizer and new gloves and performed a blood sugar check by wiping Resident 18's finger with an alcohol pad. RN-A then poked the resident's finger and wiped away blood. RN-A next applied a drop of blood to glucometer stick. Insulin was then given to the resident according to the physician's order. RN-A then took a bleach wipe and wiped off the insulin pen and glucometer for approximately 5 seconds. The glucometer was not wrapped in the wipe and no wet time was performed. The glucometer was then placed on top of the medication cart with no barrier. An observation on 02/11/21 at 12:07 PM revealed RN -A applied hand sanitizer and new gloves and performed a blood sugar check by wiping Resident 21's finger with an alcohol pad. RN-A then poked the resident's finger and wiped away blood. RN-A applied a drop of blood to the glucometer stick. Insulin was then given to the resident according to the physician'ss order. RN-A then took a bleach wipe and wiped off the insulin pen and glucometer for approximately 5 seconds. The glucometer was not wrapped in the Clorox wipe and no wet time was performed. The glucometer was then placed on top of medication cart with no barrier. An interview on 02/11/21 at 12:10 PM with RN-A revealed (gender) was unaware of the glucometer needing to have a wet time kill time and was instructed to just wipe off glucometer after use and not to touch it for 2 minutes. An interview on 2/11/21 at 12:15 PM with the DON ( Director of Nursing) revealed the facility used to have timers that counted down the 2 minutes but currently no longer used them as felt it was not homelike environment for residents with timer going off. Record review of the facility policy dated 3/6/2020 titled Glucometer Guidelines revealed the following information: -wipe the meter off with disinfectant according to contact time on the disinfectant. The facility bleach wipes directions revealed the need for a 30 second contact time to kill the bacteria [MEDICAL CONDITION] on the label except a 3 minute contact time is required to kill [MEDICAL CONDITION] spores. Reapply as necessary to ensure that the entire surface remains visibly wet for entire contact time. An additional observation on 2/17/21 at 2:30 PM revealed the Corporate Nurse used a bleach wipe to wipe off a glucometer for approximately 5 seconds. The glucometer was then placed on the table and a timer started at 45 seconds. The glucometer was no longer wet. An interview on 2/17/21 at 2:40 PM with the Corporate Nurse confirmed a 3 minute contact time is not possible without wrapping the glucometer in the bleach wipe.

Licensure Reference Number 175 NAC 12 -006.09B1 (3) Based on observation, interviews and record reviews; the facility failed to ensure Resident 11's nutrition assessment was completed related to weight loss and oral infections. The facility census was 34. Findings are: An interview with Resident 11 on 02/10/21 at 11:18 AM revealed that the resident had a weight loss and food just does not taste good after starting a new medication. Record Review of Resident 11's MDS (Minimum Data Set: part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 11/30/20 revealed the following information: -Section C (Cognitive ability BIMS) (Brief Interview for Mental Status) (The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition) Resident 11's score was 13 indicating the following Resident 11's cognitive function in intact. -Section K (Nutrition) No swallowing issues. -Section L (Swallowing) Obvious or likely cavity or broken natural teeth? YES Record Review of Resident 11's Weight logs revealed the following weights: -11/17/20 (Re-Admission);180 pounds -1/13/21; 178.8 pounds -2/10/21; 170 pounds Record review of Resident 11's weight record revealed a 5.56% weight loss since readmission. An interview on 02/16/21 at 5:17PM with the Corporate Dietician confirmed (gender) was aware of Resident 11's weight loss in the last 90 days. The Corporate Dietician revealed that a supplement wasn't started due to the resident;s mouth issues. Record review of Resident 11's Progress notes revealed the following: -On 1/2/2021 at 04:53 both corners of the resident's mouth had open slits, bleeding with painful sores, green draining, and yellowish fluid lower lip slightly swollen. Physician notified of residents change in condition. -On 1/19/2021 at 01:58 Resident 11 received initial dose of Keflex ( antibiotic) 500mg at bedtime for UTI ( urinary tract infection). -On 1/28/2021 at 16:57 Resident 11 received a new order related to mouth pain related to white patches in resident's mouth. Magic mouthwash (antifungal medication) 5mL 4 times per days 7 days; [MEDICATION NAME]( antibiotic) 100mg bid x 7 days; COVID test if no recent one. Family updated of these orders. -On 2/10/2021 at 17:46: Resident 11's Physician was updated on residents continued redness and swelling of oral cavity. -On 2/13/2021 at 01:15 Resident 11 continues on [MEDICATION NAME] (antifungal medication) as ordered with no adverse reactions. Mouth red in corners with green mucus on lips. Oral cares given and mouth moisturizer applied. Record review of Resident 11's Nutrition assessment dated [DATE] revealed Resident 11's weight as 179.4 pounds and revealed the following note: Resident 11 is able to make the resident's own food choices. Fills out (gender) own menu when in use. Eats independently. Intakes have been good per intake charting. Resident is able to get to & from dining room independently with wheelchair, but prefers assist when dining room is open. Fluids offered & encouraged at & between meals. Snacks offered AM, PM, HS & PRN. No skin issues at this time per nursing. Will continue to monitor. RD will review charts as needed. An interview on 02/16/21 at 4:54 PM with the DON (Director of Nursing) revealed that Resident 11 has had dry red corners of mouth and irritated mouth. Facility has been in contact with physician and have tried swish and spit, antibiotics, and antifungal medications. If the current treatment does not work then resident will be sent to physician. An interview on 2/16/21 at 5:00 PM with Corporate Dietician confirmed that only nutrition assessment completed on Resident 11 was on 11/19/20. No additional progress notes are listed in relation to weight loss.

Based upon observation, interview, and record review, the facility failed to ensure that infection control practices were implemented during the cleaning of resident rooms to reduce the possible spread/transmission of infections. Specifically, Environmental Services staff (ES1) failed to sanitize her hands upon entering, cleaning, and exiting multiple residents' rooms. The facility did not have any residents with COVID-19 currently or in the past. The facility census was 38. Findings include: An observation on 6/18/2020 at: 8:25am showed, ES1 applied gloves to both hands, without performing hand hygiene, and entered R1's room with her mop and cleaning cloth. 8:26am showed, ES1 exited R1's room, removed her gloves and placed them in the trash, applied a new mop head to the mop, applied fresh gloves, without performing hand hygiene, and entered R2's room with her mop and new cleaning cloth. 8:27am showed, ES1 cleaned the sink and sink counter, entered the resident's bathroom, exited the resident's bathroom to obtain her mop, mopped the resident's bathroom, and vacuumed the floor of the resident's room. 8:34am showed, ES1 exited R2's room, removed her soiled gloves, and without performing hand hygiene, applied a fresh set of gloves. 8:36am showed, ES1 entered R3's room and entered the bathroom with her cleaning cloth and mop. 8:38am showed, ES1 exited R3's room, removed her gloves and placed them in the trash, applied fresh gloves, without performing hand hygiene, and entered R4's room. 8:44am showed, ES1 exited R4's room, removed her gloves and placed them in the trash and applied fresh gloves, without performing hand hygiene. 8:45am showed, ES1 entered R5's room with her mop and cleaning cloth. 8:47am showed, ES1 exited R5's room, removed the used mop head and replaced it with a clean one, removed her gloves and placed the gloves in the trash and applied fresh gloves, without performing hand hygiene. An interview with ES1 on 6/18/20 at 8:49am showed: She had been educated on Infection Control Practices to prevent cross-contamination between residents and between staff and residents. The facility has trained staff on handwashing and using alcohol based hand rub to sanitize their hands. Environmental Services staff are supposed to change their gloves every time they enter a different resident room. She has been trained on hand hygiene a couple of times. She doesn't have to wash her hands between rooms as long as she changes gloves. She was instructed to use alcohol based hand rub if the opportunity arises. An interview with the Environmental Services Supervisor on 6/18/20 at 9:45am showed: All Environmental Services staff have received training on COVID-19, Infection Control practices to prevent cross-contamination, and on hand washing and use of alcohol based hand rub (ABHR) if staff is unable to wash their hands. All staff are expected to perform hand hygiene upon entering and exiting a resident room, and whenever they have to change their gloves. It would not be appropriate for facility staff to change gloves in between resident rooms without performing hand hygiene. All ES staff have been trained to wash their hands or use ABHR whenever they remove gloves, and before applying fresh gloves. An interview with the Education Coordinator (EC) at 10:35am showed: All staff have been trained on Infection Control and Hand Hygiene procedures. She has completed competencies on all staff to ensure hand hygiene is done appropriately and is in the process of completing the second competency on all staff. Environmental Services staff have all been trained to wash their hands or use alcohol gel every time they enter or exit a resident's room before proceeding to the next one. All staff are expected to perform hand hygiene after removing gloves, and upon entry and exit of a resident's room. It would not be appropriate to only change gloves between resident rooms and not perform hand hygiene. Record Review on 6/18/20 of the Infection and Exposure Prevention and Control Program showed: The infection prevention and control program is set up to provide: A sanitary environment to avoid sources and transmission of infections and communicable diseases and interventions to reduce or prevent exposure, such as Personal Protective Equipment (PPE), and work practice controls. Record Review on 6/18/20 of the facility's COVID-19 Guideline showed: The recommended measures to prevent COVID-19 outbreaks mimic the same interventions advised by the Centers for Disease Control (CDC) to implement routinely for Influenza and other similar respiratory based infections. The facility maintains an Infection Prevention and Control Program. Everyday standard precautions and preventive actions, and universal source control efforts should be used and include: Appropriate hand hygiene. Wash your hands for at least 20 seconds especially after using the restroom, before eating and after blowing your nose, coughing, or sneezing. Hands must be washed if visibly soiled. Staff is to use an alcohol based hand sanitizer if soap and water is not readily available and/or when hands are not visibly soiled. Hand washing and use of PPE competencies to be completed.

Licensure Reference Number 175NAC 12-006.05(21) Based on observation and interview, the facility failed to ask residents in the dining room for permission prior to putting clothing protectors (a fabric cover placed over the resident chest to protect the resident clothing from contact with liquids or foods) on 11 residents (Residents 6, 7, 13, 22, 23, 25, 27, 30, 34, 37, and 189) of 36 residents that dined in the facility dining room. This had the potential to impact resident dignity and resident choice. The facility census was 40. Findings are: A. Observation on 6/19/19 at 12:12 PM revealed that Nursing Assistant (NA) A put a clothing protector on Resident 34 without asking for permission. Observation on 6/19/19 at 12:13 PM revealed that Physical Therapy Assistant (PTA) B put a clothing protector on Resident 189 without asking for permission. Observation on 6/20/19 at 7:52 AM revealed that NA C put a clothing protector on Resident 30 without asking for permission. Observation on 6/20/19 at 8:02 AM revealed that the Dietary Manager put a clothing protector on Resident 27 without asking for permission. Observation on 6/20/19 at 8:04 AM revealed that the Unit Coordinator put a clothing protector on Resident 37 without asking for permission. Observation on 6/20/19 at 12:05 PM revealed that NA C put a clothing protector on Resident 37 without asking for permission. Observation on 6/24/19 at 8:00 AM revealed that NA A put a clothing protector on Resident 25 without asking for permission. Observation on 6/24/19 at 8:05 AM revealed that NA A put a clothing protector on Resident 7 without asking for permission. Observation on 6/24/19 at 8:11 AM revealed that the Director of Nursing (DON) put a clothing protector on Resident 6 without asking for permission. Observation on 6/24/19 at 8:13 AM revealed that NA [NAME] put a clothing protector on Resident 189 without asking for permission. Interview with the DON on 6/24/19 at 8:16 AM confirmed that permission should be obtained from a resident prior to placing a clothing protector on a resident. Interview with the Dietary Manager on 6/25/19 at 2:11 PM confirmed that 36 residents ate their meals in the facility dining room. B. Observation on 06/19/19 from 12:11 PM - 12:27 PM in dining room revealed: - CNA H placed a clothing protector on Resident 22 without asking the residents preferance. - CNA I placed a clothing protector on Resident 23 without asking the residents preferance - Medication Aide J) placed a clothing protector on Residents 13 without asking resident preferance.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, record review and interviews; the facility failed to ensure that staff performed hand hygiene and gloving in a manner to prevent cross contamination and to ensure that hand sanitizer was used according to manufacturer's recommendations, in a manner to prevent cross contamination. This had the potential affect 3 residents, Residents 26, 7 and 29. The facility census was 40. Findings are: A. Observation on 06/24/19 at 11:27 AM-11:38 AM of NA (Nurse Aide) A providing perineal (the area of the body that includes the genital area to the buttock area) care for Resident #26. NA A initially washed hands and applied gloves, and provided cleaning of the genital area. NA A then removed gloves and reapplied gloves without performing hand hygiene. NA A proceeded to clean the buttock area. NA A then removed gloves and reapplied gloves without performing hand hygiene, then put dirty linen in trash bag, removed gloves and applied new gloves without performing hand hygiene and then placed clean incontinent brief on Resident #26. Interview with Director of Clinical Education on 06/24/19 at 11:39 AM confirmed that hand hygiene should be performed whenever gloves are removed and before new gloves are applied. Review of facility procedure entitled Perineal Care dated 05/08/09 revealed that when gloves are removed, hands should be sanitized before applying new gloves. B) Record Review of an undated Hand Washing policy revealed hand washing is the single most important way to prevent the spread of infection and disease. Hands must be washed before and after direct contact with a resident, before putting on gloves, after removing them and any time they could be soiled. Step 12. Hands may be washed using alcohol based hand sanitizer when soap and water are not readily available. To do this apply a liberal amount and until hands until dry. Remember this is not a substitute for proper hand washing. Hands should be washed with soap and water as soon as is possible. (Isogel can be used up to 8-10 times before soap and water but rather use soap and water if available). Record review of a policy entittled Dressings, Dry/Clean Procedure dated (MONTH) 2010 revealed the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Step number 2. states place clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. Step 12. Using clean technique, open other products prescribed dressing, dry, clean gauze. Observation on 06/20/19 from 1:20 PM to 1:40 PM revealed RN F and MDS nurse sanitized hands with hand sanitizer, RN F applied gloves and cleaned the over bed table. RN F then left room to gather supplies: Nexodyn ( prescription wound cleanser) spray bottle in box; Plurogel ( medication gel used to treat wounds and burns) jar in box and Collagen pad (type of covering sourced from animals used for different types of wounds). Upon returning to Resident 7 room RN F had a towel with Nexodyn and Plurogel boxes against ( gender) uniform. RN F placed above supplies on a towel on the overbed table. RN F sanitized hands and applied gloves, Resident 7 was turned to there side with the assistance of the MDS nurse, residents pants and brief were removed and back perineal care (cleaning of genitals and buttocks) was performed. RN F removed gloves and hands sanitized, with hands that were visible wet. RN F was attempting to apply gloves when MDS nurse instructed RN F she should wait until her hands were dry to apply gloves. RN F then removed the soiled dressing, removed gloves, sanitized hands, hands again were not completely dry when new gloves were applied. RN F opened 2 pieces of 4x4 gauze and removed Nexodyn spray bottle from box; sprayed Nexodyn and wiped wound with gauze all with the same gloves that touched medication box. RN F removed gloves, sanitized hands, and applied new gloves. RN F then removed scissors from a pocket and did not clean the scissors prior to opening collagen pad package. RN F then cut a dime size piece of Collagen pad; placed collagen piece in wound and took sterile q-tip and pushed collagen piece into wound. Plurogel container was then removed from box, plurogel was then removed from container with sterile q-tip and applied on top of collagen pad piece in wound. A foam dressing ( water proof, adhesive edge dressing) was applied that was dated and initialed. RN F then removed gloves and sanitized hands. Interview on 6/24/19 at 3:50 PM with DON confirmed hands should be rubbed dry after application of hand sanitizer per manufactures instruction. DON also confirmed medications used during treatment should be placed on clean surface not on a towel which had touched the nurses uniform. Scissors removed from a nurses pocket should not be used without cleaning as pocket is considered contaminated. C. Review of the undated facility policy titled Hand Washing revealed that employees must wash their hands for at least 20 seconds using soap and water before and after direct contact (touching) with a Resident, before putting on gloves, after removing them and any time they could be soiled (dirty). Observation of the tube feeding (a liquid form of nourishment that is delivered to your body through a flexible tube) for Resident 29 on 06/24/19 at 9:49 AM revealed that Registered Nurse (RN) F knocked on Resident 29's room door and entered Resident 29's room. RN F performed hand washing with soap and water for 18 seconds and then put on disposable gloves. RN F placed a washcloth under the gastrostomy tube (a flexible tube placed through the skin into the stomach) and removed the [MEDICATION NAME] from the end of Resident 29's gastrostomy tube. RN F inserted a syringe (a plastic cylinder with a plunger used to insert or withdraw liquids) into the end of the gastrostomy tube and pulled back on the plunger and checked for residual (a volume of fluid remaining in the stomach) with no residual obtained. RN F removed the syringe from the gastrostomy tube and placed the [MEDICATION NAME] into the end of the gastrostomy tube. RN F removed the gloves and performed hand washing with soap and water for 10 seconds and put on a new pair of gloves. RN F removed the [MEDICATION NAME] from the end of the gastrostomy tube and placed the syringe with the plunger removed into the end of the gastrostomy tube and initiated the tube feeding. RN F completed the tube feeding and removed the syringe from the end of the gastrostomy tube and replaced the [MEDICATION NAME] into the end of the gastrostomy tube. RN F removed the wash cloth from under Resident 29's gastrostomy tube. RN F turned on the tap water at the sink faucet and rinsed the syringe. RN F removed the gloves and performed hand washing with soap and water for 8 seconds. Interview with the facility Director of Nursing (DON) on 6/24/19 at 3:52 PM confirmed that staff were to scrub for a minimum of 20 seconds when washing with soap and water.

Licensure Reference Number 175 NAC 12-006.097b Based on observation, record review, and staff interview; the facility failed to assess for, identify, and implement interventions in order to ensure residents safety related to falls with injury for one resident (Resident 46). Findings are: An observation on 11/10/2014 at 12:58 PM revealed MA (Medication Aide)-C and NA (Nursing Assistant)-D assisting Resident 46 to transfer from the wheel chair to the bed for a rest period. Upon completion of the transfer and after providing assistance with positioning the resident's call light was not within Resident 46's reach. When asked about the placement of Resident 46's call light, the MA & NA reported the resident usually placed the call light down (gender) shirt in order to locate it when needed. MA-C was then observed to go back and locate the call light and hand it to Resident 46 who then placed it down the front of (gender) shirt. A review of the Interdisciplinary Notes (IPN) dated 8/23/14-8/28/14 revealed Resident 46: had a fall resulting in a fractured right hip, was hospitalized for [REDACTED]. An IPN dated 8/29/14 at 12:33 PM revealed Resident 46's Primary Physician was notified of the resident's continual agitation and delusional state. A new Doctor's (DR) order was received to obtain UA (urinalysis) and blood work. An order to start Risperdal (an antipsychotic medication) as needed every 8 hours for delusional/agitated state. Further review of the IPNs revealed intermittent confusion continued for Resident 46 following readmission to the facility and on 9/2/14 at 12:42 AM the resident was found on the floor next to the bed. The IPN also revealed Resident 46 stated (gender) was getting up to go to the toilet stool, referring to the bedside commode and the bed alarm did not sound. A review of the facility's RISK FOR FALLS EVALUATION DETAIL REPORT revealed a fall risk assessment was completed for Resident 46 on 5/27/14 and 9/2/14. Further review revealed no documented evidence of a fall risk assessment being completed upon readmission to the facility on [DATE]. During an interview on 11/12/14 at 1:22 PM with the Director of Nursing (DON), the DON confirmed a fall risk assessment was not completed following Resident 46's readmission to the facility following the 1st fall on 8/23/14. The DON also confirmed that there were no new safety interventions put into place upon Resident 46's return to the facility on [DATE]. A review of Resident 46's care plan revealed a Problem originally dated 3/3/14 of potential for falls/injuries related to poor vision from macular degeneration (a disease of the eye resulting in vision loss), arthritis, and anxiety. Interventions that the facility had put into place prior to 8/23/14 included: encourage and remind to call for assist, monitor for steadiness, and provide assist as needed, non-slip footwear, bedside commode for toileting. Further review of the care plan revealed no new safety interventions were added between the falls dated 8/23/14 and 9/2/14. A review of the facility's investigation of the fall on 9/2/14 revealed Resident 46 sustained a fracture to the right femur (thigh bone) as a result of the fall.