Every finding on record at Oakland Heights

Licensure Reference Number 175 NAC 12-006.09(G)(ii) Based on record review and interview, the facility failed to ensure that a discharge summary was completed for 1 resident (Resident 89) when they transferred to hospital via the emergency department. The facility had a census of 36. Findings are: A record review of Resident 89's nursing progress note dated 5/27/2025 revealed the resident required SLOC (Skilled Level Of Care - a level of care requiring the expertise and supervision of licensed health care professionals such as nurses and therapists) secondary to (due to) post colostomy placement (a surgical procedure connecting the colon to the outside of the body, allowing stool to exit) secondary to bowel obstruction (a condition in which digested material is prevented from passing normally through the bowel). Resident has a RLQ (Right lower quadrant - referring to the abdomen) JP drain (Jackson Pratt drain is a surgical drain used to remove excess fluid and prevent buildup around a surgical site), a midline abdominal (middle of the abdomen) incision closed with staples and a LLQ (Left lower quadrant - referring to the abdomen) ostomy (a surgically created opening). A record review of Resident 89's progress notes dated 5/31/25 revealed the Resident had a fever of 100.4F with increased purulent (containing pus) drainage from their abdominal incision. Resident 89 was evaluated at the nearest Emergency Department (ED). A record review of a physician's order dated 5/31/2025 stated OK to send the resident to the nearest ED to be evaluated. A record review of Resident 89's progress note dated 6/1/25 revealed a call placed to the hospital which confirmed the resident is on IV (intravenous - medication administered by a needle and tubing through a vein) antibiotics and will be staying at the hospital. Resident's husband requested a bed hold (a reservation for a bed while the resident is out of the facility) for the resident. A record review of the resident progress note dated 6/2/25 revealed the following: Progress Note Called Hospital and was given an update on resident condition. Possibly has touch of Pneumonia. Will be in Hospital through tomorrow. Unsure of return at this time. A record review of resident progress notes dated 6/4/25 revealed the following: Resident returns from hospital where they were treated for pneumonia, given IV antibiotics and received 1 unit of packed red blood cells, chest x-ray showed pneumonia. A record review of Resident 89's progress notes did not reveal a note stating that transfer discharge documentation was sent with the resident. A record review of the facilities undated Transfer and Discharge Policy revealed the following: Policy Explanation and Compliance Guidelines: 10. Emergency Transfers to Acute Care: A. The facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. B. The facility will contact an ambulance service and provider hospital, or facility of residents' choice, when possible, for transportation and admission arrangements. C. For a transfer to another provider, ensure necessary information listed in #8 of this policy is provided along with, or as part of, the facilities transfer form: a) Contact information of the practitioner who was responsible for the care of the resident b) Resident representative information, including contact information. c) Advance directive information. d) All other information necessary to meet the resident's needs, which includes but may not be limited to: i) Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii) Diagnoses and Allergies; iii) Medications (including when last received; iv) Most recent relevant labs, other diagnostic tests, and recent immunizations; e) All special instructions and or precautions for ongoing care, as appropriate such as: i) Treatments and devices (oxygen, implants, IVs, tubes/catheters; ii)Transmission based precautions such as contact, droplet or airborne; iii) Special risks such as for falls, elopement, bleeding or pressure injury and/or aspiration precautions; f) The residents comprehensive care plan goals. D. The original copies of the transfer form and Advance Directives will accompany the resident. Copies will be retained in the medical record. E. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand. F. Document assessment findings and other relevant information regarding the transfer in the medical record. G. Provide a notice of transfer and the facilities bed hold policy to the resident and the representative as indicated. H. Social services director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. I. The resident will be permitted to return to the facility upon discharge from the acute care setting. An interview on 6/11/25 at 11:05 AM with the Director of Nursing (DON) confirmed Resident 89 did not have a record of transfer discharge documentation sent with them to the Emergency Department. The DON confirmed they were unable to provide evidence that the staff followed a transfer discharge procedure. An interview on 6/11/25 at 12:51 PM with the Assistant Director of Nursing (ADON) revealed new nurses in training are given a training packet which contains the following undated Discharge Process To ER/Hospital sheet. The following steps are to be followed: 1. Obtain order to send resident as indicated. 2. Print out physician orders; face sheet, CODE status, write short summary of why resident is being sent on the Doctor Sheet. 3. Call 911 (if indicated) - Note time 4. Squad arrives - note time. 5. Call Family. 6. Give hospital/ER nurse, nurse to nurse report. 7. Notify DON or designee. 8. Can do 1 progress note; just add all the times. 9. Get a bed hold from the family. An interview on 6/10/2025 at 1:10 PM with the DON confirmed they could not provide evidence the staff member who discharged the resident to the hospital followed the transfer discharge requirement.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].04c3A(6) Based on interview and record review, the facility failed to ensure the Resident Representative had been notified of a change in condition related to the active dying process for 1 of 1 sampled resident (Resident 92). The facility census was 37. Findings Are: A record review of the facility policy titled Change in a Resident's Condition or Status, with a revision date of [DATE], revealed the following; -A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) and impacts more than one area of the resident's health status. -Unless otherwise instructed by the resident, the Charge Nurse or designee will notify the resident's family or representative when there is a significant change in the resident's physical, mental, or psychological status. -Resident receiving Hospice care: facility staff and Hospice will collaborate to communicate significant changes to resident's family or representatives. A call was placed to St Croix Hospice on [DATE] at 12:27 PM to speak with the nurse that had cared for Resident 92. The call revealed that the nurse was no longer working for the company, so the interview was conducted with manager HM-B who stated (gender) would pull the chart and return the phone call. An interview on [DATE] at 01:54 PM with HM-B revealed that the facility did keep Hospice aware of Resident 92's condition. HM-B reported that the Resident Representatives had been aware of Resident 92's decline in condition and on [DATE] the Resident Representatives had requested Resident 92 be placed in a private room, however one was not available. HM-B reported that on [DATE] a conversation was held with Resident Representatives regarding medication changes and on [DATE] regarding the medications which Resident Representatives had requested including a medication for constipation. HM-B reported that plans were made for the Hospice nurse to meet with the Resident Representatives at the facility during the next hospice visit to the facility. HM-B revealed that the visit had yet to be scheduled when hospice had been notified of Resident 92's death on [DATE]. Record review of the Progress Notes dated [DATE] through [DATE] revealed that Resident 92 had been unable to taking medications, food or fluid beginning on [DATE] and had also began having periods of apnea (a cessation of breathing). The record reviewed revealed Resident 92 had been displaying restlessness and air hunger on [DATE] at 04:02 AM and ,d+[DATE] second periods of apnea at 05:57 AM with no indications that hospice or family had been updated. The record review of the Progress Notes dated [DATE] through [DATE] revealed that Resident 92 had been found with no pulse or respirations at 06:32 AM with a call to family and hospice at that time. An interview on [DATE] at 11:30 AM with the DON (Director of Nursing), after review of the Progress Notes dated [DATE], confirmed that the Representatives of Resident 92 had not been notified of the change in the resident's condition and should have been when the resident started showing signs of the active dying process.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to obtain and monitor blood presures prior to administering a blood pressure medication for 1 of 3 sampled residents (Resident 22). The facility census was 37. Findings Are: A record review conducted on 08/09/23 at 10:00 AM of the MAR (Medication Administration Record) dated August 2023 revealed Resident 22 had the following medication order; Metoprolol Tablet 50 milligrams (MG) Extended Release (ER) take 1 tablet by mouth at bedtime. Do Not Crush (Hold for SBP (Systolic Blood Pressure -- top number) less than 100 or pulse less than 50). Record review conducted on 08/09/23 at 10:00 AM of the MAR dated August 2023 for Resident 22 revealed no blood pressures had been documented in relation to the Metoprolol order. An interview on 08/14/23 at 10:03 AM with LPN-C, after review of the August 2023 MAR for Resident 22, confirmed that no blood pressures were being documented related to the blood pressure parameters ordered for the Metoprolol. An interview on 08/14/23 at 10:09 AM with the DON (Director of Nursing) after review of the August 2023 MAR for Resident 22, confirmed that no blood pressures were being documented related to the blood pressure parameters ordered for the Metoprolol. A record review of the July 2023 MAR for Resident 22 revealed no blood pressures had been documented in relation to the Metoprolol order. A record review of the June 2023 MAR for Resident 22 revealed no blood pressures had been documented in relation to the Metoprolol order since 6/13/23.

Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interviews, the facility failed to ensure hand hygiene was completed between touching surfaces and preparing food to prevent the potential for food borne illness. This had the potential to affect all residents that eat food from the facility kitchen. The facility census was 38. Findings are: Observation on 07/25/22 at 9:17 AM revealed Cook B removed a baking tray from the rack and placed it on the table, covered the bottom of the tray with aluminum foil and opened the refrigerator door and obtained the bowl containing washed sweet potatoes. Cook B obtained the spray butter and sprayed the tray. Cook B was observed placing the sweet potatoes on the tray and without performing hand hygiene. Cook B went to the supply area and obtained a can of an oily substance and opened the cabinet and obtained a squirt bottle. Cook B then filled the squirt bottle with the yellow oily liquid and poured the liquid over the sweet potatoes without performing hand hygiene during the procedure. Cook B was observed putting on gloves and covered the food scale with plastic wrap. Without changing gloves Cook B lifted the turkey out of the pan and began to cut the turkey breast into slices. Cook B without completing hand hygiene opened the cabinet and took a pitcher out of the cabinet, went to the coffee machine, and put hot water in pitcher and placed it near the food processor. Cook B placed a loaf of bread on the counter and proceeded to make pureed food without completing hand hygiene. Interview on 7/25/2022 at 9:50 AM with the Dietary manager revealed Cook-B should completed hand hygiene after touching multiple surfaces during food preparation. This would affect all residents eating from the kitchen.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to ensure that staff donned specific Personal Protective Equipment (PPE), failed to ensure laundry carts were sanitized per manufacture's recommendations, failed to ensure Resident 21's Positive Airway Pressure (PAP)(a machine that delivered positive airway pressure to a resident's airway to prevent the airway from closing) mask was cleaned daily and the [CONDITION(S)] filter was cleaned monthly, and failed to ensure hand hygiene was preformed between resident medication administration for 3 Residents (Resident 40,15, and 31). This had the potential to affect all residents in the facility. Total census was 38. Findings are: A. A record review of the Oakland Heights COVID-19 Isolation Zones Chart in the Standard Precautions Policy dated 10/25/2021 revealed that Team Members should have donned (put on) a surgical mask and eye protection in a Green Zone. An observation on 07/20/2022 at 11:45 AM revealed Cook-B had a surgical mask located below the chin and eye protection resting on the top of the head while plating food in the kitchen. An observation on 07/21/2022 at 07:38 AM revealed the Bed Maker (BM)-E pushed the laundry cart past the nursing station and down the 300 Hall to the laundry room without a mask on. In an observation and interview with the Director of Nursing (DON) on 07/21/2022 at 07:40 AM, the DON confirmed BM-E was not wearing a surgical mask and should have been wearing a surgical mask. An observation on 07:21/2022 at 01:22 PM revealed the Licensed Beautician (LB)-F was in the Chapel doing the resident's hair for pictures while wearing a cloth mask and no eye protection. In an observation and interview with the DON on 07/21/2022 at 01:23 PM, the DON confirmed LB-F had a COVID-19 vaccine exemption and should have been wearing an N-95 (a close-fitting facemask that had very efficient filtration of airborne particles) mask and eye protection but was not. In an interview with the DON on 07/20/2022 at 08:47 AM, the DON confirmed the entire facility was a Green Zone and the facility staff was required to donn a minimum of a surgical mask and eye protection while in the facility. B. A record review of the undated Oakland Heights: Laundry Policy revealed that contaminated laundry carts must be cleaned and disinfected when visibly soiled and according to a schedule developed by the facility. In an interview with Laundry-F on 07/26/2022 at 09:32 AM, Laundry-F confirmed that Laundry-F disinfected the laundry carts daily with Spartan Chemicals Super HDQ Neutral One-Step Disinfectant. Laundry-F confirmed that the cart is sprayed with the Spartan Chemicals Super HDQ Neutral One-Step Disinfectant and wiped off immediately. A record review revealed that Spartan Chemicals Super HDQ Neutral One-Step Disinfectant directions on the label say to spray the surface and allow the surface to remain wet for 10 minutes before the excess liquid was removed. In an interview on 07/26/2022 at 10:31 AM, Laundry-F confirmed the laundry carts were not being left wet for the recommended 10 minutes per manufacturer's instructions after being sprayed with the Spartan Chemicals Super HDQ Neutral One-Step Disinfectant. C. A record review of the facility's Undated Cleaning Positive Airway Pressure (PAP) Equipment revealed the facility was to wash a PAP mask with warm water and a mild detergent daily and check the air filter monthly and replace as necessary. A record review of Resident 21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 21's Treatment Administration Record (TAR) revealed the PAP mask had been cleaned between 06:00 AM and 08:00 AM. The TAR also revealed the PA filter had been checked 07/15/2022 between 06:00 AM and 02:00 PM. An observation on 07/21/2022 at 11:51 AM revealed Resident 21's PAP mask had a hard brown substance on the top left of the seal, and the PAP filter was full of a gray, fuzzy and powder substance. An observation and interview with the DON observed the PAP mask and filter, and the DON confirmed the PAP mask was not clean and should have been, and the PAP filter was full of debris and needed replaced. D. A record review of the facility's undated Hand Hygiene (cleaning/disinfecting) Policy revealed hand hygiene was to be performed: - routinely (regularly) - before and after resident contact - before medication preparation - after direct resident contact during medication administration (given to a resident) - after contact with inanimate (a thing that is not alive) objects in the vicinity (around) a resident An observation on 07/20/2022 at 11:30 AM revealed Licensed Practical Nurse (LPN)-A pushed the medication cart into the dining room and prepared medication for Resident 18 without having performed hand hygiene. LPN-A proceeded to Resident 18 and administered medication while the left hand touched Resident 18's shoulder, then walked to the end of the Dining Room to move a chair and assist Resident 3 while touching the resident's shoulder and the resident's serving utensils, and then back to the medication cart and prepared medications for Resident 34 without having performed hand hygiene. LPN-A delivered medications to Resident 34, returned to the medication cart and prepared medications for Resident 7 and did not perform hand hygiene. LPN-A delivered the medications to Resident 7 and placed a clothing protector around Resident 7 while touching the resident's neck and hair and returned to the medication cart and prepared medications for Resident 28 without having performed hand hygiene. LPN-A then administered medications to Resident 28. An observation on 07/20/2022 at 11:48 AM revealed LPN-A went back and forth between Resident 2, Resident 28, and Resident 3 to assist the residents and touched the resident's, items on the table, and each resident's eating utensils without performing hand hygiene between the residents. An observation on 07/21/2022 at 08:11 AM revealed LPN-A took the blood pressure and administered medications to Resident 14 and returned to the medication cart and prepared medications for Resident 38 without having performed hand hygiene. LPN-A administered medications to resident 38 while LPN-A touched Resident 38's shoulder and returned to the medication cart and prepared medications for Resident 21, administered medications to the resident, grabbed the resident's drinking cup with bare hands spun the cup with the thumb and fingers on the drinking surface without having performed hand hygiene and returned to the medication cart. In and interview on 07/26/2022 at 09:55 AM, the DON confirmed that it is the expectation of the facility that LPN-A would have performed hand hygiene between each resident during medication administration and assistance in the Dining room. E. Observation on 7/26/2022 at 7:15 AM revealed Medication Aide (MA) C provided medication to Resident 33 and did not complete hand hygiene prior to administering eye drops to Resident 31. Observation on 7/26/2022 at 7:40 revealed MA-C provided medications to Resident 192 and did not use hand gel prior to preparing medications for the next resident. Observation on 7/26/2022 at 8:00 AM revealed Licensed Practical Nurse (LPN) A assisted Resident 40 to the table, talk to kitchen staff, and obtain orange juice from kitchen staff. Placed orange juice on medication cart and add to a smaller cup. No hand hygiene completed. LPN A then obtained oral medications for Resident 40 without completing and hygiene. Observation on 7/26/2022 at 8:04 AM revealed LPN A prepared and administered medication to Resident 16's then returned to the medication cart and did not use hand gel prior to preparing medications for Resident 15. Review of the facility undated policy titled Hand Hygiene revealed indications for handwashing and hand antisepsis includes: Before medication preparation, after resident direct contact during medication administration, and after medication administration only if direct contact with resident Interview on 07/26/22 at 9:36 AM with the Director of Nursing (DON) revealed staff should perform hand hygiene between medication administration for each resident.

Based on interview and record review, the facility failed to ensure that the Advanced Beneficiary Notices (ABN)(a notice given to a resident to inform the resident of charges that Medicare will not cover) included all items, services, and cost information for 3 (Residents 20, 29, and 35) out of 3 sampled residents. Total census is 38. Findings are: A. A record review of the facility's un-dated Notice of Medicare Non-Coverage Policy revealed an ABN is the notice the facility used to notify a resident of the potential shift of financial liability to the resident for non-covered Medicare Part B items and services. A record review of Resident 20's Resident Census dated 07/25/2022 revealed the facility was billing Resident 20's Medicare Part A (a government insurance plan) until 04/16/2022 when the facility started billing the resident as Private Pay (resident is responsible for the charges). A record review of Resident 20's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage dated 04/13/2022 revealed that beginning 04/16/2022 Resident 20 may have to pay out of pocket for this care if the resident did not have other insurance that may cover the cost. For the care of Room and Board, there was not an associated cost, it was just listed as: Per Minimum Data Set (MDS)(a screening and assessment tool of health status which forms the foundation of the comprehensive assessment for residents) rate. Resident 20 chose Option 3, which was Resident 20 did not want the care of Room and Board. In an interview with the Director of Nursing (DON) on 07/26/2022 at 11:40 AM, the DON confirmed the Skilled Services that Medicare covered for Resident 20 was not listed on the ABN. The DON went on to confirm the actual charges were not listed on the ABN. The DON confirmed the resident was instructed to choose Option 3 and that was the wrong option since the resident wanted to remain in the facility. B. A record review of the facility's un-dated Notice of Medicare Non-Coverage Policy revealed an ABN is the notice the facility used to notify a resident of the potential shift of financial liability to the resident for non-covered Medicare Part B items and services. A record review of Resident 29s Resident Census dated 07/25/2022 revealed the facility was billing Resident 29's Medicare Part A until 05/06/2022 when the facility started billing Nebraska Medicaid (a state sponsored insurance plan). A record review of Resident 29's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage dated 05/03/2022 revealed that beginning 05/06/2022 Resident 29 may have to pay out of pocket for this care if the resident did not have other insurance that may cover the cost. For the care of Room and Board, there was not an associated cost, it was just listed as: Per MDS rate. Resident 29 chose Option 3, which was Resident 20 did not want the care of Room and Board. In an interview with the DON on 07/26/2022 at 11:40 AM, the DON confirmed the Skilled Services that Medicare covered for Resident 29 was not listed on the ABN. The DON went on to confirm the actual charges were not listed on the ABN. The DON confirmed the resident was instructed to choose Option 3 and that was the wrong option since the resident wanted to remain in the facility. C. A record review of the facility's un-dated Notice of Medicare Non-Coverage Policy revealed an ABN is the notice the facility used to notify a resident of the potential shift of financial liability to the resident for non-covered Medicare Part B items and services. A record review of Resident 35's Resident Census dated 07/25/2022 revealed the facility was billing Resident 35's Medicare Part A until 05/05/2022 when the facility started billing the resident as Private. A record review of Resident 35's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage dated 05/02/2022 revealed that beginning 05/05/2022 Resident 35 may have to pay out of pocket for this care if the resident did not have other insurance that may cover the cost. For the care of Room and Board, there was not an associated cost, it was just listed as: Per MDS rate. Resident 35 chose Option 3, which was Resident 20 did not want the care of Room and Board. In an interview with the DON on 07/26/2022 at 11:40 AM, the DON confirmed the Skilled Services that Medicare covered for Resident 35 was not listed on the ABN. The DON went on to confirm the actual charges were not listed on the ABN. The DON confirmed the resident was

Licensure Reference Number: 175 NAC 12-006.11D Based on observations, record review and interviews, the facility failed to prepare pureed food in a manner to ensure the nutrient value is preserved for 1 resident (Resident 21). The facility census was 38. Findings are: Review of the facility menu revealed the serving size for the turkey was 4 ounces. Observation on 7/27/2022 at 9:45 AM revealed Cook-B placed an unmeasured amount of turkey in the food processor and processed the meat until it was a ground texture. Cook B placed an unmeasured amount of ground turkey in the food Processor in preparation to puree the meat. Cook-B obtained hot water in a pitcher and placed it near the food processor. Cook-B brought a loaf of bread to the counter. Cook-B placed a slice of bread in the food processor stating this was her bread serving. The food processor was turned on and water of an unmeasured amount was poured into the food processor. Review of the facility process for pureed food revealed: 1. Decide on number of portions needed of pureed meat 2. Figure needed number of ounces of meat per menu. 3. Add liquid to desired consistency. 4. Liquid must be broth, gravy, juice, or milk. (Water should not be used) 5. Measure total completed amount of product. 6. Divide total by initial number of servings Interview on 7/25/2022 at 9:55 AM with the Dietary manager revealed Cook-B should have used gravy or broth and not water as it would decrease the nutrient value. Interview on7/27/2022 at 2:30 PM with the Director of Nursing revealed 1 resident (Resident 21) receives pureed food from the kitchen.

NAC Licensure Reference Number 175 NAC 12-006.17A and 12-006.17B Based on observation, and interview; the facility failed to prevent potential for cross contamination of COVID-19 related to storage of surgical facemasks for use in an isolation room for 1 resident (resident 1) of 3 sampled residents. The facility had a total census of 39 residents. The findings are: A. An observation on 6/29/20 at 10:15 am of resident 1's room revealed several paper bags hanging on a bulletin board on outside door labeled with a Gray zone (residents transferred from hospital to facility are kept in this zone for 14 days) label. B. An observation on 6/29/20 at 1:08 pm revealed Nursing Assistant A performed hand hygiene, applied standard isolation gown, performed hand hygiene, took brown paper bag with nursing assistant A name on it, took out surgical mask, put surgical mask on paper towel, tacked brown paper bag back on bulletin board, performed hand hygiene with ABHR (alcohol based hand rub), applied face mask and face shield, completed hand hygiene with ABHR, applied gloves and entered resident 1's room to empty Foley catheter (a flexible tube that a clinician passes through the urethra (the duct by which urine is carried out of the body from the bladder) and into the bladder to drain urine). Nursing Assistant A removed gown, and gloves, performed hand hygiene with soap and water for 25 seconds. Walked out of resident 1's room, applied ABHR for 20 seconds, removed face shield, placed face shield on paper towel on plastic cube. Completed hand hygiene with ABHR, removed brown paper bag off bulletin board with nursing assistant A name on it. Placed dirty surgical mask in brown paper bag, and tacked back up on bulletin board with rest of brown paper bags. Nursing Assistant A performed hand hygiene with ABHR. C. An interview on 6/29/20 at 1:20pm with staff member Nursing Assistant A revealed, that staff have their names on the brown paper bags hanging outside of the Gray zone door with 2 surgical masks in each brown paper bag. D. An interview on 6/29/20 at 1:25pm with the DON (Director of Nursing) confirmed a potential for cross contamination due to putting a dirty mask with a clean mask in the same brown paper bag. DON confirmed the brown paper bags were not dated. DON reported that the facility started putting 2 masks in the brown paper bags on June 24, 2020. DON reported we were told we could put the 2 different face masks in the paper bags. DON confirmed no policy for reuse of surgical masks in same brown paper bag.

LICENSURE REFERENCE NUMEBER 175 NAC 12-006.04D2 Based on record review and interview; the facility failed to have a Certified Dietary Manager (CDM). This had the potential to affect all residents in the building. The facility staff identified a census of 41. Findings are: Record review of the Dietary Manager (DM) Job Description revised on 1-03-2018 revealed the Dietary Manager was to be certified. On 10-21-19 at 7:40 AM an initial inspection was completed of the facility kitchen with the Dietary Manager. During the initial inspection when asked if the DM was certified the DM stated no.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility staff failed to have indications to administer an As Needed (PRN) medication for 1 (Resident 89) of 5 sampled residents. The facility staff identified a census of 41. Findings are: Record review of a Face Sheet dated 1-14-19 revealed Resident 89 was admitted to the facility on [DATE]. Record review of a practitioners order dated 3-7-19 revealed orders for [MEDICATION NAME] (anti-anxiety medication) 0.5 milligram's (mg's) to 2 mg's every 2 hours PRN anxiety or comfort. Record review of Resident 89's Medication Administration Record [REDACTED] -3-07-2019 at 11:30 PM for comfort. -3-08-2019 at 1:44 AM for comfort. -3-08-2019 at 3:44 AM for comfort. -3-08-2019 at 5:47 AM for comfort. Record review of Resident 89's Progress Notes for 3-07-2019 starting at 11:30 AM through 3-08-2019 to 5:47 AM revealed there was not any indication Resident 89 had been having discomfort. Record review of Resident 89's Behavioral Monitoring sheet for (MONTH) 2019 revealed Resident 89 had episodes of anxiety. Further review of Resident 89's Behavioral Monitoring sheet for (MONTH) 2019 revealed Resident 89's anxiety was relived with redirection, 1 to 1 and a change in positioning. On 10-23-19 at 2:01 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview RN A confirmed the indication to use the PRN [MEDICATION NAME] had not been identified in Resident 89's medical record and confirmed should be completed prior to administering PRN medications.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to notify the state agency in the required time frame of a significant injury for 2 (Resident 42 and 24) of 4 reviewed. The facility staff identified a census of 42. Findings are: A. Record review of a Event Report with a closing date of 7-03-2018 revealed Resident 42 on 6-30-2018 at 4:45 PM reported having fallen in the bathroom and had pulled self up onto toilet. According to the Event Report closed on 7-30-2018 Resident 42 had severe pain and sent to the hospital. Review of Resident 42's Progress Note dated 6-30-2018 at 6:50 PM the facility staff had called the hospital and was informed Resident 42 had a fractured left hip. Record review of Verification of Investigation (VOI) dated 6-30-2018 revealed the facility staff notified the State agency at 9:43 PM, 2 hours and 53 minutes after being aware of the significant injury. On 8-07-2018 at 7:05 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported not being aware an significant injury was to be reported to required State Agency within 2 hours and confirmed the notification had not been completed on time. B. Review of Resident 24's nursing progress notes dated 02/09/2018 revealed Resident 24 was found in Resident 24's room lying on the floor at 2:30 PM. Resident 24 complained of pain in right buttock area. Family member requested Resident 24 to be seen at the hospital. Review of Resident 24's Medication Administration Record [REDACTED]. Review of the nursing progress notes dated 2/9/2018 revealed the facility was notified at 5:34 that Resident 24 was being admitted to the hospital due to a large hematoma (a collection of blood). Review of the facility investigation revealed the facility notified APS at 7:52 PM.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 The facility failed to have an effective infection control program related to the failure to obtain culture and sensitivity testing and failed to identify the organism that caused infection. This had the potential to affect all facility residents. The facility staff identified a census of 37. Findings are: Record review of the facility Infection control logs for April and May 2017 revealed the facility staff were not obtaining cultures and sensitivities (C&S) for potential infection with the initiation of antibiotics. In addition, the organism was not being identified on the infection control log. An interview was conducted with the Director of Nursing (DON) on 5-24-2017 at 3:25 PM. During the interview, review of the infection control logs for April and May 2017 was reviewed with the DON. The DON confirmed the C&S's were not obtained prior to the start of an antibiotic and further confirmed the facility would not be able to determine if the antibiotic was effective without the C&S. Record review of an undated Policy and Procedure for Infection Control revealed the following information: -Principle: - It will be the policy of Oakland Heights to provide the care and prevention of infection cases according to the following procedures. A. Investigate, control and prevent infections in the facility. C. Maintain a record of infections and corrective actions.

LICENSURE REFERENCE NUMBER 12-006.11A1 Based on observation record review and interview, the facility kitchen staff failed to use the correct portion size for pureed textured food. The kitchen staff identified 5 residents (Resident 6, 12, 13, 25 and 40) who received pureed textured meals. The facility staff identified a census of 37. Findings are: A. Record review of the noon menu for 5-24-2017 revealed the facility residents were to receive for lunch: butter bread, 4 meat balls, mashed potatoes and gravy, mini carrots, angel food cake with icing, and drinks of choice. Observation on 5-24-2017 at 10:23 AM revealed Cook A, counted out 20 meat balls, added broth and pureed the meat balls. Observation on 5-24-2017 at 11:25 AM revealed Cook A using a #12 scoop to serve the purred meatballs with the mashed potatoes and pureed carrots for the residents on pureed diets. On 5-24-2017 at 12:07 PM, an interview was conducted with Cook A and the Dietary Manager (DM). During the interview Cook A reported the #12 scoop provided 2 and 2/3 ounces of the pureed meat balls. The DM reported the minimum residents on pureed diets should have received was 3 ounces. Cook A obtained 4 leftover meat balls, purred the meatballs with broth and measured the pureed meatballs in a measuring cup. The amount of 4 pureed meat balls measured 4 ounces. On 5-24-2017 at 12:40 PM a follow up interview with Cook A was conducted. During the interview, Cook A confirmed the amount of pureed meatballs served to the residents on pureed diets was not enough. Cook A stated I thought like it wasn't enough. On 5-24-2017 at 12:50 PM a follow up interview was conducted with the DM. During the interview the DM confirmed residents on pureed diets were not served enough of the pureed meatballs.

Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based upon record review and interview; the facility failed to notify the physician of a change in diet for one resident (Resident 11) due to a charge in the resident's diet . The facility census was 37. Findings are: A record review of Resident 11's progress notes, dated 01/10/2017, by the Registered Dietitian revealed that Resident 11's diet was regular, mechanical soft and Resident 11 was eating 75-100%. Resident 11 received whole milk with meals and staff would fortify meals. A record review of Resident 11's progress notes, dated 01/10/2017, by the dietary manager revealed that Resident 11 was offered 8 oz (ounces) whole milk at all meals instead of a house supplement as the resident stated the supplement made (gender) sick. A record review of Resident 11's progress notes, dated 03/17/2017, by the dietary manager revealed that Resident 11 received a regular, mechanical soft diet with fortified whole milk. A record review of Resident 11's progress notes, dated 04/05/2017, revealed that Resident 11's diet wad regular, mechanical soft with fortified whole milk. A record review of dietary's undated fluid order page for Resident 11 revealed the following : - Breakfast-4 oz prune, 4 oz milk, small bowel of applesauce; - Lunch-4 oz cranberry, 4 oz milk; and - Supper-4 oz cranberry, 4 oz milk. A record review of meal and fluid intake sheet for the month of May 2017 revealed that, for each meal served, Resident 11 received 4 oz of milk. A record review of physician orders, dated 05/08/2017, revealed the ordered diet was Regular with small portions, may have ground meat. There was no order found for fortification of meals or any supplements. An interview with the Dietary Manager (DM) on 05/24/2017 at 2:20 PM confirmed that Resident 11 should be receiving 8 oz of whole milk with fortified meals. Upon reviewing the undated fluid order page and meal & fluid intake information for May 2017, the DM confirmed Resident 11 was not receiving the 8 oz of whole milk as identified back in 01/10/2017 Dietary Manager and Registered Dietitian progress notes. The DM further confirmed that the physician was not notified about changing Resident's 11 diet by adding the extra milk as identified in the 01/10/2017 progress notes or to fortify Resident 11's meals as identified in the 03/17/2017 progress note. The DM also confirmed that the physician should probably be notified when changing a resident's diet.

Based on record review and interview, the facility failed to ensure recommendations for a Pre-Admission Screening and Resident Review (PASRR) was completed for 1 resident (Resident 12) out of 1 sampled residents. The facility census was 37. Findings are: Record review of Resident 12's PASRR form dated 3-20-2009 revealed, in Section 2, Resident 2 required ongoing medication review by a psychiatrist and a physician. Review of Resident 2's medical record revealed there was no evidence that Resident 12 was being seen by a psychiatrist. An interview was conducted with the Director of Nursing (DON) on 5-24-2017 at 10:29 AM. During the interview, the DON confirmed Resident 12 was not being seen by a psychiatrist.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(1) & 12-006.18B3 Based on observations and interviews, the facility failed to maintain wheelchairs in good repair and a clean manner for Resident 11 and 36, and failed to maintain EZ stand lifts (a lift to help staff transfer residents) in a clean manner and in good repair for Lifts 1, 3, & 6. This had the potential to affect 9 Residents who utilized the EZ stand lifts. Findings are: Wheelchair and lift cleaning schedule policy (no date) stated: Wheelchairs and lifts may be cleaned any of the following ways: 1. Place water and disinfectant in a basin or bucket of water and wipe down the entire wheel chair with special attention given to dried on spillage. 5. If the wheelchair fabric covering is soiled and cannot be cleaned by wiping it off, take off the coverings so it can be laundered. Arrange for an alternate wheel chair while the covering is drying, if necessary. Observations were made on 2/8/16 at 12:19 PM of Resident 11 in wheelchair. Wheel chair (wc) was dirty and stained with crusted food particles on handles and seat cushion. Observations were made on 2/9/16 at 10 am of Resident 11 in wheelchair, wc cushion was dirty with crusted on food particles. Observations were made on 02/09/2016 at 3:03 PM of EZ stand lift 6 (a device to assist staff to transfer residents) 6 observed in the 200 hall, the legs were dirty, the base where residents put feet were dirty and the top of the lift with the lift mechanism had a glob of something dark stuck on it. Tour done with the Director of Nursing (DON) on 2/10/16 at 8 am revealed: - EZ stand lift 6 observed in 400 hall had skid strips peeling up off the base and the base was dirty with dried food particles gathered in the corners and along the edges. - EZ stand lift 3 observed in the 300 hall had skid strip 1/2 off the base - EZ stand lift 1 observed in room 306 had skid strips curling up off the base, edge of the handle cover coming off and inner padding exposed leaving an uncleanable surface - Resident 36's wc arm was worn on the back with vinyl off and padding exposed, leaving an uncleanable surface - Resident 11's was observed in hallway wheeling self to dining room and wc cushion had dried on crusted particles, dirty appearance, no cover to cushion. Interview with Christina, DON 02/10/2016 8:06:16 AM stated that the facility maintenance staff should be doing the upkeep and maintenance of lifts and wcs, and that nursing staff are to do a good cleaning weekly and as needed of lifts and res wcs. When shown the above, the DON agreed the lifts and wcs were not clean and were not in good repair. Interview with Licensed Practical Nurse A on 2-10-16 at 10 AM stated that 9 residents use the EZ stand lifts in the facility.

Based on record review and interview, the facility failed to monitor the blood flow for a [MEDICAL TREATMENT] for Resident 16. The facility census was 43. Findings are: Review of Resident 16's Care Plan revealed resident has a [DIAGNOSES REDACTED]. Review of printed Treatment Administration Record (TAR) dated printed on 2/9/2016 revealed no orders for completing a Bruit and Thrill assessments (an assessment of blood flow of the [MEDICAL TREATMENT]) of Resident 16's [MEDICAL TREATMENT] site. Review of the TAR and progress notes for Resident 16's revealed no entries indicating if bruit and thrill have been checked on a routine basis. Review of facility policy dated 7/2012 titled [MEDICAL TREATMENT] revealed the nurse was to check the site after [MEDICAL TREATMENT] for bleeding, pain, redness, swelling and blood flow (signs of a clogged access site). Interview on 02/10/2016 at 7:26 AM with the Director of Nursing (DON) revealed Resident 16 does have a fistula ([MEDICAL TREATMENT] access graft site) and that the checking of Bruit and thrill should be documented on the TAR. The DON confirmed it is not documented and was not being done.

Based on observation, record review and interview; the facility failed to maintain a medication error rate of less than 5% related to 8 errors out of 27 opportunities. The medication error rate was 30%. This affected a resident (Resident 10). The facility census was 43. Observation on 2/9/2016 at 7:50 AM of LPN-A administering medications to Resident 10 revealed LPN-A approached resident table and set medications down on the table and stated to Resident 10 here are your pills and walked away from the table. LPN-A returned to the medication cart. Observation on 2/9/2016 at 7:55 AM revealed the medication cart was positioned in a location that LPN-A was unable to see Resident 10. LPN-A did not reapproach Resident 10 or watch Resident 10 take the medication. Interview on 02/09/2016 at 1:31 PM with the Director of Nursing (DON) revealed no residents have been assessed as safe to self medicate. Review of the undated facility policy titled Medication and Treatment administration revealed the licensed nurse or medication aide is responsible for verifying the identity of the resident, and monitoring the residents response to the medication. Interview on 02/10/2016 at 8:30 AM with LPN-A revealed that LPN-A did leave the medications at the table for Resident 10 to take independently and did not watch Resident 10 take the medication. Interview on 02/10/2016 at 9:02 AM with the DON revealed LPN-A should not have left the medication at Resident 10 table without visually monitoring that the medications were taken.

Based on observation, record review, and interview; the facility failed to ensure the glucometer was disinfected after use to prevent the potential for cross contamination for Resident 28. The facility census was 43 Findings Are: Observation on 02/09/2016 at11:00 AM of glucometer (device to check blood sugar) check for Resident 43 revealed the following: - Licensed Practical Nurse (LPN)-B reached onto housekeeping cart and obtained trash bags. - LPN-B returned to medication cart and put on gloves without using hand sanitizer or hand washing. - LPN-B removed supplies from the medication cart and entered Resident 28's room. - After the blood sugar reading was obtained LPN-B picked up glucometer, wiped the glucometer with a bleach wipe. - LPN B placed glucometer on the dresser without a barrier. - LPN-B removed the gloves and picked up the glucometer without completing hand washing and placed the glucometer on the top of the medication cart. Review of the facility undated policy titled Hand Hygiene revealed handwashing and hand antisepsis should be performed at the following times: 3. before having direct contact with patients 6. after contact with body fluids. 8. contact with an inanimate objects in the immediate vicinity of the patient Review of the facility undated policy titled Cleaning Glood Glucose Monitoring System revealed The cleaning and disinfecting is very important in the prevention of infectious disease. Interview on 02/10/2016 at 9:04 AM with the DON revealed the LPN-B should have not placed the glucometer on the dresser and recontaminated the glucometer before removing the glucometer from the room.

Licensure Reference Number: 175 NAC 12-006.09D2a Based on observation, record reviews and interviews; the facility failed to put interventions in place to prevent the occurrence of a pressure ulcer for 1 resident (Resident 6). Facility Census was 44. Observation on 3/4/15 at 9:52 AM revealed Resident 6 had a large area of dark eschar (piece of dead tissue) noted on the left heel. Interview on 3/4/15 at 10:00 AM with RN-A (Registered Nurse) revealed the area on heel was noted "a couple of days after admission". Review of Resident 6's Progress Notes revealed Resident 6 was admitted to the facility on [DATE] from the hospital after having surgery. Review of Resident 6's medical record revealed an Admission Skin assessment dated [DATE] that documented that Resident 6 had no areas of non-intact skin except the surgical incision Review of Resident 6's initial care plan on admission revealed no interventions to prevent pressure to skin related to Resident 6's immobility. Resident 6's MDS (Minimum Data Set- a federally mandated evaluation for use to develop an individualized care plan) dated 1/14/15 revealed Resident 6 required extensive assistance of two people for bed mobility. Review of Resident 6's progress notes dated 1/14/15 revealed the resident had developed a deep tissue injury (an injury to tissue caused by ongoing pressure) on the left heel measuring 4.4 cm(centimeters) x3.7 cm. Interview on 03/04/2015 at 8:22 AM with the DON revealed the area was caused by pressure and no interventions were put in place on admission to prevent the area from occurring.

Licensure Reference Number 175 NAC ,[DATE].09D Based on record reviews, observations, and staff interviews, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directive for 1 (Resident 1) of 7 sampled residents as a result Resident 1 passed away at the facility without receiving CPR. In addition, the facility failed to provide education to staff and clarify the facility CPR policy following the incident to prevent possible reoccurrence in order to protect 6 other residents of the facility who had requested CPR. The facility had a total census of 31 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] according to the Face Sheet. History and Physical for Resident 1 dated [DATE] listed the following [DIAGNOSES REDACTED]. A review of Resident 1's CPR/No CPR form revealed Resident 1 had marked CPR as the choice that Resident 1 wanted the facility to follow and had signed the form on [DATE]. Observation of Resident 1's medical record on [DATE] revealed Resident 1's medical record had a lime green dot on the chart indicating Resident 1 wanted CPR. A review of Resident CPR Status list maintained in facility medication room identified Resident 1 as wanting CPR. Resident 1's name had been crossed off the list. B. Undated facility policy titled "Cardiopulmonary Resuscitation (CPR) stated the following: "CPR or No CPR will be performed according to the resident's wishes. Procedure: 1. The Administration, or designee, will have the resident or resident representative sign the CPR determination form upon admission. 2. The licensed nurse will inform the physician by sending the form to the doctor. 3. The chart will be marked with a green sticker, when CPR is to be done. The resident's name, outside of the resident's room, will be underlined as an indication the resident wants to have CPR. 4. When sudden [MEDICAL CONDITION] is witnessed, on a resident who wants to have CPR, the nurse will initiate and do CPR until the ambulance arrives." C. The facility CPR/No CPR form stated the following: "To choose to have a CPR order, the resident will have CPR initiated in the event of an acute cardiac or respiratory arrest." A review of the CPR/No CPR form completed by residents to designate residents' wishes to have or not have CPR did not stated that CPR will only be provided if the [MEDICAL CONDITION] is witnessed. D. LPN (Licensed Practical Nurse) A was interviewed on [DATE] between 12:,[DATE]:17 PM. LPN A reported having CPR recertification in ,[DATE] but the training did not include information about the policy at the facility. LPN A reported residents who were a code were identified by a lime green sticker on the resident's record. LPN A reported it was facility policy that CPR be started if the [MEDICAL CONDITION] was witnessed. LPN A reported talking with Resident 1's spouse who wanted Resident 1's physician called. When LPN A went to call the physician and rescue squad, Resident 1's spouse came out of Resident 1's room and wanted someone to come to Resident 1's room. LPN A reported sending an aide to the room while LPN A got the oxygen. LPN A reported when LPN A reached Resident 1's room, Resident 1 wasn't breathing, and had no pulse or respirations. LPN A stated no CPR was started as Resident 1 wasn't breathing and there was no pulse. LPN A reported the squad arrived after LPN A got to the room. LPN A confirmed Resident 1 was a code. LPN A reported no one had discussed the incident with LPN A since it happened. E. A review of Interdisciplinary Progress Notes dated [DATE] for Resident 1 revealed the following: -At 6 PM; The resident ate 25% of supper, became nauseated, and was returned to room. -At 7:45 PM; The spouse was at bedside. -At 8 PM; Medication was given for pain. The resident was restless and trying to take clothes off. Skin was pale, warm, and dry. -At 8:15 PM; The resident was given medication for nausea. The blood glucose level was checked and registered at 91. Four ounces of orange juice was taken by the resident. -At 8:30 PM; The spouse called staff to the room and the resident was found to be unresponsive. Oxygen was started at 3 liters per nasal cannula after the physician was notified and order received. -At 9 PM; The resident had no pulse and the skin was pale and cool. The physician was notified and an order obtained to release the body to the mortuary. There was no documentation of any staff member initiating CPR during this period. F. Lack of staff knowledge of when to initiate CPR in accordance with facility policy was indicated by the following: -In an interview on [DATE] at 11:35 PM, LPN E reported lime green stickers were placed on the charts of residents who wanted CPR. LPN E reported completing CPR recertification every 2 years but did not recall any in-services regarding facility policy related to CPR. -In an interview on [DATE] at 11:45 AM, LPN B reported there is a list of residents with their code status kept in the medication room and a light green sticker is placed on the chart of residents who want CPR. LPN B reported if a resident who wanted CPR was observed taking their last breath, CPR would be started but if it had been a while since the resident had passed, CPR would not be started. LPN B reported LPN B would check the resident's color and skin temperature to make a determination. -In interviews at 12 PM and 12:20 PM on [DATE], RN C reported completing CPR recertification training last year but did not recall any in-service training regarding facility CPR policy. RN C reported there is a list of residents with code status in the medication room and a light green dot is placed on the charts of the residents who want CPR. RN C reported if a resident who wanted CPR was discovered after being deceased for awhile as indicated by color, stiffness, and mottling, RN C would not start CPR. -In an interview at 12:06 PM on [DATE], Acting DON RN D reported there is a list of residents with code status kept in the medication room and light green stickers are placed on the chart of residents who want CPR. RN D reported facility policy is only mentioned during CPR recertification training. RN D reported if a resident who wanted CPR was discovered with a cold skin temperature and purple color, RN D would not start CPR. -A review of list of in-services given in 2010 and updated proposed in-services for 2011 did not reveal any in-services regarding facility CPR policy or code status of residents. -A review of the facility policy did not reveal any specific signs or symptoms which would indicate CPR should not be started. G. A review of Resident CPR Status list maintained in the medication room revealed 6 of the current 31 residents of the facility wanted CPR. Observations of the 6 resident medical records and name tags by each resident door revealed each medical record had a lime green dot and each of resident's names were underlined in accordance with Resident CPR list. H. An interview on [DATE] at 12:18 PM, Acting DON (Director of Nursing), RN (Registered Nurse) D, revealed the ADON was not aware of any follow-up being done related to not providing CPR to Resident 1. In an interview on [DATE] at 12:34 PM, the Administrator reported the incident with Resident 1 not receiving CPR had not been brought to the Administrator's attention. Interviews with the Acting DON and the Administrator revealed no action had been taken to clarify the facility CPR policy or to educate staff members regarding the CPR policy in order to prevent a reoccurrence and protect the 6 current residents of the facility who had requested CPR be provided. I. The following interventions were implemented by the facility on [DATE] and [DATE] to abate the immediacy of the situation and protect residents who wanted to have CPR: -The facility CPR was updated to stated the following: "Policy: All residents have the choice regarding their cardiopulmonary resuscitation status Procedure: 4. When a sudden [MEDICAL CONDITION] is witnessed OR un-witnessed on a resident who desires to have CPR, CPR will be initiated by trained CPR personnel and will continue to do so until emergency medical technician (EMT) arrives and takes over care of resident 5. Nurse will direct staff to: A) Call 911 B) Gather Oxygen, backboard, ambu bag in Oxygen room C) Direct staff to be available to perform CPR as needed" -All facility nursing staff including nurse aides, LPN, and RNs were educated on the new CPR policy in-services held [DATE] at 8 PM or [DATE] at 9 AM or by telephone. -In an interview on [DATE] at 11:14 AM, Acting DON RN D reported LPN A had been suspended pending an internal investigation. -Based on the facilities actions, the IJ status was abated on [DATE].