Every finding on record at Rose Blumkin Jewish Home

Licensure Reference Number 175 NAC 12-006.18 (B & D)Licensure Reference Number 175 NAC 1-005.06(D)Based on observation, interview, and record review, the facility failed to ensure staff followed hand washing and gloving practices following cares for 2 (Resident 2 and 3) of 2 sampled residents; failed to ensure staff donned (applied) and doffed (removed) required personal protective equipment (PPE) while working with a resident in contact isolation for 1 (Resident 2) of 1 sampled residents; failed to ensure staff did not allow potentially contaminated surfaces to contact staff clothing; and failed to sanitize potentially contaminated resident care equipment after use. This had the potential to affect all 24 residents who resided on the secured unit.Findings are:Record review of facility policy entitled Hand Hygiene & Gloving dated modified July 2023 revealed: -Hand hygiene may be performed using soap and water or by using an alcohol-based hand rub (ABHR). ABHR can not be used if hands are visibly soiled or when in contact with Clostridioides difficile [C. diff}, norovirus or other spore producing infections. -Wash hands vigorously for approximately 20 seconds, being careful to cover every area. -Gloves will be worn when contact with body fluids, mucous membranes and non-intact skin is anticipated and hand hygiene will be performed prior to and after the removal of gloves. Record review of facility policy entitled Infection Prevention and Control Program modified December 2025 revealed: -Environmental Controls: Multiple resident use equipment that has the potential for contamination with blood and other body fluids will be cleaned with approved cleaning wipes after each Resident use. These devices include but are not limited to the nurse's personal stethoscope. Record review of facility education entitled C. diff dated 03/2026 revealed: -Wash your hands with soap and water only, no hand sanitizer can be used. -Bleach wipes to clean/sanitize. No purple lid wipes, they do not kill the bacteria. A. Record review of Resident 2's Diagnosis Report revealed the resident had diagnosis of enterocolitis due to clostridium difficile. Record review of Resident 2's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed staff were to wash hands with soap and water, use gown and gloves when caring for the resident dated 03/26/2026. Observation on 04/14/2026 from 11:52 AM to 12:08 PM revealed Registered Nurse (RN)-B administered Resident 2's tube feeding. RN-B and Nurse Aid (NA)-E were both utilizing gown and gloves. NA-E was in the room, finished cares with Resident 2, doffed gloves and removed the trash liner for the receptacle. RN-B asked NA-E for assistance with getting Resident 2 to the bathroom so Resident 2 could brush teeth. With bare hands, NA-E used the left hand to move the gown out of the way and used the right hand to dispense hand sanitizer with the right hand meeting the hip area of NA-E's uniform. NA-E donned gloves and assisted Resident 2 and RN-B into the restroom. NA-E remained in the room to finish oral care with the resident. RN-B doffed gown and gloves exited the room, and applied alcohol-based hand rubbed. RN-B proceeded to the medication cart where they documented the care that was performed. Interview on 04/14/2026 at 12:09 PM with RN-B confirmed ABHR was used for hand hygiene. RN-B further confirmed they should have washed hands with soap and water. Interview on 04/14/2026 at 1:25 PM with NA-E confirmed use of ABHR before donning new gloves in Resident 2's room. NA-E reported they were unaware soap and water must be used when working with residents who have a C. diff infection. Interview on 04/14/2026 at 1:36 PM with the Infection Preventionist (IP) confirmed soap and water must be used for hand hygiene when working with residents who were infected with C. diff. The IP confirmed the failure to wash hands with soap and water had the potential for cross contamination. B. Observation on 04/15/2025 at 5:48 AM with Licensed Practical Nurse (LPN)-A revealed LPN-A donned gown, gloves, and goggles and entered Resident 2's room to disconnect the tube feeding at the ordered time. LPN-A reported to the surveyor they needed the medication/treatment cart before continuing. LPN-A doffed gown and gloves, exited the room without performing hand hygiene with soap and water, and retrieved the cart. LPN-A returned to the room, washed hands with soap and water for 21 seconds, donned PPE and disconnected the tube feeding. LPN-A, utilizing a personal stethoscope placed the bell of the stethoscope on Resident 2's abdomen to check for placement of the feeding tube. LPN-A completed tasks, doffed gloves, washed hands for 22 seconds and donned new gloves. LPN-A touched the sink, a graduate, and a new syringe package that was previously removed from the cabinet in the restroom. LPN-A moved their gown, and with gloved hands, used the right hand to reach into the pocket to retrieve a marker. LPN-A labeled supplies in the room and replaced the marker in the right pocket. LPN-A doffed all PPE, washed hands with soap and water for 20 seconds and exited the room. In the hallway, LPN-A used a purple-top wipe (sanitizing cloth) and cleansed the personal stethoscope. Interview on 04/15/2026 at 6:12 AM with LPN-A confirmed they did not wash hands with soap and water when they left the room to retrieve the cart. LPN-A further confirmed a purple-top disinfecting wipe was used to cleanse the personal stethoscope and that the gloved right hand came in contact with objects in the resident's room before retrieving a marker out of the right pocket. LPN-A reported they had received training from the facility regarding C. diff but could not recall when or in what method the training was delivered. Interview on 04/15/2026 at 6:16 AM with the Director of Nursing confirmed bleach wipes must be used for equipment and further confirmed purple-top wipes would not kill C. diff spores. The DON confirmed LPN-A should have used soap and water to wash hands when leaving the room and confirmed the potential for cross contamination when LPN-A placed the gloved hand in the uniform pocket. C. A record review of the United States (US) Centers for Disease Control and Prevention's (CDC) C. diff (Clostridioides difficile) Facts for Clinicians) dated 03/05/2024 revealed C. diff sheds in feces and any surface, device or material that becomes contaminated with feces could serve as a reservoir (a source where an infectious agent lives, grows, and multiplies) for the C. diff spores (a cell that certain fungi, plants, and bacteria produce). If C. diff is suspected or confirmed the resident should be isolated (physical separation of individuals who have a contagious disease from those who are health to prevent the spread of the infection) and placed in contact precautions (a type of transmission-based infection control designed to prevent the spread of infections transmitted by direct or indirect contact with a patient's body fluids or contaminated environment). https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html#:~:text=Treatment%20and%20recovery,including%20oral%20vancomycin%20or%20fidaxomicin. A record review of two undated signs located by the door to Resident 2's room revealed a sign that indicated the resident was in contact precautions and everyone must clean their hands before entering and when leaving the room and providers and staff must also put on gowns and gloves before entering and before leaving the resident's room. The other sign was a sign that indicated the resident was in Enhanced Barrier Precautions (EBP) and everyone must clean their hands before entering and when leaving the room and providers and staff must also put on gowns and gloves when performing high-contact Resident Care Activities that included transferring. A record review of Resident 2's Care Plan Report with a print date 04/15/2026 revealed a problem area of the resident was at risk of infection and had C. diff, a gastrostomy tube (a tube inserted into the stomach for direct access to nutrients, hydration, and medication delivery) and a nephrostomy tube (a tube inserted into the kidney to drain urine into an external bag. The report had interventions of EBP and C diff – wash hands with soap and water, use precautions of gown/gloving when caring for the resident. An observation on 04/14/2026 at 1:33 PM – 150 PM revealed Resident 2 was in sitting in a wheelchair in the middle the main hallway of the Southwest unit (resident rooms 401 – 421). The resident was speaking with the resident's nurse practitioner, Occupational Therapist (OT)-C, and Physical Therapy Assistant (PTA)-D. At 1:38 PM, PTA-D assisted the resident from the wheelchair to a standing position, and the resident walked down the main hallway with a walker and PTA-D beside the resident holding the resident gait belt and touching the resident nephrostomy tube drain bag with PTA-D's right hand. PTA-D had gloves on, but neither the resident nor PTA-D had a gown on. OT-C followed the resident with the resident's wheelchair with gloved hands, no gown. Resident 2, PTA-D, and OT-C walked all the way down the main hall and to the resident's room with PTA-D's and OT-C's clothing and PTA-D's bare left arm touching the resident, the resident's clothing, and/or the resident's wheelchair. When they got to the resident's room, PTA-D assisted the resident into the resident's wheelchair and removed the gait belt. OT-C entered the resident's restroom without donning (putting on) a gown, removed OT-C's gloves, washed hands, exited the resident's room and donned new gloves. PTA-D entered the resident's room without a gown, got the footrests for the resident's wheelchair, exited the room, and put the footrests on the wheelchair. PTA-D then touched Resident 2's thighs and lower legs to correctly position onto the footrests. OT-C and PTA-D then entered the resident's room while assisting the resident and made the resident comfortable while touching the curtain, bed, call light, and overbed table all without gowns on. OT-C removed gloves and washed OT-C's hands for greater than 20 seconds before exiting the room. PTA-D removed gloves, exited the room, and used hand sanitizer before walking back into the unit. In an interview on 04/14/2026 at 1:50 PM OT-C, confirmed OT-C was the Therapy Director and the staff should only have to wear a gown if they were coming in contact with the resident's diarrhea. They would not have taken the resident out of the room if the resident was incontinent (unable to control bowels). OT-C confirmed that PTA-D should have washed hands with soap and water instead of using hand sanitizer since the resident had C. diff. In an interview on 04/15/2026 at 6:55 AM, the DON confirmed OT-C and PTA-D should have worn gowns when working with Resident 2 and when entering Resident 2's room. The DON confirmed PTA-D should have washed hands with soap and water instead of using hand sanitizer after working with Resident 2. D. A record review of Resident 3's Care Plan Report with a print date of 04/14/2026 revealed the resident had a PEG (percutaneous endoscopic gastrostomy) tube (a tube inserted into the stomach to deliver nutrients, hydration, and medications) and the resident was on EBP. The resident had orders for enteral feeding (delivery of nutrients directly to the stomach), PEG tube flushes, and medication delivery through the PEG tube. In an observation on 04/15/2026 at 4:54 AM – 5:26 AM revealed LPN-A applied gloves after performing handwashing with soap and water for 7 seconds before adjusting the resident's room to prepare for cares, starting cares on the resident. Removed gloves and applied new gloves after handwashing with soap and water for 5 seconds before preparing PEG tube flush water. Removed gloves and applied new gloves after handwashing with soap and water for 8 seconds before starting the PEG tube flush and medication administration through the PEG tube. Removed gloves and applied new gloves after performing handwashing with soap and water after PEG tube cares and before removing trash and cleaning supplies. In an interview on 04/15/2026 at 5:26 AM, LPN-A confirmed LPN-A should have washed hands with soap and water for at least 20 seconds each time and did not. In an interview on 04/15/2026 at 7:06 AM, the DON confirmed LPN-A should have washed hands with soap and water for at least 20 seconds.

Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on record review and interview, the facility failed to update the care plan with new interventions to prevent the potential for accidents for 1 (Resident 23) of 2 sampled residents. Facility staff identified a census of 95.Findings are:Record review of facility policy entitled Minimum Data Set (MDS) and Comprehensive Care Plan dated modified October 2023 revealed: - The comprehensive care plan is designed to meet the Resident's medical, nursing, mental and psychosocial needs as identified in the MDS [a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems] and as assessed by the Interdisciplinary Team (IDT). - The Comprehensive Care Plan may include the following areas, if appropriate, but not limited to, services to attain and maintain residents highest level of functioning: - Risks for: elopement, falls, skin breakdown, incontinency, dehydration, weight loss. - The care plan will be updated by floor staff as changes occur with a resident when the change occurs. - The Care Plan is to be modified as the Resident's condition warrants. All members of the team are responsible for updating the Care Plan.Record review of Resident 23's Progress Notes (PN) dated 02/22/2026 revealed Resident 23 reported they sustained an unwitnessed fall earlier in the day. Resident 23 reported they fell asleep in the wheelchair and slid out of the seat and onto the floor. Resident 23 further reported they got themselves up off the floor and back into the wheelchair independently. Facility staff notified the Advanced Practice Registered Nurse (APRN) and orders were received to complete an x-ray of the left shoulder for complaints of pain and difficulty moving left arm. Record review of Resident 23's PNs dated 02/23/2026 revealed the facility was notified of a fracture to Resident 23's left clavicle (collarbone).Record review of facility investigation dated 02/26/2026 revealed the following safety measures were implemented: bed alarms remained in use, increased monitoring implemented, therapy continued to evaluate mobility and seating options, staff were instructed to assist Resident 23 to bed if sleepy, and ongoing communication maintained with resident and spouse.Record review of Resident 23's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) printed 04/15/2026 revealed no new interventions added to the care plan after the fall.Interview on 04/15/2026 at 10:54 AM with the Director of Nursing (DON) confirmed implemented interventions from the fall on 02/22/2026 were not listed on the care plan and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)Based on record review, observation, and interview, the facility failed to obtain an order for tube feeding that included the formula type and strength and failed to record the amount of tube feeding administered for 1 (Resident 2) of 2 sampled residents. Facility staff identified a census of 95.Findings are:Record review of facility policy entitled Gastrostomy Tube/Jejunostomy Tube (G-Tube, a tube placed in the stomach to deliver nutrition, hydration, and/or medications. J-Tube a tube placed directly in the small intestine to deliver nutrition, hydration, and/or medications) modified August 2022 revealed: -The physician must prescribe the formula type, strength and rate. -Tube feeding pumps must be cleared each shift and intake total recorded each shift when receiving continuous feedings.Record review of Resident 2's Census List showed the facility readmitted the resident on 02/26/2026.Record review of Resident 2's Diagnosis Report showed Resident 2 had diagnoses that included dysphagia (difficulty swallowing).Record review of Resident 2's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/05/2026 identified Resident 2 had weight loss and was not on physician-prescribed weight-loss regimen. Further review of the MDS identified Resident 2 had a feeding tube and received 51 percent (%) or more of total calories and 501 milliliters (mL) of fluid intake per tube. Record review of Resident 2's Order Summary Report revealed an Enteral Feed Order every shift for nutrition to administer 73 ml per hour for 18 hours from 12:00 PM to 6:00 AM and off 6 hours (6:00 AM to 12:00 PM). The order did not include the formula type or strength.Record review of Resident 2's Medication Administration Record for April 2026 revealed there was no area to document the amount of tube feeding administration.Record review of Resident 2's Electronic Health Record (EHR) including scanned documents and progress notes did not identify any progress notes regarding the amount of tube feeding administered, nor any notes regarding any significant amount of time the feeding tube pump was not running during administration times.Observation on 04/14/2026 from 11:52 AM to 12:08 PM revealed Registered Nurse (RN)-B began the infusion of Nutren 1.5 and set the pump to a flow rate of 73 mL per hour.Observation on 04/15/2026 from 5:48 AM to 6:10 AM revealed Licensed Practical Nurse (LPN)-A disconnected Resident 2's tube feeding and flushed the tube. The tube feeding pump read 1070 mL's were administered.Interview on 04/15/2026 at 6:10 AM with LPN-A confirmed the tube feeding pump read 1070 mL's were administered. LPN-A reported they clear the pump totals when the administration is completed.Interview on 04/15/2026 at 7:47 AM with RN-F revealed there was no place in the medical record to their knowledge to record the amount of tube feeding administered to a resident.During an interview on 04/15/2026 at 9:49 AM, the Director of Nursing (DON) confirmed the total amount of tube feeding to be administered of 18 hours was 1,314 mL. The DON reported the facility was not recording tube feeding amounts and were relying on if there was a significant amount of time the tube feeding was held, the nurse would make a progress note. The DON confirmed there were no progress notes from 04/14/2026 to 04/15/2026 that showed the tube feeding was held. The DON reported they were unable to confirm Resident 2 received the full tube feeding amount because the feeding pump may have been cleared at any point in the night.Phone interview on 04/16/2026 at 10:53 AM with the DON confirmed the tube feeding formula type and strength were not listed in the order on the MAR and should have been. The DON further confirmed facility staff would rely on the order listed in the MAR to know what type and strength of tube feeding formula that should be administered.

Based on interview and record review, the facility failed to ensure the initial comprehensive and alternating regulatory visits for 2 (Residents 2 and 3) of 2 sampled residents were completed by a physician. The facility census was 95. Findings are:A record review of the facility's Physician Visit policy with a revised date of January 2018 revealed a nurse practitioner (APRN), clinical nurse specialist (CNS), or physician assistant (PA) may make every other required visit after the initial physician visit while the resident is Skilled Medicare A. For residents who are not admitted under a Skilled Medicare A stay, after the initial physician visit, the APRN, CNS, or PA may conduct all follow up visits. A. A record review of Resident 3's Clinical Census dated 04/14/2026 revealed that the resident was admitted to the facility 11/11/2025 as private pay (not Skilled Medicare A). The resident was sent to the hospital on [DATE] and returned to the facility as a Skilled Medicare A resident on 01/07/2026. A record review or Resident 3's Client Uploaded Files dated 04/15/2026 revealed the APRN completed the: - 11/12/2025 initial comprehensive visit. - 12/12/2025 a 30-day certification visit. - 01/12/2026 a 60-day certification visit instead of the physician completing a new initial comprehensive visit since the resident was re-admitted as a Skilled Medicare A resident on 01/07/2026. - 2/12/2026 a 90-day certification visit, but it should have been a 30-day visit, but the physician still had not completed the initial comprehensive visit. - 03/18/2026, 03/19/2026, and 03/21/2026 visits were completed but not labeled as a certification visit. - 04/09/2026 a 60-day certification visit was completed but should have been the 90-day certification visit from the 01/07/2026 re-admission. - It did not reveal that a physician visit had been completed. A record review of Resident 3's Progress Notes dated 11/11/2026 – 04/14/2026 did not reveal an initial comprehensive visit was completed by a physician. The Progress notes did reveal the APRN completed a visits with the resident on 11/12/2025, did a chart review on the resident 12/2/2025, did not reveal a visit was done 12/12/2025, completed a visit on the resident 01/08/2026, did not reveal a visit was completed 01/12/2026 but the resident was sent to the emergency room that day to related to a fall, saw the resident 02/02/2026, 02/06/2026, 02/12/2026, 02/17/2026, 02/23/2026, and 03/19/2026. In an interview on 04/15/2026 at 7:06 AM, the Director of Nursing (DON) confirmed that Resident 3's doctor was the facility's Medical Director (MD) and MD has not seen the resident at the facility, just the APRN. In an interview on 04/15/2026 at 9:50 AM, the DON confirmed the only visit Resident 3 had on admissions was the ones that were done by the APRN. The provider visits the resident had, would be in the miscellaneous tab in the computer. The resident did not have a follow-up visit by MD. In an interview on 04/15/2026 at 11:08 AM, MD confirmed MD had not seen Resident 3 and MD delegated all the visit tasks to the APRN. B. Record review of Resident 2's Census List revealed the facility admitted the resident on 01/27/2026. Further review of the census list showed the resident discharged on 01/28/2026 and was readmitted on [DATE]. Record review of Resident 2's admission and Medicare 5-day Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed Resident 2 was readmitted on [DATE] on a Medicare Part A stay. Record review of visit note created by the APRN dated 02/27/2026 revealed the reason for the visit was for admission history and physical. Record review of Resident 2's Electronic Health Record (EHR) which included scanned documents and progress notes revealed no documentation that Resident 2 was seen by a medical doctor for the initial comprehensive visit. Interview on 04/15/2026 at 6:54 AM with the DON confirmed there were no records of the medical doctor completing a visit with Resident 2. The DON reported the medical doctor had delegated visits to the APRN. Interview on 04/15/2026 at 11:08 AM, the MD confirmed they had not seen Resident 2 and delegated visit tasks to the APRN.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(6)Based on interview and record review the facility failed to change an indwelling catheter and monitor post void residuals for 1(Resident 1) of 3 residents sampled. The facility census was 93. The findings are:Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility's staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required substantial assistance with upper body dressing and hygiene.-required total assistance with toileting, bathing, lower body dressing, bed mobility and transfers. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 08-11-2025 revealed Resident 1 had an indwelling foley catheter (a tube inserted into the bladder to drain urine) due to obstructive and reflux uropathy (a condition where the outflow of urine is blocked and urine backs up into the kidneys).Record review of Resident 1's Treatment Administration Record (TAR) for September 2025 revealed an order to change to indwelling catheter every 30 days, leave the catheter out and monitor post void residual (the amount of urine left in the bladder after an individual has voided). If the post void residual volume was greater than 500 milliliters (ml) the facility staff were to replace the indwelling catheter. According to the TAR, this was due on 09-15-2025 and there was no initial in the box indicating the staff changed the catheter. The TAR also revealed an order for indwelling catheter care every shift. An interview with the Director of Nursing (DON) on 10-02-2025 at 8:45 AM confirmed Resident 1's catheter was not changed on 09-15-2025 and the catheter should have been changed and post void residuals should have been monitored.

Licensure Reference Number 175 NAC 12-006.08 Based on interview and record review, the facility failed to notify a resident's medical practitioner of a significant weight loss for one (Resident 8) of one sampled resident. The facility census was 71. Findings are: Review of Resident 8's weights revealed that [gender] had a 7.91% weight loss from 9/1/24 to 10/1/24 based on the following weights: -9/1/24: 139.6 lbs (lbs-pounds), -10/1/24: 128.6 lbs. Review of Resident 8's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 10/2/24, revealed that Resident 8 had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and that [gender] was not on a physician-prescribed weight-loss regimen. Review of Resident 8's electronic health record and paper chart revealed no documentation of [gender] medical practitioner being notified of the significant weight loss. Interview on 10/31/24 at 9:36 AM, the Director of Nursing confirmed that Resident 8 had a significant weight loss and that there was no documentation available that indicated that [gender] medical practitioner had been notified of the weight loss. Review of the policy, [NAME] of Condition-Reporting to Physician, Resident Representative and Staff, dated 9/2024, revealed the following: -To communicate with physicians, resident representative any changes in Resident conditions and to ensure appropriate medical follow-up. -Change in condition: 2. non-immediate notification a. new or worsening symptoms that do not meet above criteria (immediate notification: any symptoms, sign or apparent discomfort that is acute or sudden in onset, marked change in relation to usual symptoms and signs or unrelieved by measure already prescribed)

Licensure Reference Number 175 NAC 12.006.17B Based on observation, interview, and record review, the facility staff failed to sanitize multiple resident use equipment when exiting an Enhanced Barrier Precaution room for 1 (Resident 24) of 1 sampled residents, and failed to store oxygen tubing to prevent potential cross contamination for 1 (Resident 18) of 1 sampled residents. The facility identified a census of 71. Findings are: A. An observation of the provision of medications and G-tube feeding (method of delivering nutritional liquid through a small, flexible tube inserted into the stomach) for Resident 24 on 10/28/2024 at 2:04 PM revealed a sign on the resident 24's door that stated Enhanced Barrier Precautions (an infection control strategy that uses personal protective equipment to reduce the spread of multidrug resistant organisms in nursing homes). Licensed Practical Nurse (LPN)-A entered room, washed [gender] hands for more than 20 seconds, put on an isolation gown and gloves. LPN-B was in the room and observing LPN-A. LPN-A used a stethoscope that was resting around LPN-A's neck and placed the bell of the stethoscope on Resident 24's stomach and verified the tube placement. LPN-A put stethoscope back around their neck and then administered ordered medications and nutritional feeding through Resident 24's G-tube. An observation on 10/28/2024 at 3:07 PM revealed LPN-A exited the room without cleaning or sanitizing the stethoscope around [gender] neck. An interview with LPN-A on 10/29/2024 at 3:10 PM confirmed that the stethoscope should have sanitized when leaving an Enhanced Barrier Precaution room. An interview with LPN-B on 10/29/2024 at 3:10 PM confirmed that LPN-A should have sanitized the stethoscope when leaving an Enhanced Barrier Precaution room. An interview with Director of Nursing (DON) on 10/29/2024 at 3:14 PM confirmed that any medical equipment, including a stethoscope, should be sanitized when leaving a room with Enhanced Barrier Precautions. A record review of the facility's Infection Prevention and Control Program Policy drafted March 2011 and Modified March 2022 revealed Environmental Controls: -Multiple Resident use equipment that have the potential for contamination with blood and other body fluids will be cleaned with approved cleaning wipes after each resident use. These devices include but are not limited to : blood glucose monitoring machine, blood pressure machine, spot oximetry machine, thermometer, pacemaker check devices, etc. B. review of the facility policy titled Oxygen Therapy, last modified on February 2018 stated: Oxygen will be administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. A record review of Resident 18 Care Plan (undated entry) revealed Resident 18 has diagnoses of: Acute systolic (congestive) heart failure (CHF) (a serious condition that occurs when the heart's left ventricle is unable to pump enough blood to the body.) CHF produce symptoms (not limited to) of Shortness of breath, fatigue and a persistent cough or wheezing. A record review of resident 18's Care Plan dated 04/18/2024 reveals a problem stated: Potential for infection related to potential exposure to Respiratory syncytial virus, Influenza, COVID. An intervention was listed for this problem: Standard precautions. A record review of resident 18's Treatment Record revealed an order dated 10/29/2024 for: Oxygen at 4 liters per minute every night at bedtime, this order is without an end date. An observation on 10/28/2024 at 3:10 PM revealed Resident 18's oxygen tubing was laying under the bed. The Oxygen tubing and nasal cannula were touching the floor. The oxygen concentrator did not have any devices for storage of the oxygen tubing or nasal cannula attached to it. Resident 18 was not in the room at that time. An observation on 10/29/2024 at 2:58 PM revealed Resident 18's nasal cannula and oxygen tubing were laying on the floor in front of the oxygen concentrator. Resident 18 was sitting in their room in the recliner chair placed at the opposite corner of the room. An observation on 10/30/2024 at 2:33 PM revealed Resident 18's oxygen tubing and nasal cannula were laying on the floor under Resident 18's bed. Resident 18 is not in the room. An interview on 10/29/2024 at 2:58 PM with Resident 18 revealed [gender] denied self-removing the oxygen tubing and the nasal cannula. An interview with Registered Nurse-C (RN-C) 10/29/2024 at 2:58 PM confirmed the oxygen tubing and nasal cannula should not be on the ground, the oxygen tubing and nasal cannula should be stored hanging on the wall on a provided hook. RN-C confirms the oxygen tubing and nasal cannula were located on the floor under Resident 18's bed and the hook for the wall could not be located. An interview with the Director of nursing (DON) on 10/29/2024 at 3:25 PM confirmed storage of the oxygen tubing and nasal cannula should not be touching the ground. 50683

Licensure Reference Number 12-006.11D Licensure Reference Number 12-006.17D Based on observation, interview and record review, the facility failed to ensure proper hand hygiene was performed during food preparation and assisting residents with eating, maintain a fan in clean condition in the kitchen, and failed to store foods in a manner to prevent cross-contamination. The facility failure had the potential to affect all residents. The facility identified a census of 85. Findings are: A. Hand washing and sanitization of temperature probes: Record review of a facility policy titled Hand washing Policy - Dietary Department dated October 2016 revealed It is the policy of the [NAME] Blumkin Jewish Home to ensure that Dietary Staff follow standards for Health and personal hygiene to prevent contamination of food. The procedure states: Hand hygiene requires soap and hot water and disposable towels, hands must be washed for a minimum of 20 seconds. Observation on 8/31/23 at 7:15 AM - 7:30 AM revealed Cook-B was in the facility kitchen and had gloves on both hands. Cook-B had eggs in the Robocoup (commerical blender) and pureed the eggs, placed them in a pan, covered them with plastic wrap, and put them on a portable steam table. Cook-B returned to the kitchen and removed [gender] gloves and performed hand hygiene with soap and water for 10 seconds. Cook-B donned new gloves on both hands, retrieved additional eggs and placed the eggs into the Robocoup. Cook-B purred the eggs, added milk to the eggs from a milk carton, placed them in a pan, and covered with plastic wrap. Cook-B then removed [gender] gloves and performed hand hygiene with soap and water for 5 seconds. Observation on 8/31/23 at 7:30 AM - 7:35 AM revealed Dietary Aide-B had gloves on both hands and was placing fresh fruit in 3 large insulated pans with their gloved hands. Dietary Aide-B then removed [gender] gloves and took the soiled pan to the dishroom and pushed it through the dish machine. Dietary Aide-B did not perform hand hygiene and returned to cover the 3 large insulated pans with fruit with plastic wrap. Dietary Aide-B then labeled the insulated pans and pushed the cart out of the kitchen to a unit within the facility. Observation on 8/31/23 at 10:20 AM - 10:30 AM revealed Cook-A took out a pan of fish from the oven. Cook-A performed hand hygiene with soap and water for 7 seconds, wiped their hands on [gender] apron, then obtained a towel off of the 3-compartment sink area and wiped their hands on the towel. Cook-A then removed a pan of vegan taco rounds from the oven, cut, and placed the rounds into pans with bare hands. Cook-A covered the pans with plastic wrap and placed into the oven. Cook-A then performed hand hygiene with soap and water for 4 seconds and dried their hands on a towel sitting on the counter. Observation on 8/31/23 at 10:55 AM - 11:00 AM revealed Cook-A performed hand hygiene with soap and water for 6 seconds and dried their hands on a cloth towel. Cook-A then removed a cherry cake from the oven, left the prep area, and placed it on a steam table. Cook-A returned to the prep area with no hand hygiene performed and placed cod and vegetables into the oven to cook. Interview on 09/05/23 12:15 PM with Dietary Manager (DM): revealed that hand hygiene should be performed for 20 seconds. DM confirmed hands should be washed if staff leave the prep area and then return, after they remove gloves and before they touch any other items. B. Sanitation concerns: Record review of the Equipment Cleaning Schedule dated revised 3/21/2007 did identify that the dish room gets clean every week on Thursday AM but it did not identify the fan as a part to be cleaned. The cleaning schedule identified the following as a part of the cleaning schedule: Remove all dish dollies and racks from dish room. Clean all walls and sinks with all-purpose cleaner. Sweep floor. Set out wet floor signs. Set up mop bucket with floor cleaning solution. Using cleaning solution and deck brush to scrub floor, and rinse with hose and mop to dry. Return all dollies and racks. Observation on 08/30/23 at 7:20 AM - 7:40 AM revealed a fan attached to the wall in the Dish room which had a coating of a gray fuzzy substance present on the fan blades and the exterior surface of the fan cover. The fan was turned to off and was not blowing. The fan was positioned to blow on the clean side of the dish room where the clean dishes come out of the dishwasher. Observation on 09/05/23 at 11:40 AM with the DM revealed the fan in the dish room was turned on and was blowing on the clean side of the dish machine. The DM turned off the fan and waited for it to stop turning. When it did stop, there was a coating of a gray fuzzy substance which resembled dust on the fan blades. Interview on 09/05/23 at 11:45 AM with the DM confirmed there was a gray substance present on the fan blades and that the fan had been blowing onto the clean section of the dish room. Interview on 09/06/23 at 9:45 AM with the DM revealed the facility did not have a cleaning schedule that the staff check off daily and that there is just the list of what is to be done daily. The DM confirmed that the fan in the dish room was not on the list of items to be cleaned in the dish room. C. Foods not dated when opened: Record review of a facility policy entitled Food Storage dated September 2016 for Refrigerated Storage revealed Food placed in the walk-in refrigerators and the neighborhood refrigerators will be labeled when it is opened and properly sealed. The dates of the opened or re-refrigerated foods will be clearly marked on the packaging. A use by date will also be indicated. The Food Service Director or designee will monitor the refrigerated food to ensure the dates are marked and the food is not beyond the accepted date. If the food is beyond the accepted date or is not dated, it will be discarded. Observation on 09/05/23 at 11:30 AM - 12:10 PM with the DM revealed the following food items in the walk-in refrigerator that were not labeled or dated when opened: - 5 bags of lettuce - 5 bags of fresh parsley - 1 bag of frozen raspberries - 1 bag of Turkey slices - 1 bag of carrots - 1 bag of mixed vegetables - 1 bag of frozen spinach Interview on 09/05/23 at 12:15 PM with the DM confirmed that food items needed to be dated when opened. 48271 E. Observation on 08/31/23 at 12:15 PM revealed Cook-A was in the 200/300 facility dining room. Cook-A put an apron and gloves on prior to plating food from the steam table. Cook-A then wiped their gloved hands on their apron and wiped their nose. Cook-A continued to serve food without performing hand hygiene or changing gloves. Interview on 08/31/23 at 1:44 PM with the IP (the infection preventionist) confirmed that gloves should be removed, hand hygiene performed, and new gloves placed after touching items or personal body parts. 45641 F. A record review of the Hand Hygiene (sanitizing) and (&) Gloving Policy modified July 2023 revealed all staff that worked in the facility were required to perform hand hygiene to prevent the spread of infection. Hand hygiene would be completed before and after direct resident contact, handling food, after removing gloves, and after handling soiled care items. An observation on 8/31/2023 at 8:00 AM - 8:43 AM did not reveal Nursing Assistant (NA)-A performed hand hygiene before and after direct resident contact, handling food, after removing gloves, and after handling soiled care items during the following: NA-A gave a resident a drink of water by touching cup, sat the cup back down, took out and viewed a cell phone, then assisted Resident 39 with drink of water. NA-A then took the phone back out of NA-A's pocket, sat it on the table, and assisted Resident 35 with eating. NA-A put gloves on and assisted Resident 39 with a bite of eggs with the right hand, then with same right hand, assisted Resident 35 with a bite of food, then back to Resident 39 with the same gloved right hand. NA-A cut sausage with Resident 39's fork, then back and assisted Resident 35 with a bite of food. NA-A was then observed assisting Resident 28 with same gloved right hand. NA-A then grabbed Resident 39's toast and tore into bite size pieces with both gloved hands, then removed gloves. NA-A proceeded to assist Resident 35 with NA-A's right hand, then back to Resident 29 with the same right hand. NA-A then got up, moved Resident 25's utensils and plate and assisted Resident 25 with several bites of food off the plate. NA-A went back to Resident 39 and assisted with a bite of eggs with NA-A's right hand and then Assisted Resident 35 with eating with right hand. NA-A got up, assisted Resident 25 with bites of food with same right hand, then went back to Resident 39 and assisted eating with same right hand. NA-A then reached and assisted Resident 35 with eating with same right hand. NA-A then gave Resident 39 a drink, touched the back of Resident 39's wheelchair with NA-A's right hand, grabbed Resident 35's plate, got a spoonful of food and assisted Resident 35 same right hand. NA-A then went back to Resident 39 and assisted with a bite of food, then got up and gave Resident 25 several bites with NA-A right hand while touching Resident 25's food containers and have Resident 25 a drink of water. NA-A returned to Resident 39 and assisted with eating with NA-A's right hand. NA-A adjusted Resident 35's clothing protector, then assisted Resident 39 with eating again. NA-A then went back to Resident 35 and assisted with eating, NA-A got up and gave Resident 25 a drink of water and several bites of food, wiped Resident 25's mouth with the clothing protector, sat back down and assisted Resident 39 with a bite of food. Na-A wiped Resident 25's mouth with the napkin and returned to Resident 35 and went back and forth between Resident 35 and Resident 39 assisting with bites of food. NA-A then placed the right hand on Resident 39's wheelchair and went back to assisting Resident 39 and 35 with eating with the same right hand that touched the wheelchair. NA-A went back to Resident 25 and assisted with several bites of food. NA-A then removed Resident 25's clothing protector, wheeled Resident 25 away from the table, moved a dining room chair, and assisted Resident 41 with eating. The entire observation did not reveal NA-A performed hand hygiene. In an interview on 08/31/2023 at 08:58 AM, NA-A confirmed hand hygiene should have been completed between residents in the dining room. In an interview on 09/06/2023 at 10:17 AM, the Infection Preventionist (IP) confirmed that Residents 39, 35, 25, and 41 were all cognitively impaired and all required some form of assistance with eating. In an interview on 08/31/23 01:42 PM, the IP confirmed hand hygiene should have been performed between residents, between glove changes, after touching any resident belongings, wheelchair, personal items, clothing, and after touching the staff member's or resident's face, hair, or other body parts.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, record review and interview; the facility staff failed complete outbreak testing and implement interventions to prevent the potential spread of COVID-19 and failed to complete hand hygiene prior to performing feeding tube care for 1 (Resident 52) of 2 sampled residents. The facility staff identified a census of 71. Findings are: A. Record review of the facility COVID-19 Response Plan modified on 3/2022 revealed the following information: -Definitions: -Exposure: an individual who has had close contact (within 6 feet for a total of 15 minutes or more) to a person with COVID-19 who has symptoms (in the period from 2 days before symptom onset until they meet the criteria for discontinuing home isolation: or a person who has tested positive for COVID-19 in the 2 day before the specimen was obtained. -Outbreak testing: occurs when there has been a positive COVID-19 case among residents or staff. All residents and staff will be tested every 3 to 7 days for at least 14 days since the most recent positive results. -Response to an Outbreak: - AN outbreak exits when a new nursing home onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). When a new case is identified, the facility should immediately began outbreak testing. -Zones: -Yellow: All asymptomatic residents who may have been exposed to COVID-19. Record review of a spread sheet provided by the facility on 8-02-2022 revealed a list of staff were identified as testing positive for COVID-19 in July 2022. Further review of the spread sheet revealed Licensed Practical Nurse (LPN) J was symptomatic for COVID-19 on 7-26-2022 and tested positive for COVID-19 on 7-27-2022. Record review of a Daily Schedule sheet dated 7-24-2022 revealed LPN J worked the evening shift and the night shift ( into the morning of 7-25-2022). Record review of the Daily schedule dated 7-25-2022 revealed LPN J did not work. On 8-04-2022 at 7:35 AM an interview was conducted with Registered nurse (RN) D. During the interview RN D reported LPN J was symptomatic for COVID-19 on 7-26-2022. RN J reported LPN J had worked a double on 7-24-2022. RN J reported contact tracing was not completed. According to Merriam-Webster. com, the definition of contact tracing is the practice of identifying, notifying, and monitoring individuals who may have had close contact with a person having a confirmed or probable case of an infectious disease as a means of controlling the spread of infection. On 8-04-2022 at 9:20 AM an interview was conducted with the facility Assistant Administrator (AA). During the interview the AA confirmed contact tracing should have been completed to determine the level of outbreak testing that would be required. B. An observation on 08/02/2022 at 05:09PM of tube feeding and medication administration via G-tube by LPN-G revealed the following: LPN-G donned gloves and informed surveyor that they had washed their hands earlier. Surveyor did not witness LPN-G performing hand hygiene. LPN-G turned on room and bathroom lights, performed G-tube placement check, gave Resident 52 liquid [MEDICATION(S)] and a 300ml water flush and started G-tube feeding without replacing their gloves or washing their hands. A record review of the Facility's Gastrostomy Tube/Jejunostomy Tube Policy and Procedure revealed the following: -Hand hygiene will be performed before and after handling the tube.

Licensure Reference Number: 12-006.12B (5) Based on record review and interviews, the facility failed to complete a drug regimen review for 5 residents (Residents 51,4,5,19,11) and failed to develop and implement a medication regimen review policy. The facility census was 71. Findings are: A. A record review of Resident 5's physician orders revealed Resident 5 has been prescribed [MEDICATION(S)] 45mg daily and [MEDICATION(S)] 2.5mg daily. An interview on 08/03/2022 at 3:20PM with RN-D (Registered Nurse) revealed that the facility does not have a Medication Regimen Review policy/procedure. An interview with RN-D confirmed the Pharmacist conducts a monthly medication review and if there is an issue the pharmacist will contact the facility. An interview with RN-D confirmed that if an issue is not identified by the pharmacist there will be nothing in the resident chart except the note: Chart reviewed refer to pharmacy report B. Record review of Resident 19's electronic health record revealed Resident 19 is followed by a pyschiatrist on a monthly basis. A record review of Resident 19's Physician notes reveal discussions between Resident 19 and Pyschiatrist related to medication wishes of Resident 19 and Physician's rational for prescriptions. A record review of Resident 19's care plan revealed interventions and strategies to work with Resident 19's behaviors. An interview on 08/03/2022 at 3:20PM with RN-D revealed that the facility does not have a Medication Regimen Review policy/procedure. An interview with RN-D confirmed the Pharmacist conducts a monthly medication review and if there is an issue the pharmacist will contact the facility. An interview with RN-D confirmed that if an issue is not identified by the pharmacist there will be nothing in the resident chart except the note: Chart reviewed refer to pharmacy report. C. An observation at lunch on 08/1/22 at 11:45AM revealed Resident 51 was displaying exaggerated oral movements. An observation at breakfast on 08/02/2022 at 08:00 AM revealed resident 51 had no exaggerated oral movements. A record review of Resident 51's Electronic health record revealed Resident 51 was seen by Psychiatrist on 4/22/2022, 6/23/2022 and 7/28/2022. A record review revealed Resident 51 was prescribed Aripripazole. 10mg daily and [MEDICATION(S)] 200mg at bedtime. An interview on 08/03/2022 at 3:20PM with RN-D revealed that the facility does not have a Medication Regimen Review policy/procedure. An interview with RN-D confirmed the Pharmacist conducts a monthly medication review and if there is an issue the pharmacist will contact the facility. An interview with RN-D confirmed that if an issue is not identified by the pharmacist there will be nothing in the resident chart except the note: Chart reviewed refer to pharmacy report. D. Record review of Resident 4's Medical record revealed the facility Pharmacist when completing the monthly drug regimen review since 1-2022 did not identify if there were any irregularities or not in Resident 4's medical record. On 8-03-2022 at 7:30 AM an interview was conducted with RN D. During the interview RN D confirmed the facility Pharmacist did not identify irregularities or not in Resident 4's medical record. E. Review of Resident 11's Electronic Medical Record (EMR) revealed on the following dates the Pharmacist documented Chart reviewed refer to Pharmacy Report: 5/19/2022 6/27/2022 7/19/2022 Review of Resident 11's medical record revealed no pharmacy report in Resident 11's medical record. Interview on 8/4/2022 at 3:20 PM with RN-D revealed no pharmacy report in Resident 11's medical record. Interview on 08/03/22 at 3:20 PM with RN-D revealed the process is the pharmacist conducts a monthly medication review and if there is an issue the pharmacist will contact the facility, however, if no issue is identified there is nothing in the resident chart except a note that the review was completed.

Licensure Reference Number: 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure required registry checks were completed for 2 of 5 staff files reviewed. The facility census was 71. Findings are: Review of 5 random employee files revealed 2 of 4 Nursing Assistant (NA) personnel files did not contain a NA registry check for disciplinary action. After the review was completed the facility provided NA registry checks printed on 8/3/2022 for NA A and NA B indicated that the check was not completed prior to staff starting employment. Review of the facility policy dated 3-2019 titled Abuse Prohibition/Reporting Abuse and Crime revealed for nursing staff, the Director of Nursing/designee will contact the applicable Nursing License Registry or state nurse Aide Registry to determine current status and standing. Interview on 8/3/2022 at 4:00 PM with RN-C revealed the registry forms were printed after the review of the files and were not present on hire. Interview on 08/04/22 at 11:39 AM with the Assistant Administrator revealed all staff should be checked on the registry prior to starting work.

Based on record review and interview, the facility failed to ensure residents or resident representatives were notified in writing of reason for transfer for 1 resident (resident 5). The facility census was 71 Findings are: A record review of Resident 5's Electronic Health Record revealed the following: -4/14/2022 at 22:55, resident transferred to Hospital. Rescue squad arrived and left with resident at 22:54 going to Methodist. Spouse will meet resident at the hospital. An interview on 8/3/2022 at 03:45PM with RN-C (Registered Nurse) confirmed that the facility does not send a written transfer/discharge notice to the resident or resident representative but calls the resident representative to inform them of the transfer.

Based on record review and interviews, the facility failed to ensure residents or resident representatives were provided with a copy of the bedhold policy when transfered to the hospital for 2 residents (Residents 5, 20). The facility census was 71. Findings are: A. Record review of Resident 5's Electronic Health Record revealed the following: -4/14/2022 at 22:55, the resident transferred to Hospital. Rescue squad arrived and left with resident at 22:54 going to Methodist. Spouse will meet the resident at the hospital. An interview on 8/3/2022 at 03:45PM with RN- C (Registered Nurse) confirmed the facility did not provide a written notice of the bed hold policy or reserve payment policy if needed to the resident representative. B. Review of Resident 20's medical record revealed Resident 20 was admitted to the hospital on 5/4/2022. Review of Resident 20's medical record revealed no documentation of Bed Hold Policy being provided to the resident or the residents representative at the time of transfer indicating what the cost was to hold the bed while the resident was in the hospital. Review of the facility policy dated 2003 titled Bed Hold and Readmission policy revealed: - Residents or the resident's representative will be offered the opportunity to hold the Resident's current bed during hospitalization or leave of absence. - A facility representative will provide written notification of the bed hold policy to the Resident or the Resident representative at the time of each hospitalization or leave of absence. - In the event of hospitalization , a letter regarding the bed hold policy will also be sent to the Resident's Representative via United States Postal Service. - A facility representative may contact the Resident or Resident Representative via telephone to confirm a bed hold status. - Private Pay Residents will be charged a bed hold fee, equivalent to the daily room rate charge not including ancillary charges, until such time as the facility is notified of the Resident's or Resident Representative's desire to discharge from the facility. Review of Record revealed No bed hold policy signed by the resident or resident representative and no documentation in the medical record that the bed hold policy was provided to Resident 20 or Resident 20's representative at time of transfer to the hospital. Interview on 8/3/2022 at 4:00 PM with RN-D revealed no bed hold was provided on transfer to the hospital.

Licensure Reference Number: 175 NAC 12-006.09C3 Based on record review and interview, the facility failed to complete a discharge summary to include a recapitulation of residents stay for 1 resident (Resident 68). The facility census was 71. Findings are: Review of Resident 68's medical record revealed no discharge summary including a recapitulation of residents stay. Review of Resident 68's progress notes regarding the discharge planning contained no status documentation by departments of Resident 68's status at the time of discharge and no recapitulation of stay. Interview on 8/3/2022 at 4:00 PM with Registered Nurse (RN-D) revealed discharge summaries were not being completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observations, record review and interview; the facility staff failed to identify and monitor bruising for 1(Resident 7) of 5 sampled residents. The facility staff identified a sample of 71. Findings are: Record review of Resident 7's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 5-04-2022 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental status was a 15. According to the MDS Manuel a score of 13 to 15 indicated a person is cognitively intact. -Limited assistance with personal hygiene. -Extensive assistance with bed mobility. -Total assistance with transfers. Observation on 8-02-2022 at 1:15 PM revealed staff provided personal cares to Resident 7. Further observations on 8-02-2022 at 1:15 PM revealed Resident 7 had multiple areas of bruising to both lower legs. On 8-02-2022 at 1:15 PM an interview was conducted with Resident 7. During the interview Resident 7 reported staff cased the bruising to the lower legs when holding onto them. Resident 7 further reported bruising easily and that the bruising has been there a few days. Review of Resident 7's medical record that included progress notes, skin monitoring sheets, care plan, and practitioners orders revealed there was not an indication Resident 7 had the bruising to both lower legs. Record review of a Initial Alteration in Skin Integrity Observation (ASIO) sheet dated 8-02-2022 with a time of 830 PM revealed the facility staff identified the following bruised areas on Resident 7: -The back of the left hand bruising measured 3 centimeters (cm) by 2 cm's. -Right outer ankle bruising measured 5 cm's by 4.5 cm's. -Right inner shin bruising measured 2.8 cm's by 2.0 cm's. -Left outer shin bruising measured 3 cm's by 1.8 cm's. -Left inner shin bruising measured 3 cm's by 2.8 cm's. -Front of left foot bruising measured 3.5 cm's by 2.1 cm's. -Medial knee bruising measured 5 cm's by 4 cm's. -Left outer forearm bruising measured 5 cm's by 4.5 cm's. -Under right knee lateral side bruising measured 7 cm's by 4.5 cm's. Record review of the facility Skin Integrity Program modified on 10/2020 revealed the following information: -Documentation : -Alterations in skin integrity identification, measurements and description will be documented completely and thoroughly, weekly, and as needed in the residents medical record. -#6. If the alteration is a skin tear greater than 1 cm or the bruise of unknown origin, the nurse will notify administration so further investigation can take place. On 8-04-2022 at 8:04 AM an interview was conducted with Registered Nurse (RN) D. During the interview RN D confirmed Resident 7's bruising had not been monitored.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on observations, record review and interview; the facility staff failed to evaluate and implement interventions to meet nutritional needs for 1 (Resident 65) of 2 sampled residents. Findings are: Record review of an Order Summary Report (OSR) sheet printed on 8-02-2022 revealed Resident 65 practitioner order Resident 65 was to have nothing by mouth (NPO) as of 3-30-2021. Further review of the OSR sheet printed on 8-02-2022 revealed Resident 65's was to receive [MEDICATION(S)] ( feeding formula) 1.5 starting at 9:00 am of a container that held 1000 milliliters (ml) via tube. Record review of Resident 65's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 65's medical record that included progress notes, practitioners orders and Comprehensive Care Plan (CCP) revealed no indications a comprehensive nutritional evaluation had been completed to ensure Resident 65's nutritional requirements were being meet. Observation on 8-02-2022 at 10:00 AM revealed [MEDICATION(S)] 1.5 was being provided via feeding pump with a setting of 39 ml per hour. On 8-02-2022 at 1:50 PM an interview was completed with Registered Nurse (RN) E. During the interview RN E confirmed the [MEDICATION(S)] 1.5 infusing rate was 39 ml per hour for 20 hours. On 8-02-2022 at 1:59 PM an interview was conducted with the facility Registered Dietician (RD). During the interview the facility RD confirmed there was not a comprehensive nutritional evaluation completed and further confirmed the [MEDICATION(S)] 1.5 at 39 ml for 20 hours was not enough to meet resident 65's nutritional needs. On 8-4-2022 the facility RD completed a Nutritional Evaluation of Resident 65's daily requirement revealed Resident daily calorie needs was 1525. Further review of the Nutritional Evaluation completed on 8-04-2022 revealed the [MEDICATION(S)] 1.5 at 39 ml for 20 hours provided 1170 calories per day. On 8-4-2022 at 9:05 AM an interview was completed with the facility RD. During the interview review of Resident 65's Nutritional Evaluation dated 8-4-22 was completed . The facility RD confirmed the [MEDICATION(S)] 1.5 at 39 ml for 20 hours did not meet Resident 65's nutritional daily needs. The RD further reported a full comprehensisve assessment should have been completed when the resident was totally NPO.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6(1) Based on observations, record review and interview, the facility staff failed to check placement of a feeding tube for 1 (Resident 65) of 2 sampled residents and failed to ensure the head of the bed was elevated to prevent the potential for aspirations of stomach contents during tube feeding for 1 (Resident 52) of 2 sampled Residents. The facility staff identified a census of 71. Findings are: A. Record review of the facility Policy and Procedure for Gastronomy Tube/Jejunostomy Tube modified on 3/2021 revealed the following information: -Policy: -It is the policy of Rose Blumkin Jewish Home to provide for safe enteral nutrition, hydration, and medication administration and limiting the risk for complications. -Procedure: -2. Position Resident upright, head above chest, during feeding and for at least 1 hour after feeding if feeding is intermittent. -4. Check tube placement before each feeding, and at least once per shift if the feeding is continuous. Tube placement may also be checked by aspirating gastric contents. B. Record review of an Order Summary Report (OSR) sheet printed on 8-02-2022 revealed Resident 65 practitioner order Resident 65 was to have nothing by mouth (NPO) as of 3-30-2021. Further review of the OSR sheet printed on 8-02-2022 revealed Resident 65's was to receive [MEDICATION(S)] ( feeding formula) 1.5 starting at 9:00 am of a container that held 1000 milliliters (ml) via tube. Observation on 8-03-2022 at 9:35 AM Revealed Licensed Practical Nurse (LPN) H obtained Resident 65's [MEDICATION(S)] formula and the required tubing. LPN H completed hand hygiene and donned gloves. LPN H hung the bottle of [MEDICATION(S)] on an IV pole and connected the feeding to the feeding pump. LPN H without checking placement connected the the tubing to Resident 65's feeding tube. LPN H set the rate at 39 ml's on the feeding pump and set it to start the infusion. On 8-03-2022 at 9:35 PM an interview was conducted with LPN H. During the interview, LPN H reported did not need to check placement of the feeding tube. During the interview LPN H checked Resident 65's electronic practitioners orders and confirmed placement of the feeding tube was to be checked prior to starting the feeding. C. Record review of Resident 52's electronic health record revealed Resident 52 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Nothing by mouth) Tube feeding via G-tube (Gastrostomy tube is a tube inserted through the abdomen that is used to bring nutrition directly to the stomach) is used to provide nutrition. The tube feed order is for [MEDICATION(S)] 1.5 55 cc an hour for 15 hours. Tube feeding to be off from 8 a.m. to 5 p.m. Check and record residuals every shift, notify MD of residuals per order. Flush tube with 300 cc water 4 times a day. An observation on 08/02/2022 at 05:09PM of tube feeding and medication administration via G-tube by LPN-G revealed the following: LPN-G (Licensed Practical Nurse) donned gloves and informed surveyor that they had washed their hands earlier. LPN-G entered Resident 52's room and turned on the light with their gloved hands. LPN-G set 30ml liquid [MEDICATION(S)] on Resident 52's side table and then woke the resident and explained what that they would be hooking up the tube feed. The tube feed was marked at an earlier time with the resident room number, the tube feed start time, the date 8/2/2022 and the LPN initials. Resident 52 was resting in bed on their back with the head of the bed slightly elevated. LPN-G did not check to see if the angle of the bed was elevated to 30 degrees or more. LPN-G entered the bathroom and turned on the light using their gloved hand. LPN-G then went to the bathroom sink, turned on the hot water and filled a graduated cylinder with 300ml of warm water. LPN -G placed the graduated cylinder and 60ml syringe on Resident 52's side table. LPN-G removed a stethoscope from the side table and pulled Resident 52's bedding down and raised the gown to expose the G-Tube. LPN-G placed a towel beneath the G-tube, uncapped the tube and attached the syringe with 20cc of air. LPN-G explained that she was about to check G-tube placement and placed the stethoscope earpieces in their ears and placed the stethoscope disc on the resident's abdomen. LPN-G pushed air through the syringe to confirm placement. LPN-G removed the stethoscope and pulled back on the plunder to check residual. The plunger was removed and LPN-G poured some water into the syringe and allowed it to feed through by gravity. LPN-G poured the [MEDICATION(S)] into the syringe. When the medication had drained through the syringe, LPN-G poured the remainder of the 300ml of water through the syringe. When the syringe was clear, LPN-G removed the syringe and attached the tubing and the tube feed. LPN-G then initiated the feeding pump with the previously entered settings and started the tube feeding. LPN-G removed the towel from the resident and resettled her gown and bedding. LPN-G returned the syringe and the graduated cylinder to the bathroom counter. LPN-G turned off the lights and left the room. LPN-G doffed their gloves at the med cart. An interview with LPN-G confirmed that this is the process they follow for tube feed administration. Record review of Resident 52's care plan revealed the following intervention: -Elevate HOB (head of bed) higher than chest at all times during feeding for at least 30-40 minutes after feeding has stopped. An observation on 08/04/2022 at 07:16AM revealed Resident 52 lying on their back in bed with the head of the bed slightly elevated. Resident 52 was asleep with tube feed running at 55milliliters an hour. The measured angle of the head of the bed was 11.3 degrees. An interview with LPN-F confirmed LPN-F saw the measured degree of the head of the bed and confirmed it was 11.3 degrees. An interview with LPN-F confirmed that degree of bed rise was too low. Interview with LPN-F confirmed that they did not know how high it should be. A record review of the facility Tube Feeding policy revealed Position Resident upright, head above chest, during feeding and for at least 1 hour after feeding, if feeding is intermittent. The American Nurse Association Standard of practice suggests the head of the bed should be elevated 30 degrees or higher during feeding and for at least 30 minutes after the feed to reduce the risk of aspiration. (sucking food into an airway).

Licensure Reference Number: 175 NAC 12-006.10D Based on observation, interview and record review, the facility failed to ensure medication rate of under 5 %. The observed medication error rate was 6.98%. This affected Resident 24. The facility staff identified the census at 71. The findings are: An observation conducted on 8-3-2022 at 7:55 AM of Licensed Practical Nurse (LPN) -F administering medications to Resident 24 revealed that LPN-F verified medications to be given with Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident took the medications with a spoon and swallowed. The medications administered included: [MEDICATION(S)] (extended release) 25mg (cardiac). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Omeprazole Delayed Release 20mg (for stomach) Potassium Chloride ER (extended release) 20mEq (supplement) Information from Web MD identifies directions for the medications as follows: [MEDICATION(S)] is a medication that is given for control of chest pain, heart failure, high blood pressure. Do not crush or chew extended-release tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Also, do not split extended-release tablets unless they have a score line and your doctor or pharmacist tells you to do so. Swallow the whole or split tablet without crushing or chewing. Omeprazole Delayed Release is a medication that is given for gastric reflux. Directions include Do not crush, break, or chew this medication. Swallow the medication whole. Potassium Chloride ER is a mineral supplement used to treat or prevent low amounts of potassium in the blood. Do not crush, chew, or suck on the tablets. Doing so can release all of the drug at once, increasing the risk of side effects. On 8/4/2022, review of Facility Policy/Procedure regarding Oral Medication Administration revealed the procedure for crushing medications includes If a medication cannot be crushed, the pharmacist may recommend an alternative and the nurse will notify the physician for an order. Medications that require specific instructions for administration are administered in a way that complies with manufacturer's recommendations. On 8/3/2022 at 9:00 AM, an interview with Charge Nurse, Registered Nurse (RN)- I regarding crushing of medications that are delayed release or extended release medications revealed that they can crush meds unless the order specifies do not crush but they get clarification from the Dr for extended release and delayed release medications. RN-I indicated that clarification had not been received for the 3 medications that Resident 24 was administered.

Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review and interview, the facility failed to develop a Comprehensive Care Plan [CCP, a written interdisciplinary comprehensive plan which detailed how to provide quality care for a resident] related to [CONDITION(S)] [the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately function on their own] for 1 (Resident 43) of 2 residents that received [CONDITION(S)] services. The facility census was 72. Findings are: Record review of Resident 43's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 43 dated 1/2/2020 revealed in section O (Special Treatments, Procedures, and Programs) question O0100J that Resident 43 received [CONDITION(S)] while a resident of the facility. Observation on 4/21/21 at 10:15 AM with Registered Nurse [RN] C revealed Resident 43 seated in a wheelchair and ready to transport to [CONDITION(S)] treatment. Present in Resident 43's upper left chest was a dual port catheter [a plastic tube with 2 ports which provides vascular access into the body] [CONDITION(S)] access site. The catheter insertion site was covered with a square gauze dressing and held to the skin with medical tape. The skin around the dressing looked clear with no redness or signs of infection present. Interview on 4/21/21 at 10:20 AM with RN C revealed that Resident 43 received [CONDITION(S)] on Mondays, Wednesdays and Fridays each week. Record review of the CCP dated 3/31/21 for Resident 43 revealed that resident 43 was on [CONDITION(S)] 3 times per week and was to be up and ready to go to [CONDITION(S)] before 10:20 AM on [CONDITION(S)] days. The CCP did not identify which days of the week were [CONDITION(S)] days. The CCP did not include specific information related to the location of the [CONDITION(S)] access site, ongoing monitoring of the access site, parameters for blood pressure monitoring, documentation and monitoring of potential complications, pre and post [CONDITION(S)] assessments of vital signs and weights, assessment or documentation of the care of access site. Interview on 4/22/21 at 11:10 AM with the DON confirmed that a CCP for Resident 43 had not been developed related to [CONDITION(S)] services, the location of the [CONDITION(S)] access site, ongoing monitoring of the access site, parameters for blood pressure monitoring, documentation and monitoring of potential complications, pre and post [CONDITION(S)] assessments of vital signs and weights and assessment or documentation of the care of access site.

Based on observation, interview and record review, the facility failed to evaluate the clinical status [vital signs, weight, physical condition] and access site [a vascular port of entry used to deliver [CONDITION(S)] treatment] prior to and following [CONDITION(S)] [the process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally] treatments and failed to maintain policies and procedures for the care and services for [CONDITION(S)] for 2 (Residents 29 and 43) of 2 residents that received [CONDITION(S)] services. This had the potential for the residents to experience serious complications related to not monitoring prior to or post [CONDITION(S)] treatments. The facility census was 72. Findings are: A. Interview on 4/20/21 at 3:07 PM with the Director of Nursing [DON] revealed that the facility had no policies or procedures related to the care and services to be provided for [CONDITION(S)] services. B. Record review of Resident 29's admission Clinical Resident profile dated 4/22/21 revealed an admitted [DATE] with End Stage [CONDITION(S)] [[CONDITION(S)], kidney failure in which the kidneys are only functioning at 10 to 15 percent of their normal capacity and [CONDITION(S)] is necessary to stay alive] as the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident 29's Minimum Data Set [MDS, a mandatory comprehensive assessment tool used for care planning) Quarterly dated 2/17/21 revealed that Resident 29 had a Brief Inventory of Mental Status [BIMS] score of 08 which indicated moderate cognitive impairment. The MDS identified a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident 29's Care Plan [CP, a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident] revised on 2/23/21 revealed that Resident 29 had End Stage Renal Failure with [CONDITION(S)] 3 times per week. Interventions included: - [CONDITION(S)] at offsite [CONDITION(S)] Treatment center 3 times per week -Feed lunch prior to leaving. - If has bleeding to [CONDITION(S)] port, hold pressure 5 - 10 minutes with gauze, if continuous, should be seen by ER [emergency room ]. - remove [CONDITION(S)] dressing Mon / Wed / Fri before bed - Son transports to [CONDITION(S)], staff to take resident to the door for son to take. Observation on 4/21/21 at 7:55 AM with Registered Nurse [RN] A revealed the presence of a fistula [a surgical connection between an artery and a vein used for [CONDITION(S)] access] [CONDITION(S)] access site in Resident 29's upper right arm. The access site appeared clear with no signs of bleeding, redness or infection present. Interview on 4/21/21 at 8:05 AM with RN A revealed that Resident 29 had [CONDITION(S)] treatments on Monday's, Wednesdays and Fridays at an offsite [CONDITION(S)] treatment center. RN A revealed that a BP was taken in the opposite arm from the access site arm every AM and RN A confirmed that the resident access site was routinely checked for thrill and bruit [a nursing assessment used to determine if an access site is functional] but did not document the assessments for Resident 29. RN A confirmed that no pre or post assessment of resident condition, vital signs or the access site had been completed prior to going to any [CONDITION(S)] treatment. Interview on 04/20/21 at 03:00 PM Licensed Practical Nurse [LPN] B confirmed that Resident 29's [CONDITION(S)] access site is in the upper right arm. LPN B confirmed that the dressing over the access site was removed every [CONDITION(S)] day at bedtime and that was documented on the Treatment Sheets. LPN B stated that Resident 29's access site was not checked for Thrill or Bruit and the condition of the site was not documented. LPN B stated no vital signs were obtained after Resident 29's return from [CONDITION(S)] treatments. Record review of Resident 29's Physician Visit Forms dated 4/7/21, 4/12/21, 4/14/21, 4/16/21 and 4/19/21 on [CONDITION(S)] days revealed no documentation of pre or post [CONDITION(S)] assessments, vital signs, weights, resident condition or the condition of the fistula access site. Record review of Resident 29's Electronic Medical Record and paper chart revealed no documentation of pre or post [CONDITION(S)] assessments related to vital signs, weight or condition of the fistula access site. Record review of Resident 29's Progress Notes between 4/2/21 and 4/19/21 revealed no documentation of assessments of pre or post [CONDITION(S)] vital signs, resident condition or condition of the access site. The resident received 8 [CONDITION(S)] treatments during that time period. Interview on 4/22/21 at PM with the DON confirmed that the facility did not evaluate Resident 29's clinical status (vital signs, weights, general condition) or condition of the [CONDITION(S)] access site prior to or following [CONDITION(S)] treatments. C. Record review of Resident 43's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 43's MDS identified a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed in section O (Special Treatments, Procedures, and Programs) question O0100J that Resident 43 received [CONDITION(S)] while a resident of the facility. Interview on 4/21/21 at 8:05 AM with RN C revealed that Resident 43 had [CONDITION(S)] treatments on Monday's, Wednesdays and Fridays at an offsite [CONDITION(S)] treatment center. RN C revealed that the staff did not look at the catheter access site and did not do pre or post treatment vital signs or an assessment of resident condition or the [CONDITION(S)] access site. RN C confirmed that no pre or post assessment of resident condition, vital signs or the access site had been completed prior to or after going to any [CONDITION(S)] treatment. RN C stated no vital signs were obtained after Resident 43's return from [CONDITION(S)] treatments. RN C confirmed that the staff don't document the condition of the catheter access site unless there are problems. Observation on 4/21/21 at 10:15 AM with Registered Nurse [RN] C revealed Resident 43 seated in a wheelchair and ready to transport to [CONDITION(S)] treatment. Present in Resident 43's upper left chest was a dual port catheter [a plastic tube with 2 ports which provides vascular access into the body] [CONDITION(S)] access site. The catheter insertion site was covered with a square gauze dressing and held to the skin with medical tape. The skin around the dressing looked clear with no redness or signs of infection present. Record review of Resident 43's Electronic Medical Record and paper chart revealed no documentation of pre or post [CONDITION(S)] assessments related to vital signs, weight, resident condition or condition of the catheter access site. Record review of Resident 43's Progress Notes between 4/2/21 and 4/19/21 revealed no documentation of assessments of pre or post [CONDITION(S)] vital signs, resident condition or condition of the access site. The resident received 8 [CONDITION(S)] treatments during that time period. Interview on 4/22/21 at PM with the DON confirmed that the facility did not evaluate Resident 43's clinical status (vital signs, weights, general condition) or condition of the catheter access site prior to or following [CONDITION(S)] treatments.

LICENSURE REFERENCE 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to re-evaluate pain indicators and implement interventions to manage pain for 1 (Resident 112) of 1 residents reviewed. The facility staff identified a census of 86. Findings are: Record review of Resident 112's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-26-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 3. According to the MDS Manual, a score of 0 to 7 indicated severe cognition impairment. -Independent with bed mobility. -Supervision with personal hygiene. -Limited assistance with on and off the unit. -Extensive assistance with dressing and toilet use. -Received as needed (PRN) pain medication or was offered and the resident declined the medication. Record review of Resident 112's Comprehensive Care Plan (CCP) dated 6-13-2016 revealed Resident 112 had back pain. The goal for Resident 112 was that Resident 112 would rate pain below a 4 on the pain scale. Typed in interventions on the CCP were to balance rest and activity, use numeric scale to rate pain, Tylenol and [MEDICATION NAME] (pain medication) PRN.[MEDICATION NAME] (pain medication) PRN. Further review of Resident 112's CCP dated 6-13-2016 revealed a hand written entry update that Resident 112 received an x-ray due to increased pain and the update dated 10-26-2016 that Resident 112 was to receive Tylenol routine for back pain. Observation on 11-30-2016 at 8:02 AM of personal care for Resident 112 revealed Nursing Assistant (NA) E and NA F washed hands and donned gloves. Resident 112 was observed to be in bed. Resident 112 yelled out Oh that hurts and was heard to moan and groan as NA F started to cleans the front peri area. Resident 112 continued to yell out stop at NA F and then started to hit at NA F. NA E assisted Resident 112 into a right laying position for further cleaning. Resident 112 yelled out Your killing me, Oh God Help me, it hurts, Daddy Daddy, oh boy that hurts. NA E and NA F positioned Resident 112 onto a back laying position and pulled up Resident 112's clothing. When asked by NA F if (gender) wanted to go to breakfast, Resident 112 reported, no. NA E and NA F did not stop the procedure when Resident 112 complained of pain to report it to the charge nurse. On 11-30-2016 during the observation of care at 8:02 AM, NA E said Resident 112 was always in pain. Observation on 11-30-2016 at 1:10 PM of Resident 112 being transferred from a wheelchair to the bed revealed NA E and NA F placed a transfer belt around Resident 112. Both NA E and NA F explained the transfer task to be completed to the resident. NA E and NA F began to transfer Resident 112 from the wheelchair and Resident 112 yelled out in pain stating ouch, that hurts and was transferred into bed. NA E and NA F pulled down Resident 112 pants and positioned the resident onto the resident ' s right side. During the repositioning, Resident 112 yelled out Oh it hurts, help me god, don't move me. NA E and NA F completed the personal care. An interview was conducted on 11-30-2016 at 1:10 PM after the personal care was completed. When attempting to ask Resident 112 to rate the pain, Resident 112 stated little bit, little bit with furrowed brows. Resident 112 was not able to state a number on a scale of 0 to 10. An interview on 11-30-2016 at 2:01 PM was conducted with Licensed Practical Nurse (LPN) B. During the interview, LPN B reported that NA E and NA F had informed (gender) about Resident 112's pain. LPN B reported Resident 112 had identified the pain as a little bit. When asked if LPN B had evaluated Resident 112's pain after being notified, LPN B stated no. Record review of The Facility Pain assessment and Treatment Program Policy and Procedure dated 7-2013 revealed the following information: -Policy: All residents will have their pain recognized, assessed and treated. Pain may manifest itself as verbal expression of pain, moaning, sleep disturbances, agitation, rocking, grimacing, withdrawal, crying, and guarding of affected area(s). -Procedure: -1. The resident will be assessed for pain by the licensed nurse at admission, re-admission, quarterly and as needed. -5. Staff will continue to monitor for verbal and nonverbal signs of pain. It may be necessary to ask the resident are you having pain?, are you comfortable?, do you have discomfort or do you ache anywhere?. The pain assessment scale will be utilized to rate the severity of pain. -6. Information regarding the resident's pain, interventions and management will be included in the resident's plan of care. This will be reviewed and modified needed. -treatment plan: [REDACTED] -1. treatment of [REDACTED]. -2. Non-Pharmacological interventions can include repositioning, music, relaxation, distraction, exercise, physical or occupational therapy and application of ice or heat. -4. It may also be necessary to administer pain medication prior to certain activities such as physical or occupational therapy or medical procedures. -5. The licensed nurse will notify the physician if the residents is not experiencing relief with the current treatment plan or are experiencing a new acute onset of pain and pain is interfering with their comfort and/or functional status. The resident will be placed on triggered charting until the resident is free of pain or the pain controlled within the resident's stated acceptance level The facility staff did not provide additional information prior to survey exit.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to maintain food temperatures in a range to prevent food borne illness. The facility staff identified 86 of 87 resident who ate out of the facility kitchen. The facility staff identified a census of 87. Findings are: Observation on 8-12-2016 at 11:30 AM revealed a weekly Deli style lunch was being offered to the facility residents and outside community. An interview was conducted on 8-12-2016 at 11:40 AM with the Director of Food Service (DFS). During the interview the DFS confirmed food for the weekly Deli was prepared in the facility kitchen. When asked if the facility residents could have their lunch from the Deli, the DFS stated yes. On 8-12-2016 at 11:55 AM an interview was conducted with the Assistant Director of Food Service (ADFS). During the interview when asked if a resident could have their meal served from the Deli, the ADFS stated yes. The ADFS reported if residents wanted to eat from the Deli, the staff would take the food order sheet to the residents' nurse to see if what was ordered was with in the diet for the resident. Observation on 8-12-2016 at 12:05 PM revealed the Deli style lunch was being served to those community members and residents who had placed lunch orders. Further observation of the meal service revealed there was a pan of raw Tuna steak. There was brownish liquid partially covering the Tuna Steak and upon request, Cook G using the facility thermometer, obtained the temperature of the Tuna steak. Cook G reported the Tuna Steak was 50 degrees. Continued observation of the Deli service revealed Egg Salad and Tuna Salad were available for community members and residents to order. The Egg salad and the Tuna salad were observed to be sitting on top of a pan of ice. When requested, Cook B using the facility thermometer, obtained the the temperature of the Egg Salad with a resulting temperature of 48 degrees. Cook B then obtained the temperature of the Tuna Salad with the resulting temperature of 48 degrees. The DFS who was assisting with the Deli service was informed of the resulting temperatures of the Tuna and Egg Salad. The DFS stated that's not cold enough and instructed Cook B to retake the temperature of the Egg and Tuna Salad. Cook B using the facility thermometer, obtained the temperature of the Egg Salad with a result of 50 degrees and the Tuna Salad was 52 degrees. Cook B reported the results to the DFS at 12:13 PM on 8-12-2016. The Tuna Salad, Egg Salad and Tuna Steaks were not removed and discarded. Observation on 8-12-2016 at 1:40 PM revealed the deli service was completed. Cook B obtained the temperature of the remaining Egg Salad with a result of 56 degrees and the remaining Tuna Salad temperature was 58 degrees. An interview with the DFS was conducted on 8-12-2016 at 1:40 PM. During the interview the DFS confirmed the Tuna Salad, Egg Salad and Tuna Steaks were too warm and further confirmed the foods were served to residents and guests. An interview on 8-12-2016 at 1:45 PM was conducted with the Catering Coordinator (CC). During the interview the CC reported the food temperature had not been taken for the Deli foods. On 8-12-2016 at 3:35 PM the facility staff identified and provided order sheets of 6 residents who ate from the Deli on 8-12-2016. B. Record review of the facility Production Area Cook sheet revealed start and end temperatures of the specific food items for the facility residents meals revealed the following: -5-19-2016; Pasta Salad Creamy D, starting temperature was 60 degrees, no ending temperature was recorded. -5-19-2016; Coleslaw Creamy D, starting temperature was 60 degrees, no ending temperature was recorded. -5-21-2016; Macaroni Salad, starting temperature was 60 degrees, no ending temperature was recorded. -5-21-2016; Pureed Macaroni Salad, starting temperature was 60 degrees, no ending temperature was recorded. -5-24-2016; Turkey Sandwich, starting temperature was 60 degrees, no ending temperature was recorded. -5-24-2016; Ground Turkey Sandwich, starting temperature was 60 degrees, no ending temperature was recorded. -6-02-2016; Coleslaw Creamy, starting temperature was 59 degrees and the ending temperature was 67 degrees. -6-04-2016; Borscht (soup), starting temperature was 63 degrees and ending temperature was 69 degrees. -6-04-2016; Coleslaw Creamy and Cucumber Onion in Sour Cream, starting temperature was 53 degrees for both and ending temperature for both was 61 degrees. -8-05-2016; Prime Rib, starting temperature was 132 degrees and ending temperature was 146 degrees. -8-09-2016; Ground Chicken Salad, starting temperature 61 degrees and ending temperature was 70 degrees. -8-09-2016; Pureed Chicken Salad, starting temperature was 58 degrees and ending temperature was 69 degrees. -8-11-2016; Coleslaw Creamy, starting temperature was 56 degrees and the ending temperature was 63 degrees. An interview on 8-12-2016 at 4:55 PM was conducted with the FSD. During the interview,review of the recorded food temperatures was completed. The FSD confirmed the cold food temperatures were too warm. The FSD further confirmed the Turkey sandwich was a cold sandwich and should have been below 41 degrees. Record review of the facility recipes printed on 8-24-2016 for Egg Salad, Turkey Salad, Chicken Salad, Creamy Pasta Salad,Tuna Salad and Coleslaw Creamy revealed these foods were to be maintained at a temperature of 40 degrees or lower. On 8-24-2016 at 9:13 AM a follow up interview was conducted with the ADFS. The ADFS reported during the interview that food temperatures were taken to keep foods out of the danger zone. The ADFS confirmed the recorded food temperatures were not being monitored prior to 8-12-2016. According to the USDA Food Safety and Inspection Service (FSIS) found at www.fsis.usda.gov, the danger zone of food was between 40 degrees and 140 degrees as the bacteria grows rapidly in this range. Additional information from the FSIS revealed that to prevent illness,hot foods should be kept at or above 140 degrees and cold food at or below 40 degrees. C. Record review of a Resident Illness sheet revealed between 5-25-2016 and 6-7-2016, 23 residents were identified as having diarrhea or vomiting. D. Record review of a Staff Illness sheet revealed between 5-24-2016 and 6-04-2016, 14 staff members were identified with diarrhea or vomiting. According to information at www.foodsafety.gov, symptoms of food poisoning include upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever and dehydration. On 8-12-2016 at 5:15 PM the facility Administrator provided a signed Plan of Correction to abate the immediacy of the situation and protect residents from food borne illness. This abatement statement revealed the following information: -1. The egg and tuna salad identified during the deli service was disposed. -2. Temperature of all foods will be checked and recorded before leaving the kitchen. If any food item is outside of the accepted temperature range, that food will be discarded. The cook checking the food temperatures will immediately notify the Food Service Director or designee. -3. Temperatures of all remaining food from a meal will be checked and recorded at the end of the meal services. Food that is outside of the accepted temperature range will be discarded. The cook will immediately notify the Food service Director or designee. -4. The Food Service Director or designee will in-service all dietary personnel that are currently working (8-12-2016) regarding food temperature safety and safe food handling. All other employees will be in-serviced prior to their next scheduled work day. An employee will not be allowed to work until they have received the training. The training will include when to take temperatures, acceptable temperature range for cold and hot food, documenting temperatures, what to do in the event the temperatures are out of range and safe food handling. The food Service Director or designee will in-service all new dietary staff regarding taking food temperatures and safe food handling. -5. The Food service Director or designee will review all temperature recording on a daily basis to ensure that staff are recording and reporting temperatures correctly. -6. The Food Service Director or designee will audit food handling and temperature monitoring at a minimum of weekly at varying times to ensure that staff are handling food correctly. If a discrepancy is noted, the auditor will intervene immediately. -7. The Food Service Director or designee will report to the QAPI (Quality Assurance Performance Improvement) Committee monthly regarding any temperature out of range and any mishandling of food and the corrective action taken.

Licensure Reference 175 NAC 12-006.09D7b. Based on observation, interview, and record review; the facility failed to complete an evaluation of potential causal factors for falls and implement interventions based on that evaluation for two residents (Residents 1 and 4). The facility had a total census of 90. Findings are: A. Resident 4 was admitted to the facility on [DATE] with unspecified dementia (a group of thinking and social symptoms that infers with daily functioning) without behavioral disturbance according to the Face Sheet. Observations on 3/10/16 at 5:03 AM revealed the call light was going off and the light was flashing over Resident 4's door. On entering Resident 4's room, Resident 4 was observed seated on the floor mat next to the bed. Resident 4's bed was in a low position with an U shaped pillow on the bed. Resident 4 was calling out. In an interview on 3/10/16 at 5:15 AM, LPN A (Licensed Practical Nurse) said that Resident 4 had been up to the bathroom at 4:30 AM and had been given medication for pain. LPN A reported Resident 4 was usually up at this time but may be up all night. A review of Resident 4's Care Plan revealed a problem dated 12/10/15 that said the resident needed assistance with activities of daily of living due to a [DIAGNOSES REDACTED]. Fall prevention interventions included low bed with mats, safety alarm when unsupervised, private caregiver provided at times, and monitor whereabouts. Resident 4's care plan was updated on 2/1/16 to indicate Resident 4 could walk with 2 assist, a wheeled walker, and a gait belt. A review of Resident Incident Reports revealed Resident 4 had 3 other falls between 4 AM and 6:19 AM between 12/25/15 and 2/29/16. A review of a Resident Incident Report dated 12/25/15 at 6:19 AM revealed Resident 4's bed alarm sounded and Resident 4 was sitting on the floor mat with Resident 4's sitter beside Resident 4. The resident was found to not have an injury. A Nurses Note dated 12/26/15 at 2:42 AM as a late entry for 12/25/16 at 6:41 AM revealed Resident 4's sitter reported that Resident 4's right arm had a cast from the right hand to elbow and had been on top of the pressure alarm and it had prevented the alarm from sounding sooner. An Adverse Event Investigation dated 12/25/15 indicated an intervention of keeping the pressure sensitive alarm on Resident 4. A review of a Resident Incident Report dated 2/9/16 at 4 AM revealed Resident 4 opened the door and fell . According to the Resident Incident Report, Resident 4's bed alarm did not go off. Resident 4 was found on their right side. Resident 4 had 4 cm (centimeter) abrasion to top of left shoulder, 2 cm abrasion to right knee, 6 cm laceration to middle of forehead and two 6-7 cm abrasions to the scalp. Resident 4 was transferred to the hospital. According to the facility investigation as a follow up report to 2/10/16, Resident 4 received stitches to their forehead and returned to the facility. A review of the facility investigation revealed Resident 4's bed alarm was replaced. A review of a Resident Incident Report dated 2/29/16 at 4:41 AM revealed Resident 4 was found on the floor mat next to bed. Resident 4's bed alarm had failed to sound. Resident 4 had sustained a small abrasion to the right upper arm. Post Incident Actions dated 2/29/16 at 4:41 AM stated Resident 4's alarm was checked and was found to be working. A review of Nurses' Notes dated 3/1/16 at 10:46 AM and an Adverse Event Investigation dated 2/29/16 revealed staff felt possibly repeated awakening to check and change the resident's brief could have contributed to the resident being awake and rolling out of bed. Interventions implemented included completion of an overnight brief assessment to see if waking Resident 4 less would allow Resident 4 to sleep through the night. A review of Resident 4's Sleep-Incontinent-Behavior Assessment revealed the assessment was to be completed for 3 days. Resident 4's Sleep-Incontinent-Behavior Assessment was started at 8 PM on 2/29/16 and completed through 1 PM on 3/1/16. The assessment was not completed between 2 PM on 3/1/16 and 7 AM on 3/2/16 or between 10 AM and 1 PM on 3/2/16. In an interview on 3/10/16 at 9:17 AM, the Director of Nursing confirmed the Sleep-Incontinence-Behavior Assessment had not been completed. The Director of Nursing reported no changes in Resident 4's care plan had occurred related to Resident 4 being up at night or the resident's brief changes at night. B. Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 3/18/16 at 5:02 PM revealed Resident 1 asleep in bed with the bed in the low position. The fall alarm was on and functioning with a wheeled walker next to the bed. A review of Resident 1's care plan revealed a problem dated 5/22/14 of activity of daily living deficit and at risk for falls due to falls at home. Interventions for fall prevention was listed as silent alarm when in bed or in chair and unsupervised by private caregiver. Resident 1 was identified as ambulating with wheeled walker and stand by assist. A review of a Resident Incident Report dated 11/29/15 at 3:15 AM revealed Resident 1 had been found lying on the floor after Resident 1's bed alarm went off. Resident 1 reported Resident 1 was trying to answer the phone. Resident 1 was evaluated with no apparent injuries found. The Immediate Post Incident Actions included continue to have bed at low setting, with bed alarm, call light in reach, and continue to check frequently. The Adverse Event Investigation for the fall on 11/29/15 listed interventions of resistive to any cares, seen by geriatric psychology, and alarm on door. The Resident Incident Report dated 2/20/16 at 4:45 PM revealed Resident 1 had been found lying on their back and crying. Resident 1 was bleeding from the head and had sustained a 2.5 cm x .5 cm head injury on the left parietal side of head with a hematoma surrounding the wound. Pressure was applied to the head wound to contain bleeding and the resident was sent to the emergency room . Immediate post incident actions were for staff to continue with present interventions in place and respond to bed alarm faster. Nurse's Notes dated 2/20/16 at 6:08 PM revealed Resident 1's bed alarm had gone off and the nurse aide had immediately responded to bed alarm but it was too late and the resident had hit their head on the room door. A review of an undated facility investigation stated Resident 1 was admitted to the hospital on [DATE] for continued observation and returned to the facility on [DATE]. Resident 1 received staples to Resident 1's head wound. An Adverse Event Investigation for the event on 2/20/16 was not completed for explanation of the event and causal factors. In the intervention section, appropriate interventions in place was written in. In an interview on 3/10/16 at 9:10 AM, the Director of Nursing confirmed the explanation of the event and causal factors section was not completed on the adverse event investigation. The Director of Nursing confirmed no other interventions had been attempted after Resident 1 fell on [DATE].

Licensure Reference: 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to implement fall alarm interventions for 1 (Resident 3) of 4 sampled residents. The facility had a total census of 95. Findings are: A. Resident 3 was admitted to the facility on [DATE] according to Face Sheet. Resident 3's physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. Incident Report for Resident 3 dated 11/5/11 at 12:32 AM stated the following: "Resident calling out for help, noted lying on floor at 12:30 AM c/o (complaint of) pain in left hip." Radiology Report dated 11/5/11 for Resident 3 stated Resident 3 had a fractured right hip. Nurse's Note dated 11/5/11 stated Resident 3 was transferred to the hospital at 4:10 AM. A review of Resident 3's 11/11 MAR (Medication Administration Record) revealed alarm on at all times was signed off as being applied by LPN (Licensed Practical Nurse) B on the 11/4/11 evening shift. A review of a undated facility investigation revealed Social Services had been in contact with Resident 3's family 1 week prior to Resident 3's admission to the facility and the family had requested that the resident have alarms on in bed due to Resident 3 trying to get out of bed on own. The investigative report stated Nurse Manager F had spoken with the day and evening charge nurses on 11/4/11 (RN (Registered Nurse) A and RN G) about Resident 3 requiring an alarm. The facility investigation also included documentation of interviews of the evening shift staff that had cared for Resident 3 on 11/4/11. The investigation stated RN A and LPN B from the evening shift had been interviewed and neither nurse could recall if Resident 3 had an alarm on. According to the investigation, Resident 3 did not have an alarm on when NA C left at 9 PM. The investigation did not contain any documentation of the night shift being interviewed regarding Resident 3's alarms. RN D, the nurse that had worked the night shift beginning on 11/4/1 and completed the incident report for Resident 3, was interviewed between 1:30-1:41 PM on 11/17/11. RN D reported hearing a call for help from Resident 3 but not an alarm going off when RN D discovered Resident 3 on the floor. According to the interview, RN D and RN E checked Resident 3's room for an alarm and were not able to locate one. RN D reported RN E obtained an alarm and it was applied to Resident 3 after the fall when Resident 3 was lifted back in to bed. In an interview on 11/17/11 between 1:50-1:55 PM, the DON (Director of Nursing) reported the DON had interviewed RN D after Resident 3's fall. The DON confirmed RN D had told the DON that Resident 3 did not have an alarm on at the time of the fall. The DON agreed that the interview of RN D should have been included in the facility investigation. B. In an interview on 11/17/11 between 1:50 -1:55 PM, the DON reported since the incident occurred with Resident 3 a memo was sent to the nursing staff regarding checking placement and function of alarms. Undated Memo to all nurses stated the following: "Effective Immediately: I have created an icon on the computer at each nurses station, titled "Alarms". Double click the icon and there is a list of every current resident that requires an alarm. The list needs to be kept up to date, every day, by each station. It is the charge nurses responsibility to check the list each shift and make sure the alarms are in place and functioning at the beginning of your shift (within the first 15 minutes of the start of your shift). If a resident falls that was suppose to have an alarm in place and the alarm was not there, I will hold you directly responsible." A review of logs for checking alarms at the first 15 minutes of shift revealed logs were implemented on 11/10/11. The logs for 2 of the 4 nurses' stations were in complete. The log on the Northwest nurses' station was incomplete for 6 of 23 shifts between 11/10/11-11/1711 and the log for the Southeast nurses' station was incomplete for 2 of 23 shifts between 11/10/11-11/17/11.