Every finding on record at South Haven Living Center

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observation, interview, and record review; the facility failed to provide toileting and repositioning for 1 (Resident 18) of 1 sampled resident who required staff assistance with these tasks. The facility census was 77.Findings are:Record review of Resident 18's admission Record dated 7/8/25 revealed the resident was admitted to the facility on [DATE].Record review of Resident 18's document titled Diagnosis dated 7/8/25 revealed diagnoses of personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), frontotemporal neurocognitive disorder (a neurodegenerative brain disorder that occurs when nerve cells in the frontal and temporal lobes degenerate, causing the lobes to shrink), and mild neurocognitive disorder due to known physiological condition without behavioral disturbance (a condition where a person experiences a decline in cognitive abilities, such a memory or thinking skills, due to a known medical condition, but this decline doesn't significantly impact their daily life or cause noticeable behavioral changes).Record review of Resident 18's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 4/7/25 revealed the following information about the resident:-Section C: a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 6, indicating Resident 18 had severe cognitive impairment.-Section G: the resident had no limitation in upper ROM (range of motion), no limitation in lower ROM, and used a wheelchair. The resident was dependent on staff assistance for rolling left to right in bed, transfers, and toileting hygiene. -Section H: the resident was always incontinent of urinary and bowel.-Section M: the resident was at risk for pressure ulcers (PU, an injury to skin and underlying tissue resulting from prolonged pressure on the skin), no PU present. The resident had pressure reducing devices in their bed and wheelchair.Record review of Resident 18's Braden Scale (a risk assessment tool that predicts a patient's likelihood of developing pressure ulcers - generally a score of 18 or less indicates at-risk status) score was 13 which indicated the resident was at moderate risk for developing pressure ulcers. The assessment was done on 7/6/25.Record review of Resident 18's Care Plan (a document that outlines the specific healthcare, personal care, or support a person will receive) dated 7/8/25 revealed: 1.ADL (activities of daily living) self-care performance deficit related to bipolar, diabetes mellitus, seizures, morbid obesity, and personal history of a traumatic brain injury.-Bed Mobility: 2 assists with turning side to side. -Toilet use: 2 assists, is incontinent of bladder and bowel, provide peri cares with brief changing as needed, check and change on a routine basis.-Transfer: the resident utilized a Hoyer mechanical lift.2. Potential for alteration in bowel elimination related to decreased mobility, antidepressant meds, history of diverticulitis and blood in the stool. -Bowels will be managed without complications through the review date.-monitor bowel elimination pattern PRN, monitor/document/report PRN complications related to bowel elimination.3. Potential/actual impairment to skin integrity related to diabetes, immobility and incontinence. History of a stage 2 pressure ulcer to the tailbone that was healed on 11/12/24.-offload coccyx by turning left/right at frequent intervals.-Pressure-relieving devices to chair (aqua gel cushion) and bed.-Provide peri care after each incontinent episode. Observation on 7/7/25 at 9:34 AM of Resident 18 revealed the resident was sitting in their wheelchair, tilted back, in their room with the TV on. The resident was sleeping and there was a Hoyer lift sling underneath the resident. Observation on 7/8/25 at 6:55 AM of Resident 18 revealed the resident was sitting in their wheelchair in an upright position by the nurse's station with the Hoyer sling underneath the resident. Observation on 7/8/25 at 7:20 AM of Resident 18 revealed the resident was sitting up to the dining room table in their wheelchair in an upright position waiting for breakfast with the Hoyer sling underneath resident.Observation on 7/8/25 at 8:10 AM of Resident 18 revealed the resident continued to be sitting at the dining room table in their wheelchair in the same upright position waiting for their breakfast tray with the Hoyer sling underneath resident.Observation on 7/8/25 at 8:45 AM of Resident 18 revealed the resident had finished eating and was taken back to their room. The resident was sitting in their wheelchair in a tilted back position and sitting in front of the TV. Resident 18 had a blanket covering them with the Hoyer sling underneath resident. Observed the wheelchair front wheels were turned toward the bed.Observation on 7/8/25 at 9:33 AM of Resident 18 revealed the resident was asleep in their wheelchair with Hoyer sling remaining underneath resident. The wheelchair front wheels remained turned toward the bed and the wheelchair was tilted back in the same position. Observation on 7/8/25 at 9:56 AM of Resident 18 revealed the resident remained in the same position as prior observation.Observation on 7/8/25 at 11:00 AM of Resident 18 revealed the resident remained in the same position as prior observation. The resident was holding a washcloth and washing their face with an empty basin sitting on their lap. Resident 18 continued to have a Hoyer sling underneath them. Observation on 7/8/25 at 11:30 AM of Resident 18 revealed the resident was asleep holding onto washcloth and the basin was on the floor. The resident remained in the same position and the lift sling remained under the resident.Observation on 7/8/25 at 11:48 AM revealed Nurse Aide (NA)-A and Medication Aide (MA)-B were performing peri cares and repositioning for Resident 18. NA-A and MA-B changed the resident's clothes, incontinence brief, lift sling and provided peri care. The resident's incontinence brief was observed to be saturated with urine and bowel movement, which were leaking out of the brief.An interview on 7/8/25 at 1:47 PM with NA-A confirmed that Resident 18 had not been toileted between getting out of bed and 11:48 AM and should have been. NA-A also confirmed the resident should have been repositioned more frequently. Interview on 7/8/25 at 1:50 PM with the Director of Nursing (DON) confirmed the staff should remove the lift sling from underneath Resident 18 after getting resident up into the wheelchair, and Resident 18 should have been repositioned and toileted that morning after breakfast. The DON also confirmed that the resident had a history of a pressure ulcer, that their Braden Scale indicated they were at moderate risk for pressure, and that the lift sling increased this risk.Record review of the facility's Skin and Wound Management Standard policy, revised 4/2019 revealed in the Preventative Measures section that once risk has been identified, initiate appropriate preventative measures to ensure minimizing the risk of pressure ulcer development. -Repositioning: All residents should be evaluated for individual needs and repositioned as necessary. Consider limiting high risk resident's time in one position, such as in wheelchair. Lay resident down, as appropriate, between meals and cue staff to position resident off their back with naps or rest periods.-Repositioning should occur during rounds, which are expected approximately every two hours.-Residents in a wheelchair should be repositioned or weight shifted approximately every hour.-Moisture: Residents with moisture issues such as perspiration or urine should have an appropriate plan to keep moisture minimized.Record review of the facility's Bowel and Bladder Management Standard policy, updated 4/18/2017 revealed in the Introduction section that the interdisciplinary team plays a significant role in bladder and bowel management, promoting open communication and monitoring the outcome of the continence programs. Continence management includes assessment for incontinence, the promotion of continence, the proper use of continence care products, appropriate toileting routines, and the evaluation of each resident's care plan to ensure the continence program is being managed effectively.In the Expectation and Philosophy section it revealed: -A resident who has a catheter or is incontinent of bladder, (either on admission or during their stay), will be identified, assessed and provide appropriate treatment and services to achieve or maintain as much normal urinary function as possible, this includes the prevention of urinary tract infections. -Residents with fecal incontinence must receive the appropriate treatment and services to restore as much normal bowel function as possible. -Incontinence products: It is important that the residents using various products be checked, toileted and changed as needed on a schedule based upon the resident's voiding pattern, accepted standards of practice, and the manufacturer's recommendations.

Licensure reference number 175 NAC 12-006.18 Based on observations, interviews, and record reviews; the facility failed to ensure staff performed hand hygiene between glove changes, perform hand hygiene via soap and water for 20 seconds, and did not use contaminated gloves when getting clean wipes out of the wipes container for 1 (Resident 18) of 1 sampled resident to prevent the potential for cross contamination. The facility census was 77.Findings are:Record review of Resident 18's admission Record dated 7/8/25 revealed the resident was admitted to the facility on [DATE].Record review of Resident 18's document titled Diagnosis dated 7/8/25 revealed diagnoses of personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), frontotemporal neurocognitive disorder (a neurodegenerative brain disorder that occurs when nerve cells in the frontal and temporal lobes degenerate, causing the lobes to shrink), and mild neurocognitive disorder due to known physiological condition without behavioral disturbance (a condition where a person experiences a decline in cognitive abilities, such a memory or thinking skills, due to a known medical condition, but this decline doesn't significantly impact their daily life or cause noticeable behavioral changes).Record review of Resident 18's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 4/7/25 revealed the following information about the resident:-Section C: a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 6, indicating Resident 18 had severe cognitive impairment.-Section G: the resident had no limitation in upper ROM (range of motion), no limitation in lower ROM, and used a wheelchair. The resident was dependent on staff assistance for rolling left to right in bed, transfers, and toileting hygiene. -Section H: the resident was always incontinent of urinary and bowel. Observation on 7/8/25 at 11:48 AM revealed Nurse Aide (NA)-A and Medication Aide (MA)-B were performing peri cares and repositioning for Resident 18. MA-B was in the resident's room wearing gloves and had Resident 18 hooked up to the Hoyer lift (an assistive device that helps transfer patients between resting places like beds or chairs). NA-A applied alcohol based hand rub (ABHR) to their hands and then applied gloves. MA-B started to lift Resident 18 using the Hoyer lift and noted some loose bowel movement dripping onto the floor, lift sling, and the lift leg bar. NA-A cleansed the lift leg bar off and the floor with a cleansing wipe to remove the loose stool. NA-A removed their gloves and performed hand hygiene with soap and water for 7 seconds, dried their hands and applied new gloves. The resident was then assisted into bed. NA-A and MA-B removed the resident's sling and pants. NA-A and MA-B took cleansing wipes out of the wipes container with their contaminated gloves several times while wiping bowel movement off the resident's inner legs. NA-A and MA-B then removed the resident's incontinence brief that was saturated with urine and loose bowel movement. MA-B removed cleansing wipes from the wipes container several different times with the same contaminated gloves and finished cleansing resident's groin, peri-area, and buttocks with different wipes each time. NA-A performed hand hygiene with soap and water for 5 seconds and then applied new gloves. MA-B changed their gloves without performing hand hygiene. NA-A and MA-B then placed a clean brief and clothes on Resident 18 and assisted the resident up into their wheelchair with the Hoyer lift.An interview on 7/8/25 at 1:45 PM with MA-B confirmed the MA should have performed hand hygiene when changing gloves and should not have used contaminated gloves while getting new cleansing wipes out of the container. An interview on 7/8/25 at 1:47 PM with NA-A confirmed they should have performed hand hygiene for 20 seconds when using soap and water and should not have used contaminated gloves while getting new cleansing wipes out of the container.An interview on 7/8/25 at 1:50 PM with the Director of Nursing (DON) confirmed that MA-B should have performed hand hygiene when changing gloves, NA-A should have performed hand hygiene for 20 seconds with soap and water. The DON also confirmed that NA-A and MA-B should not have used contaminated gloves while getting new cleansing wipes out of the container. Record review of the facility's Hand Hygiene Competency policy revised 12/2019 revealed the following procedure: 1. Check for paper towels before starting hand hygiene procedure. 2. Turn on water and wet hands. Water should be warm, not hot or cold. 3. Apply soap, use friction, rub hands together. Clean around and under nails/jewelry and between fingers. Wash up on to wrist (approximately 2 inches above wrist). 4. Lather and rub hands together for full 20 seconds. 5. While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. (These areas are always considered soiled). Do not shut off water. Leave it running. 6. Dry hands well with paper towels. When finished drying hands, discard paper towel and take a clean paper towel to shut off water faucet. Discard paper towel. When to wash hands: -After handling contaminated items (linens/garbage/briefs, etc). -Before and after gloving.

Licensure Reference Number 175 NAC ,d+[DATE].11E Based on observation, interview, and record review; the facility kitchen failed to label and date a clear container of lemonade, failed to dispose of expired drink and food items in the kitchen, and failed to remove dented cans for resident use to prevent the potential of food borne illness. This had the potential to affect 78 residents. The facility census was 78. Findings are: An observation on [DATE] at 7:50 AM of the refrigerator in the kitchen revealed 3 clear beverage dispensers, one with red colored fluid dated [DATE], one with pink colored fluid dated [DATE], and one with yellow colored fluid with no label or date. A clear container of chicken salad dated [DATE] was also in the refrigerator. A bottle of Kitchen bouquet browning and season sauce is on a metal shelf in the kitchen and has an open date of [DATE] but a use-by date of [DATE]. An observation on [DATE] at 8:00 AM in the dry storage revealed a dented can of refried beans on the shelf for resident use. An observation on [DATE] at 8:20 AM of the refrigerator in the Lakemont kitchenette revealed 3 clear beverage dispensers, a pink colored fluid dated [DATE], fruit punch dated [DATE], and grape juice dated [DATE]. An observation on [DATE] at 9:31 AM during a final walk through of the kitchen revealed a dented can of applesauce and a dented can of diced peaches on the shelf in the dry storage room. An interview on [DATE] at 8:10 AM with the FSS (Food Services Supervisor) revealed the [gender] had removed all food/fluid items that were previously observed and confirmed they were expired and should have been removed for use along with the dented can of refried beans. An interview on [DATE] at 8:20AM with NA-D revealed NA-D did not know the expiration date of the drinks in the refrigerator. When notified that they should be removed after 3 days, NA-D said, I thought so, and disposed of the drinks. An interview on [DATE] at 9:32 AM with the FSS revealed the dented can of applesauce and peaches should have been removed from the shelves. An interview on [DATE] at 11:01 AM with the RD (Registered Dietician) confirmed that dented cans should be removed from use for the residents. The RD stated [gender] placed a copy of the Dented Can Guide from Sysco in the dry storage room and would in-service staff on All about Can Safety. A record review of the facility policy Food Storage dated 2010 stated under Procedure: 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. A record review of the undated Dented Can Guide from Sysco stated to discard cans with severe dents on side seam, sharp dents parallel to rim, sharp dents on the side that prevent stacking, buckled or pinched tops and bottoms, leaks, bulges or puffed ends, ends that give or flip and bulge on the other end when pushed, and severe dents on the rims, seam, or bent rims.

Licensure Reference Number 175 NAC 12-006.09D3(5) Based on interview and record review; the facility failed to monitor bowel movements and provide prn medication per facility elimination protocol to prevent the potential of constipation for 1 (Resident 40) of 5 sampled residents. The facility census was 78. Findings are: A review of the facility Elimination Protocol revised 6/2014 stated each night, after midnight, the night nurse will review the elimination records for their nurses' station. From this review, they will generate a list of residents who are in need of interventions for bowel management. This list will be documented below: -1st Day (24-hour period without a BM) -Offer 4 oz prune juice or natural laxative and document in the intervention column, -2nd Day (48-hour period without a BM)-Give 30 milliliters Milk of Magnesia by mouth (or whatever as needed medication is ordered by their physician) on the 6-2 shift. Document on the MAR and intervention column. -3rd Day (72 hours without a BM)-Charge nurse to assess bowel sounds, palpate and document assessment results. The bowel assessment should be done by day charge nurse (in event there are absent bowel sounds hat indicate physician notification) and again by the evening charge nurse prior to suppository administration. You will also determine if resident is uncomfortable and document. Then give Dulcolax or glycerin suppository as ordered to be given rectally at a time that is agreeable to the resident (generally given on 2-10 PM shift, after supper unless otherwise requested by resident) Document on the MAR, 24-hour sheet (form used by nurse to relay information about residents from one shift to the next), and intervention column. -4th Day-If above interventions have not been successful, advance to enema as ordered and continue with bowel assessments each shift until resolved. The attending physician should also be contacted as appropriate. A record review of Resident 40's Medical Diagnosis dated 5/8/2024 revealed Resident 40 admitted to the facility on [DATE] with diagnoses of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), delusional disorder (a mental health condition in which a person can't tell what's real from what's imagined), anxiety (a feeling of fear, dread, and uneasiness), depression (persistent feeling of sadness and loss of interest interfering with daily activity) and hypertension (elevated blood pressure). A record review of the Quarterly MDS (Minimum Data Set-a comprehensive assessment that measures a residents functional, medical, psychosocial, and cognitive status) dated 3/25/2024 revealed a BIMS (Brief Interview for Mental Status) score of 7 which suggests severe cognitive impairment. Further review of Section H: Bladder and Bowel indicated the resident is frequently incontinent of urine and always continent of bowel. Further review of Section GG: Functional Abilities and Goals indicated the resident requires supervision to touching assistance with ambulation with walker, partial to moderate assistance to transfer on and off the toilet, and substantial to maximal assistance for hygiene after using the toilet and clothing adjustment. A record review of the Order Summary Report printed 5/8/2024 revealed the following bowel medications that are ordered for the resident: -Dulcolax suppository (medication used to treat constipation) every 24 hours as needed -Milk of Magnesia (used for constipation) 30 milliliters daily as needed -Miralax (used for constipation) every 24 hours as needed A record review of the resident's bowel elimination records for February, March, April, and May revealed bowel movements on the following days: 2/3/2024, 2/5/2024, 2/7/2024, 2/8/2024, 2/13/2024, 2/14/2024, 2/22/2024, 2/24/2024, 2/28/2024 3/2/2024, 3/4/2024, 3/5/2024, 3/8/2024, 3/12/2024, 3/16/2024, 3/18/2024, 3/19/2024, 3/23/2024, 3/24/2024, 3/26/2024, 3/27/2024, 3/30/2024 4/2/2024, 4/3/2024, 4/4/2024, 4/5/2024, 4/6/2024, 4/7/2024, 4/8/2024, 4/9/2024, 4/13/2024, 4/15/2024, 4/18/2024, 4/19/2024, 4/21/2024, 4/22/2024, 4/24/2024, 4/29/2024 5/4/2024, 5/6/2024, 5/7/2024, 5/9/2024, 5/12/2024, 5/13/2024. A record review of the February 2024 MAR (Medication Administration Record-record used to document medications administered to a resident) revealed Miralax and a Dulcolax suppository were administered on 2/19/2024 and Milk of Magnesia was administered on 2/21/2024. There is no documentation of a medication given for bowels between 2/8/2024 and 2/13/2024 or between 2/24/2024 and 2/28/2024. A record review of the March 2024 MAR revealed Milk of Magnesia was administered on 3/20/2024. There is no documentation of a medication given for bowels between 3/8/2024 and 3/12/2024, 3/12/2024 and 3/16/2024, and 3/27/2024 and 3/30/2024. A record review of the April 2024 MAR revealed no bowel medications were given between 4/9/2024 and 4/13/2024, 4/15/2024 and 4/18/2024, and 4/24/2024 and 4/29/2024. A record review of the May 2024 MAR revealed no bowel medications were given between 4/29/2024 and 5/4/2024 and 5/9/2024 and 5/12/2024. A record review of Resident 40's progress notes revealed three notations related to bowels since 2/1/2024. A notation on 2/21/2024 at 5:32 AM stated the resident was on Day 6 with no documented bowel movement and resident denied abdominal pain or tenderness. Bowel sounds were active in 3 quadrants of the abdomen and less active in 1 quadrant of the abdomen. The resident was offered and attempted a Dulcolax suppository and resident refused. A notation on 4/5/2024 at 1:49 PM indicated the resident was complaining of rectal pain and was noted to have 3 external hemorrhoids and a fax was sent to the medical doctor requesting an order for Preparation H (ointment for hemorrhoid relief). A notation on 5/9/2024 at 2:05 PM indicated the medical doctor was faxed regarding Resident 40's ongoing constipation issues and requested an order for daily Miralax. An interview on 5/9/2024 at 10:15 AM with LPN-C (Licensed Practical Nurse) and MA-H (Medication Aide) revealed staff follow a bowel protocol. MA-H stated a list is given to them by the night nurse of those residents that need a natural laxative or as needed medication for their bowels. When asked if there are any residents that might be able to say they feel constipated, MA-H revealed 2 residents and that this resident might be able to. When asked if it is an issue if a resident goes 3,4, or 5 days without a bowel movement, MA-H said it depends on the issue and commented some residents might be on hospice. MA-H said agency staff do not seem to pay attention to the bowel documentation and probably forget to chart. LPN-C also stated it depends on their meal intake as well. When asked if this resident could toilet themselves, the response was maybe. LPN-C mentioned this resident has pancake call light under them so staff know when [gender] gets up and staff can then go assist [gender]. LPN-C further commented that the resident often uses a wheelchair for mobility. An interview on 5/9/2024 at 12:40 PM with Resident 40 regarding how often [gender] has a bowel movement, the resident commented oh, I go in the morning, I go in the afternoon, and I go in the evening, and laughed afterwards. A sign is observed on the bathroom door that says to use call light for help. An interview on 5/9/2024 at 10:30 AM with the DON (Director of Nursing) regarding residents' going 3, 4, 5 days without a bowel movement and no as needed medication is provided led to no response provided by the DON. An interview on 5/9/2024 at 12:00 PM with the DON revealed the facility had no specific bowel management policy but an Elimination Protocol that is followed. The DON further stated they have a PIP (Performance Improvement Project-a concentrated effort on a particular problem in one area of the facility or facility wide) in place for this issue. A copy of the PIP was requested. A record review of the PIP titled BM (bowel movement) Elimination Protocol revealed a start date of 3/12/2024 with a goal that the elimination protocol will be followed by charge nurses and medication aides. Reasons provided by the facility for issues with bowel management include bowel movements not assessed or charted, residents eliminate independently, memory care residents forgetting whether they have or have not had a bowel movement, nurses and med aides not giving medications per the protocol. The PIP stated weekly elimination protocol forms are to be viewed and addressed with the charge nurses, one on one education with the nurses, and a skills fair checkoff to all nursing team members is the action plan to improve bowel management. An interview on 5/9/2024 at 1:50 PM with the DON led to a request of the education provided to staff or audits since 3/12/2024 to show whether there has been improvement or not. An interview on 5/9/2024 at 2:59 PM with the DON revealed a sheet of paper with 4 dates (3/12/2024, 4/15/2024, 4/24/2024, and 5/3/2024) of one-on-one education for 6 different nurses but no specific details of the education are listed. No audits provided. The DON stated there has been some improvement but there needs to be more. An interview on 5/9/2024 at 1:10 PM with NA-E revealed [gender] no training on bowel management this year but stated [gender] did do some training about how to do peri-care (cleaning of resident genitalia/rectal area). An interview on 5/9/2024 at 1:45 PM with MA-F regarding how staff knows if someone needs medication to promote a bowel movement, MA-F revealed there is a list of those residents that show what day they are on and to follow the protocol. When asked if [gender] has received any education about bowel management, MA-F replied that [gender] had not in the last couple of months but stated there was something on the dashboard in PCC (PointClickCare-software used by health care facilities to collect/store data about residents in the facility) about following policies and procedures. An interview on 5/9/2024 at 2:05 PM with MA-G regarding how staff know if a resident is constipated or needs something to help promote bowel movement, MA-G stated [gender] didn't think it was up to them to decide and would need to ask the charge nurse. If a medication was given, [gender] would document the medication as given on the MAR and bowel movements are documented in PCC.

Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview; the facility failed to perform hand hygiene between the removal of soiled gloves and application of new gloves during resident care and applied an incontinence brief that was picked up off the floor and failed to perform hand hygiene prior to application of cream to prevent the spread of infection and prevent the potential of cross contamination for 2 (Resident 53 and Resident 55) of 3 sampled residents. The facility also failed to prevent the potential of cross contamination by picking up a dropped medication on the medication cart with bare fingers for 1 (Resident 18) of 4 sampled residents. The facility census was 78. Findings are: A. An observation on 5/9/2024 at 10:00 AM revealed LPN-C (Licensed Practical Nurse) had completed flushing Resident 53's indwelling foley catheter. LPN-C proceeded to wash around the resident's urinary meatus (opening where urine exits the body). LPN-C performed hand hygiene with soap and water at the sink for 20 seconds. LPN-C applied gloves and applied Nystatin cream to resident's penis/urethral area. LPN-C removed soiled gloves and applied new gloves. LPN-C then palpated the resident's abdomen, pulled the trash can closer to the bed, assisted the resident to [gender] side with assistance from NA-E (Nursing Assistant) to assess buttocks. The resident's soiled brief was removed and placed in the trash by LPN-C. LPN-C bent down to pick up an opened brief (skin side down) off the floor and applied the brief to the resident. The resident's pants were pulled up by both staff members. LPN-C lowered the bed with control. LPN-C then removed and threw away the soiled gloves. An interview on 5/9/2024 at 10:15 AM with LPN-C confirmed that [gender] should have performed hand hygiene between removal of soiled gloves and application of new gloves and a brief that was lying on the floor should not have been used on the resident. An interview on 5/9/2024 at 10:30 AM with the DON (Director of Nursing) confirmed that hand hygiene needs to be performed between glove exchange and a brief that was lying on the floor should not have been used for resident use. A record review of the facility policy Hand Hygiene revised 8/20/2023 from the [NAME] Procedural manual stated that washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore forming pathogens is strongly suspected or proven, and after using the rest room. An alcohol-based hand rub is appropriate for decontaminating the hands: -before direct patient contact, putting on gloves, or inserting an invasive devise, -when moving from a contaminated body site to a clean body site during patient care, -after contact with a patient or with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings, -after contact with inanimate objects in the patient's environment, -after removing gloves. 47406 B. Record review of Resident 55's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 3/6/24 revealed Resident 55's admission was 03/09/2022. Record review of Resident 55's Diagnosis Sheet dated 5/16/24 revealed retention of urine, unspecified and Flaccid Neuropathic Bladder, not elsewhere classified. Record review of Resident 55's MDS dated [DATE] revealed in section C, a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 13 indicating resident is cognitively intact. Section H 9 revealed as Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. Record review of Resident 55's Physician Orders revision date 4/15/24 revealed Monthly catheter change 16 FR with 10cc balloon every evening shift every 1 month. Observation of Resident 55's catheter cares on 5/13/24 at 7:25 am with Medication Aide (MA)-A. NA-B assisted with resident's positioning. MA-B and NA-B donned a gown, a face shield and gloves outside the room. MA-A prepared supplies for cleansing. MA-A washed resident's groin and abdominal skin fold with soap and water using washcloth, then rinsed with another washcloth, and dried. The abdominal fold was red in color. NA-B called the charge nurse to bring in nystatin cream for the MA. MA-A applied nystatin cream to abdominal folds without changing gloves and performing hand hygiene. MA-A retracted the foreskin and cleansed the penis, then rinsed with a clean wet washcloth, and dried. Then washed and rinsed catheter tubing from urethra opening out several inches. A small amount of bleeding noted at edge of foreskin and MA-A said a small wound was there and had NA-B call the charge nurse to assess wound. The MA-A doffed gloves, then performed hand hygiene with soap and water times 20 seconds and applied new gloves. The old urinary drainage bag was dated 4/15/24. There was thick cloudy light-yellow urine with mucous and sediment in tubing and bag. MA-A cleaned the connection between the catheter and the drainage bag tubing with alcohol pads prior to attaching new urinary drainage bag. Placed the drainage bag tubing in the catheter securement device on leg and attached the bag to the bed frame. Interview on 5/13/24 at 7:37 am with MA-A revealed Yes, I should have changed my gloves, I figured my gloved hands were in the soapy water. I'm used to working in surgery. Record review of Indwelling urinary catheter (Foley) care and management, home care policy revised 12/11/2023. Policy revealed under Implementation: -Perform perineal care using mild soap, warm water, and a washcloth as appropriate. Gently clean the urethral meatus first and then clean the rest of the perineal area from front to back to avoid contaminating the urinary tract. For a patient with an uncircumcised penis, gently retract the foreskin to clean beneath it and return the foreskin to its normal position after cleaning to avoid constriction of the penis, which can cause edema and tissue damage. Rinse the area carefully and pat it dry with a towel. Avoid aggressively cleaning the meatal area and creating traction on the catheter because these actions can cause meatal irritation, tissue trauma, and infection. -As appropriate, replace the drainage bag system when clinically indicated (such as when clouding, a foul odor, or discoloration is present) and as recommended by the manufacturer using no-touch technique. To replace the drainage bag, clamp the catheter, clean the connection between the catheter and the drainage bag tubing with a disinfectant pad, and disconnect the tubing from the catheter. Then clean the tip of the new drainage bag tubing with a disinfectant pad, connect the tubing to the catheter, and unclamp the catheter. 49380 C. An observation on May 9th at 9:50 AM with MA-I as they prepared medication for Resident 18 the medication Mybetriq (a medication to treat overactive bladders) when pushed out of the bubble pack hit MA-I's ungloved hand, bounced off MA-I ungloved hand and landed on top of the medication cart. MA-I picked up the medication Mybetriq with an ungloved hand and placed it into the medication cup. MA-I then proceeded to hand the medication cup filled with Resident 18's medications and handed them to (gender) and Resident 18 swallowed the medicaiton. An interview on May 9th, 2024 at 10:10 AM with MA-I stated if a medication falls onto the top of the medication cart the medication is to be discarded and replaced with a new pill. MA-I confirmed she should have discarded the dropped medication and replaced it with a new pill. An interview on May 9th, 2024 with DON confirmed if a medication falls anywhere other than the medication cup prior to administration the medication should be discarded and replaced with a new pill. DON confirmed the medication should have been replaced to prevent contamination of the medication.

Licensure Reference Number 175 NAC 12.006.09D7a Based on observation, interview, and record review, the facility failed to ensure the facility's front door was monitored and secured to prevent an elopement (leave the facility without staff knowing) for 1 (Resident 1) of 3 sampled residents. The total facility census was 77. Findings are: A record review of the facility's Elopement Prevention And Management Standard dated 01/2016 revealed an elopement is when a resident left the facility without staff knowledge, intervention, or the exit security system failed to activate. Residents that exhibited exit seeking behaviors should be considered for a Memory Support Household. Residents with a transmitter device bracelet would have their bracelets checked daily by nursing. All door systems would be on at all times and tested daily. A record review of Resident 1's Clinical Census dated 02/15/2024 revealed the Resident was admitted to the facility on [DATE]. A record review of Resident 1's Admission Record dated 02/15/2024 revealed the Resident had diagnoses of: Dementia in Other Diseases Classified Elsewhere, Mild, with Psychotic Disturbance (confusion with behaviors), Depression, Unspecified, and Anxiety Disorder, Unspecified. A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 11/06/2023 revealed Resident 1 had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 6 of 15 which indicates the Resident was severely cognitively impaired. Resident 1 was independent with all activities of daily living (ADLs) and mobility. The MDS revealed the Resident exhibited wandering (walking around aimlessly) behaviors 1 to 3 days and did not have restraints or alarms. A record review of Resident 1's Care Plan revealed a Focus area of the Resident was an elopement risk related to wandering behaviors and short- and long-term memory impairment. Resident 1 had interventions in place of provide 1 on 1 when Resident was looking for [gender] spouse, educate team members to orient Resident to the direction of the neighborhood (unit) and the facility would not interfere with activities schedule in town hall, intervene as soon as anxious behavior noted to prevent behavior escalation, Provide a safe uncluttered area in which to wander every day, and when Resident was expressing confusion of where the resident needed to be or where going, assist the resident to the neighborhood (unit). A record review of Resident 1's Elopement/Wandering Review dated 11/01/2023 revealed the Resident had a score of 45 which indicated [gender] was at high risk for elopement or wandering. The Resident was cognitively impaired, had depression, was able to ambulate independently (walk on own), had a history of elopement, expressed a desire to go home, wandered aimlessly, and the family voiced concerns that would indicate the Resident may wander or try to leave. A record review of the facility's Resident Elopements list with multiple dates revealed Resident 1 eloped 11/01/2023 and 02/13/2024. A record review of Resident 1's Progress Note dated 02/13/2024 at 4:44 PM by Licensed Practical Nurse (LPN)-A revealed Resident 1 was seen by a member of the nursing staff ambulating down the hall with another resident and was heard stating that Resident 1 didn't know the way to the resident's room. Resident 1 was then seen walking down a hallway towards an exit. Following this, the outside door alarm was heard. The nursing staff member then went down the hall Resident 1 had just gone down to look for the resident and noted that resident was not in hall. Upon opening the door, the staff member noted that the resident was walking toward the front door of the facility. The staff member followed the resident to ensure the resident got safely inside. Once inside, the resident knew how to get to the resident's room and went directly there. A record review of the facility's Investigation Report dated 11/01/2023 revealed Resident 1 eloped from the facility on 11/01/2024 at 4:00 PM. The Guest Relations Coordinator (GRC) observed Resident 1 enter the facility through the front door. The GRC stepped into the Business Office Manager's office for about 2 minutes prior to observing the Resident returning through the facility's front doors. The Resident was last seen on the Nursing unit at 3:50 PM. Resident 1 went to the parking lot looking for [gender]'s spouse. The resident was returned to the Nursing unit. The Resident was provided 1 on 1 care until the anxiousness about the spouse's whereabouts subsided. Resident 1 was to be considered for the secure memory support unit, but it was full at the time. Contractors were contacted to modify the front door for a requirement for a code exit on the front doors. In an interview on 02/15/2024 at 10:22 AM, LPN-A confirmed LPN-A worked 02/13/2024 and on 11/01/2023 when Resident 1 eloped. LPN-A confirmed the events of the elopements as written. An observation on 02/15/2024 at 6:51 AM revealed the front doors to the facility were unlocked and staff were not visible. At 7:07 AM staff was heard at the [NAME] end of the hall and observed coming out of an office. An observation on 02/15/2024 at 7:27 AM revealed the Resident 1 was in [gender] room on an unsecured unit. Resident 1 was able to answer questions but was confused and did not recall any attempts to leave the facility. The Resident's door was located next to an emergency exit. The observation did not reveal an elopement prevention device or alarm. In an interview on 02/15/2024 at 8:59 AM, the Director of Nursing (DON) confirmed the facility did not use elopement prevention devices or alarms on any residents. An observation on 02/15/2024 at 9:08 AM revealed Resident 1 was sitting in the Chapel waiting for services to begin but did not reveal staff in the Chapel to monitor the Resident. The Chapel was about 48 feet from the front door. An observation on 02/15/2024 at 9:14 AM did not reveal staff visible at the front door area, the door was not locked. An observation on 02/15/2024 from 9:23 AM until 9:27 AM did not reveal staff visible at the front door area. An observation on 02/15/2024 from 9:52 AM until 9:57 AM did not reveal staff visible at the front door area. An observation on 02/15/2024 at 10:50 AM with the Administrator revealed the door the Resident eloped from on 02/13/2024 was at the South end of the Lakemont nursing unit's hall. The door opened with minimal pressure, but the alarm system was activated on the facility's communication system within 6 seconds of the door being opened. In an interview on 02/15/2024 at 11:15 AM, the facility's Guest Relation (GR)-B confirmed [gender] sits by the front door to monitor pedestrian traffic (people walking in and out) in and out of the facility. GR-B confirmed [gender] worked Monday - Friday 8:00 AM until 4:30 PM. Weekends were covered by 1 GR that worked 8:00 AM - 4:30 PM and 1 GR that worked 9:00 AM - 4:00 PM. GR-B confirmed the GR staff was to monitor the front door and make sure residents did not leave the facility throughout the day and to notify the nursing staff when the GR staff was leaving for the day. GR-B denied knowledge of the events of Resident 1's elopement on 11/01/2023. GR-B confirmed the GR staff did not lock or unlock the front doors. In an interview on 12/15/2024 at 12:25 PM, GR-B confirmed if the GR staff were to leave the front door area for any reason, the GR staff were to contact the administrator first, the Health Information Manager (HIM) next if the Administrator was busy, then the DON to ensure staff was available to watch the area while the GR was gone. In an interview on 02/15/2024 at 11:35 AM, the Administrator confirmed there was no set times the front door was locked and unlocked. The Administrator confirmed the front door was usually unlocked every day at 7:00 AM and locked by the nurses between 6:30 PM and 8:00 PM when the nurses were done passing the resident's medications. The administrator confirmed there was not staff to monitor the front door before 8:00 AM and after 4:30 PM when the GR was not working. The GR was to contact the Administrator first, then the HIM, then the DON when leaving the front door during the GR's shift. The Administrator confirmed the facility was aware it was a problem and had received a quote for a code in/code out system for the front door on 11/14/2023 after Resident 1's first elopement, but there were not scheduled plans in place to have the system installed yet. In an interview on 02/15/2024 at 1:42 PM, the Administrator confirmed the Administrator was not aware of the GR staff member leaving the front door area during the observed times in the morning of 02/15/2024.

Licensure Reference Number 175 NAC 12-006.17A(1) Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure infection control measures were followed to prevent the potential spread of COVID-19 related to Personal Protective Equipment (PPE) use and COVID-19 zoning and failed to ensure that staff were performing hand hygiene and changing gloves to prevent cross contamination during wound care for Resident 70 and catheter care for Resident 2. This had the potential to affect all residents that resided in the facility. Total census is 76. Findings are: A. Record review of the facility's COVID-19 Guidelines dated 12/29/2021 revealed the following: Prevention Measures: Everyday standard precautions and preventive actions should be used and include: Wash your hands for at least 20 seconds before each resident contact, after touching a resident or handling their belongings, after handling contaminated items, before and after gloving, and whenever indicated. Clean and disinfect frequently touched objects and surfaces using organization approved disinfectant. PPE usage. All team members will wear a face mask or respirator (a device designed to protect the wearer from inhaling fumes, vapors, gases, dust, and airborne microorganisms) at all times except in a private office or during meals. If in counties with substantial to high transmission levels team members must wear eye protection at all times while in resident care areas to protect staff. Eye protection/face shield should be disposed of or disinfected prior to zone changes. Surgical mask can be extended use in green zones but should be changed if the surgical mask is taken off. N95 (a face mask used that filters at least 95% of airborne particles) can be extended use while working in the same color zone. A new N95 should be used when entering a different color zone. N95 should be removed in a safe area and a clean mask applied Record review of the facility's COVID-19 Guidelines dated 12/29/2021 revealed the following Red Zone - Dark Red - COVID-19 Full Personal Protective Equipment (PPE, Respirator, eye protection, gown and gloves to prevent the spread of infections) Yellow Zone - Light Red - COVID-19 Full PPE Yellow Zone - Yellow Zone - COVID-19 Full PPE Yellow Zone - Modified Yellow - Nebraska Infection Control Assessment and Promotion Program(ICAP) recommends healthcare worker continue to wear N95 and eye protection when in resident room and resident door must remained closed Green Zone - Surgical mask, eye protection as part of standard precautions will always be needed. Gray Zone - COVID-19 Full PPE Observation of Resident 125's room door on 01/03/2022 at 09:43 AM revealed a sign on the door that this resident is in a Gray Zone (a zone indicating that full personal protective equipment (PPE) is required) isolation room. The sign said the following PPE items needed to be worn: KN-95/N-95 mask (a face mask used that filters at least 95% of airborne particles), face shield, isolation gown (a gown worn to protect ones clothing from becoming contaminated), and gloves with every room entry. Regular uncovered trash cans and with regular garbage bags were in the hallway for doffed (remove an item of clothing) PPE. Observation of Resident 125 on 01/03/2022 at 12:23 PM revealed Resident 125 was seated in a wheelchair in main hallway by the nurse's station with an over bed table in front of the wheelchair, prepared for a meal. Resident was from a Gray Zone isolation room and the only PPE Resident 125 was wearing was a surgical face mask and it was not pulled up over Resident 125's nose. Observation on 01/03/2022 at 02:28 PM revealed staff member CC entered Resident 125's room to take a picture of the resident. Resident 125 was in a Gray Zone room. Staff member CC was masked and donned (put on an item of clothing) a gown and then gloves on without hand hygiene and entered Resident 125's room. Staff member CC took a phone/camera and clipboard in room. Staff member CC then came back out carrying same items and did not disinfect the items. Staff member CC exited the room and then doffed the isolation gown and gloves in hallway. Staff member CC disposed of the isolation gown and gloves in the uncovered trash cans that were located in the hallway and then proceeded down the hallway. Observation of Resident 125 at 01/03/2022 at 02:58 PM revealed Certified Nurses Aide (CNA)-B don a gown, then a mask, then gloves with no hand hygiene. CNA-B then entered the Gray Zone isolation room to work with resident. CNA-B then came back out and doffed gloves, then gown, then mask and discarded the PPE in the uncovered trash cans in the hallway. CNA-B then went into room [ROOM NUMBER] without performing hand hygiene. Observation of resident 125 on 01/04/2022 at 08:03 AM revealed Resident 125 was seated in a wheelchair in main hallway by the nurse's station prepared for a meal with an over bed table in front of the wheelchair. Resident was from a Gray Zone isolation room and the only PPE Resident 125 was wearing was a surgical face mask and it was not pulled up over Resident 125's nose. Observation on 01/05/2022 at 08:04 AM observed Resident 125 was seated in a wheelchair in main hallway by nurse's station with no PPE except a surgical mask that is below the chin while eating breakfast. Gray Zone isolation sign still on Resident 125's door to the room. Uncovered regular trash cans are still in hallway. Interview on 01/04/2022 at 11:42 AM with Medication Aide (MA)-C revealed MA-C was not sure what PPE items was required for a Gray Zone isolation room. MA-C thought it was an isolation gown and gloves. MA-C stated the requirement of donning PPE before entering the room and doff PPE when outside the room. Interview with the Administrator on 01/04/2022 at 03:49 PM confirmed that the resident should not be out of a Gray Zone isolation room for meals (per undated zoning policy). The Administrator confirmed that doffing of PPE should be done prior to exiting resident rooms. The Administrator confirmed that discarded PPE should be in containers inside the room, not in the hallway outside the resident's room. Record review of a document dated 01/05/2022 at 03:04 AM from the Corporate Nurse to the Administrator states: For true Gray Zone need, those folks would not be candidates for communal dining. In circumstances like need for assistance or observation related to aspiration, I would recommend a risk assessment that shows the thought process (including symptoms screening, testing regimen, and distancing from others. Interview with the Administrator on 01/05/2022 at 03:13 PM again confirmed that since the Resident 125 was in a Gray Zone isolation room, the resident should not be in the hallway eating without all PPE on or documentation as to why the Resident had to be in the hallway. B. Interview with the Administrator on 01/06/2022 at 07:42 AM revealed that Registered Nurse (RN)-E tested positive for COVID-19 on the night of 01/05/2022 at 06:30 PM and that the entire 100 hallway was placed in Yellow Zone (a zone indicating that full PPE is required in that area) isolation. Observation through window to the 100 hall on 01/06/2022 at 08:06 AM revealed an unidentified Medication Aide (a nursing staff member that delivers medication to the residents) come out of one resident's room with a yellow isolation gown on, proceed to medication cart (a locked cart used to store medications), get medications for another resident, proceed to another resident's room to deliver the medications, go back out into the hallway and start walking to nurses station. Unidentified medication aide then stopped in the hallway, remove the isolation gown, and did hand hygiene. Unidentified Medication Aide never wore gloves. Observation through window to the 100 hall on 01/06/22 at 08:12 AM revealed an unidentified staff member with an isolation gown on, no gloves, and items in hand go in and out of 2 different resident's rooms without changing PPE, performing hand hygiene, or disinfecting items being carried. Interview on 01/06/2022 at 08:13 AM with the Administrator confirmed that the 100 hall is a Yellow Zone and staff should don and doff PPE when entering and exiting each resident's room. The Administrator confirmed there are 24 resident's in 100 hall that are on Yellow Zone Isolation C. Observation on 01/06/22 at 01:57 PM revealed Licensed Practical Nurse (LPN) I standing at the medication cart near the nurse's station on the 300 hall with a surgical mask pulled below the chin. Interview with the Director of Nursing (DON) on 01/06/22 at 02:06 PM confirmed that the expectation is for masks to be pulled up and covering both the nose and mouth. D. On 01/05/22 at 09:16 AM an observation of dressing changes to Resident 70's left heel, left ear, and left buttock, as well as application of medicated powder to abdominal folds and under breasts revealed LPN K entered Resident 70's room and without performing hand hygiene LPN K put on gloves and obtained a basin of warm soapy water. LPN K placed dressing supplies and scissors directly on the table in front of Resident 70 without cleaning the area or placing a barrier. LPN K then opened the dressings and placed the opened packages on the floor. LPN K placed the basin of soapy water on the floor. Without changing gloves, LPN K removed the sock on Resident 70's left foot. LPN K without changing the soiled gloves cleaned the open area to Resident 70's left foot, then hung the soiled washcloth on the side of the basin. Without changing the soiled gloves, LPN K then cut the dressings to fit the size of the wound with scissors that had been placed on Resident 70's table. LPN K then applied those dressings to the left heel. LPN K put the soiled scissors back on the table and removed gloves. Without performing hand hygiene, LPN K applied the cover dressing to heel. LPN K performed hand hygiene with ABHR and put Resident 70's sock back on. LPN K then put on gloves. LPN K obtained a clean washcloth, wet it in the basin of soapy water, and washed both sides of Resident 70's abdominal folds. LPN K without obtaining a clean washcloth wiped both sides of groin with the same washcloth. LPN K removed the gloves, and without performing hand hygiene or donning gloves, reached into the trash can under the used trash bag, and got out two new trash bags. LPN K did not perform hand hygiene and put on new gloves. LPN K applied medicated powder below both of Resident 70's breasts, in abdominal folds, and to both sides of the groin without changing gloves. LPN K then removed gloves, performed hand hygiene, and put on new gloves. LPN K refilled basin with new water and new washcloth and towel, put the washcloth and towel on the bed, and placed the basin on top of them. LPN K washed (gender) hands with soap and water for 3 seconds, put on new gloves, and removed the old dressing behind Resident 70's left ear. LPN K changed gloves without performing hand hygiene, cleaned open area behind Resident 70's left ear with clean washcloth. LPN K using the same soiled gloves applied medication using gloved finger. LPN K then removed gloves, did not perform hand hygiene, and cut a strip of dressing material with the soiled pair of scissors. LPN K put on new gloves, applied the strip of dressing, and ensured that the oxygen tubing was in place to hold dressing on. LPN K then removed gloves, and did not perform hand hygiene. LPN K cut a piece of dressing material with the soiled scissors and placed that piece on top of the wrapper for the cover dressing. Without performing hand hygiene, LPN K applied new gloves, placed the basin on the floor and placed the piece of dressing material on Resident 70's over-bed table without cleaning the surface or placing a barrier. LPN K removed the old dressing to Resident 70's left buttock and without changing gloves cleaned the open area to Resident 70's left buttock. LPN K changed gloves without performing hand hygiene and applied medication using gloved finger, then applied piece of dressing. LPN K changed gloves without performing hand hygiene and opened and applied cover dressing. LPN K emptied basin into the sink and threw it away, then removed gloves and washed hands with soap and water for 2 seconds. LPN K bagged the used linens and trash for removal from room, then washed hands with soap and water for 7 seconds. After disposing of bags, LPN K performed hand hygiene with ABHR and placed the scissors into the treatment cart without sanitizing them. Interview with LPN K on 01/05/22 at 09:45 AM revealed that hand washing should last for 2 happy birthdays and estimated that to be 1.5-2 minutes, that the nurse should change gloves between dressing changes and when going from a soiled area to a clean one and should perform hand hygiene between pairs of gloves. Stated that basin that had previously been placed on the floor should not have been placed on top of clean linens that were meant to be used for a resident. Stated (gender) did not sanitize the scissors unless they touched a resident. Interview with the DON on 01/06/22 at 04:15 PM confirmed that scissors should be sanitized between residents, that basin which had previously been on the floor should not have been placed on top of clean linens intended for use on the resident, and that wound care supplies should not be placed directly on a resident's table without providing a clean surface. DON further confirmed that handwashing should be done for 20 seconds, that gloves should be changed between touching a soiled area and a clean one, and that hand hygiene should be performed between gloves when changing gloves. E. On 01/06/22 at 07:59 AM an observation of personal cares and catheter cares for Resident 2 revealed Certified Nurse Aide (CNA) M entered the room and put gloves on without performing hand hygiene. CNA M pulled down the top sheet and bedspread, used the bed controller to elevate the head of the bed, and then assisted Resident 2 to lift feet up into bed. Wearing the same soiled gloves, CNA M obtained an alcohol wipe, a graduate cylinder, and a towel. CNA M put the towel on the floor, and placed the graduate cylinder and alcohol wipe on it, then removed gloves. CNA M washed hands with soap and water for 4 seconds, then put on new gloves. CNA M placed a package of wipes on the bed, used the bed controller to raise the bed for cares, and without changing gloves pulled Resident 2's undergarment down. Wearing the same soiled gloves, CNA M used wipe to clean Resident 2's front peri-area. Without performing hand hygiene, CNA M changed gloves and performed catheter cares. Wearing the same gloves, CNA M adjusted Resident 2's catheter leg strap and pulled up Resident 2's undergarment. CNA M then changed gloves, did not perform hand hygiene, and emptied the catheter bag. CNA M removed gloves and washed hands with soap and water for 7 seconds. CNA M then put the supplies away and disposed of the trash. CNA M then washed hands with soap and water for 23 seconds. Interview with CNA M on 01/06/22 at 08:11 AM confirmed that hand hygiene should be performed between gloves, and hand washing should be done for 20 seconds. Interview with DON on 01/ at 04:15 PM confirmed that handwashing should be done for 20 seconds, that gloves should be changed between touching a soiled area and a clean one, and that hand hygiene should be performed between gloves when changing gloves. F. Review of hand hygiene competency form revised 12-2019 revealed the following: Hand hygiene using antimicrobial soap and water: 4. Lather and rub hands together for a full 20 seconds. Hand hygiene using hand sanitizer: Examples of when hand sanitizer can be used includes: After removing gloves or between changing gloves. FINDINGS ARE: G. An interview on 01/03/22 at 08:20 AM with the facility Administrator revealed that 1 staff member had tested positive for Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) this AM. The interview revealed that this staff member worked on the locked memory care unit and that one resident on the unit had begun to display signs and symptoms of Covid-19 and was tested with negative results. The interview revealed that the memory care unit would now be a Yellow Zone (isolation rooms designated for residents who may have symptoms of Covid-19 and/or known exposure) An observation on 1/4/22 at 10:10 AM of all staff working the locked unit, which is currently a Yellow Zone, revealed staff wearing gowns and N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) masks and goggles but no gloves or face shields. An interview on 1/4/22 at 10:10 AM with LPN-I, Charge Nurse on the locked unit, revealed that staff doff PPE outside of the resident rooms and not inside the room. An observation on 1/4/22 at 10:15 AM revealed 2 hospice staff members had entered the unit with no gloves or face shield on. The interview with LPN-I on 1/4/22 at 10:10 AM revealed that staff were not required to wear gloves unless providing direct contact cares. A record review of the undated policy titled Zone Action revealed that it contained guidelines to include the following steps regarding a Yellow Zone: Yellow Zone -- Quarantine Zone This zone occurs when there is a potential exposure - Covid-19 positive team member who interacted with residents or COVID positive resident identified in this area Set up and Practices: Team member to wear full PPE (Personal Protective Equipment) used to protect healthcare workers, patients, and others from potentially contacting and/or spreading potential infections -- including gowns with cares (extended wear of and eye protection, N95 respirators-clean gown with every resident including gown/glove change between roommates in a companion room/toe to toe room) Door signage in place or posters for precautions on fire doors or strategic locations to indicate the proper precautions. An observation on 1/4/22 at 10:15 AM of the door signage present on the entrance doors to the locked unit revealed it to be a Yellow Zone and instructed PPE needed to include gowns, gloves, face shield and N95 mask. A record review of the PPE policy dated 12/29/21 and titled HOW TO SAFELY REMOVE PERSONAL PRTECTIVE EQUIPMENT, EXAMPLE 1 contained the following instructions: Remove all PPE before exiting the patient room except a respirator if worn. An interview on 1/4/22 at 3:26 PM after review of the facility policy titled HOW TO SAFELY REMOVE PERSONAL PRTECTIVE EQUIPMENT, EXAMPLE 1 and review of observations confirmed that PPE requirements for the Yellow Zone were not being followed and doffing of PPE should not be done in the hallways.

Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observation, interview, and record review, the facility failed to ensure the cleaning and storage of respiratory equipment to meet professional standards for Resident 57, 69, 126, 128 and 130. This affected 5 of 8 sampled residents. Total census was 76. Findings are: A. Record review of the facility's policy Nebulizer (a machine used to deliver liquid medication to a resident) therapy, small volume with a revised date of 11/17/2017, page 3 states: After treatment, rinse the nebulizer with sterile water and allow it to air-dry, or discard it after the treatment. Observation on 01/03/2022 at 09:48 AM of Resident 126's room revealed the resident's Nebulizer Administration Set (a kit placed on a small machine that pumps air though it to turn liquid medication into a mist) was unclean and draped on residents over bed table. Observation on 01/03/2022 at 03:36 PM of Resident 126's room revealed the resident's Nebulizer Administration Set was unclean and draped on residents over bed table. Observation on 01/04/2022 at 08:03 AM of Resident 126's room revealed the resident's Nebulizer Administration Set was unclean and draped on residents over bed table. Observation on 01/05/2022 at 08:08 AM of Resident 126's room revealed the resident's Nebulizer Administration Set was unclean and draped on residents over bed table. Interview on 01/04/2022 at 10:56 AM with RN-A (Registered Nurse) revealed the charge nurse is to clean the respiratory supplies daily. The nurse is to take the Nebulizer Administration Sets and clean with soap and water. After that, the Nebulizer Administration Set is to be placed on a wash cloth to air-dry. Observation and interview with the Administrator on 01/05/2022 at 04:25 PM revealed and confirmed the Nebulizer Administration Set was on the over bed table and not dismantled, cleaned or placed on a washcloth. The Administrator confirmed the Nebulizer Administration Sets are to be cleaned after each treatment. B. Record review of the facility's undated policy: Your Continuous Positive Airway Pressure ([CONDITION(S)])/Bi-Level Unit (a machine used to deliver positive airway pressure (PAP) to a resident to prevent the throat from closing), revealed the Daily Cleaning section stated: 1. Wash hands. 2. Wipe the portion of the mask that comes in contact with your skin with a damp cloth. 3. Empty any remaining water from the humidifier chamber. 4. Fill the chamber with soapy warm water and shake vigorously. 5. Rinse the chamber with clean water. 6. Air dry. C. Record review of the Active Orders dated 01/04/2022 for Resident 126 revealed orders to: Wipe [CONDITION(S)] mask with damp cloth, wash and air dry humidifier daily every day shift for Obstructive Sleep Apnea (OSA, intermittent airflow blockage during sleep. Observation on 01/04/2022 at 08:03 AM of Resident 126's room revealed the resident's [CONDITION(S)] mask and tubing was unclean and draped on residents over bed table, and the humidifier chamber was still full of water. Observation on 01/04/2022 at 11:22 AM of Resident 126's room revealed the resident's [CONDITION(S)] mask and tubing was unclean and draped on resident's over bed table, and the humidifier chamber was still full of water. Observation of Resident 126's room on 01/05/2022 at 08:08 AM revealed the [CONDITION(S)] machine was placed on the nightstand at the foot of the bed with the tubing attached and the humidifier chamber full of water. Interview on 01/04/2022 at 10:56 AM with RN-A revealed the charge nurse is to clean the respiratory supplies daily. The nurse is to take the [CONDITION(S)] mask and apart, clean with soap and water daily and set on the counter to air dry. Observation and interview with the Administrator on 01/05/2022 at 04:25 PM revealed and confirmed the [CONDITION(S)] machine and tubing were attached to the [CONDITION(S)] machine on the nightstand in the corner of the room. The Administrator confirmed the [CONDITION(S)] supplies are to be cleaned daily. D. Observation of Resident 57's room on 01/03/2022 at 01:39 PM revealed the [CONDITION(S)] machine was placed on the nightstand at the head of the bed with the uncleaned mask and tubing attached to the [CONDITION(S)] machine and the humidifier chamber full of water. Observation of Resident 57's room on 01/04/2022 at 08:03 AM revealed the [CONDITION(S)] machine was placed on the nightstand at the head of the bed with the uncleaned mask and tubing attached to the [CONDITION(S)] machine and the humidifier chamber full of water. Observation of Resident 57's room on 01/05/2022 at 08:11 AM revealed the [CONDITION(S)] machine was placed on the nightstand at the head of the bed with the uncleaned mask and tubing attached to the [CONDITION(S)] machine and the humidifier chamber full of water. Resident 57 confirmed in an interview on 01/04/2022 at 11:17 AM that the [CONDITION(S)] mask and tubing was uncleaned and laying on the resident's nightstand. The resident confirmed the humidifier chamber was still full of water. The resident stated that the nurse does clean the [CONDITION(S)] and supplies about twice a week and the last time it had been cleaned was about a week ago. Interview on 01/04/2022 at 10:56 AM with RN-A revealed the charge nurse is to clean the respiratory supplies daily. The nurse is to take the [CONDITION(S)] mask and apart, clean with soap and water daily and set on the counter to air dry. Observation and interview with the Administrator on 01/05/2022 at 04:25 PM revealed and confirmed the [CONDITION(S)] mask and tubing were attached to the [CONDITION(S)] machine on the nightstand. The Administrator confirmed the [CONDITION(S)] supplies are to be cleaned daily. E. Observation of Resident 69s room on 01/03/2022 at 09:43 AM revealed the [CONDITION(S)] machine was placed on the nightstand at the head of the bed with the uncleaned mask and tubing attached to the [CONDITION(S)] machine and the humidifier chamber full of water. Observation of Resident 69's room on 01/04/2022 at 08:03 AM revealed the [CONDITION(S)] machine was placed on the nightstand at the head of the bed with the uncleaned mask and tubing attached to the [CONDITION(S)] machine and the humidifier chamber full of water. Observation of Resident 69's room on 01/05/2022 at 08:13 AM revealed the [CONDITION(S)] machine was placed on the nightstand at the head of the bed with the uncleaned mask and tubing attached to the [CONDITION(S)] machine was hanging on the trashcan and the humidifier chamber full of water. Interview on 01/04/2022 at 10:56 AM with RN-A revealed the charge nurse is to clean the respiratory supplies daily. The nurse is to take the [CONDITION(S)] mask and apart, clean with soap and water daily and set on the counter to air dry. Observation and interview with the Administrator on 01/05/2022 at 04:25 PM revealed and confirmed the [CONDITION(S)] mask and tubing were attached to the [CONDITION(S)] machine on the nightstand. The Administrator confirmed the [CONDITION(S)] supplies are to be cleaned daily. F. An observation on 01/03/22 at 01:54 PM revealed that Resident 128's oxygen tubing that was connected to the oxygen concentrator, to have the nasal cannula end of the oxygen tubing to be resting on the floor under the end of the bed. The observation revealed that Resident 128 had a second oxygen tubing that was connected to the portable oxygen tank and resting with the nasal cannula touching the outside of the tank. An observation on 1/4/22 at 09:29 AM revealed Resident 128's oxygen tubing to be tucked into the handle of the concentrator with the nasal cannula touching the machine. The observation revealed that the oxygen tubing that was connected to the portable oxygen tank to be wrapped around the top of the tank with the nasal cannula touching the outside of the tank. A record review of the facility policy titled Lippincott Procedure, Nebulizer therapy, small volume with a revised dated of November 17, 2017, revealed the following steps: * encourage the patient to cough and expectorate; suction the patient's airway, as needed * rinse the nebulizer with sterile water and allow it to air dry, or discard it after the treatment. An interview with the Director of Nursing (DON) on 1/4/22 at 12:10 PM after review of the facility policy titled Lippincott Procedure, Nebulizer therapy, small volume with a revised dated of November 17, 2017, confirmed that the policy was not being followed related to cleaning of the nebulizer kit. The interview confirmed that the storage of oxygen tubing when not in use was to be placed in a bag to protect the cannula. G. An observation on 01/03/22 at 02:42 PM revealed that Resident 130 had an oxygen concentrator at the bedside with oxygen tubing attached with the nasal cannula draped across the machine and touching the front of the machine. An observation on 01/03/22 at 02:42 PM revealed that Resident 130 had a nebulizer machine with the kit still intact and lying on the floor next to bedside chair. An observation on 1/4/22 at 09:37 AM revealed MA-N had entered Resident 130's room and turned off the nebulizer machine, retrieved a wash cloth from the bathroom and placed Resident 130's nebulizer kit on the cloth and placed on the tray table and left the room with no cleaning or rinsing of the nebulizer kit or mouth piece. The observation on 1/4/22 at 09:37 AM revealed Resident 130's oxygen tubing to be draped over the machine with the nasal cannula touching the machine. A record review of the facility policy titled Lippincott Procedure, Nebulizer therapy, small volume with a revised dated of November 17, 2017, revealed the following steps: * encourage the patient to cough and expectorate; suction the patient's airway, as needed * rinse the nebulizer with sterile water and allow it to air dry, or discard it after the treatment. An interview with the DON on 1/4/22 at 12:10 PM after review of the facility policy titled Lippincott Procedure, Nebulizer therapy, small volume with a revised dated of November 17, 2017, confirmed that the policy was not being followed related to cleaning of the nebulizer kits.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure that all items on resident food trays were covered prior to transportation to the resident's room. This had the potential to affect all residents receiving food trays in their rooms. Total census is 76. Findings are: Observation on 01/04/2022 at 12:23 of the Dining Room revealed NA-O (Nurse Aide) covered the meal entrée on the meal tray with Aluminum Foil. NA-O then placed the beverages and the dessert on the meal tray and delivered the meal tray to a resident's room with the dessert and beverages uncovered. Observation on 01/04/2022 at 12:26 of the Dining Room revealed RN-J (Registered Nurse) covered the meal entrée on the meal tray with Aluminum Foil. RN-J then placed the beverages and the dessert on the meal tray and delivered the meal tray to a resident's room with the dessert and beverages uncovered. Interview on 01/04/2022 at 01:40 PM with DA-D (Dietary Aide) confirmed all items being delivered to resident rooms on meal trays are to be covered, not just the entrée. Interview with the Administrator on 01/04/2022 at 03:49 PM stated they do not track the number of residents receiving meal trays and confirms that all items on a meal trays being delivered to resident rooms should be covered.

Based on observation, interview, and record review, the facility failed to ensure 3 Nurse Aides (CNA-F, CNA-G, CNA-H) of 5 sampled unvaccinated staff were tested for COVID-19 in accordance with the facility's Community Transmission Rates. This had the potential to affect all residents that reside in the facility. Total census was 76. Findings are: A. Review of a Centers for Medicare and Medicaid Services (CMS) memo QSO-20-38-NH revised 09/10/2021 revealed that routine testing of unvaccinated staff should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the last week. Record review of the facility's undated, employee vaccination document that listed all staff members and their vaccination status revealed that the following staff were not vaccinated for COVID-19: -Certified Nursing Assistant (CNA)-F -CNA-G -CNA-H Record review of undated, un-named document tracking the Saunders County Transmission Rate for 08/03/2021 - 01/03/2022 revealed: -09/14/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -10/04/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -10/18/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -11/01/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -11/15/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -12/03/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -12/20/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. -01/03/2021, testing color was red and the testing frequency indicated unvaccinated staff needed to be tested 2 times per week. Record review of the unnamed staff COVID-19 testing logs for 11/27/2021 - 01/01/2022, and the South Haven Staffing Daily Schedules for 12/01/2021 - 01/06/2022 revealed the following: -CNA-F was last tested [DATE] and worked 12/20/2021, 12/21/2021, 12/22/2021, 12/25/2021, 12/30/2021 without a test documented again and CNA-F called in sick twice in that date range. -CNA-G last test date was not documented, and worked 12/23/2021, 12/24/2021, 12/26/2021, and 12/30/2021. -CNA-H only test result documented was 12/29/2021, and worked 12/07/2121, 12/09/2021, 12/22/2021, 12/23/2021, 12/24/2021, and 12/28/2021. Interview on 01/06/2022 at 04:13 PM with the facility's DON confirmed that testing of the unvaccinated staff listed was not done according to the facility's Community Transmission rates. B. Record review of the facility's COVID-19 Guidelines dated 12/29/2021, page 6 states: Any resident with a fever (temperature of 100 or greater) or any other symptoms outlined in the UDA will immediately be restricted to their room and appropriate isolation precautions initiated. If screening triggers need for increased monitoring or positive symptoms the facility will initiate the COVID-19 Q 12 Hour Symptom Evaluation. Record review of the facility's COVID-19 Guidelines dated 12/29/2021, Page 9 states: Residents who Become Symptomatic of COVID-19: Resident will remain in room Initiate contact and droplet precautions Will be immediately tested Verify initiation of COVID-19 Symptom Evaluation UDA per schedule Notify PCP Track resident following facility control surveillance log Ensure limited exposure by having 1-2 consistent staff each shift Record review of the 01/02/2022 at 06:58 AM Progress Note for Resident 32 revealed: Resident had a new cough. Resident had a runny nose. Congestion, cough, scattered wheezes on expiration, COVID test was negative. Record review of Resident 32's Progress Note dated 01/06/2022 at 8:59 AM there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 32's Progress Note dated 01/06/2022 at 01:44 PM documents a PCR test was performed. Resident was to remain in the resident's room until results were determined. Record review of Resident 32's Progress Note dated 01/06/2022 at 05:05 PM documents that Positive PCR test results were received, laboratory results were received and faxed back to physician with another fax requesting order to do a 2nd PSR. Record review of the unnamed document dated 01/06/2022 which is the facility's contact tracing (a document that documents all information for COVID-19 tacking) for Resident 32 reveals the date of onset of symptoms was 01/02/2022. Resident 32's room was on the [NAME] hall and it was a Green Zone. The resident had been out of the room and in the Dining Room. The resident had been fully vaccinated. The Resident was placed in Red Zone (all staff and visitors are required to wear all COVID-19 personal protective equipment) isolation. Interview with the Administrator on 01/10/2022 at 09:25 AM confirmed the resident did have symptoms 01/02/2022 and the symptoms diminished after that. The Administrator confirmed Resident 32 tested positive for COVID-19 on 01/06/2022 and was placed in Red Zone isolation after that. Interview with Resident 32 on 01/10/2022 at 09:39 AM revealed the resident did have a cough the entire time from the first COVID-19 negative test on 01/02/2022 through the COVID-19 positive test on 01/06/2022 and was not placed in isolation until 01/06/2022.

Based on record review and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) coding was reflected on Resident 45's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities). The sample size was 18. The facility census was 76. Findings are: Record review of Resident 45's Significant Change in Status MDS section A1500 dated 11/26/21 revealed the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was answered no. Record review of Resident 45's PASRR dated 6/19/2018 showed that Resident 45 met the criteria for having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the MDS/RN (Registered Nurse) on 01/06/22 at 03:04 PM confirmed that the response in the MDS related to the resident not meeting the State Level II PASRR requirements was incorrect.

Licensure Reference 175 NAC 12-006.09C1c Based on record reviews and interview, the facility failed to revise the Comprehensive Care Plan (CCP-written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) and put interventions in place to prevent urinary tract infections (UTIs) for Resident 68. This affected 1 of 2 residents sampled for care plan revision. The facility census was 76. Findings are: During initial interview with Resident 68 on 01/03/22 at 02:13 PM revealed that (gender) has had 2 UTIs since admission. Resident 68 further confirmed that this was unusual. Record review of a Face Sheet revealed Resident 68 was initially admitted on [DATE] and readmitted on [DATE] after a hospital stay that started 9/17/21. Resident 68 has a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of active orders revealed Resident 68 was on [MEDICATION(S)] (an antibiotic used to treat UTIs) 100 milligrams (mg) twice a day for 5 days for [CONDITION(S)]. This medication was started on 1/3/22. Review of an Order Recap Summary revealed Resident 68 also received [MEDICATION(S)] 100 mg twice a day for 5 days for [CONDITION(S)] starting 11/19/21. Record review of CCP focus potential for alteration in bladder function, revealed interventions were initiated on 9/7/21. One intervention stated to monitor for signs and symptoms of [CONDITION(S)] and report changes to the charge nurse. Interventions had not been updated since 9/7/21, and there were no other mention of UTIs. Record review of labs revealed urinalysis (UA) and urine culture were done 11/16/21 with bacteria identified and an antibiotic ordered, and again on 12/31/21 with bacteria identified and an antibiotic ordered for a total of 2 [CONDITION(S)]'s since admission. Interview with the Director of Nursing (DON) on 01/06/22 at 04:15 PM confirmed that the CCP focus for prevention of UTIs was not created when Resident 68 had a [CONDITION(S)] on 11/19/21. The DON further confirmed that the focus for potential for alteration in bladder function had not been revised since 9/7/21.

Licensure Reference 175 NAC 12-006.12E1 Based on observation, record review and interview, the facility failed to secure medications for 2 residents (Resident 54 and 70) in a locked storage compartment to ensure medications could only be accessed by the resident and authorized personnel. The facility census was 76. Findings are: A. On 01/03/22 at 04:08 PM observation of Resident 54's room revealed a container of [MEDICATION(S)] powder (a medicated powder applied to the skin to treat fungal infections) on the bathroom counter. Record review of a Medication Self Administration Screen for Resident 54 dated 11/31/21 revealed no mention of [MEDICATION(S)]. Record review of Resident 54's Comprehensive Care Plan (CCP-written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) last revised 12/15/21 revealed no mention of self-administration of [MEDICATION(S)] powder. Interview with Licensed Practical Nurse (LPN) I on 01/06/22 at 01:57 PM confirmed that Resident 54 had a container of [MEDICATION(S)] powder on the bathroom counter. B. On 01/03/22 at 10:38 AM observation of Resident 70's room revealed 2 inhalers (both [MEDICATION(S)]-an inhaled medication used to make breathing easier) on the table in front of Resident 70, and a specimen cup containing a pink ointment and a tube of Proctosol (a medicated cream for hemorrhoids) on the bathroom counter. On 01/05/22 at 09:16 AM observation of Resident 70's room revealed a tube of [MEDICATION(S)] (a medication applied to the skin to treat pain) on Resident 70's over-bed table in a clear plastic bag. Record review of Medication Self Administration Screen form dated 11/3/21 for Resident 70 revealed IDT (Interdisciplinary Team) reviewed appropriate for self administration and keeping at bedside meds as ordered for [MEDICATION(S)] and [MEDICATION(S)] (a brand name of [MEDICATION(S)]). Interview with Registered Nurse J on 01/03/22 at 01:41 PM confirmed that the pink ointment in the specimen cup on the bathroom counter was [MEDICATION(S)] (a medication applied to the skin to treat or prevent minor skin irritations,) and that the tube of Proctosol remained on counter. Interview with LPN K on 01/06/22 at 01:51 PM confirmed the presence of [MEDICATION(S)] inhalers on the table in front of Resident 70, and a [MEDICATION(S)] tube in plastic bag on the over-bed table. C. Record review of a Self Administration of Medications policy dated 2/2018 revealed the following: -2. A Medication Self-Administration Screen Assessment must be completed in PCC (PointClickCare-an electronic charting method) of (sic) by the MDS (Minimum Data Set-a comprehensive assessment of each resident's functional capabilities)/Care Plan Coordinator or another nurse designee. Each medication must be observed to ensure that the resident can safely administer each route of medication to be self administered. -6. The guidelines on labelling and secured storage of medications for the facility shall also apply to any medication the resident stores in his/her room. All medications stored in each resident room will be locked in a secured area with the resident having a key to access his/her medications. A spare key will be maintained by nursing personnel. -8. The resident's comprehensive care plan should reflect their request and process for self administration of their medications. Interview with the Director of Nursing (DON) on 01/06/22 at 04:15 PM confirmed that the facility's policy required that medications stored in each resident room should be locked in a secured area with the resident having a key for access and a spare key should be maintained by nursing personnel.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control guidelines to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure staff utilized hand washing or hand sanitizer while re-filling and distributing water to residents on the secured unit and failed to ensure staff appropriately held linens when placing the linens in the clean linen closet on one of four units. Findings include: During observation on 6/18/20 at 9:06am, Housekeeper (H1) removed clean linens from a cart, tucked them under her arm, unlocked the linen closet door and placed them in the closet for use. During observation on 6/18/20 at 9:12am on the secured unit, Nurse Aide (NA1) wore gloves. NA1 brought each resident's water cup into the hall, removed the lid and filled the cup with ice. NA1 re-entered the room filled the cup with water, placed the lid back on the cup and went into the next resident room repeating the pattern for each resident. NA1 did not change gloves or sanitize his hands between filling each cup. At this time NA1 indicated he should have changed his gloves or sanitized his hands in between each resident when he filled the cups on the unit. NA1 indicated the box of gloves on the cart were provided for him to use. During an interview on 6/18/20 at 10:01am, the laundry supervisor indicated staff should carry the laundry away from their bodies and it should not touch their clothing. During an interview on 6/18/20 at 10:52am, the Director of Nursing (DON) indicated staff should not carry clean laundry up against their clothing. The DON indicated NA1 should have changed his gloves after filling each cup. The 4/9/2020 COVID-19 Guidelines under the subtitle Prevention Measures recorded the facility maintains an Infection Prevention and Control Program. Everyday standard precautions and preventive actions should be used and include: Appropriate hand hygiene -Wash your hands for at least 20 seconds especially after using the restroom, before eating and after blowing your nose, coughing or sneezing. Always wash your hands when they are visibly soiled. -Use an alcohol-based hand sanitizer if soap and water is not readily available and/or when hands are not visibly soiled.

Licensure Reference Number 12-006.05(20) Based on observation, interview and record review, the facility failed to ensure EMR (Electronic Medical Records) were not accessible to the public. This had the potential to affect all residents in the facility. The facility census was 80. Findings are: An observation on 12/02/19 at12:28 PM of the EMAR (Electronic Medication Administration Record) Screen was left open to Resident information on the medication administration. LPN (Licensed Practical Nurse) K. An interview on 12/02/19 at 12:28 PM with LPN K confirmed that the EMAR had been open when not present at the computer. An observation on 12/03/19 at 02:38 PM of the Computer screen left open to PCC (Point Click Care- a software for documentation), Nurse LPN Mel An interview on12/03/19 at 02:39 PM with LPN L confirmed; that the public had access to the medical records of residents. Record review of HIPPA Security Agreement dated 12/15/14 revealed; not to exhibit or divulge the contents of any record or report except to fulfill a work assignment in accordance with facility HIPPA Policy. An interview on 12/04/19 at 01:09 PM with the Administrator confirmed; all computer terminals should be closed when the staff is not present at the terminal. The facility does not have a policy related to computer and EMR(Electronic Medical Record) they follow HIPPA guidelines.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interview, the facility failed to have a competency assessment for 1 agency staff member reviewed. This had the potential to affect all residents in the facility. The facility census was 80. Findings are: No documentation of competency assessment for AS (Agency Staff) LPN M was provided by the facility. Record review of AS LPN M's daily timesheets revealed that AS LPN M worked at the facility on 12/2/18, 12/4/18, 12/5/18, 1/3/19, 1/4/19, 1/5/19 and 1/6/19. Interview on 12/05/19 at 03:40 PM with Administrator confirmed that the facility did not have a competency assessment on AS LPN M and that AS LPN M worked at the facility on 12/2/18, 12/4/18, 12/5/18, 1/3/19, 1/4/19, 1/5/19 and 1/6/19.

Licensure Reference Number 175 NAC 12-006.18C Based on observation, interview and record review the facility failed to ensure a policy was in place for all linens prior to transport were handled in a manner to prevent the potential for cross contamination. This had the potential to affect all residents in the building. The facility failed to ensure hand hygiene was performed after glove removal for 2 residents (Resident 71 and 78). The facility census was 80. Findings are: [NAME] An observation on 12/05/19 02:20 PM of the laundry area revealed; Resident's clothing was in a soiled laundry container without being bagged. An interview on 12/5/19 at 2:20 PM with the Director of Nursing confirmed; that the staff do not bag linen or laundry unless it is soiled, the linen was transported without being bagged. Record review of Departmental Guidelines for infection Prevention revealed; the policy for Laundry handling did not address protocol for all linen removal to be bagged prior to transport to prevent the potential for cross contamination. B. Observation on 12/04/19 from 08:52AM - 9:05AM of perineal care for Resident 78 by NA [NAME] and NA F. Both NA [NAME] and NA F washed their hands and donned gloves, and proceeded to assist Resident 78 on the toilet. Both NA [NAME] and NA F then removed their gloves, NA [NAME] then performed hand hygiene and NA F did not perform hand hygiene after removing gloves. NA [NAME] donned clean gloves and provided perineal care, wiping front area with wipes and then wiping back side with new wipes. NA [NAME] then pulled up Resident 78's briefs and pants and then removed gloves and without performing hand hygiene, touched multiple items including Resident 78, wheelchair, lift sling, wheelchair pedals, call light and telephone. Observation on 12/04/19 from 09:10AM - 9:29AM of catheter cares for Resident 71 being completed by NA F and NA E. Both NA F and NA [NAME] washed their hands and applied gloves and proceeded to assist Resident 71 on the toilet. NA F and NA [NAME] then removed gloves and performed hand hygiene. NA F and NA [NAME] then donned gloves and NA F provided cares, wiping front area with wipes and then wiping back side with new wipe. NA F then pulled up briefs and pants, NA [NAME] then removed gloves and without performing hand hygiene, touched Resident 71, lift and lift sling. Review of facility glove policy, undated, entitled Key Elements for Practical Glove Use revealed on pg. 30, always remember anytime you remove gloves, you must wash your hands. Anytime you go from a dirty site to a clean site, stop and perform hand hygiene and change your gloves. Interview on 12/04/19 at 03:55 PM with DON confirmed that staff should be doing hand hygiene after removing gloves.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview and record review the facility failed to ensure that hand hygiene was performed to prevent the potential for cross contamination during food service, the facility also failed to ensure hair nets/chef hats completely enclosed all hair, and that dishes were handled in a manner to prevent the potential for food borne illness. This had the potential to affect all residents on the 100, 300, and 400 halls that are served meals. The facility census was 80. Findings are: [NAME] An observation on 12/04/19 at 11:12 AM food service and pureed food. Cook I took the temperature of the meat loaf at 180 degrees. The blender was cleansed with a cloth from the sink. Meatloaf was added to the blender with broth. The meatloaf was placed in containers for the steam table then placed in the oven. The first tin temperature was 161 and the second tin temperature was 167. The blender was cleansed. An observation on 12/04/19 at 11:15AM of the Cook I's chef's hat had not encompassed the hair, hair was visible from the sides of the hat and the back of the hat. Cook I had performed Hand hygiene from 11:20:49 to 11:21:01 (12 seconds). Cook I had donned gloves and cleansed the thermometer. The gloves were doffed. Cook I performed Hand hygiene from 11:22:01 to 11:22:08 (7 seconds). Then Cook I went to the walk in refrigerator and retrieved a banana. Cook I performed Hand Hygiene from 11:23:37 to 11:23:44 (7 seconds). Gloves donned the banana was peeled and placed in the blender, the Gloves were doffed, milk was added to the blender and the bananas were pureed. The bananas were placed in a liquid measuring cup and a liquid thickener was put into the bananas first 3 pumps and then another 2 pumps. The pureed bananas were placed in 2 cups with covers and names and dated and placed in the walk in freezer. An observation on 12/04/19 at 11:30 AM of DS (Dietary Staff) J for meal service, the meals were transported to the unit in a covered cart. On top of the cart was plates with chefs salads covered by wax paper, the salads could be seen from the sides of the tray. The food was moved from the cart to the steam table that was on at 11:32 and the lids were removed from the food. The food temperatures were as follows: Mashed Potatoes 151.8, Squash 172, Baked Potatoes 174.2, Gravy was 169.1 Pureed meat was 157, Meatloaf was 172.9. The cold trays chef salads were temped at 40.8. DS J performed Hand hygiene from 11:46:31 to 11:46:46 (15 seconds), the faucet was shut off with the hand. DS J had donned gloves. The DS J took a glove from the box, with gloved hands to open a drawer to get a fork. DS J had not removed gloves or performed hand hygiene. At 12:08 the DS J touched the walkie button with the right hand to call the kitchen for ground meat. DS J had not removed gloves or performed hand hygiene. A tray was set up and served out. DS J performed Hand Hygiene from 12:09:58 to 12:10:24 (26 seconds). At 12:10 DS J touched their face and then donned gloves, at 12:13PM touched face with gloved hand. DS J had not removed gloves or performed hand hygiene. The DS J picked up a potato and placed it on a plate with right hand that had touched DS J's face. At 12:18 PM the DS J had opened drawers to get a knife from the drawer with gloved hands, gloves were not removed and hand hygiene had not been performed. At 12:21 PM the right hand touched the walkie button to call the kitchen for meatloaf. DS J had not removed gloves or performed hand hygiene. At 12:22 PM both hands touched the baked potato that was placed on the plate. DS J had removed a glove from the right hand to get a bowl from the cupboard, soup was placed in the bowl and the bowl placed in the microwave. Both hands touched the soup can. DS J performed Hand Hygiene from 12:25:30 to 12:25:50 (20 seconds) and gloves donned. DJ S at12:27 PM touched the cart with the left hand to move the cart and then touched a potato to place it on the plate with both hands. At 12:29 PM DS J removed the soup from the microwave, and opened the cupboard was opened to get crackers. DS J had not removed gloves or performed hand hygiene. An observation on 12/4/19 at 12:30 PM of DS J had facial hair growth that was not covered by a hair net. An interview on 12/05/19 08:43 AM with the DM (Dietary Manager) confirmed; that gloves should be removed and hand hygiene performed when opening drawers, touching face and touching the walkie. The DM confirmed that there was a potential for cross contamination while using a separate glove to open drawers with gloved. The DM confirmed that hair should be encompassed by the hair net or the chef's hat. DM confirmed; facial hair was to be covered by a hair net. An interview on 12/05/19 08:45 AM with the Dietary Manager confirmed; that the hand hygiene was to be completed for 20 seconds. B. Observation of Dining on 12/2/19 from 11:55am-12:38pm on the Reliance Dining Room area revealed DS (Dietary Staff) H putting thumb into salad bowl with ungloved hand, putting thumb over side of plate when picking up plates and putting thumb of ungloved hand over side of plate when handing it another staff or placing it on a tray. DS H had hairnet on which didn't completely cover all hair in the front and in the back. DS H changed gloved hand 2 times and handwashing was not completed either time glove ws removed and replaced. DS H touched glasses on face and touched several times and then placed her thumb on plate by food. Observation of Dining on 12/3/19 at 08:25AM on the Reliance Dining Room area revealed DS H's hairnet not completely covering all hair in front and back and placed thumb over side of plates when picking them up to plate food on plate. NA (Nursing Assistant) G put thumb over side of plate when taking it from DS H. Record review of the Nebraska Food Code, Effective date 7/21/16, Hair Restraints 2-402.11 Effective revealed; (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENs; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Interview on 12/5/19 at 8:36 AM with Dietary Manager confirmed that hairnets should cover all hair, and that staff shouldn't put thumb over top of plates and that hands should be washed after removing gloves. C. Record review of the facility Hand Hygiene (hand washing) Competency dated 2/2017 revealed: Step 2. Turn on water and wet hands. Step 3. Apply soap. Using friction, rub hands together. Step 4. Lather and rub hands together for full 20 seconds. Step 5. While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. Step 6. Dry hands well with paper towels. Observation on 12/2/19 at 11:51 AM revealed that Certified Nursing Assistant A (CNA-A) applied soap to dry hands and then scrubbed the hands underneath running water for 12 seconds at the Lakemont dining room sink. CNA-A dried the hands with a paper towel. CNA-A then served a meal to an unidentified resident in the dining room. Observation on 12/2/19 at 11:56 AM revealed that Dietary Aide B (DA-B) wet hands, applied soap, and then scrubbed the hands for 2 seconds at the dining room sink. DA-B rinsed and dried the hands. Observation on 12/2/19 at 12:00 PM revealed that Certified Nursing Assistant C (CNA-C) wet hands, applied soap, and then scrubbed for 5 seconds at the dining room sink. CNA-C then rinsed the hands and dried the hands with a paper towel. CNA-C then served a meal to an unidentified resident in the dining room. Observation on 12/2/19 at 12:03 PM revealed that Certified Nursing Assistant A (CNA-A) applied soap to dry hands and scrubbed the hands underneath running water for 10 seconds at the dining room sink. CNA-A dried the hands with a paper towel and continued to assist with resident meal service. Observation on 12/2/19 at12:05 PM revealed that Dietary Aide B (DA-B) wet the hands, applied soap, and scrubbed the hands for 5 seconds at the dining room sink. DA-B rinsed the hands and then dried the hands with a paper towel. DA-B then put on disposable gloves and applied whip topping onto pudding bowls. Observation on 12/2/19 at 12:07 PM revealed that Dietary Aide B (DA-B) removed the disposable gloves and put the tray of pudding bowls into the refrigerator. DA-B then wet the hands, applied soap, and performed 4 second scrubbing with soap at the dining room sink. DA-B then rinsed the hands and dried the hands with a paper towel. DA-B then put on disposable gloves and removed bread slices from the bread package. Observation on 12/2/19 at 12:12 PM revealed that Certified Nursing Assistant C (CNA-C) wet the hands and applied soap. CNA-C scrubbed the hands with soap for 14 seconds and then rinsed the hands at the dining room sink. CNA-C dried the hands with a paper towel and then continued to assist with resident meal service. Observation on 12/2/19 at 12:12 PM revealed that Dietary Aide B (DA-B) removed the disposable gloves, wet the hands, applied soap, and then scrubbed the hands for 6 seconds at the dining room sink. DA-B then rinsed the hands and dried the hands with a paper towel. Observation on 12/2/19 at 12:17 PM revealed that Registered Nurse D (RN-D) wet the hands, applied soap, and then scrubbed the hands for 14 seconds at the dining room sink. RN-D then rinsed the hands and dried the hands with a paper towel. Observation on 12/2/19 at 12:18 PM revealed that Certified Nursing Assistant A (CNA-A) applied soap to dry hands and then scrubbed the hands underneath running water for 9 seconds at the dining room sink. CNA-A then dried the hands with a paper towel and continued to assist with resident meal service. Observation on 12/2/19 at 12:20 PM revealed that Dietary Aide B (DA-B) removed disposable gloves and opened a cupboard door. DA-B then wet the hands, applied soap, and then scrubbed the hands for 3 seconds at the dining room sink. DA-B then put on new disposable gloves and resumed food service. Observation on 12/2/19 at 12:22 PM revealed that Dietary Aide B (DA-B) removed disposable gloves, wet the hands, applied soap, and then scrubbed the hands for 2 seconds at the dining room sink. DA-B then rinsed the hands with a paper towel. DA-B sat a plate on the steam tray and then put on new disposable gloves. Observation on 12/2/19 at 12:24 PM revealed that Certified Nursing Assistant A (CNA-A) applied soap to dry hands and then scrubbed the hands underneath running water for 7 seconds at the dining room sink. CNA-A then dried the hands with a paper towel and continued to assist with resident meal service. Observation on 12/2/19 at 12:25 PM revealed that Registered Nurse D (RN-D) delivered a tray with a meal to an unidentified resident. RN-D sat the tray on the resident table and served the meal. RN-D returned to the meal service counter and sat the tray on the counter. RN-D then wet the hands, applied soap, and scrubbed the hands for 8 seconds at the dining room sink. RN-D then rinsed the hands and dried them with a paper towel. Observation on 12/2/19 at 12:27 PM revealed that Certified Nursing Assistant C (CNA-C) wet the hands, applied soap, and scrubbed the hands for 7 seconds at the dining room sink. CNA-C then rinsed the hands and dried the hands with a paper towel. Observation on 12/2/19 at 12:28 PM revealed that Dietary Aide B (DA-B) wet the hands, applied soap, and then scrubbed the hands for 6 seconds at the dining room sink. DA-B then rinsed the hands and dried the hands with a paper towel. Observation on 12/2/19 at 12:32 PM revealed that Registered Nurse D (RN-D) took a fork and knife from an unidentified resident and cut up the meat on the plate for the resident. RN-D then went to the dining room sink and wet the hands and applied soap. RN-D scrubbed the hands for 7 seconds and then rinsed the hands and dried the hands with a paper towel. Interview with the facility Director of Nursing (DON) on 12/5/19 at 12:56 PM confirmed that during handwashing, staff are required to wet the hands prior to applying soap and then scrub the hands for 20 seconds before rinsing the hands. The DON confirmed that scrubbing the hands with soap is not to be performed underneath running water.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to identify a change in skin condition for 1 resident (Resident 47). The facility census was 80. FIndings are: Review of physician orders [REDACTED]. Review of Resident 47's Treatment Administration Records for (MONTH) and (MONTH) 2019 revealed that weekly skin check were documented as being completed on 7/4/19, 7/11/19, 7/18/19, 7/25/19 8/1/19, 8/8/19, 8/15/19, 8/22/19 and 8/29/19. No documentation of results of weekly skin check for Resident 47 was found in electronic health record. Interview on 12/05/19 at 10:05 AM with Director of Nursing confirmed that there is no documentation of results of weekly skin checks done in (MONTH) and (MONTH) 2019 for Resident 47.

Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide in writing for 2 sampled residents (Resident 20 and 15) to the state ombudsman regarding discharge to the hospital. Facility census was 80. Findings are: [NAME] Record review of Nursing Note dated 11/5/2019 09:20 AM revealed; Received blood from lab drawn from right antecubital at 0620, received urine via clean catch at 0720 and sent to hospital, received call from tech at the hospital of Resident 20's critical lab, call placed to Providers nurse, updated them on Resident 20's status and lab. A return call from the Provider at 0855, order to send to the hospital for direct admit for acute [MEDICAL CONDITION]. Record review of Hospital Transfer Notice dated 11/6/19 revealed; that Resident 20 and Resident 20's representative were notified in writing of the reason for transfer to the hospital. An interview with the Administrator on 12/05/19 10:27 AM confirmed that the facility had not notified the ombudsman of Resident 20's discharge to the hospital on [DATE]. B. Record review of Resident 15's progress notes dated 9/27/19 at 4:06PM revealed that Resident 15 was transferred and admitted to Lakeside Hospital. Record review of Resident 15's progress notes dated 10/2/19 revealed that Resident 15 arrived back to facility at 4:06PM from hospital. Interview with the Administrator on 12/05/19 at 10:26 AM confirmed that the ombudsmen was not notified of Resident 15's discharge to the hospital on [DATE].