Every finding on record at St. Jane de Chantal

Licensed Reference Number 175 NAC 12-006.11(E)Based on observations, record reviews and interviews, the facility failed to ensure that the kitchen staff completed hand hygiene for 15 seconds and failed to ensure no cross contamination to prevent foodborne illness during meal preparation. This had the potential to affect 67 residents in the facility. The facility census was 80.Findings are:Observation of meal preparation on 01/06/2026 from 7:30 AM to 8:40 AM revealed the following:At 7:35 AM an observation of [NAME] D preparing the noon meal with gloves on puts all premeasured ingredients into a pot to cook and then mixes the hamburger, ground turkey into another pot and then takes soiled dishes to the dirty dish room. [NAME] D removed gloves and completed hand hygiene for 12 seconds, wipes sink, shuts off water and continued to dry hands with the same soiled paper towel. At 7:45 AM [NAME] F while preparing French toast with gloves on, picked up utensils and other items, then picked up French toast with the same soiled gloves on. [NAME] F removed gloves, completed hand hygiene and then wiped the sink and shut off the water with the same paper towels utilized to dry hands. At 8:00 AM [NAME] E while preparing eggs on the griddle with gloves on, cracked the eggs, touched the utensils and then poked the egg yolks on several eggs with the soiled gloved finger.At 8:05 AM [NAME] D added all premeasured dry ingredients in with the cooked meat mixture, washed hands for 15 seconds, wiped sink and shut off water with a paper towel that was then used to dry [NAME] D's arms. [NAME] D applied gloves and mixed the meat mixture by hand, with forearms touching the meat mixture and leaving visible tomato sauce on the cook's arm. The cook removed gloves and completed hand hygiene for 15 seconds, then uses the same paper towel to shut off the water and dry the cook's arms. Record Review of the facility policy titled Infection Prevention Hand Hygiene Procedure last revised 06/10/2025 revealed under number 2 that hand hygiene should be completed for 15 seconds and to not dry hands with the same paper towel used to turn off faucets. An interview on 01/06/2026 at 8:25 AM with the Production Manager (PM) confirmed that the cooks should not use soiled gloves to break egg yolks. An interview on 01/06/2026 at 8:26 AM with the Dietary Manager (DM) confirmed that hand washing should be longer than 10 seconds and that staff should not use the same paper towel to shut off water and wipe down sinks to dry their arms.

Based on record reviews and interviews, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for Resident 11 when new diagnoses were received. This affected 1 of 2 residents reviewed for PASARR completion. The facility reported a census of 80. Findings are:A record review of Resident 11's Face Sheet dated 01/08/2026 revealed the resident was admitted on [DATE].A record review of Resident 11's admission history and physical (H&P) dated 04/07/2020 revealed the resident had a diagnosis of depression. There was no mention of Post Traumatic Stress Disorder (PTSD)-a mental health condition triggered by experiencing or witnessing a traumatic event) or Intellectual Developmental Disabilities (IDD)- involves significant limitations in both intellectual functioning and adaptive behavior.A record review of Resident 11's Minimum Data Set (MDS - a standardized, federally mandated assessment tool used in nursing homes to comprehensively evaluate resident's health, functional abilities and needs), dated 10/08/2025 revealed a Brief Interview for Mental Status (BIMS -a quick 15-point cognitive screening tool used in healthcare to assess orientation, short-term memory and the BIMS assessment uses a point system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) for Resident 11's score is a 15.A record review of Resident 11's PASARR dated 03/31/2020 revealed Resident 11 is a Level 1(a screening is used to identify if an individual has or suspected of having, a serious mental illness, IDD or condition related to IDD. A positive finding on Level 1 results in a Level 2 to be done.) no level 2 was required. A record review of Resident 11's PASARR dated 04/28/2020 revealed major depression with no level 2 required.A record review of a Psychiatric Progress Note dated 07/15/2022 revealed diagnoses of mild intellectual disability, post-traumatic stress disorder, and major depressive disorder.A record review of a diagnosis list dated 12/24/2025 revealed diagnoses of PTSD, IDD and Major Depressive Disorder were included.A record review of quarterly care plan (written instructions needed to provide effectiveness and person-centered care of the resident that meets professional standards of quality care)-dated 12/26/25 revealed no mention of moods, behaviors, IDD, or PTSD.A record review of the PASARR policy last revised 3/12/2024 revealed no guidance regarding receipt of new MI (Mental Illness) or IDD diagnoses.An interview with Resident 11 on 01/05/2026 at 11:40 AM revealed Resident 11 experienced trauma from the death of parents and grandparents. Resident 11 stated my father drank a lot and molested me during bath time.''An Interview on 01/07/2026 at 10:30 AM with Registered Nurse (RN) MDS A confirmed that when a resident returns from a provider appointment the facility will obtain the office notes. RN MDS A will then add new diagnosis to the MDS, then a copy is given to the unit secretary where they then add the diagnoses to the face sheet.An interview on 01/07/2026 at 11:00 AM with SS-B confirmed that the facility did not know Resident 11 had new diagnoses of PTSD and IDD as of 07/15/2022. The SS-B further confirmed that a new PASSAR should have been done, and the diagnoses should have been added to Resident 11's care plan. An interview with RN MDS A on 01/07/2026 at 11:15 AM confirmed that they were not aware of a process to report new diagnosis and did not know with Resident 11's new dx on 07/15/2022 would trigger a new PASSAR or that it should have been care planned.An interview on 01/07/2026 at11:15 AM with RN MDS A is not aware of a process to report new diagnoses and did not know with Resident 11's new diagnoses that would trigger a new PASARR or that it should have been care planned. RN MDS A states that she does not know if the unit supervisor looks at consultation notes when resident returns from appointment. RN MDS A also confirmed that with a new diagnosis of PTSD/IDD it would be significant to obtain a new PASAAR and did not care plan the new diagnoses. An interview on 01/07/2026 at 11:25 AM with Licensed Practical Nurse (LPN) C revealed that the only information that comes back from an appointment is if there are any new orders or if they have a follow up appointment. LPN C confirmed that the unit secretary obtains any progress notes from any consultant appointments. LPN C also confirmed that leadership can add diagnoses or objectives to care plan.

Based on record review and interviews, the facility failed to identify or provide recommended behavioral health services for 1 (Resident 11) of 1 sampled resident with a diagnosis of Post Traumatic Stress Disorder and Intellectual Disability. The facility identified a census of 80. Findings are: An interview with Resident 11 on 1/05/2026 at 11:40 AM revealed that when the resident was asked if they had a history of trauma, the resident stated that the resident's father drank a lot and molested me as a child. Record review of Resident 11's face sheet revealed the resident was admitted [DATE] with the following diagnosis, bilateral knee pain, osteoarthritis, and heart failure. There is no mention of post-traumatic stress disorder (PTSD). Record review of Resident 11's admission history and physical dated 4/07/2020 revealed no diagnosis or mention of PTSD. Record review of Resident 11's preadmission screening and resident review (PASARR) (a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) dated 03/21/2020 revealed the resident was a Level 1, indicating no serious mental illness or intellectual disability. Record review of Licensed Mental Health Practitioner consultation note dated 04/09/2021 indicated no risk factors were identified for Resident 11. Record review of Resident 11's Minimum Data Set (MDS) (A federally mandated assessment used to identify cares for a resident) dated 10/8/2025 revealed the following: Section C, a Brief Interview Mental Status (BIMS) (is a screening tool to help determine the resident cognition, a score of 15 being cognitively intact), the resident had a score of 15. Section D revealed the resident 11 feels down, has trouble sleeping, has little energy, has a poor appetite, and has trouble concentrating. The Patient Health Questionnaire (a validated interview that screens for symptoms of depression. It provides a standardized severity score and rating for evidence of depressive disorder) revealed Resident 11 had a score of 10, which indicated moderate depression. Section GG revealed that the resident is dependent for transfers and toileting. Section I revealed a diagnosis of depression and PTSD. Section N revealed that the resident takes an antidepressant. Record Review of Resident 11's quarterly care plan dated 12/26/25 revealed a Quality-of-Life problem under mood and behavior that indicated that the resident was at risk for decreased quality of life, social interaction, and mood decline due to the history of severe degenerative joint disease to bilateral knees causing immobility, no mention of PTSD. Comments under this problem reflect that the resident gets frustrated and angry with the roommate, comments of feeling the resident would be better off dead, noted to throw temper tantrums, paranoid and delusional. Many notations of being agitated. According to the comments the resident was seen by psychiatry 5/5/2020 and was started on Lamictal 25 milligrams. On 2/26/2021 the resident Lamictal was increased and started on Ativan 1 milligram twice a day for anxiety. On 6/17/2022 revealed the Lamictal was increased to 50 milligrams at bedtime. On 9/1/2023 Lamictal was increased to 100 milligrams at bedtime. on 9/21/2023 the Lamictal was changed back to 50 milligrams (mg) at bedtime due to dizziness. On 3/06/2024 a note of the Resident being angry and agitated, on 11/13/2024 being irritable. On 2/06/2025 feeling socially isolated, this is documented again on 5/03/2025, 07/24/2025,10/09/2025 and 1/02/2026. Record Review of Resident 11's of psychiatric consultation dated 7/15/2022 revealed a new diagnosis (DX) of Intellectual Disability (ID) and PTSD with the recommendation for therapy for the resident's PTSD. Record review of Resident 11's psychiatric visit dated 12/16/2022 revealed the resident was still having periods of anxiety due to resident's past trauma. Record review of Resident 11's psychiatric visit dated 9/1/2023 revealed that the resident was still having issues with anxiety from resident's past trauma and issues with sleeping. An interview on 1/07/2026 at 10:30 AM with Registered Nurse (RN)A revealed they were not aware that a new diagnosis of Intellectual Disability would trigger a new PASARR and care plan should have been updated. An interview on 1/07/2026 at 11:00 AM with Social Services (SS) B confirmed that a new PASSAR should have been completed for Resident 11 and the care plan updated. Record review of Resident 11's progress notes from admission to 01/08/2026 revealed Resident 11 had anger, outburst towards staff and other residents, Resident 11's has a long history of depression and suicidal thoughts, and medication adjustments made over time. Resident 11 was seen by a psychiatrist in 2022 and there was a recommendation for therapy for newly Dx PTSD. No documentation that the facility implemented recommendation for therapy for Resident 11 due to new diagnosis of PTSD. Record review of behavior documentation by nursing for Resident 11 revealed the following:10/6/2025 - resident angry, impulsive, irritable.10/24/2025- anxious, behavior fluctuates, resident is getting upset easily stating I'm just going to my room to get out of everyone's way resident voice is harsher and more aggressive with conversations.11-11-25- agitated, anxious01-01-26- calm, cooperative, relaxed made no attempt to leave the unit remained in room all day Record Review of Electronic Medical Record (EMR) under mood and documentation revealed the following: 02/19/2023- verbally abusive, yelling03/16/2023 - rejection of cares, not listening to staff03/26/2023- wandering at 7:59 PM not listening to staff and socially inappropriate09/30/2024- socially inappropriate behavior12/31/2025- wandering through the facility An interview with SS-B on 01/08/2026 8:10 AM revealed that about a year and half ago, the facility started asking upon admission if a resident had a history of trauma. SS-B also verbalized that if a new diagnosis is identified during a resident's stay in the facility, the SS worker then does the trauma assessment that was added a year and a half ago. During the interview, the SS-B gave the surveyor a sheet of paper titled Trauma on the top of the page, with no date or facility identification to indicate this was a facility policy. Record review of the facility policy titled Behavior Management and Modification, last revised 8/04/2025 does not mention trauma screening. An interview on 1/08/2026 at 8:45 AM with SS-B confirmed the trauma screen was never completed for Resident 11 and should have been.

Licensure Reference Number 175 12-006.09(H)Based on observations, record review and interviews the facility failed to complete a wheelchair screening to ensure proper positioning for one (Resident 11) of one sampled resident. The facility identified a census of 80.Findings are: Record Review of Resident 11's Minimum Data System (MDS) (is a standardized, federally mandated assessment tool used in nursing homes to comprehensively evaluate resident's health, functional abilities and needs) dated 10/08/2025 reveled Section C Brief Interview for Mental Status (BIMS) (a quick 15-point cognitive screening tool used in healthcare to assess orientation, short-term memory and recall) Resident 11's score was a 15, indicating the residents cognition was intact. Section D of MDS revealed Resident 11 feels down, trouble sleeping, little energy, poor appetite, and trouble concentrating. The MDS also revealed a severity score of 10 on a Patient Health Questionnaire-9(PHQ-9) (which is a brief self-administered tool used for screening, diagnosing, and monitoring depression severity by asking for nine common symptoms) but revealed that there was no rejection of care, or behaviors to others. Section GG revealed that eating is independent(I), bed mobility rolling is independent, sit to lie is touch assist, sit to stand is dependent, transfers dependent, toileting is dependent. Section I revealed diagnoses of Heart Failure, Depression, Post Traumatic Stress Disorder (PTSD) and Orthopedic conditions. Section O revealed- No special programs or procedures. Section J revealed that Resident 11 receives scheduled pain medication, with no complaints of pain.An observation of Resident 11 on 01/05/2026 at 11:47 AM revealed Resident 11's buttocks are on the edge of the wheelchair cushion. The resident has complained that the resident is not comfortable in current wheelchair. The wheelchair arm rests are torn and that the metal wheel frame is dented. An observation of Resident 11 on 01/06/2025 at 9:30 AM propelling own wheelchair, leaning back in wheelchair, head on the top of the back rest, buttocks on the edge of wheelchair seat, and seat belt on for safety. An observation of Resident 11 on 01/07/2026 at 9:40 AM revealed the resident seated on edge of wheelchair cushion with feet down, seatbelt on tightly.An observation on 01/07/2026 at 1:35 PM revealed Resident 11 propelling self in wheelchair, not sitting upright, leaning back with head rested on back of back support, buttocks on the edge of wheelchair cushion and seat belt is on.An observation of Resident 11 on 01/07/2026 at 3:55 PM revealed Resident 11 sliding out of wheelchair and the seatbelt is holding Resident 11 in wheelchair. Resident 11 seat belt is so tight it is showing an indentation on Resident's abdomen. Resident 11 stated wheelchair is not comfortable. Resident 11 states I feel like I am sliding out of my wheelchair all the time.An observation of Resident 11 on 01/08/2026 at 9:25 AM observed buttocks on the front of wheelchair cushion and seat belt was secured tightly. A record review of an Outpatient of Physical Therapy (PT) evaluation from 02/18/2025 revealed no mention of evaluating Resident 11 for a new wheelchair.A record review of the facility inpatient division seating procedure, last revised 07/2024, revealed for a consult, states that if wheelchair is needed that a therapy consult should be placed prior to getting an order for a wheelchair evaluation. A record review of the facility inpatient therapy division seating and positioning specialist procedure, last revised 07/2024, revealed a new process for admission in the inpatient division but not for long term care division.An interview on 01/07/2026 at 1:45 PM with Licensed Practical Nurse(LPN) - C revealed that Resident 11 had fallen out of wheelchair on 08/14/2024 when volunteer staff pushed Resident 11 back from an activity without foot pedals on. LPN-C confirmed that when a resident complains of wheelchair issues, resident's get placed on a wheelchair clinic list that takes place every Tuesday. LPN-C confirmed that Physical Therapy is involved with wheelchair clinics.An Interview on 01/07/2026 at 2:42 PM with LPN-C confirmed that Resident 11 had not been seen in the wheelchair clinic.An interview on 01/07/2026 at 2:45 PM with Physical Therapist (PT)I confirmed that Resident 11 had not been evaluated at the wheelchair clinic that is performed every Tuesday in the facility.

Licensure reference Number 175 NAC 12-006.18Based on observations, record reviews, and interviews, the facility failed to ensure infection control practices related to hand hygiene (HH-cleaning the hands with soap and water or the use of an alcohol-based hand rub [ABHR] to help prevent the spread of infection) and use of personal protective equipment (PPE-special equipment, including gloves, gown, masks, and eye protection, worn to prevent exposure to hazards such as infectious materials) were followed during catheter (a flexible tube inserted into the body to drain fluid, such as into the bladder to drain urine) care for 1 (Resident 2) of 5 sampled residents for catheter care, and during wound care for 2 (Resident 2 and Resident 61) of 8 residents sampled for wound care. The facility census was 80.Findings are: A record review of the facility's Infection Prevention: Hand Hygiene policy last reviewed 06/04/2025 revealed that staff should use alcohol-based hand rub (ABHR) or wash their hands under the following circumstances: -before and after having any contact with a patient or patient environment, -after handling used dressings, catheters, linen or any patient care item, -after offering incontinence care or Foley (a type of catheter for draining urine) care, -before and after manipulating a feeding tube, -before and after emptying Foley catheter drainage bag or manipulating the catheter or the tubing, even if wearing gloves, -after contact with feces or open skin, -after handling items potentially contaminated with any patient's blood, excretions, or secretions, A record review of the facility's Use of Standard Precautions policy last reviewed 07/31/2025 revealed that Enhanced Barrier Precautions (EBP) refer to the use of gown and gloves during high contact resident cares to prevent the spread of Multi-Drug Resistant Organisms (MDRO). EBP should be followed during High Contact Care Activities. The policy referred the reader to the EBP Guidelines document. A record review of the facility's Enhanced Barriers Precautions Guidelines document updated 04/26/2024 revealed a table labelled Enhanced Barrier Precautions by Task. Further review of the table revealed: PPE needed for a full or partial bed bath was gloves and gown, PPE needed for changing bed linens if the resident was not in bed was gloves, and if the resident was in bed was gloves and gown. A record review of the facility's undated Standard Precautions Guideline revealed hand hygiene should be performed immediately after glove removal, and gloves should be changed frequently, including when moving from a dirty to a clean task. A record review of the facility's Indwelling Urinary Catheter (IUC) Maintenance Guidelines last updated 06/29/2022 revealed in the instructions for peri/catheter care that staff should Follow proper catheter care procedure, hold tube next to body, clean the tubing starting at the body and wiping away from the body. A. A record review of Resident 2's undated demographics sheet revealed that Resident 2 was admitted on [DATE]. A record review of Resident 2's Active Orders Report printed 01/06/2026 revealed the resident had a history of MDRO and was on EBP. Further review revealed the resident had orders to care for a feeding tube (a tube placed through the skin into the stomach), a Foley catheter (a tube placed into the bladder to drain urine), an abdominal wound and wounds to the areas below the breast and the abdominal folds, and a tracheostomy (a surgically created hole in the neck to create an airway). An observation on 01/07/2026 from 11:00 AM to 11:36 AM revealed cares provided to Resident 2 by Registered Nurse (RN) G and Nurse Aide (NA) H. RN G and NA H were both wearing gowns and gloves. NA was rubbing lotion onto the resident's legs, and RN was cleaning the resident's abdominal wound. The RN, without changing gloves or performing HH washed and patted dry the feeding tube site, applied a new dressing, then changed gloves without performing HH. The NA changed their gloves with no HH, cleaned under Resident 2's left breast and armpit, changed gloves with no HH and got clean washcloths out of the resident's drawer. NA H, without changing gloves or performing HH, applied a cream to Resident 2's inner thighs, then changed gloves with no HH done. RN G patted the abdominal wound with a dry washcloth, then applied betadine to the area using swabs and changed gloves without performing HH. NA H cleaned below the resident's abdominal fold then began doing peri-care (washing the genitals and anal area) and catheter cares. The resident had been incontinent of feces, and the catheter tubing had feces on it. NA H cleaned the catheter tubing by holding the tubing and wiping it towards the resident's body. The NA then removed their gloves, did not perform HH, and got more clean washcloths, put on new gloves, then got the washcloths wet. RN G patted the area under Resident 2's left breast dry and applied a new dressing, then changed gloves without performing HH. The RN and NA then assisted Resident 2 to lie on their side. RN G continued cleaning Resident 2's buttocks and anal area. NA H removed their gloves, did not perform HH, went to get more washcloths wet, then put on new gloves. RN G changed gloves without performing HH, finished cleaning the resident's buttocks, changed gloves with no HH and positioned a disposable absorbent underpad under the resident. The RN and NA then positioned the resident on their back. RN G then wiped the resident's inner thighs with a damp washcloth. NA H changed gloves with no HH and held Resident 2's inner thighs and labia while the RN patted them dry. Without changing gloves, the RN and NA then used the ceiling lift to reposition the resident. NA H removed their gown and gloves, did not perform HH, then put on new gloves and no gown and repositioned a pillow and assisted to put on pressure relief boots for Resident 2. The NA's clothing did come into contact with Resident 2's gown during this process. RN G changed gloves with no HH, hooked up Resident 2's tube feeding. RN G and NA H both removed PPE and performed HH prior to leaving the resident room. An interview on 01/07/2026 at 11:40 AM with RN G confirmed that RN G and NA H should have performed hand hygiene with glove changes and did not. An interview on 01/07/2026 at 11:40 AM with NA H confirmed that they should have wiped the catheter tubing away from the resident's body, put a gown back on before leaning over the resident to reposition the pillow and put on the boots, and should have performed hand hygiene with glove changes and did not. B. A record review of admission record for Resident 61 revealed that Resident 61 was admitted to the facility on [DATE] with the diagnosis of -Pyelonephritis, Right hip wound (Pyelonephritis is a severe kidney infection, while a right hip wound refers to an injury or surgical incision in the hip area. These conditions can potentially be linked, as severe deep-seated infections, can spread to adjacent structures, including the hip region) -Gangrene (the death of body tissue, typically in arms or legs, caused by a severe lack of blood flow (ischemia) or serious bacterial infection) -Pressure injury of sacral region, unstageable (injury is located at the tailbone, An unstageable pressure injury (sacral region) means full-thickness skin and tissue loss where the wound's true depth -Pressure injury of Left hip stage 2 (partial skin loss, appearing as a shallow open wound, blister, or scrape with a pink/red base, -Pressure injury of right hip state 4 (a severe, full-thickness wound extending into muscle, tendon, or even bone, characterized by deep, crater-like damage with visible bone/tissue, often with rolled edges, tunneling, pus, foul odor, and potential for serious infection) -Paraplegia (paralysis affecting the lower half of the body, including the legs, lower trunk, and pelvic organs, resulting from damage to the spinal cord in the thoracic, lumbar, or sacral regions) -Neuromuscular dysfunction of the bladder (a condition where nerve damage disrupts the communication between the brain and bladder muscles, preventing proper urine storage or emptying, leading to issues like incontinence, retention, urgency, or frequency, often seen with spinal cord injuries) A record review of Assessment and Interventions dated 12-17-17-2025 for the left hip pressure injury revealed for Resident 61 wound assessment- 12-17-2025 measurement for the left hip injury 2 with the length of 5cm, width of 1.8cm and depth of 1.4cm with undermining tunneling of 2.7cm and 2.8 cm exudate amount - light. A record review of Assessment and Interventions dated 12-17-2025 for the Right Hip injury stage 4 for Resident 61 revealed: Right hip stage 4 measurements:; Length 2.9cm, width 3 cm, and depth 0.4cm with exudate amount light A record review of Assessment and Interventions dated 12-17-2025 for the Coccyx full thickness/surgical, with measurements of length 1.6cm width 0.2 cm and depth 0.8cm. A record review of Nursing orders for Resident 61 revealed -left hip dressing change daily. Cleanse with soap and water, apply 3m no string skin prep, apply Vashe solution (used for cleaning, debriding, and moistening various wounds (cuts, burns, ulcers, scrapes) to create an optimal healing environment) moistened kerlix (cotton gauze bandage) to wound tucking into the tunneling, Cover with a 4x4 mepilex( soft silicone foam wound dressings) border dressing -Right hip dressing change 2 times a day. Cleanse with soap and water, moisten gauze with Vashe solution and lightly fill wound, cover with a ABD (is a large, highly absorbent gauze dressing used for heavily draining wounds) pad, tape to hold. -Coccyx dressing change 2 times a day. Cleanse with soap and water, apply a mepilex dressing An observation on [DATE]th 2025 at 11:10AM with Licensed Practice Nurse (LPN)-J revealed preparing to do dressing change on Resident 61. LPN-J gathered some abdominal pads from the supply room and put in their scrub top pocket. LPN -J did have on a face mask but did not put a gown on. LPN -J went into Resident 61's room with face mask and no gown and gathered the supply basket with dressings, packing strips, wound cleanser and tape that was in Resident 61's room. LPN -J put the dressing supplies on the bed with no barrier protection down. LPN -J then went into the bathroom and wet some wash clothes and put in a wash basin. LPN -J laid down the dry towel on the bed with no barrier protection. LPN -J did the Right hip ulcer wound first for Resident 61. LPN-J did apply gloves with no gown on and removed the dressing that had no drainage on the dressing. LPN-J then sprayed the wound cleanser into the wound and wiped with a wet wash cloth going over the wound back and forth twice with the same side of the wash cloth and then patted dry the wound with a towel. LPN-J did not perform hand hygiene or remove the gloves prior to placing the clean dressing to the right hip wound. LPN-J opened the abdominal pad and placed over the ulcer wound and put tape on each side of the abdominal pad. LPN-J then removed (gender) gloves and asked Resident 61 to roll onto the other side to be able to do the left hip ulcer. LPN-J then applied new gloves. LPN-J moved the catheter to the right side of the bed that had been on the left side of the bed. LPN-J did not change (genders) gloves after moving the catheter to the other side of the bed. LPN-J proceeded to remove the dressing from the left hip ulcer that had large amount of brown drainage on the dressing. LPN-J sprayed the wound cleanser on the wound and then took a wet wash cloth from the basin and proceeded to wash the wound with going back and forth across the wound 2 times with the same side of the wash cloth and then patted the wound dry with the same towel (gender) used for the right hip dressing change. LPN-J cut the packing strips applied the Vashe solution and packed the wound were it had started tunneling. LPN-J did not change gloves or wash hands after removing the soiled dressing. LPN -J put on a new Mepilex. LPN -J removed gloves. LPN-J did not wash hands. LPN -J applied new gloves to do the wound care on the coccyx. LPN-J removed the old Mepilex and sprayed the area with wound cleanser. LPN-J with a wet wash cloth wiped the area going back and forth x 2 and then patted the wound dry with the towel that was used for the right hip and left hip dressing change. LPN-J applied no sting skin prep to the coccyx and applied the Mepilex. LPN-J removed (genders) gloves. An interview on 11/5/26 at 11:45 AM with LPN-J confirmed that (gender) didn't change (genders) gloves in between dirty and clean of the dressing change between the right hip, left hip and coccyx wounds. LPN-J confirmed that (gender) should of changed gloves after moving the catheter from one side of the bed to the other before starting the wound care. LPN-J confirmed that (gender) should of washed (genders) hands in between the dressing changes. A record review of the Procedure: Infection Prevention: Hand Hygiene: With last review date of 6/10/2025 revealed D) Use alcohol-based hand rub or wash hands -before performing dressing care -After handling used dressings, urinals, bedpans, catheters, contaminated tissues, linen or and patient care item -before and after emptying foley catheter drainage bag, or manipulating catheter or tubing, even when wearing gloves -After handling items potentially contaminated with any patients blood, excretions or secretions. Record review of facility's Enhanced Barrier Precautions Guideline updated 4/26/24 revealed the following: -All staff will continue to follow Standard Precautions for all residents and patient care. -Horizontal infection Prevention Interventions (HIPI)- to be followed for all residents with indwelling medical devices (including ostomy, wound care) and /or certain targeted MDRO's. Enhanced Barrier Precautions (EBP) employ targeted gown and gloves use during high contact resident care activities when transmission based precautions do no otherwise apply. -Enhanced Barrier Precautions by Task: -Wound care that require a dressing PPE needed Gloves and gown -Gown if changing bed linens with resident is in bed. An interview on 01/08/2026 at 09:54 AM with the Director of Nursing confirmed that LPN-J should of placed a gown on before doing wound care and LPN-J should of performed hand hygiene between the dirty to clean dressing changes and LPN-J should of changed gloves and performed hand hygiene after moving the catheter from one side of the bed to the other side of the bed.

Licensure Reference Number 175 NAC 12-006.05(G)Based on observation, record review, and interviews, the facility failed to ensure informed consent was obtained before applying a physical restraint for 1 resident (Resident 2) of 1 sampled for restraints. The facility census was 80.Findings are:An observation on 01/06/2026 at 10:42 AM revealed Resident 2 wearing mitten restraints (padded, soft gloves used in healthcare to prevent patients-usually with a mental deficit-from pulling out vital tubes, such as tracheostomy [a surgically created hole in the neck to create an airway], catheter [a flexible tube inserted into the body to drain fluid, such as into the bladder to drain urine], or feeding tubes) on both hands.An observation on 01/06/2026 at 2:50 PM revealed Resident 2 resting on their back in bed with mitten restraints on both hands.An observation on 01/07/2026 at 7:25 AM revealed Resident 2 resting on their back on bed with mitten restraints on both hands.A record review of Resident 2's undated demographics sheet revealed that Resident 2 was admitted on [DATE].A record review of Resident 2's History and Physical (H&P) dated 09/30/2025 revealed the resident had diagnoses of respiratory failure, heart failure, obesity, difficulty swallowing, and encephalopathy (a change in brain function caused by injury or disease). Further review of the H&P revealed the resident had a tracheostomy, a catheter, and a feeding tube inserted into the stomach through the skin.A record review of Resident 2's Active Orders Report printed 01/06/2026 revealed the resident had an order for the following: Restraints, Medical. Agitation: YesImpulsive behaviors: YesImpaired judgement: YesMitt-Left: YesMitt-Right: YesMinimize risk for injury to self: YesInterference with treatment devices: YesStart: 1/5/2026 Stop: 1/6/2026PURPOSE OF RESTRAINT:; Minimize risk for injury to self DUE TO; Agitation; Impaired Judgement; Interference with treatment devices; Impulsive Behaviors TYPE OF RESTRAINT:; Mitt-Right; Mitt-LeftA record review of the Patient Orders (Displayed Orders) printed 01/08/2026 revealed that the order for restraint use was present when Resident 2 was admitted on [DATE].A record review of Resident 2's Comprehensive Care Plan (CCP- written instructions used to provide the resident with effective and person-centered quality care that meets professional standards) printed 01/06/2026 revealed the resident had a restraint care plan with a start date of 09/30/2025 to address the need for a physical restraint to prevent the resident pulling at the tracheostomy. Interventions for this care plan were to obtain signed consent before applying the restraint, and to fully inform the resident or family member of the risks and benefits of all options being considered, both with start dates of 09/30/2025.A record review of Resident 2's electronic health record revealed no evidence of the resident or family member being educated on the risks and benefits of restraint use, or of informed consent being obtained.A record review of the facility's Restraints procedure last reviewed 10/18/2023 revealed no mention of informed consent.An interview on 01/07/2026 at 3:03 PM with the Administrator (ADM) confirmed the facility did not have a consent form for the restraint.

Based on interview and record review, the facility failed to identify a history of trauma and failed to follow the recommended behavior therapy for 1 (Resident 11) of 1 sampled resident. The facility identified a census of 80.Findings are: An interview with Resident 11 on 1/05/2026 at 11:40 AM revealed that when the resident was asked if they had a history of trauma, the resident stated that the resident's father drank a lot and molested the me as a child. Record review of Resident 11's face sheet revealed the resident was admitted [DATE] with the following diagnosis, bilateral knee pain, osteoarthritis, heart failure. There was no mention of post-traumatic stress disorder (PTSD). Record review of Resident 11's admission history and physical dated 4/07/2020 revealed no diagnosis or mention of PTSD. Record review of Resident 11's preadmission screening and resident review (PASARR) (a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) dated 03/21/2020 revealed the resident was a Level 1 indicating no serious mental illness or intellectual disability. Record Review of Resident 11's Minimum Data Set (MDS) (A federally mandated assessment used to identify cares for a resident) dated 10/8/2025 revealed the following: Section C, a Brief Interview Mental Status (BIMS)(is a screening tool help determine the resident cognition, a score of 15 being cognitively intact), the resident had a score of 15. Section D revealed that the resident 11 feels down, trouble sleeping, little energy, poor appetite, and trouble concentrating. The Patient Health Questionnaire (PHQ-2 to 9, a validated interview that screens for symptoms of depression. It provides a standardized severity score and rating for evidence of depressive disorder) the resident had a score of 10, which indicated moderate depression. Section GG revealed that the resident was dependent for transfers and toileting. Section I revealed a diagnosis of depression and PTSD. Section N revealed that the resident takes an antidepressant. Record Review of Resident 11's quarterly care plan dated 12/26/25 revealed a Quality-of-Life problem under mood and behavior that indicated that the resident was at risk for decreased quality of life, social interaction, and mood decline due to the history of severe degenerative joint disease to bilateral knees causing immobility, no mention of PTSD. Comments under this problem reflect that the resident gets frustrated and angry with the roommate, comments of feeling the resident would be better off dead, noted to throw temper tantrums, paranoid and delusional. Many notations of being agitated. According to the comments the resident was seen by psychiatry 5/5/2020 and was started on Lamictal 25 milligrams. On 2/26/2021 the resident Lamictal was increased and started on Ativan 1 milligram twice a day for anxiety. On 6/17/2022 revealed the Lamictal was increased to 50 milligrams at bedtime. On 9/1/2023 Lamictal was increased to 100 milligrams at bedtime. On 9/21/2023 the Lamictal was changed back to 50 milligrams (mg) at bedtime due to dizziness. On 3/06/2024 a note of the Resident being angry and agitated, on 11/13/2024 being irritable. On 2/06/2025 feeling socially isolated, this is documented again on 5/03/2025, 07/24/2025,10/09/2025 and 1/02/2026. Record Review of Resident 11's of psychiatric consultation dated 7/15/2022 revealed a new diagnosis (DX) of Intellectual Disability(ID) and PTSD with the recommendation for therapy for the resident's PTSD. Record review of Resident 11's psychiatric visit dated 12/16/2022 revealed the resident was still having periods of anxiety due to resident's past trauma. Record review of Resident 11's psychiatric visit dated 9/1/2023 revealed that the resident was still having issues with anxiety from resident's past trauma and issues with sleeping. An interview on 1/07/2026 at 10:30 AM with Registered Nurse (RN)A revealed that a new diagnosis of intellectual disability would trigger a new PASARR and care plan should have been updated. An interview on 1/07/2026 at 11:00 AM Social Services (SS) B revealed that the facility staff currently ask about trauma upon admission, but that practice did not start until September 2023, and Resident 11 admitted prior to this date. The SS-B confirmed that they were not aware of the new diagnosis of Intellectual disability and PTSD that resident received on 7/15/2022. The SS -B confirmed that a new PASARR should have been completed and the care plan updated. Record review of the facility policy titled Behavior Management and Modification, last revised 8/04/2025 does not mention trauma screening. An interview on 1/08/2026 at 8:45 AM with SS-B confirmed the trauma screen was never completed for Resident 11 and should have been.

Based on record review and interviews the facility failed to complete a Preadmission screening and resident review(PASARR)- that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. A level 1 screening is a mandatory preliminary assessment for anyone entering a Medicaid certified nursing facility to quickly identify if they have a serious mental illness, Intellectual Disability, or Developmental Disability as defined by Medicaid. The facility failed to complete a PASARR for one (Resident 20) of two sampled residents. The facility census was 80.The findings are: Record review Resident 20's face sheet revealed admission date of 10/24/2025. Record Review of Resident 20's admission minimum data set (MDS) (is a standardized federally mandated assessment tool used in nursing homes to comprehensively evaluate the resident's health, functional abilities and needs) dated 10/19/2025 revealed the following: Section C showed a Brief Interview for Mental Status (BIMS) (is a 15-point cognitive screening tool used in healthcare to assess orientation, short-term memory, and recall, helping staff track changes in thinking learning and memory over time) revealed the resident's score was a 15, which indicated the resident was cognitively intact. Section D mood Patient Health Questionnaire -9 (PHQ 9) (self-report questionnaire for screening, diagnosing, and monitoring the severity of depression in adults by assessing symptoms over the past two weeks) showed the resident's score was a 1, indicating little depression. No other mood or behavior documented, Section GG showed the resident was dependent for all cares. Section A of the MDS revealed there was no documented PASARR in chart at this time. Section I revealed diagnoses of Arthritis, Anorexia, HTN, CKD, Weakness. Section N revealed Resident 20 is currently on antibiotics, opioids and antiplatelet.Record Review of Resident 20's care plan dated 10/24/2025 had no documentation of a PASARR being completed.Record Review of Resident 20's PASARR screening dated 12/07/2025 revealed a level 1 PASARR, that was completed after the resident went to the hospital and was readmitted to the facility.Record Review of policy Pre-admission screening and Resident Review last revised 03/12/2024 revealed that the admission team does the PASARR prior to admission to facility. This PASARR was not completed at time of admission [DATE].Interview on 01/06/2026 at 11:00AM with Social Service (SS)-B confirmed that Resident 20 was admitted on [DATE] with no completed PASARR.

Licensure Reference Number 175 NAC 12.006.18(B) and (D) Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (cleaning) and glove changes when going from a contaminated process to a clean process during wound care for 2 (Residents 3 and 77) of 5 sampled residents, failed to ensure 1 (Resident 38) of 6 sampled resident's mechanical in-exsufflator (a machine used to help produce a cough) circuit was changed monthly, and failed to rinse the nebulizer (neb)(a machine used to deliver liquid medication to the lungs) kit after each use and change weekly for 1 (Resident 56) of 6 sampled residents to prevent cross-contamination. The facility census was 83. Findings are: A. A record review of Resident 3's Transfer/Discharge/Active Orders dated 9/12/2024 revealed the resident had a wound care order on the right anterior (in front) foot wound for staff to apply a Mepilex (border dressing); Xeroform (petroleum-based gauge wound dressing) dressing on Mondays, Wednesdays, and Fridays. Cleanse with soap and water; 3M no sting skin preparation (prep). An observation on 9/11/2024 at 10:54 AM revealed Licensed Practical Nurse (LPN)-F completed hand hygiene, applied gloves, got supplies out of a cabinet in the room, removed existing Mediplex and Xeroform on Resident 3's right anterior foot, and discarded. LPN-F then cleansed the wound with soap and water, dried, wiped wound with a 3M no sting prep stick, and applied a new Xeroform and a new Mepilex. The observation did not reveal LPN-F changed gloves or performed hand hygiene when going from the contaminated process to the clean process. In an interview on 9/11/2024 at 10:54 AM, LPN-F confirmed LPN-F did not change gloves or perform hand hygiene when going from the contaminated process to the clean process during Resident 3's wound care on the right anterior foot wound. B. A record review of Resident 77's Transfer/Discharge/Active Orders dated 9/12/2024 revealed the resident had orders for wound care for the posterior (behind) neck wound and staff was to cleanse with soap and water, dry thoroughly after cleaning. Apply dry Therabond (absorbent silver-plated nylon three-dimensional fabric wound dressing), waffle side down, to wound. Cover with 4x8 white Mediplex lengthwise daily. An observation on 9/11/2024 at 7:26 AM revealed Registered Nurse (RN)-G performed tracheostomy (trach) care and posterior neck wound care on Resident 77. RN-G got supplies, performed hand hygiene, applied gloves, gown, and mask. RN-G cleansed trach stoma site with normal saline (NaCL)(sterile mixture of water and salt) on swabs, removed trach tie, removed posterior neck dressings, cleansed neck wound with soap and water, applied Therabond, applied Mepilex, applied new trach tie and 4 inch by 4 inch (4x4) split sponge around trach. RN-G then placed the resident's cervical collar (a neck brace) on the resident. RN-G removed mask, gown, and gloves and performed hand hygiene. The observation did not reveal that RN-G performed glove changes and hand hygiene when going from the contaminated process to the clean process during wound care. In an interview on 9/11/2024 at 11:08 AM, RN-G confirmed RN-G should have performed glove changes and hand hygiene when going from the contaminated process to clean process during Resident 77's wound care. C. A record review of the facility's Cough Assist Mechanical In-Exsufflator (M.I.E) policy with a last review date of 1/6/2023 revealed the staff was to complete circuit (tubing, mask, and filter) changes monthly and as needed (PRN). The staff was to date the filter when the circuit was changed. A record review of Resident 38's St. [NAME] de [NAME] LTC (long term care) Care Plan dated 9/10/2024 revealed the resident had a problem area of altered respiratory status related to respiratory failure, frequent pneumonia, excessive oral secretions (extreme amount or thickness of moth saliva), and apnea (stops breathing), and continue M.I.E. The comments revealed 6/20/2024 the resident went on hospice, and the hospice company delivered the M.I.E. The Care Plan did not reveal the frequency (how often) of circuit changes. A record review of Resident 38's Transfer/Discharge/Active Orders dated 9/12/2024 revealed the resident had orders for M.I.E 2 times per day (BID) at a pressure setting -35 +40 centimeters of water pressure (cmH2O). The Transfer/Discharge/Active Orders dated 9/12/2024 did not reveal the M.I.E. circuit was to be changed. A record review of Resident 38's Worklist Current Visit dated 7/14/2024 to 9/12/2024 did not reveal that the resident's M.I.E.'s circuit had been changed. An observation on 9/9/2024 at 11:14 AM revealed Resident 38's M.I.E.'s circuit and filter were not dated, the mask was in a plastic bag and the mask had facial oils on it. An observation on 9/10/2024 at 11:40 AM revealed Resident 38's M.I.E.'s circuit and filter were not dated, the mask was in a plastic bag and the mask had facial oils on it. An observation on 9/11/2024 at 8:05 AM with LPN-D revealed Resident 38's M.I.E.'s circuit and filter were not dated, the mask was in a plastic bag and the mask had facial oils on it. In an interview on 9/11/2024 at 8:05 AM, LPN-D confirmed Resident 38's M.I.E. mask had facial oils on it and LPN-D cleaned it before administering the M.I.E. treatment. LPN-D also confirmed the M.I.E. circuit was to be changed weekly, the filter should be dated but was not, and LPN-D was not sure the last time the circuit had been changed. In an interview on 9/12/2024 at 12:38 PM, LPN-A, who was the unit manager for the 400-hall, confirmed Respiratory Therapy used to change Resident 38's M.I.E. circuit but that had been changed to nursing. LPN-A confirmed the M.I.E. circuit had not been changed since the resident went on hospice on 6/20/2024 and the hospice company delivered their M.I.E., and it should have been changed monthly. 45613 D. Record review of an undated Admission Record revealed that Resident 56 admitted into the facility on [DATE]. Record review of an undated list of diagnoses for Resident 56 revealed a primary diagnosis of incomplete quadriplegia (paralysis that affects all of a person's limbs) due to spinal cord lesion between 1st and 4th cervical vertebra, and also a diagnosis of respiratory failure. Record review of Resident 56's quarterly Minimum Data Set (MDS -a federally mandated comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 8/7/24 revealed in 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) of 15, which indicated the resident was cognitively intact. Record review of Resident's 56's undated Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed that the resident has a potential for infection related to respiratory failure. Interventions included DuoNeb twice daily and to report any signs of respiratory distress. Observation on 9/9/24 at 1:42 PM of a neb treatment kit dated 8/27, laying on Resident 56's nightstand with a liquid noted in the chamber. There was a clear plastic treatment bag used for infection control purposes dated 8/20 hanging on the resident's wall. Observation on 9/10/24 at 10:01 AM of neb treatment kit dated 8/27, laying on Resident 56's nightstand with liquid noted in the chamber. There was a clear plastic treatment bag used for infection control purposes was dated 8/20 hanging on the resident's wall. Observation on 9/11/24 at 11:29 AM of neb treatment kit dated 8/27, laying on Resident 56's nightstand with liquid noted in the chamber. There was a clear plastic treatment bag used for infection control purposes dated 8/20 hanging on the resident's wall. Interview on 9/11/24 at 11:31 AM with LPN - H confirmed that the neb kit should have been changed weekly and it was not done, it was further confirmed that the neb kit should have been rinsed out after each use and had not been done and the infection control bag had not been changed and it should have been. Record review of Resident 56's physician orders revealed: -Change nebulizer kit every Tuesday at 4:00 PM. -Albuterol/ipratropium inhaler (DuoNeb) 2.5/0.5/3 milliliters (ml) solution twice daily. During an observation on 9/12/24 at 10:41 AM with LPN - A, the unit coordinator it was confirmed that the infection control bag was dated 8/20 and that there was liquid medicine in the chamber and it had not been rinsed out. Interview on 9/12/24 at 10:42 AM with LPN-A, the unit coordinator confirmed that the clear plastic bag used for infection control purposes that was hanging on the resident's wall had not been changed and that there was still liquid medicine in the neb kit and it had not been rinsed out. Interview on 09/12/24 at 10:43 AM with Resident 56 confirmed that (gender) took the breathing treatments in the morning and in the evening and that the neb treatment was done that morning and no one rinsed out the kit out after the treatment. Record review of facility's policy titled Aerosol Therapy with a last reviewed date of 2/23/24 revealed aerosol med nebulizers will be rinsed using a saline, sterile or tap water following treatments. Return nebulizer to treatment bag when not in use. Aerosol med nebulizers and treatment bag will be changed weekly and prn if damaged or soiled. Nebulizers kits and treatment bags will be dated.

Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review; the facility failed to ensure interventions were followed for 1 (Resident 22) of 1 sampled resident to prevent potential accidents. The facility census was 83. Findings are: A record review of Resident 22's Clinical Summary Report dated 9/12/2024 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses of chronic diastolic congestive heart failure (CHF), age-related osteoporosis (weak bones), Post COVID-19, Type 2 diabetes mellitus with diabetic polyneuropathy (uncontrolled blood sugar that affects the nerves in the arms, hands, kegs, and feet), weakness, and cigarette nicotine dependence. A record review of Resident 22's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) dated 7/30/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 15 of 15 which indicated the resident was cognitively aware. The resident was dependent on staff for all activities of daily living (ADLs) except eating and oral hygiene (cleaning). The resident had arthritis and asthma. The resident was a current tobacco user. The MDS did not reveal the resident had skin problems or burns. A record review of Resident 22's St. [NAME] de [NAME] LTC (long term care) Care Plan dated 7/22/2024 revealed the resident had a problem of at risk for injury due to smoking cigarettes. At times does not get cigarette properly disposed. Apron in front during smoking sessions, takes walkie talkie outside to call nursing back when finished. There were interventions of: smokes safely, monitor for proper disposal of cigarettes, wear smoking apron over legs, feet, and foot pedals when outside smoking. Supervised for safely lighting the cigarette, cigarette ring holder. Keeps smoking material in medication room or nursing treatment cart. Resident to use designated smoking areas when going outside to smoke. Smoking Assessment quarterly (every 3 months) and as needed (PRN). Assess respiratory status after smoking PRN. There were also comments of: -4/28/2020 - had a lit cigarette in foot pedal when coming in from smoking. -2/16/2022 - resident dropped cigarette into right slipper burning a hole in slipper and sock. Did receive a burn to the right inner foot. -8/31/2022 - resident caught smoking in the room. -12/19/2023 - resident found smoking in the room. -7/11/2024 - resident complained of pain in hands and fingers and had difficulty holding cigarettes. -7/16/2024 - resident complained of pain in hands and fingers. -7/22/2024 - resident had a drop in blood pressure after smoking several cigarettes. -7/24/2024 - staff limited resident to 2 cigarettes. -7/30/2024 - Occupational Therapist reported burn to right middle finger. -7/30/2024 - noted old burn marks between second and third fingers on the right hand. Areas are scabbed, no redness or infection. Resident had a hard time holding cigarettes between fingers, so it slides down. Ordered a Cigarette ring holder for resident to try. A record review of Resident 22's Transfer/Discharge/Active Orders dated 9/12/2024 revealed the resident had an order for staff to apply a smoking apron on resident during smoking 3 times per day but did not reveal a smoking assistive device or that supervision was required. A record review of Resident 22's Quarterly Smoking assessment dated [DATE] revealed there was no change in the smoking assessment, Resident 22 smoked safely with minimal supervision and a smoker's apron. The resident kept smoking material in the resident's room. A record review of Resident 22's Risk Assessment/Screening LTC dated 7/29/2024 revealed there was no change in the smoking assessment, Resident 22 smoked safely with minimal supervision and a smoker's apron. The resident was to limited to smoking to 1-2 cigarettes due to becoming hypotensive (low blood pressure), nursing to keep smoking material in the treatment cart. An observation on 9/9/2024 at 12:56 PM revealed Resident 22 had a burn on their right hand between the index and middle fingers. An observation on 9/10/2024 at 11:47 AM revealed a Nursing Assistant (NA) assisted Resident 22 in a wheelchair down the hall and out of the North center exit of the building with a smoking vest on. The resident had a burn on their right hand between the index and middle finger. The NA assisted the resident with getting the ashtray close, left the resident, and returned to the resident's hallway. The resident got a cigarette and lighter out and lit the cigarette. The resident then got a white extension piece out and struggled but did get it placed it on the filter end of the cigarette. The resident continued to smoke the cigarette, holding it by the paper portion not the holder, between their index and middle finger of their right hand. The resident was in the smoking area alone and there were no staff outside or inside that could see or supervise the resident from 11:47 AM until 12:18 PM. An observation on 9/11/2024 at 11:35 AM revealed Resident 22 was sitting alone outside smoking at the end of the North center hall. The resident had a different cigarette adaptive device that weaved around the fingers and held the cigarette away from the fingers. There was an NA that was in and out of the area, would get on the computer, and watch a different resident eat. Resident 22 was observed struggling with getting a cigarette in the adaptive device enough that the resident gave up and placed the cigarette between the index and middle finger, light it, and continued to smoke. The resident then dropped the cigarette on the table, the ashtray was smoking, and the resident dropped a cigarette on the ground below the resident, and the resident just lit another cigarette. The NA that was in and out of the area did not respond to any of the previous mentioned concerns. In an interview on 9/10/2024 at 12:56 PM, Resident 22 confirmed the resident smoked and had a recent burn between the index and middle finger of the right hand. The resident confirmed the cigarette slid down between the fingers and the resident had a new adaptive device, but it was missing, and the resident had to use an old one. In an interview on 9/10/2024 at 3:55 PM, Resident 22 confirmed the resident got burns from smoking about every 3-4 days when a cigarette would slide down between the resident's fingers. Resident 22 used to get burned clothes a lot, but now the resident had a smoking apron. The resident confirmed the resident had only 1 burn since the smoking apron when the resident dropped a cigarette between the chest and the apron, so now the resident had the staff tighten the apron more around the neck. The resident's newest adaptive device had been missing 4-5 days and the staff was aware but couldn't find it. In an interview on 9/12/2024 at 12:26 PM, Licensed Practical Nurse (LPN)-B confirmed the staff did not supervise Resident 22 when smoking. LPN-B confirmed the resident had a burn on the right hand between the index and middle finger and the resident did not report it to the staff. In an interview on 9/12/2024 at 1:06 PM, Occupational Therapist (OT)-C confirmed Resident 22 should have a black, ring style adaptive smoking device, but it was stretched out and the staff has had to try and tape it to stay on. OT-C confirmed the resident had poor hand dexterity (use of hands), was unable to load cigarettes in the devices, and the resident has had multiple burns. In an interview on 9/12/2024 at 1:15 PM, LPN-A, who was a charge nurse, confirmed Resident 22 was allowed to smoke with minimal supervision. Minimal supervision meant the staff could observe from a distance. LPN-A confirmed the facility did not have enough staff to supervise the resident one-on-one while smoking and the staff should at least be in the lounge right inside the building by the smoking area to supervise the resident while smoking.

Licensure Reference Number 175 NAC 12-006.10 Based on observation, record review, and interview; the facility failed to ensure that residents were free of significant medication errors while administering insulin (a medication used to reduce the amount of blood sugar in the blood of residents with diabetes) to 1 (Resident 56) of 1 residents sampled. The facility census was 83 at the time of survey. Findings are: Record review of the facility's policy titled Medication Safety with a last reviewed date of 7/22/24 revealed that the short acting insulin administration schedule was based around meal delivery times. Record review of undated Admission Record revealed that Resident 56 was admitted into the facility on [DATE]. Record review of Resident 56's list of diagnoses revealed a primary diagnosis of incomplete quadriplegia (paralysis that affects all of a person's limbs) due to spinal cord lesion between 1st and 4th cervical vertebra. Also listed were respiratory failure and Type 2 Diabetes Mellitus (a condition that occurs when the body does not produce enough insulin or doesn't use insulin properly). Record review of Resident 56's quarterly Minimum Data Set (MDS -a federally mandated comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 8/7/24 revealed in 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) of 15, which indicates the resident was cognitively intact. Insulin injections were marked as administered 7 days during the look back period (standard 7 day time frame for assessment). Record review of Resident 56's undated Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed Resident 56 required extensive assist with ADL's related to quadriplegia from a motor vehicle accident (MVA) and contractures. Also revealed Resident 56 has the potential for hypo/hyperglycemia. Interventions included to monitor for signs and symptoms of hypoglycemia, and to give insulin as ordered. Record review Resident 56's of physician orders revealed the following: -Insulin Lispro PEN (DPS/humaLOG) Sliding Scale Insuline (SSI) (Moderate) Unit(s) -0 Unit(s) if Blood Glucose (BG) 60 - 149 -2 Unit(s) if BG 150 - 199, -4 Unit(s) if BG 200 - 249, -6 Unit(s) if BG 250 - 299, -8 Unit(s) if BG 300 - 349, -10 Unit(s) if BG 350 - 399, -12 Unit(s) if BG 400 - 999, -SubCutaneous, 4 times/day with meal/bedtime. -time critical medication. -if BG below 70 initiate hypoglycemia protocol; if BG above 400 notify physician. Observation on 9/9/24 at 1:16 PM revealed Licensed Practical Nurse (LPN) - H entered into Resident 56's room to obtain the resident's accucheck (blood glucose) and give the insulin after resident had returned to their room after eating lunch in the dining room. The resident's accucheck was 225 and LPN-H gave the resident 4 units of humalog insulin per the resident's sliding scale orders. Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 56 revealed that LPN-H completed the accucheck and gave 4 units of insulin on 9/9/24 at 1:19 PM. Interview on 9/11/24 at 11:27 AM with LPN - H confirmed that on 9/9/24 the resident's accucheck and insulin were completed late and should have been done before the resident ate lunch. Record review of Resident 56's most recent Hemoglobin A1c (lab levels used to monitor how well diabetes is being managed) dated 12/20/2023 was 6.7 which was out of the normal range of 4.0-6.0. Record review of Resident 56's accuchecks for July, August, and September 2024 revealed a range in blood sugars from 94 - 253. Interview on 9/12/24 at 8:48 AM with LPN - A, the unit coordinator, confirmed that the expectation was that accuchecks and insulin were to be done before the resident ate the meal.

Licensure Reference Number 175 NAC 12-006.17 Based on record review and interview, the facility failed to ensure that all staff were screened for signs and symptoms of COVID-19 before starting their work shift. This had the potential to affect all residents in the facility. Facility census was 94. Findings are: A record review of the document COVID TALKING POINTS FOR SURVEY, dated 8/11/2022 revealed the facility requires all staff to be screened for COVID symptoms prior to shift. An interview with the Infection Control Preventionist on 9/1/2022 at 02:15PM confirmed the expectation is staff screen themselves at the screening kiosk set up at the main entrance to the facility. This is the only screening kiosk in the facility. A record review of the staff daily roster by unit for the Ventilator Assist Unit (VAU) dated 8/28/2022 along with a comparison of the staff screening logs dated 8/28/2022 revealed that 14 of the 49 people on the roster did not screen themselves for signs and symptoms of COVID-19. A record review of the staff daily roster by unit for Extended Care North (ECN) dated 8/28/2022 along with a comparison of the staff screening logs dated 8/28/2022 revealed that 13 of the 47 people on the roster did not screen themselves for signs and symptoms of COVID-19. A record review of the staff daily roster by unit for the Ventilator Assist Unit (VAU) dated 8/29/2022 along with a comparison of the staff screening logs dated 8/28/2022 revealed that 13 of the 45 people on the roster did not screen themselves for signs and symptoms of COVID-19. A record review of the staff daily roster by unit for Extended Care North (ECN) dated 8/29/2022 along with a comparison of the staff screening logs dated 8/28/2022revealed that 4 of the 41people on the roster did not screen themselves for signs and symptoms of COVID-19. An interview with the Administrator on 9/6/22 at 4:15PM confirmed the administrator is aware that not all staff are going through the screening process and the expectation is that all staff screen each day they are on duty in the facility.

Based on observation, record review and interviews; the facility failed to ensure the exhaust ventilation system was operational on two areas of the facility. The facility census was 94. Findings are: Observations on 8/31/2022 during the intial tour revealed exhaust vents in the bathroom of 4 rooms (rooms 404, 415, 347, 343 where not drawing with 1 ply toilet paper. Environmental tour on 09/07/22 at 10:23 AM was completed with the maintenance supervisor and Maintenance Director. Confirmed that ventilation system was not working on the 400 hall including rooms 404, 405, 416. Interview on 9/7/2022 at 10:25 AM with the maintenance supervisor revealed vents are checked on a routine maintenance schedule and filters are changed. Review of the facility Preventive Maintenance sheets printed 9/7/2022 revealed the facility does check the exhaust vents routinely and the last date the ventilation system was checked was 8/8/2022. Interview on 9/7/2022 at 12:30 PM with the Maintenance Director revealed according to the maintenance software the units are running but the ventilation system is not drawing in two areas of the facility affecting all residents in those areas. The last time the belts were checked were on 8/2022 and the facility was unaware the ventilation system was not working.

Licensure Reference Number 175 NAC 12-006.17D Based on observation interview and record review the facility failed to ensure that gloving and hand hygiene was performed when indicated to prevent the potential for cross contamination during treatments for 5 resident (Residents 42,101, 82, 84, 53) an during medication administration for 2 residents (Residents 9 and 51) of 23 sampled residents. The facility census was 115. Findings are: A. An observation on 05/30/19 at 10:30 AM of wound care for Resident 82 revealed; on entry to room, RN I performed hand hygiene by using the hand sanitizer and donned gloves, RN I removed the packing from the wound and doffed gloves and without hand hygiene donned gloves. RN I used soap and water on a wash cloth to cleanse the wound. RN I rinsed the wound with wound cleanser. RN I changed doffed gloves and without hand hygiene and donned gloves. RN I applied skin prep ([MEDICATION NAME] no sting) to the skin surrounding the wound and applied gauze soaked with Vashe (a wound solution that has a skin friendly PH) into the wound. RN I doffed gloves and without hand hygiene donned gloves. RN I applied 4x4 Vaseline gauze applied and 4x4 followed by an ABD (Abdominal Pad thick dressing used for draining wounds) RN I doffed gloves and without hand hygiene donned gloves. RN I removed the dry Therabond (a wet to dry dressing used to help debride wounds) from the wound, cleansed the wound with soap and water, no glove change or hand hygiene was performed, a new piece of Therabond was cut to size, moistened and placed over wound. RN I doffed gloves and without hand hygiene donned gloves. RN I assisted with Resident 82's repositioning. RN I replaced supplies, cleansed table with wipes (Sani). RN I used hand sanitizer was used. B. An observation on 5/30/19 at 10:50 AM of wound care for Resident 101 performed by LPN (Licensed Practical Nurse) J of wound care for Resident 101. LPN J used hand sanitizer on entry to the room. LPN J donned gloves, had wet wash cloths. LPN J removed the dressing from the buttock wounds. LPN doffed gloves and without hand hygiene donned gloves. LPN J patted the wound with soap and water wet cloths. LPN doffed gloves and without hand hygiene donned gloves. The new dressings were prepared by soaking the Surgifoam (an absorbable gelatin sponge used for bleeding wounds) soaked with triple antibiotic ointment. LPN doffed gloves and without hand hygiene donned gloves. LPN J applied ointment and the soaked Surgifoam to the wounds. LPN J doffed gloves and without hand hygiene donned gloves and applied a third soaked Surgifoam sponge and moistened gauze was to the coccyx area. LPN doffed gloves and without hand hygiene donned gloves. LPN J assisted with dressing Resident 101. LPN J doffed gloves and used hand sanitizer. C. An observation on 6/3/19 at 12:55PM of medication administration by RN K for Resident 51 revealed hand hygiene was not performed prior to the medication administration. RN K measured the medications [MEDICATION NAME] 30mL (Milliliters metric system used to measure medications). RN K donned gloves. RN K measured tap water 100mL. RN K checked residual and equaled 60MmL and this was replaced. RN K mixed approximately 30mL of water with the measured medication and drew it into the syringe. No flush was performed by RN K. RN K administered the medication/water mixture by push and the remainder of the water was administered via gravity flow. D. An observation on 6/4/19 at 12:00PM of medication administration by LPN H revealed hand hygiene was not performed prior to entry to the room for medication administration. Record review of infection prevention Hand Hygiene policy dated with review date of 4/19/19 revealed; when hands were visibly soiled or contaminated with protienaceous material or visibly soiled with blood or other body fluids wash hands with soap and water. Step: 1) Vigorously lather hands with soap and rub for 15 seconds under a moderate stream of running water at a comfortable water temperature. 2) Rinse hands thoroughly, hold hands down lower than wrists, do not touch the inside of the sink 3) Dry hands thoroughly with paper towel and then turn off faucets with those towels. 4) Discard towels into the trash do not dry hands with same towel used to turn off sink. If hands are not visibly soiled alcohol based hand rub may be used for routinely decontaminating hands using the following process 1) Apply enough product to thoroughly wet both hands to the palm of one hand. 2) Rub hands together covering all surfaces of hands and fingers until hands are dry. Use alcohol based hand rub or wash hands: 1) When coming on duty. 2) Before performing invasive procedures. 3) Before preparing or handling medications, 4) Before performing dressing care, 5) Before touching preparing or serving food, 6) Before and after having contact with patient or patient environment. 7) After contact with patients on isolation, 8) After handling used dressing, urinals, bedpans catheters, contaminated tissues, linen, or patient care item. 9) After offering incontinence care, Foley care. 10) Before and after manipulation of feeding tubes. 11) Before and after manipulation of IV sites even when wearing gloves. 12) Before and after empty Foley catheter or tubing even when wearing gloves. 13) After contact with blood, urine, feces, oral secretions, mucous membranes or broken skin, 14) After handling items potentially contaminated with any patient blood excretions or secretions. 15) After personal body function use of toilet, blowing nose, wiping nose, smoking or combing hair. 16) Before and after eating. 17) Upon completion of the day. E. Record review of Resident 53's physician progress notes [REDACTED]. Record review of Resident 53's Transfer/Discharge/Active Orders dated 5/29/19 revealed [MEDICAL CONDITION] (a surgically created opening through the neck into the windpipe with a tube place to provide an airway and to remove secretions from the lungs) care was ordered to be done 2 times per day. Observation on 6/3/19 at 9:45 AM of RN-B (Registered Nurse) and RN-C providing [MEDICAL CONDITION] care for Resident 53 revealed RN-B and RN-C used hand sanitizer and applied masks and gloves. RN-B removed the dressing from the [MEDICAL CONDITION] and discarded, then changed gloves without performing hand hygiene. RN-B cleaned around the edge of the [MEDICAL CONDITION] using swab sticks, discarding after use. RN-B changed gloves without performing hand hygiene. RN-B and RN-C removed the [MEDICAL CONDITION] ties (a band that goes around the neck to hold the [MEDICAL CONDITION] in place) and RN-C held the [MEDICAL CONDITION] while RN-B washed and dried the resident's neck. RN-B got the new [MEDICAL CONDITION] tie and RN-B and RN-C secured the [MEDICAL CONDITION]. RN-B changed gloves without performing hand hygiene and applied the new [MEDICAL CONDITION] dressing, then removed gloves and performed hand hygiene. RN-B offered suctioning (removes thick mucus and secretions from the trachea), but Resident 53 refused. F. Review of Resident 42's Pressure Ulcer/Wound record dated 5/29/19 revealed the resident had a closed stage 3 pressure injury (full thickness skin loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) to the right ankle, a closed stage 2 pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed), and unstageable deep tissue injuries (purple area of discolored intact skin due to damage of underlying soft tissue) to the left 5th toe, back of the right ankle, and back of the left ankle. The resident also had a partial thickness (loss of skin presenting as a shallow open ulcer with a red/pink wound bed) wound to the right shin. The resident also had a surgical incision to the right buttock. Record review of Resident 42's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform (dressing used to maintain a moist wound environment) and [MEDICATION NAME] (absorbent foam dressing) to the wounds on the back of the right and left ankles, on the left foot, and on the right shin. The resident also received Nutrashield lotion to the intact incision line and [MEDICATION NAME] AG (dressing impregnated with silver) to the small open area near the perineum. Observation on 05/30/19 at 11:01 AM of RN-E completing wound care for Resident 42 revealed RN-E cleaned the scissors used for cutting the dressings, performed hand hygiene, and gathered supplies for the dressing change. RN-E applied gloves and pulled the resident's blankets back and removed the prafo boot (boot that alleviates pressure from the heel) from the resident's left foot. RN-E removed the dressing from the back of the resident's ankle. RN-E removed gloves, used hand sanitizer, and applied new gloves. RN-E cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound and applied to the wound bed, and covered with a [MEDICATION NAME] dressing. RN-E removed the dressing from the resident's left foot, cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound, then applied to the wound and covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene, inspected the resident's heels and applied Nutrashield lotion to the foot. RN-E reapplied the resident's prafo boot and changed gloves without performing hand hygiene. RN-E removed the prafo boot from the resident's right foot and removed the dressing front the resident's right shin. RN-E cleansed the wound and changed gloves without performing hand hygiene. RN-E cut Xeroform to the size of the wound and applied, then covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene and lifted the dressing to the right ankle, observed the wound, then secured the same dressing back into place. RN-E then secured the prafo boot back onto the resident's foot. RN-E changed gloves without performing hand hygiene, and cleaned the bandage scissors. NA-F (Nurse Aide) entered the room and assisted RN-E with repositioning the resident to the side. RN-E removed the dressing from the surgical incision on the resident's buttock and cleansed the area with a washrag. RN-E applied Nutrashield lotion to the incision, cut a piece of [MEDICATION NAME] AG to size and applied it to the open area at the end of the incision. RN-E and NA-F then continued to give the resident a bed bath. G. Review of Resident 84's Pressure Ulcer/Wound report dated 5/29/19 revealed the resident had an pressure injury to the right hip, a closed stage 2 pressure injury to the sacrococcyx (bottom of the spine to the tailbone), and a stage 3 pressure injury to the right ankle. Resident 84 also had wounds due to skin graft surgery to the right thigh, right hip, and left thigh. Review of Resident 84's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform secured with gauze to the right thigh, Xeroform covered with [MEDICATION NAME] to skin treated with skin prep swabs to the right hip, right ankle, and left thigh, and [MEDICATION NAME] and skin prep swabs to the coccyx. Observation on 5/30/19 at 2:13 PM of LPN-G (Licensed Practical Nurse) and RN-D performing Resident 84's wound care revealed LPN-G performed hand hygiene and gathered the supplies needed for the dressing change. LPN-G applied gloves and removed the resident's right prafo boot. LPN-G removed the dressing to the resident's right ankle, changed gloves without performing hand hygiene, and cleansed the wound. LPN-G prepped the skin surrounding the wound with a skin prep swab, changed gloves without performing hand hygiene, and cut Xeroform to fit the wound and applied it, then covered the wound with a [MEDICATION NAME] dressing. LPN-G changed gloves without performing hand hygiene and removed the dressings from the resident's right hip. LPN-G changed gloves without performing hand hygiene and cleansed the wound. LPN-G swabbed the skin surrounding the wound with skin prep and changed gloves without performing hand hygiene. LPN-G cut Xeroform to fit the lower right hip wound, applied to the wound, then covered both wounds with [MEDICATION NAME] dressings. LPN-G changed gloves without performing hand hygiene. The resident repositioned in bed and LPN-G removed the dressing from the resident's coccyx. LPN-G changed gloves without performing hand hygiene, cleansed the wound then changed gloves without performing hand hygiene. LPN-G applied a [MEDICATION NAME] dressing to the wound, changed gloves without performing hand hygiene, and secured the resident's brief. LPN-G and RN-D assisted the resident with repositioning, then LPN-G removed the wrap from the resident's left thigh, and changed gloves without performing hand hygiene. LPN-G cleansed the wound and prepped the skin surrounding the wound with the skin prep swab. LPN-G then changed gloves without performing hand hygiene, cut Xeroform gauze to fit the size of the wound, applied the Xeroform to the wound and covered the wound with a [MEDICATION NAME] border dressing. LPN-G changed gloves without performing hand hygiene, wrapped the resident's thigh with gauze, and assisted the resident with repositioning. LPN-G then removed gloves and used hand sanitizer. Review of Standard Precautions Guide dated 3/2018 revealed hand hygiene was required after glove removal, and gloves changes were required moving from a dirty to a clean task. Interview on 6/3/19 at 12:29 PM with RN-D revealed the expectation was that staff would use hand sanitizer or wash hands between glove changes.

Based on observation, record review and interview, the facility failed to ensure there was a policy in place to protect smoking residents from accidents related to smoking. This failure had the potential to affect 6 smoking residents (Resident 8, 23, 27, 62, 95, and 155). The facility census was 115. Findings On 5/29/19 at 9:30 AM an observation revealed an unknown resident exit the West St Jane's entrance un accompanied and wheel self down the sidewalk next to the street smoking. On 05/30/19 06:50 AM an observation revealed Resident #155 exit the front door un accompanied and wheel self to the southwest parking lot and proceed to smoke On 06/04/19 10:05 AM an interview with the ADM (Administrator) confirmed the policy; Tobacco-Free Campus Areas, dated 9/17/2010 was a(NAME)campus smoking policy and did not specifically address St(NAME)residents. Record review of facility policy Tobacco-Free Campus Areas dated 9/17/10 revealed no documentation on how the facility will assess or protect residents that smoke from accidents related to smoking. On 05/30/19 at 3:00 PM the DON (Director of Nursing) provided a list of smoking residents that included; Residents #8, 23, 27, 62, 95 and 155.

LICENSURE REFERENCE NUMBER 175 NAC 12-0060.5(5) Based on interview and record review, the facility failed to notify the resident's representative of the reason for transfer to the hospital in writing. This affected 2 residents (Residents 58 and 29) of 4 residents reviewed. The facility census was 113. Findings are: A. Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the reason for transfer in writing was given to the resident or resident's representative. Interview on 6/4/19 at 2:17 PM with the DON revealed the facility did not provide the reason for transfer in writing to the resident or resident's representative. B. Record review of Resident 29 face sheet revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Record review of Documentation of Communication / Event dated 12/12/18 revealed that Resident 29 was sent to the hospital for continued swelling, discoloration and pain to the right upper leg. The resident was admitted to the hospital for [MEDICAL CONDITION] (swelling) and pending tests. Interview on 5/29/19 at 3:14 PM with the family confirmed that the resident was discharged to the hospital and stated that no written information related to the reason for discharge was provided at the time of the transfer. Interview on 5/30/19 at 2:53 PM with the facility Administrator confirmed that no written notice of the reason for the transfer was provided to the resident or family at the time of the transfer.

Licensure Reference Number 175 NAC 12-006.05(4) Based on interviews and record reviews, the facility failed to ensure residents bathing preferences were assessed and provided according to the resident's preferences. This failure had the potential to affect two residents, Resident #62 and 102. The facility census was 115. Findings; A. 05/28/19 03:31 PM an interview with Resident #62 revealed that the resident wants 2 showers a week in the evenings, but is only receiving one a week during the day. Record review of MDS (Minimum Data Set, a health status screening and assessment tool used for all residents of long term care nursing facilities dated 4/9/19 revealed a BIMS (Brief interview of mental status) score of 14 (BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment , Record review of the residents care plan revealed bathing not addressed on the care plan. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. Record review of Worklist Report Visit task Shower dated from 3/4/19 to 5/31/19 revealed resident to receive 2 showers a week. Week of 3/10/19 received one shower, week of 3/17 received no showers, week of 4/7/19 received one shower, and week of 4/21/19 received one shower. Weeks 5/8/19 through 5/31/19 resident received one shower a week. Three of these showers were given in the evening. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. 06/04/19 04:39 PM DON (Director of Nursing) confirmed resident #62 was only receiving one shower a week and preferences are not documented. B An interview on 05/28/19 at 12:34 PM with Resident 102 who had expressed the preference to have a bath every other day, the resident reported that the facility had a bath schedule for twice a week. An interview on 05/30/19 at 12:08 PM with RN C confirmed that the Resident were placed on the bathing schedule on admission. The facility has a set schedule and the new admissions were added to that, if the resident was unhappy with the schedule then they would be moved to the preferred days. RN reported that they do full showers 2 times a week and partial bed baths daily. An interview on 06/03/19 at 03:47 PM with the Administrator, the Administrator confirmed the facility ask residents at the initial care plan meeting. The Administrator confirmed the facility had offered 2 baths, no more that that per week. Record review of Active orders dated 05/29/19 revealed an Order that Resident 102 was able to shower in the trauma tub scheduled bath days were Tuesdays and Saturdays. Record review of Resident 102's care plan revealed no bathing preferences were documented An interview on 06/03/19 at 05:03 PM with the DON (Director of Nurses) confirmed that the facility did not have documentation of the personal preferences regarding bathing for Resident 102 on admission. The DON confirmed no documentation of bathing preferences in the care plan

Based on record review and interview, the facility failed to submit a Pre-Admission Screening and Resident Review (PASARR, an assessment used to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for reevaluation after identification of a new mental health diagnosis. This affected 1 resident (Resident 53) of 1 resident reviewed. The facility census was 113. Findings are: Record review of Nebraska Level I Form PASARR dated 9/13/11 revealed the Resident 53 did not have any serious mental illness, including [MEDICAL CONDITION] Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), under Section 1 - Mental Illness. Record review of History and Physical dated 7/25/14 revealed Resident 53's past medical history included [MEDICAL CONDITION] Disorder. Record review of Resident 53's comprehensive MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/16/19 revealed the resident did not have a Level II PASARR (evaluation of if the resident needed specialized services). The MDS did note the resident had [MEDICAL CONDITION] Disorder. Record review of Resident 53's care plan dated 4/9/19 revealed the resident was evaluated for PASARR II with a start date of 7/30/18. Interview on 6/4/19 at 1:55 PM with the DON (Director of Nursing) revealed Resident 53 was admitted to the facility with the [DIAGNOSES REDACTED]. Interview on 6/4/19 at 1:56 PM with SW-A (Social Worker) revealed the PASARR form was completed in 2011 and was unable to provide details on why the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. SW-A revealed the resident was a Level I PASARR, and was unable to provide details on why the care plan noted PASARR II. Interview on 6/4/19 at 2:13 PM with the DON revealed the facility did not submit the PASARR for re-evaluation when the [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to provide information regarding bed hold to the resident at the time of transfer. This affected 1 resident (Resident 58) of 4 residents reviewed. The facility census was 113. Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the bed hold policy was given to the resident. Review of Resident's Rights policy dated 8/31/10 revealed the nursing staff, social worker, or admission personnel will ask if the resident wanted a bed hold if the resident would be out of the facility. Interview on 6/4/19 at 2:17 PM with the DON (Director of Nurses) revealed the DON was unable to find Resident 58's completed bed hold form. The DON revealed the bed form was not provided to the resident or completed for Resident 58's transfer to the hospital.

Based on record review and interview, the facility failed to ensure that the residents advanced directives were included on resident care plans. This had the potential to affect 6 Residents (Resident #6, 53, 62, 94, 102 and 207). The facility census was 115. Findings; A Record review of St Jane de Chantel LTC (Long Term Care) Team Care Plan dated 5/22/19 for Resident # 6 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/9/19 for Resident # 53 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/17/19 for Resident # 62 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/7/19 for Resident # 94 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/23/19 for Resident # 207 revealed advanced directives were not documented on the residents care plan. Record review of the Advanced Directives for Patients including Do Not Resuscitate Status policy revealed; no documentation to include advanced directives on the residents care plans. On 05/29/19 at 02:19 PM an interview with the DON (Director of Nursing) confirmed the facility does not include advanced directives on the residents care plans. E. Record review of Resident 102's Advanced Directives revealed the preference for a Full Code Status. Record review of St Jane de Chantel LTC Team Care Plan dated 5/14/19 revealed the Advanced Directives were not documented on the resident's care plan. An interview on 05/29/19 at 02:43 PM with the DON (Director of Nurses) confirmed that the facility had not included Advanced Directives on the care plan.