**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that resident assessments were coded incorrectly for hypoglycemic and antiplatelet on the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes to create individualized care plans based on their specific needs) . This affected 2 residents (Residents 6 and 12) of 3 sampled residents. The facility census was 49. Findings are: A. Record review of the Physician Orders reviewed on 12/16/2024 for Resident 6 revealed an order for Humalog insulin subcutaneous three times daily before meals and once at bedtime given on a sliding scale based on Resident 6's blood sugar. The physician orders also revealed an order for Levemir 12 units subcutaneous at bedtime. Record review of the MDS dated [DATE] for Resident 6 revealed the resident had a diagnosis of diabetes. Section N (Medications) subsection N0300 this resident received injections 7 days a week and in subsection N0350 that this resident received insulin injections 7 days a week. In subsection N0415 the use of hypoglycemic was not checked and indication was not noted. This information is required to provide resident specific information for payment and quality measure purposes. Interview on 12/17/2024 at 11:45 AM with the Minimum Data Set Coordinator (MDS) revealed this information is reviewed quarterly for each resident and then the resident care plan is updated. There is a specific look back period of time to review medications when creating the MDS. Interview on 12/17/2024 at 11:50 AM with MDS who (delete who) confirmed that this information for hypoglycemic was encoded incorrectly in Section N subsection N0415. B. Record Review of the Physician Orders printed on 12/12/2024 for Resident 12 revealed an order for Aspirin delayed release 81 milligram tablet once daily. (Aspirin is a medication with antiplatelet properties). Record review of the MDS data report dated 9/26/2024 for Resident 12 revealed that the resident had diagnoses of anemia, atrial fibrillation, and coronary heart disease. The MDS also revealed in Section N subsection N0415 that the resident was taking an antipsychotic, an antidepressant, and an anticoagulant. Interview on 12/17/2024 at 11:50 with MDS who confirmed that aspirin is an antiplatelet and not an anticoagulant and the MDS subsection N0415 was coded incorrectly.

Licensure Reference Number 175 NAC 1-005.06(E) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review, and interview, the facility failed to ensure that staff wore both a gown and gloves during resident care as required for Enhanced Barrier Precautions (An infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Precautions involve gown and glove use during high-contact resident care activities (Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or Assisting with toileting) for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices) for 1 (Resident 201) of 3 residents sampled to prevent the potential for cross-contamination and multidrug-resistant organisms. The facility census was 49. Findings are: Record review of the facility policy titled Enhanced Barrier Precautions dated 9/18/24 revealed that it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The section titled Prompt recognition of need revealed that all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. Residents with any of the following will be placed on enhanced barrier precautions-wounds including surgical wounds; indwelling medical devices including urinary catheters. Make gowns and gloves available inside the resident room. Note: face protection may also be needed if performing activity with risk of splash or spray such as wound irrigation. High-contact resident care activities include: dressing, bathing, transferring, device care including urinary catheters, and wound care of any skin opening requiring a dressing. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 12/16/24 for Resident 201 revealed that Resident 201 admitted into the facility on 9/27/24. The MDS revealed that Resident 201 had an indwelling urinary catheter (A flexible plastic hollow tube inserted into the bladder to continuously drain urine. An indwelling medical device.). Interview on 12/16/24 at 2:59 PM with the spouse of Resident 201 confirmed that Resident 201 has had the indwelling urinary catheter due to prostate problems and difficulty with urination. Record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 12/16/24 for Resident 201 revealed that staff are to use enhanced barrier precautions. Observation on 12/17/24 at 1:14 PM in the room of Resident 201 revealed that Resident 201 sat in the wheelchair in the middle of the room. A sign titled Enhanced Barrier Precautions was present on the wall just outside the resident room door. A second Enhanced Barrier Precautions sign hung on the wall just inside the room door next to the hanging container with gloves and gowns. The Enhanced Barrier Precautions signs directed that providers and staff must wear gloves and a gown for the following high-contact care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting, and device care or use. Nurse Aide-C (NA-C) and Nurse Aide-D (NA-D) entered the resident room with the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own). NA-C and NA-D put on yellow protective gowns. NA-C positioned the lift in front of the resident. The lift sling was underneath the resident's back and thighs. NA-C and NA-D used the bare hands to connect the lift sling loops onto the lift bar of the total body lift. NA-C put on gloves. NA-C removed the catheter urine collection bag from the privacy cover under the wheelchair and hung it on the lift. NA-C removed and discarded the gloves and performed hand sanitization. NA-C operated the lift and Resident 201 was lifted out of the wheelchair. NA-D prevented Resident 201 from hitting objects and grabbed the resident's lift sling from behind the resident. NA-D moved behind the recliner and held onto the lift sling using the bare hands to help guide Resident 201 to the back of the recliner. Resident 201 was lowered into place in the recliner. NA-C put on gloves and moved the catheter urine collection bag from the lift and hung it on the trash can. NA-D obtained a pillow. NA-C and NA-D used the bare hands to lean Resident 201 forward in the recliner. NA-C and NA-D placed the pillow behind the back of Resident 201. NA-D removed the gown and exited the resident room. Interview on 12/18/24 at 8:39 AM with the facility Director of Nursing (DON) confirmed that staff are to wear both gown and gloves during high contact care activities for residents on Enhanced Barrier Precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.19 Based on observation and interview, the facility failed to ensure a clean and sanitary environment in resident's bathrooms for 5 (rooms 9, 11, 16, 18, and 23 ) of 12 sampled rooms and failed to ensure hand sanitizer dispenser was working for 1 (Resident 23) of 49 sampled residents with a facility census of 49. Findings are: In an observation completed on 12/18/2024 at 8:05 AM the following was noted: -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that the resident would use to activate the call light was yellow brown from the middle of the cord to the end of the cord. On the faucet of the sink beneath the hot and cold-water knobs there is a buildup of porous white material that has both green and black areas on top of the white material. There is yellow white flaky build up material to the bottom portion of the faucet where it is connected to the sink. -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that resident would use to activate the call light was yellow brown in color to approximately 2 inches of the cord. The light located above the sink in the bathroom had 2 light bulbs in it only one light bulb was on and functioning. On the faucet of the sink beneath the hot water knob there is a white porous buildup with green areas on top of the buildup visible. -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that resident would use to activate the call light is dark yellow in color approximately 1 inch of the cord towards the top of the cord. -In the bathroom of room [ROOM NUMBER] the call light box is secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that resident would use to activate the call light is brown fading to yellow in color for more than ½ of the cord in its entirety. On the faucet of the sink beneath the hot and cold-water knobs there is a buildup of porous white material that has green areas on top of the white material. -Just inside the doorway to room [ROOM NUMBER] on the right side is a hand sanitizer dispenser attached to the wall. It was observed that on 12/16/2024, 12/17/2024 and 12/18/2024 to be not functioning. When hand is placed where indicated for product to be dispensed no product is dispensed. In the bathroom the call light box was secured to the wall to the left of the toilet. The porous cord hanging from the call light that the resident would use to activate the call light is yellow brown in color in an approximate 1-inch section towards the bottom of the cord. On the faucet of the sink beneath the hot and cold-water knobs and to the right side of the faucet opening is a white porous buildup of material. On top of this build up beneath the hot water know is green in color also. In an interview completed on 12/18/2024 at 8:30 AM with the Maintenance Supervisor, Housekeeping Supervisor, and Facility Administrator it was confirmed that the call light cords in bathrooms of rooms 9, 11, 16, 18, and 23 were discolored, that the faucets in the bathrooms of rooms 9, 11, 18, and 23 had build up on them and the buildup was a non-cleanable surface, and room [ROOM NUMBER] bathroom light bulb was out and room [ROOM NUMBER] hand sanitizer was not working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09(H)(iii) Based on record reviews, interviews, and observations, the facility failed to ensure interventions for constipation were put into place to promote bowel movements for 2 (Residents 6, and Resident 12) of 5 sampled residents, and the facility failed to provide wound care that prevented cross contamination for 1 (Resident 14) of 1 sampled residents. The facility census was 49. Findings are: A. Record review of the undated Bowel Movement Assessment/Monitoring policy and protocol stated the purpose is to monitor bowel regularity while taking into consideration any knowledge of bowel habit history on an individual basis. The procedure included reviewing bowel and bladder records nightly and making a note as to those who had not had a Bowel Movement (BM) for 2 days. This is forwarded to the day shift nurses who would then assess for needs of a laxative. If there had been no BM by the following morning, the day shift nurse was to assess for further laxative needs. Further laxatives may be administered. Record review of the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes to create individualized care plans based on their specific needs) dated 11/24/2024 for Resident 6 revealed the resident had a BIMS (Brief Interview for Mental Status -used to assess a person's cognitive function by evaluating their orientation and short-term memory) score of 10 which indicated moderate cognitive impairment. Resident 6 had diagnoses of cancer, hypertension, anemia, heart failure, and diabetes. Record review of the Care Plan (a detailed document outlining the specific healthcare needs and services a person requires to manage their chronic illness or disability) dated 12/4/2024 for Resident 6 revealed this resident was independent with a 4 wheeled walker in the resident room and in the facility. Resident 6 was continent of bowel. Record review of the Bowel Movement output charting found that Resident 6 did not have a bowel movement during the period of 11/20/2024 and 12/16/2024. Record review of the Medication Administration Record for Resident 6 during the time period of November 17, 2024 through December 17, 2024 revealed that Resident 6 was administered Miralax (a medication for bowel regularity) on a daily basis and received Milk of Magnesia (a medication for the relief of constipation) on 11/17/2024 and 11/18/2024. Laxatives had not been administered on 11/31/2024, 12/3/2024, 12/4/2024, or 12/5/2024. Interview on 12/17/2024 at 10:30 AM with Registered Nurse (RN-B) revealed that the nurses are given a sheet every morning at report. On this sheet we (we?- is this supposed to be a quote? ) see who hasn't had a bowel movement and who may need to have Milk of Magnesia or a suppository. If the resident is more than 4 days without a bowel movement, the physician may be called for further orders. Interview on 12/17/2024 at 11:00 AM with the Director of Nursing confirmed that the bowel program for constipation had not been followed by the nursing staff for Resident 6. B. A review of a Resident Face Sheet dated 12/16/2024 revealed that the facility admitted Resident 12 on 08/26/2024 with diagnoses of lung cancer (which is development of a cancerous lesion in the lung), and constipation ( which is the difficulty or inability to have frequent bowel movements). The comprehensive MDS dated [DATE] revealed Resident 12 had a BIMS score of 10 indicating the resident was moderately cognitively impaired. The resident was coded to be dependent on staff assistance with toilet use and transfers and the resident was always continent of bowel. Constipation being present was not coded on the MDS. Review of Resident 12's Care Plan revealed a problem of the resident requiring assistance by staff with activities of daily living including transfers and toilet use dated 08/26/24. Review of Resident 12's electronic medical health record revealed the following: -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 10/10/2024, 10/11/2024, 10/12/2024, and 10/13/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 10/26/2024, 10/27/2024, and 10/28/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 11/04/2024, 11/05/2024, and 11/06/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 11/25/2024, 11/26/2024, 11/27/2024, and 11/28/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 12/01/2024, 12/02/2024, and 12/03/2024. -No documentation present indicating the resident had a bowel movement, intervention to promote a bowel movement, or assessment of resident due to not having a bowel movement from 12/05/2024, 12/06/2024, and 12/07/2024. In an interview conducted on 12/06/2024 at 3:57 PM with Licensed Practical Nurse A (LPN-A) revealed that the night shift nurse gives a list of residents that have not had a bowel movement in 48 hours or more to the day shift nurse. The day shift nurse then provides an as needed intervention to help promote a bowel movement for the resident. If that intervention is unsuccessful by 6 AM the following morning a bowel assessment is completed including listening for bowel sounds at the abdomen and a suppository is given to promote a bowel movement. LPN-A further revealed that if the resident had still not had a bowel movement by the next morning the nurse would notify the provider and director of nursing for further interventions. In an interview conducted on 12/17/2024 at 10:08 AM with the facility DON confirmed that Resident 12 had gone periods of time as listed greater than 48 hours without a documented bowel movement, intervention to promote a bowel movement, or an assessment of the resident due to not having a bowel movement. The DON confirmed it is the facility policy to provide interventions and or assessment to the resident after 48 hours of not having a bowel movement and for these to be documented in the resident's electronic medical health record. D. Review of a facility supplied policy titled Clean Dressing Change and dated 2023 revealed to cleanse the wound outward from the center of the wound. Review of a document titled Collagenase Santyl Ointment, How to Apply dated 2024 revealed to apply Santyl Ointment directly to the wound in a 2 mm (millimeter) or about the thickness of a nickel layer. A review of a Resident Face Sheet dated 12/16/2024 revealed that the facility admitted Resident 14 on 09/27/23 with diagnoses of atherosclerotic heart disease (which is when fats, cholesterol, and other substance build up on the walls of arteries), varicose veins of the lower extremity (when the veins in the legs are bulging and enlarged), and hypertension (which is high blood pressure). The comprehensive MDS dated [DATE] revealed Resident 14 had a BIMS score of 10 indicating the resident was moderately cognitively impaired. The resident was coded to have 4 venous or arterial ulcers present (which are ulcers or wounds that are caused by irregularities in blood flow and circulation). Review of Resident 14's Physician Orders dated 12/16/24 revealed an order to apply Santyl to wound on the LLE, place a non-bordered foam over top of wound and cover with edema wear once daily. In an observation completed on 12/17/24 at 10:43 AM with Registered Nurse B (RN-B) revealed RN-B with gloved hands opened a vial of normal saline solution and squirted the solution on to the wounds located to Resident 14 left inner lower calf. RN-B held white gauze material to the lower portion of the wound. It was observed that the normal saline solution flowed off the wound and onto the pieces of gauze. RN-B then used the pieced of gauze to dab at the wound bed directly. The RN obtained more gauze pieces and again dabbed directly on the wound bed with the pieces of gauze. The RN then threw away the gauze and discarded their gloves. RN-B performed hand sanitization using an alcohol-based hand gel and applied another pair of gloves. RN-B obtained a clear medicine cup and a long-handled Q-Tip from on top of the over bed table. RN-B placed the cotton portion of the Q-Tip into the medicine cup and rolled the Q-Tip in the light cream-colored thick substance contained in the cup. RN-B applied the substance to the residents wound bed using the Q-Tip. There was no visible thickness to the layer of substance applied to the wound bed from the clear plastic medicine cup. In an interview conducted with RN-B on 12/17/24 at 11:20 AM, RN-B confirmed that the clear medicine cup contained Santyl Ointment. RN-B confirmed that they did not ensure the ointment was applied in a layer with thickness approximately of a nickel. RN-B also confirmed that they did not cleanse the wound from the inside working to the edges or outside of the wound. In an interview conducted on 12/17/2024 at 11:50 PM with the DON confirmed that the residents wound should have been cleansed from the inside and working to the outer edges. Confirmed the nurse should have checked to ensure they are applying the correct amount of ointment to the wound and should not have used the soiled gauze pads to dab at the wound after spraying the normal saline on the wound bed. The DON confirmed wound care, and topical application was not completed in compliance with facility policy.

C. Record review of the medication insert for Diclofenac gel (Voltaren, a nonsteroidal, anti-inflammatory medication for pain) revised July 2009 revealed the following. -Total dose should not exceed 32 grams per day, overall affected joints. -Voltaren Gel should be measured onto the enclosed dosing card to the appropriate 2 grams or 4 grams designation. -Lower extremities: Apply the gel (4 grams) to the affected area 4 times daily. Do not apply more than 16 grams daily to any one affected joint of the lower extremities. -Upper extremities: Apply the gel (2 grams) to the affected area 4 times daily. Do not apply more than 8 grams daily to any one affected joint of the upper extremities. Record review of the Care Plan (a detailed document outlining the specific healthcare needs and services a person requires to manage their chronic illness or disability) for Resident 26 revealed this resident has an alteration in comfort related to the diagnoses of musculoskeletal decline, impaired mobility, and osteoarthritis with signs and symptoms of pain. Medications were to be administered as ordered and Resident 26 had to be encouraged to request pain medications before the pain became unbearable. Record review of the Physician Orders for Resident 26 revealed an order for the use of Diclofenac Sodium gel a small amount to the left shoulder and arm with a start date of 12/09/24. Interview on 12/16/2024 at 1:15 PM with Licensed Practical Nurse (LPN-A) revealed when asked how much is used on the resident's shoulder for pain relief, LPN-A chose to look at the physician orders and stated immediately, Oh, I think we need to contact the physician to find out how much we are supposed to actually use. LPN-A revealed that there was a plastic measuring tool to measure the desired grams of medication applied each time which LPN-A had difficulty finding in the drawer. Once found, LPN-A revealed the use of approximately one inch of gel when applying onto the shoulder of Resident 26. LPN-A repeated that the order needed to be updated to let the nursing staff know exactly how much Diclofenac gel was supposed to be applied. Interview on 12/16/24 at 1:25 PM with the DON when asked how much Diclofenac gel is applied to Resident 26's shoulder, DON replied I guess enough to cover the area. DON confirmed the medication order needed to be more detailed and would reach out to the ordering physician and get confirmation of the dose. D. Record Review of the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes, allowing healthcare providers to create individualized care plans based on their specific needs) dated 10/17/24 for Resident 34 revealed this resident had chronic pain. Record review of the Care Plan for Resident 34 revealed this resident had an alteration in self-care and comfort related to musculoskeletal decline caused by impaired mobility, history of bursitis in the left hip, pain, weakness and deconditioning, would attempt non-pharmacological interventions for pain, and was encouraged to request pain medication before pain became unbearable. Record review of Resident 34's Physician Orders dated 12/16/24 revealed an order for Voltaren Arthritis Pain (Diclofenac Sodium) gel 1% a small amount. Apply to both wrists. May apply to lower back as needed. Interview on 12/16/2024 at 1:25 PM with the DON confirmed the medication order needed to be more detailed and would reach out to the ordering physician and get confirmation of the dose. Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the 5 rights of medicaiton administration for 4 residents, (Resident 14, 199, 26, and 34) of 8 sampled residents. This made an error rate of 16.13 %. The facility census was 49. A. Record review of Resident 14's Physician Orders dated 12/16/24 revealed Resident 14 had a physician order to apply Diclofenac Sodium which is a topical pain relief or analgesic cream. Directions to apply 2 grams to both resident's knees and lower back three times a day. In an observation on 12/17/24 at 11:30 AM with Registered Nurse-B(RN-B) revealed RN-B with a gloved hand used their fingers to scrape a clear thick gel like substance from a clear medication cup that was sitting on Resident 14's bed side table. RN-B stated to the resident this was their pain cream and would apply it to the resident's knees. Resident 14 pulled up the pant legs of their pants above both knees and RN-B applied the ointment to the left knee and rubbed it in then obtained more of the gel from the medication cup and applied it to the right knee and rubbed it in. In an interview on 11/17/24 at 11:45 AM with RN-B, revealed that the clear medication cup contained the residents ordered Diclofenac Sodium. RN-B confirmed they did not use the measuring guide to ensure was applying the prescribed 2 grams of the Diclofenac Sodium. RN-B further confirmed that they did not follow the physician prescribed orders for the Diclofenac Sodium. B. Review of a document labeled National Library of Medicine Stat Pearls dated August 28, 2023, revealed that Levothyroxine tablets and capsules should be taken on and empty stomach at least thirty to sixty minutes prior to breakfast with a full glass of water. In an observation completed on 12/16/27 at 8:50 AM with Licensed Practical Nurse A (LPN-A) revealed LPN-A obtained a cardboard bubble pack of medications labeled Levothyroxine tablet 75 micrograms (MCG), give on tablet by mouth one time a day with Resident 199's name. LPN-A popped the tablet into a clear plastic medication cup with Resident 199's other medications and walked to where Resident 199 was sitting in the dinning area at a table. On the table in front of Resident 199 was a white plate with crumbs on it, a white bowl with visible crumbs in it, and 3 glasses of different fluids all missing different amounts of fluid. The nurse handed Resident 199 the cup containing the medications, the resident lifted the cup to their mouth and ingested the medications. The nurse thanked the resident and asked if the resident wanted more to eat or if had enough to eat already. The resident stated that they had eaten all their breakfast and would finish their drinks and was full. The nurse returned to the medication cart and documented the administration of the medications in the resident's electronic medical health record. In an interview on 12/16/24 at 9:05 AM with LPN-A confirmed that the levothyroxine medication should be taken on an empty stomach prior to eating a meal. The LPN stated they did not know if the provider had given permission for the levothyroxine to be administered in an alternative manner. In an interview on 12/16/24 at 2:45 PM with the Director of Nursing (DON) confirmed that the levothyroxine medication is normally given on an empty stomach. The DON was not sure if the provider had ok'd the administration of the medication outside of recommended standards and the medication should be taken per these standards unless otherwise directed by the provider. The DON confirmed this was a medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3(1) Based on observation, record review, and interview, the facility failed to provide perineal care (which is cleansing of the genatalia of a resident) in a manner to prevent cross contamination of 2 sampled residents (Resident #5 and Resident #14). The facility census was 46. Findings are: A. A record review of Resident #14's Face Sheet dated 12/20/2023 revealed, that the facility admitted Resident #14 on 09/07/2016, with diagnoses of: Epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), Parkinson's disease (a progressive disease of the nervous system causing tremors and muscular rigidity), myocardial infarction (which is blockage of blood flow to the heart), and Benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). A record review of Resident #14's Quarterly Minimum Data Set (MDS), (which is an resident assessment and care screening tool that is used by nursing homes), dated 08/17/2023 revealed, that Resident #14 required extensive assistance by one staff member with bed mobility, transfers, and toilet use and was occasionally incontinent of urine and frequently incontinent of bowel. Resident #14 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicaited the resident had severe cognitive impairment. A record review of Resident #14 Care Plan dated 11/22/2023 revealed, the resident had an inability to care for self and staff provided one assistance with personal hygiene. In an observation completed on 12/27/2023 at 8:56 AM Nurse Aide (NA)-G used a disposable wipe to cleanse Resident #14 left buttock folded the wipe, wiped the right buttock, folded the wipe, then used the soiled wipe to wipe the middle of the buttock and threw the wipe away. NA G obtained another disposable wipe and used it to wipe Resident #14 inner right groin area, folded the wipe, wiped inner left groin area folded the wipe, and then used the soiled wipe to wipe Resident #14 penis using a downward motion wiping towards the residents urethral opening. In an interview completed on 12/27/2023 at 9:15 AM with NA-G revealed, perineal care should be completed by cleansing the male penis cleansing should occur from the urethral opening outward and down the penis. Review of a facility policy titled, Perineal Care revealed Females: cleanse perineum wiping in the direction from the front to the back, repeat this on the opposite side using a new disposable wipe, clean urethral meatus and vaginal orifice using a new disposable wipe with each stroke. Males: Cleanse the tip of the penis at the urethral meatus using a circular motion and working outward, use a new disposable wipe with each stroke. In an interview conducted on 12/27/2023 with the Director of Nursing (DNS) it was revealed, that when using a disposable wipe, a new wipe should be used for each stroke. B. A review of a Face Sheet dated 12/20/2023 revealed the facility admitted Resident #5 on 03/31/2014 with diagnoses of: Congestive Heart Failure (a condition in which your heart can not pump blood well enough to meet your body's needs), Chronic obstructive pulmonary disease(a condition that causes air flow blockage and breathing related problems in the lungs), and Neurocognitive disorder with Lewy bodies(which progressive disease that leads to a decline in thinking, reasoning, and independent function). A review of Resident #5 Annual MDS, dated [DATE] revealed, that Resident #5 was totally dependent on two staff members for transfers, extensive assistance by one staff member with toilet use, limited assistance by one staff member with personal hygiene, and always incontinent of bowel and bladder. Resident #5 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicaited the resident had severe cognitive impairment. A review of Resident #5's Care Plan dated 10/04/2023 revealed, that Resident #5 had an inability to care for self and was dependent on staff assistance for personal hygiene. In an observation completed on 12/27/2023 at 8:23 AM NA-F used a disposable wipe to cleanse Resident #5 perineal area. NA-F used a disposable wipe to cleanse Resident #5's inner right groin, folded the wipe, then used the soiled wipe to cleanse Resident #5 inner left groin then discarded the wipe in the trash can. NA-F obtained another disposable wipe and used wipe to cleanse Resident #5 outer labia (the skin folds that surround the outer opening of the vagina), wiping from front to back (pelvic bone to anus), folded the wipe and repeated this process with the soiled wipe, then discarded the wipe in the trash can. In an interview conducted on 12/27/2023 at 9:26, NA-F revealed, that during female perineal care you should wipe from front to back and use a new wipe for each stroke and during male perineal care you should wipe from urethra outwards and use a new wipe for each stroke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6(7) The facility failed to ensure respiratory equipment was cleaned and stored in a manner to prevent the potential for cross contamination related to oxygen tubing when not in use for 3 residents (Residents 2, 6, and 22) of 4 sampled residents and related to the CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask for 1 resident (Resident 36) of 1 sampled residents. The facility identified a census of 46. Findings Are: A record review of the undated facility policy titled Oxygen Safety read as follows: 7. Oxygen tubing shall be monitored for cleanliness, monitored to assure tubing is not kinked, that it does not touch the floor, and is properly stored when not in use. Tubing is change weekly by nursing staff. A. A record review of the demographic information revealed Resident 2 had been accepted into the facility on 1/19/23 with diagnoses of: included Chronic Kidney Disease (CKD) (a condition where your kidneys are losing their ability to filter waste products from your blood), Congestive Heart Failure (CHF)( a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Edema (swelling caused by too much fluid trapped in the body's tissues), and acute respiratory failure (a sudden and often reversible reduction in respiratory function). A record review of Resident 2's MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 11/30/23, Section C, revealed Resident 2 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 out of 15 which indicated the resident was cognitively intact. An observation on 12/20/23 at 10:06 AM revealed Resident 2 had a portable oxygen tank on the back of the wheelchair. The oxygen tubing connected to the portable tank was noted to have the nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) touching the wall. An observation on 12/21/23 at 09:45 AM revealed Resident 2's oxygen tubing, which was not in use, to be coiled up and hanging on the oxygen concentrator with the nasal cannula touching the machine in Resident 2's room. An interview on 12/21/23 at 10:13 AM with Registered Nurse (RN)-M confirmed that oxygen tubing should be stored in a bag when not in use. An interview on 12/21/23 at 10:15 AM with Nurse Aide (NA)-N who was also a MA (Medication Aide)) revealed that the MA's in the facility were able to transfer oxygen source from the concentrator to the portable tanks and back. NA-N voiced that the facility expectation was to hang the oxygen tubing on the concentrator when not in use and not on the ground yet made no mention of storing the tubing in a bag. B. A record review of the demographic information revealed Resident 6 had been accepted into the facility on 1/19/23 with diagnoses of: a fall resulting in a pelvic fracture and a history of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). A record review of Resident 6's MDS dated [DATE], Section C, revealed Resident 6 had a BIMS score of 09 which indicated the resident was cognitively impaired. An observation on 12/20/23 at 2:31 PM, revealed Resident 6 to have a portable oxygen tank on the wheelchair with the nasal cannula touching the wheel of the wheelchair. An observation on 12/21/23 at 9:54 AM revealed Resident 6's oxygen tubing to be draped over the nightstand with part of the tubing shut in the 2nd drawer and the cannula to be draped across the nightstand with the cannula touching the top of the nightstand. An interview on 12/21/23 at 10:13 AM with RN-M confirmed that oxygen tubing should be stored in a bag when not in use. An interview on 12/21/23 at 10:15 AM with NA (Nurse Aide)-N (who was also a MA (Medication Aide)) revealed that the MA's in the facility were able to transfer oxygen source from the concentrator to the portable tanks and back. NA-N voiced that the facility expectation was to hang the oxygen tubing on the concentrator when not in use and not on the ground yet made no mention of storing the tubing in a bag. C. A record review of the demographic information revealed Resident 22 had been re-accepted into the facility on [DATE] after being sent to the emergency room (ER) due to an unresponsive episode and low oxygen saturation rates. A record review of Resident 22's MDS dated [DATE], Section C, revealed Resident 22 had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. An observation on 12/20/23 at 1:48 PM revealed Resident 22 had an oxygen concentrator and portable tank in room with the tubing still connected and the cannula resting on the floor between the concentrator and the wall. An observation on 12/21/23 at 9:57 AM revealed Resident 22's oxygen tubing which was attached to the concentrator had the cannula end resting on the floor. An interview on 12/21/23 at 10:13 AM with RN-M confirmed that oxygen tubing should be stored in a bag when not in use. An interview on 12/21/23 at 10:15 AM with NA (Nurse Aide)-N (who was also a MA (Medication Aide)) revealed that the MA's in the facility were able to transfer oxygen source from the concentrator to the portable tanks and back. NA-N voiced that the facility expectation was to hang the oxygen tubing on the concentrator when not in use and not on the ground yet made no mention of storing the tubing in a bag. An observation on 12/27/23 at 7:58 AM revealed Resident 22's oxygen tubing had been draped across the bed with nasal cannula touching the bedspread. An interview on 12/27/23 at 7:46 AM with LPN (Licensed Practical Nurse)-O confirmed that the oxygen tubing was to be stored in a bag when not in use. D. A record review of the demographic information revealed Resident 36 had been accepted into the facility on [DATE] with diagnoses of: Chronic Respiratory Failure with Hypoxia and Heart Failure. A record review of Resident 36's MDS dated [DATE], Section C, revealed Resident 36 had a BIMS score of 15 out of 15 which indiciated the resident was cognitlvey intact. An observation on 12/20/23 10:54 AM revealed Resident 36's CPAP mask to be connected to the tubing and lying with the mask face down on the dresser and the tubing which connects the machine to the concentrator was draped across the bed. An observation on 12/21/23 at 9:59 AM revealed Resident 36's CPAP mask to be draped over the nightstand with the mask to be resting face down on the nightstand. An observation on 12/27/23 at 7:41 AM revealed Resident 36's CPAP mask to be draped over the dresser with the mask resting face down on the dresser. The observation also revealed that Resident 36's oxygen tubing was coiled and tucked under the handle of the concentrator. An interview on 12/27/23 at 7:46 AM with LPN-O revealed that the CPAP mask and oxygen tubing are to be stored in a bag when not in use. A record review of the facility's undated policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) revealed it did not contain any instruction or guidance regarding cleaning and storage of a CPAP mask when not in use.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure that dietary sanitizer solution (a substance or preparation for killing germs on food-processing surfaces and equipment) was at the required concentration (The amount of the sanitizer (chemical) in the water. Too high of a concentration is toxic, and too little will not ensure sanitation) to prevent the potential for foodborne illness. This affected all 46 residents that ate food prepared by the facility kitchen. The facility census was 46. Findings are: Record review of the Nebraska Food Code, Effective date 7/21/16 section 4-501.116 revealed that the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Record review of the Sink and Surface Cleaner Sanitizer dated 2020 revealed that test strips should be changed out every time solution in the bucket is changed out. The food code requires a new solution to be prepared every 4 hours, so it is recommended to change the strip at the same time. The strips are replaced every time the solution is changed. Customers need to use the Sink and Surface Cleaner Sanitizer test strips to ensure their use dilution falls within the acceptable concentration range. Observation on 12/21/23 at 9:40 AM in the facility kitchen revealed that Dietary Cook-A (DC-A) performed hand washing and put on gloves. DC-A placed bone in chicken pieces onto a baking sheet on the prep table. DC-A put the baking sheet into the oven. DC-A removed the yellow cloth rag from the sanitizer bucket and wiped the top of the prep table. DC-A obtained the ingredients for the sauce to be put on the baked chicken. DC-A mixed the ingredients in a bowl on the prep table. Observation on 12/21/23 at 11:15 AM in the facility kitchen revealed a sanitizer dispenser at the 3-compartment sink. DC-A confirmed that the sanitizer solution in the sanitizer bucket comes from the sanitizer dispenser. DC-A was asked about testing the sanitizer concentration level. DC-A revealed that test strips are used to test the sanitizer concentration. DC-A was unable to find any test strips. DC-A revealed that facility maintenance staff does the testing along with checking of the hot water temperature. DC-A was unsure where testing results of the sanitizer solution were documented. Interview on 12/22/23 at 2:42 PM with the facility Maintenance Director (MD) revealed that the MD does not check the sanitizer solution concentration and thinks the Dietary Manager and dietary staff check the concentration. Interview on 12/27/23 at 8:25 AM with the facility Dietary Manager (DM) revealed that the sanitizer solution concentration is checked by using test strips. The DM revealed that the concentration should be checked every time the sanitizer solution is dispensed. The DM revealed that when the sanitizer solution in the sanitizer bucket becomes cool it is to be dumped and hot solution put into the sanitizer bucket. The DM revealed that the testing of the sanitizer solution concentration was to be documented. Interview on 12/27/23 at 8:31 AM with Dietary Aide-C (DA-C) revealed that DA-C uses a bucket with sanitizer solution to wipe down the dining room tables. DA-C revealed that DA-C gets a new bucket, solution, and rag to wipe the tables. DA-C revealed that the sanitizer solution is to be tested but that DA-C had not been testing the solution concentration and does not know how to do it. Observation on 12/27/23 at 8:33 AM in the facility kitchen revealed that Dietary Cook-B (DC-B) grabbed the yellow cloth out of the red sanitizer bucket and wiped the prep table. DC-B put the yellow cloth rag back into the bucket. The bucket was cold to the touch. Observation on 12/27/23 at 8:37 AM in the facility kitchen revealed that the DM was unable to find any test strips for the sanitizer solution. The DM revealed that no one had notified the DM that they were out of test strips and that the DM would order some. The DM confirmed that the sanitizer in the sanitizer bucket was cold and should not be used. DC-B revealed that DC-B was just about to change out the solution. Observation on 12/27/23 at 9:38 AM in the facility dining room revealed that Dietary Aide-D (DA-D) and Dietary Aide-E (DA-E) cleaned breakfast dishes and refuse from the tables. A green bucket of sanitizer solution was warm to the touch. DA-D used the yellow cloth rag from the sanitizer bucket to wipe each table after the dishes and refuse were removed. DA-D confirmed that the sanitizer solution concentration could not be checked as the facility had no test strips. Interview on 12/27/23 at 11:37 AM with the facility DM confirmed that the sanitizer solution concentration was to be checked (tested) each time the sanitizer bucket solution is changed out. The DM confirmed that the facility had no test strips to ensure that the sanitizer solution was at the required concentration.

Licensure Reference Number 175 NAC 12-006.17 Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview, the facility failed to perform hand hygiene to prevent the potential for food borne illness during meal service, which had the potential to affect 46 residents; and failed to ensure a resident had a cleanable sleeping surface for infection prevention for 1 resident (Resident 6). Facility stated census of 46. Findings are: A record review of facility supplied document labeled Hand Washing Guidelines Dietary Employees revealed frequency of hand washing should be after hands have touched anything unsanitary, after hands have touched bare human body parts, and after engaging in any activity that may contaminate the hands. A. During a meal service observation on 12/24/2023 at 12:10 PM Dietary Aide (DA)-D obtained a used coffee cup from a resident and took it over to the coffee pot to refill the cup and then returned it to the resident. DA-D did not complete any form of hand hygiene prior to serving a plate of food to another resident. During a meal service observation on 12/26/2023 at 12:45 PM it was revealed DA-E obtained a used coffee cup from a resident and took it to the coffee pot and refilled the cup and returned it to the resident. DA-E did not complete any form of hand hygiene prior to serving a plate of food to another resident. The observation further revealed DA-H entered the kitchen area obtained a gallon of milk poured a glass of milk and delivered it to a resident. DA-H did not complete any form of hand hygiene prior to serving a plate of food to another resident. The observation further revealed DA-D was standing at the kitchen window and utilized their hand to adjust their hair net on their head, scratch/rub their face, and wiped their hands on their clothing. DA-H did not complete any form of hand hygiene prior to serving a plate of food to another resident. Interview on 12/26/2023 at 1:05 PM with DA-H revealed hand hygiene should have been completed after touching clothing or any other non-sanitary surface prior to serving food to residents. Interview on 12/27/2023 at 11:21 AM with the Dietary Manager (DM), revealed hand hygiene should have been performed after taking a used cup and refilling it for a resident, touching hair or face and clothing. The DM stated dietary staff should complete hand hygiene after touching any non-sanitary surface.B. A record review of the demographic information revealed Resident 6 had been accepted into the facility on 1/19/23 with diagnoses of: a fall resulting in a pelvic fracture and a history of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 10/19/23, Section C, revealed Resident 6 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 09 which indicated the resident is cognitively impaired. The MDS revealed Resident 6 was frequently incontinent. During an interview on 12/20/23 at 2:31 PM Resident 6 revealed they have pain when getting out of bed and therefore Resident 6's family member had bought a cover for their bed. An observation on 12/20/23 at 2:31 PM, revealed Resident 6 had a foam egg-crate on the bed to help decrease (gender) back pain. During the interview on 12/20/23 at 2:31 PM Resident 6 voiced being incontinent of bladder all of the time. An observation on 12/27/23 at 7:55 AM revealed Resident 6 had a foam mattress pad on the bed. An interview on 12/27/23 at 8:00 AM with Nurse Assistant (NA)-P revealed Resident 6 was incontinent of bladder most of the time. An interview on 12/27/23 at 9:42 AM with the facility Administrator revealed the facility was unaware of the foam egg crate mattress cover for Resident 6. The Administrator confirmed the facility should not utilize these as they were a foam mattress and not a cleanable surface.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure written notice of transfer was provided to the resident or resident representative for Resident 11. This affected 1 of 3 residents sampled for hospitalization. The facility census was 40. Findings are: A review of Resident 11's Census listing revealed that the resident had been transferred to the hospital on 9/30/22 and returned to the facility on [DATE]. A review of Resident 11's Progress notes between 9/28/22 and 10/7/22 revealed that the resident had gone to a physician's office visit 9/30/22 and had been admitted to the hospital from that appointment. A review of the facility's policy Transfer and Discharge (Including AMA) reviewed/revised 8/1/22 revealed the following under Section 7 Emergency Transfers/Discharges: j. Provide transfer notice as soon as practicable to resident and representative. An interview on 11/30/22 at 10:00 AM with the Social Services Worker (SS) confirmed that the facility had not provided the resident and/or resident representative with written notice of transfer/discharge upon hospitalization.

175 NAC 12-006.09D7 Based on record reviews and interview, the facility failed to identify and implement interventions to prevent injury for Resident 4. This affected 1 of 1 residents sampled for accidents. The facility census was 40. Findings are: A review of the Event History for Resident 4 revealed the following Event Reports (a document describing an injury the resident sustained): -On 2/25/22 the resident received a skin tear to the right hand. The immediate measures taken were first aid and applying a transparent dressing. -On 3/1/22 the resident received a bruise to the left lower leg. There were no immediate measures listed. -On 3/3/22 the resident received a bruise to the right upper inner thigh. There were no immediate interventions listed. -On 3/13/22 the resident received a skin tear to the left forearm, and a bruise to the left elbow. The immediate intervention taken was to apply a transparent dressing. -On 6/6/22 the resident received a bruise to the right lower extremity (leg) with a skin tear at the top of the bruise. The immediate measure taken was to apply a transparent dressing. -On 6/16/22 the resident received 2 bruises to the left lower extremity. There were no immediate measures listed. -On 7/25/22 the resident received a skin tear to the left lower leg. The immediate intervention was to clean and cover the area. -On 7/27/22 the resident received a bruise to the lower left cheek by the jaw, and a bruise under the left eye. There were no immediate interventions listed. -On 9/6/22 the resident received a skin tear to the right hand. This was described as an old skin tear that was scabbed over reopened. The only skin tear the resident had previously listed was the one received on 2/25/22. The immediate intervention was to clean and cover the area. -On 9/7/22 the resident received a skin tear to the left lower leg. The immediate intervention was to clean and cover the area. -On 9/9/22 the resident received a bruise to the right hand. There were no immediate interventions listed. -On 11/15/22 the resident received a skin tear to the upper right forearm. The immediate intervention was to clean and cover the area. -Further review of the Event Reports and the resident's Progress Notes revealed that all immediate interventions were basic first aid, and that no further investigation was done for root cause analysis of injuries. Review further revealed that no other interventions were put in place after each injury to prevent further injury. A review of Resident 4's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care) revealed a Pressure ulcer problem with a start date of 7/24/14. This problem stated that the resident had the potential for alteration in skin integrity due to a history of skin tears. There were no current skin tears listed. The most recent intervention for this care plan was dated 11/22/19. An intervention dated 8/9/19 stated Gerri sleeves (a type of protective wrap) to bilateral (both sides) arms on in AM (morning) off at HS (bedtime) as resident will allow. There were no new interventions put in place after any of the injuries in 2022. An interview on 12/01/22 at 10:02 AM with Nurse Aide (CNA) B revealed that CNA B tries to watch carefully when going through doors. The CNA B also revealed that they try to put long sleeves on the resident. CNA B also revealed that Resident 4 does not wear geri-sleeves, and is unsure if that has been discussed with the resident's family. An observation on 12/1/22 at 12:50 PM during a transfer revealed the resident did not have any geri-sleeves present on arms or legs. An interview with the Director of Nursing (DON) on 12/01/22 at 11:25 AM revealed that on 10/20/22 the facility had discussed discontinuing the resident's order for a blood thinner with the family after the resident was admitted to hospice services and the family wanted to continue the medication. The DON also revealed that the restorative nurse had talked with Resident 4's family on 10/5/22 about using a full lift instead of the sit-to-stand lift to reduce the chance for injury during transfer as the resident had been having unresponsive episodes during transfers. The resident had refused this intervention and the family wanted to respect her wishes. An interview with the DON on 12/1/22 at 1:11 PM revealed that they review things like falls and injuries at least quarterly for trends. The DON revealed that if a root cause analysis had been done, it would be in the Event Report or Progress Note. The DON further confirmed that the facility had not addressed this resident's injuries. The DON also confirmed the resident does not have protective wraps on either her arms or legs today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 174 NAC 12-006.09D Based on record review and interviews, the facility staff failed to perform pain assessments for scheduled pain medications for Resident 37 and 38 who said they experienced pain. This affected 2 out of 3 residents sampled. The facility census was 40 at the time of survey. Findings are: A. During an interview on 11/28/22 at 11:55 AM Resident 37 complained of pain all the time to the right leg due to a history of a stroke. A record review of Resident 37's demographic information revealed an admission date of 7/18/22. A record review of the Medication Administration History dated 11/01/22-11/29/22 revealed Resident 37 had an order for Tylenol (used to treat minor aches and pains, and reduces fever) 325 milligrams (mg) three times a day. A record review of the PRN (as needed) Medication Administration History dated 11/01/22-11/29/22 revealed Resident 37 had an order for Acetaminophen (used to treat minor aches and pains, and reduces fever) 325 mg give 2 tablets as needed for pain and the record showed it had been used 7 times from 11/01/22-11/29/22. A record review of Resident 37's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 10/13/2022 revealed in Section J, question J0400 Pain Frequency which asked how much of the time have you experienced pain or hurting? with an answer of almost constantly. A record review of Resident 37's MDS, dated [DATE] Section C revealed a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of a 9 for Resident 37. A record review of Medication Administration History and the Treatment Administration History dated 11/01/22-11/29/22 for Resident 37 revealed no nursing assessment to monitor pain level for routine pain medication. A record review of the electronic medical records revealed no nonpharmacological interventions had been documented before giving medications used for pain control. An interview on 11/30/22 at 12:26 PM with the Director of Nursing (DON) revealed the nurses should chart in the progress notes if an intervention was provided. A record review of the Pain Management Policy, with copyright 2022 #6 revealed: Nonpharmacological interventions will include but are not limited to: a. Environmental comfort measures b. loosening any constrictive bandage, clothing or device c. applying splinting d. physical modalities e. exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility f. cognitive/behavioral interventions. An interview on 12/01/22 at 10:17 AM with the DON confirmed the policy does not state to do nonpharmacological interventions prior to giving a pain med as needed, stating staff are to look at the careplan to know which interventions are supposed to be used. The DON confirmed it is not documented as to which specific intervention is used before the pain med is given. B. During an interview on 11/28/22 at 11:25 AM Resident 38 verbalized constant pain due to cancer and it was difficult to get into a comfortable position. A record review of Resident 38's demographic information revealed an admission date of 11/14/22. A record review of Physician Order Report dated 11/01/22- 12/1/22 revealed orders for 1. Morphine (a controlled substance used to treat severe pain) solution 100 milligrams (mg) per 5 milliliters (ml) and to give 0.25 ml every 3 hours as needed with a start date of 11/16/22 and for 2. Hydrocodone-acetaminophen tablet (an opioid used to treat pain) 5-325 mg three times a day. A record review of Resident 38's MDS dated [DATE] revealed in Section J the answer to question J0400, how much of the time have you experienced pain or hurting? with an answer of almost constantly. A record review of Medication Administration History dated 11/01/22-11/29/22 for Resident 37 revealed no nursing assessment to monitor pain level for routine pain medication. A record review of Resident 38's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 11/14/22 revealed Potential for alteration in comfort related to deconditioning, malignant melanoma, diabetes, protein/calorie malnutrition, weakness resident requesting pain medication, resident showing signs/symptoms of pain. Interventions included: -Administer medications as ordered. Evaluate and record effectiveness and any adverse side effects. -Observe for any non-verbal signs of pain (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal) and report to charge nurse. -Position for comfort using pillows for support as necessary. An interview on 11/30/22 at 04:39 PM with Registered Nurse (RN) - D confirmed that hospice was to manage wound care and infection prevention. The hospice nurse also confirmed that the resident does report pain and doesn't always ask for pain meds even when in pain. A record review of the Pain Management Policy, with copyright 2022 #6 revealed: Nonpharmacological interventions will include but are not limited to: a. Environmental comfort measures b. loosening any constrictive bandage, clothing or device c. applying splinting d. physical modalities e. exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility f. cognitive/behavioral interventions. An interview on 11/30/22 at 12:26 PM with the DON revealed that the nurses should chart in the progress notes if an intervention was provided. An interview on 12/01/22 at 10:17 AM with the DON confirmed the policy does not state to do nonpharmacological interventions prior to giving a pain med as needed, stating staff are to look at the careplan to know which interventions are supposed to be used. The DON confirmed it is not documented as to which specific intervention is used before the pain med is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to administration of an as needed (PRN) psychotropic (a medication that affects a person's mental state) medication for Resident 28 and failed to limit the timeframe for PRN psychotropic medications to 14 days for Resident 4 and Resident 28. This affected 2 out of 5 residents sampled for unneccessary medications. The facility census was 40. Findings are: A. A review of Resident 28's admission Record, dated 11/30/22, revealed Resident 28 was admitted to the facility on [DATE]. Diagnoses included Bipolar Disorder, Adult Failure to Thrive, Anxiety Disorder, and Insomnia. A review of the facility's undated Use of Psychotropic Medication policy revealed the following: -Policy Explanation and Compliance Guidelines: -6.: Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. A record review of Resident 28's physician orders, dated 11/30/22, revealed an order for the following: Alprazolam (a medication given to treat anxiety) 0.25 milligram (MG) 1 tablet (tab) twice a day (BID) PRN given for anxiety and Mirtazapine (a medication given to help with sleep) 15mg 1 tab at bedtime (HS) PRN given for insomnia. A record review of Resident 28's Medication Administration Record (MAR) from 11/9/22 to 11/30/22 revealed that Alprazolam was given twice (11/19/22 and 11/29/22) and Mirtazapine was given once (11/26/22) with no documentation of non-pharmacological interventions attempted prior to administration of either medication. In an interview, on 12/1/22 at 8:56 AM, with the Director of Nursing (DON), confirmed that documentation was not present for non-pharmacological interventions prior to PRN Alprazolam or Mirtazapine use. B. A review of Resident 28's admission Record, dated 11/30/22, revealed Resident 28 was admitted to the facility on [DATE]. Diagnoses included Bipolar Disorder, Adult Failure to Thrive, Anxiety Disorder, and Insomnia. A review of the facility's undated Use of Psychotropic Medication policy revealed the following: -Policy Explanation and Compliance Guidelines: -8.: PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). A review of Resident 28's physician orders, dated 11/30/22, revealed an order for the following: Alprazolam 0.25 mg 1 tab BID PRN given for anxiety and Mirtazapine 15mg 1 tab HS PRN given for insomnia. The physician orders further revealed that both medications had a start date for 11/9/22 and no end date indicated. In an interview, on 12/1/22 at 8:56 AM, the DON, confirmed that there was no 14 day stop date for the PRN Alprazolam or Mirtazapine and that the medications should not have been given past the 14th day. C. A review of Resident 4's admission Record, dated 11/29/22, revealed Resident 4 was admitted to the facility on [DATE]. Diagnoses included Anxiety Disorder, and Dementia. A review of Resident 4's Physician Order Report from 10/29/22-11/29/22 revealed an order for lorazepam (an antianxiety medication) 0.5 milligram (mg) tablet, 1 tablet orally every 4 hours PRN (as needed) with a diagnosis of anxiety. The start date for this order was 10/6/22 and the end date was open ended. An interview on 12/1/22 at 2:04 PM with the Director of Nursing (DON) confirmed that there was no 14 day end date for the as needed lorazepam.

175 NAC 12-006.17D Based on observation, record review, and interview, the facility failed to prevent the potential for cross-contamination related to hand hygiene during medication administration and related to disposal of used sharps (any device or object used to puncture or lacerate the skin) during point of care testing (blood testing done at the bedside, such as a blood glucose test). This practice affected Resident 4 and Resident 6. Facility census was 40. Findings are: A. An observation of Licensed Practical Nurse (LPN) A on 11/30/22 at 7:21 AM during medication administration revealed that the LPN put gloves on without performing hand hygiene, then checked Resident 4's ears to see if the resident had hearing aides in. The LPN then returned to the medication cart and prepared Resident 4's medications. The LPN then removed the gloves and administered Resident 4's medications without performing hand hygiene. The LPN then moved to Resident 6's room to check a blood glucose and did not perform hand hygiene. A review of the facility's undated Medication Administration policy revealed that the procedure includes: 3. Wash hands or sanitize prior to administering medication per facility protocol and product. 13. Administer medication as ordered in accordance with manufacturer specifications. 14. Observe resident consumption of medication. 15. Wash hands or sanitize using facility protocol and product. An interview with LPN A on 11/30/22 at 9:35 AM confirmed that the LPN had not performed hand hygiene between residents during medication administration. An interview with the Director of Nursing (DON) on 11/30/22 at 12:22 confirmed that changing gloves was not a replacement for hand hygiene and that hand hygiene should be performed between residents during medication administration. B. An observation of LPN A on 11/30/22 at 07:35 AM revealed that the LPN donned gloves without performing hand hygiene, entered Resident 6's room, and checked the resident's blood glucose. After checking the blood glucose, the LPN put the used lancet (a sharps device used to puncture the skin) in their pocket, removed their gloves, and did not perform hand hygiene. A review of the facility policy for Blood Glucose Monitoring dated 2022 revealed that the nurse should discard the lancet in a puncture resistant sharps container. An interview with LPN A on 11/30/22 at 11:26 AM revealed that the LPN put the lancet in their pocket because they were going to put it in the sharps container on the med cart. The LPN further revealed there was also a sharps container in the resident's bathroom. An interview with the DON on 11/30/22 at 12:22 confirmed that it was not acceptable to put the used lancet in a pocket, but it should be immediately placed in a sharps container.