Nye Legacy Health & Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)
Based on record review and an interview, the facility failed to ensure an as needed psychotropic medication (work by altering brain chemistry) had a 14-day stop date as required for Resident 18. This affected 1 of 3 residents review for unnecessary medication use. The facility census was 85.
Findings Are:
A record review of the facility policy Use of Psychotropic Medication Guideline with a date implemented of 2023 revealed:
-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 for a limited duration (i.e.14 days)
-If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.
A record review of the admission Record with the printed date of 4/21/25 revealed Resident 18 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of prostate (a type of cancer that originates in the prostate gland, a male reproductive organ), secondary malignant neoplasm of bone (a cancerous growth that originates in the bone or cartilage. These tumors can either be primary (starting in the bone) or secondary (spreading from another part of the body, also known as bone metastasis), and adult failure to thrive (unexplained weight loss, malnutrition, and a decline in overall physical and mental health).
A record review of Resident 18's Clinical Physician Orders with a printed date of 4/21/25 revealed a order for PRN (as needed) Lorazepam (slowing activity in the brain to allow for relaxation) with an end date of indefinite.
An interview on 4/22/25 at 10:30 AM with the Director of Nursing (DON) confirmed that the PRN Ativan should have had a stop date on it and it did not have a stop date on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.
A record review of the undated document titled Clinical Resident Profile revealed that Resident 62 had been accepted into the facility on 5/26/23 with a primary diagnosis of respiratory failure.
A record review of the MDS dated [DATE] revealed Resident 62 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, while scores of 00 or 99 indicate total confusion) score of 99.
A record review of the MDS dated [DATE], Section K, indicates Resident 62 receives enteral feedings (also known as tube feeding, a way of sending nutrition right to the stomach or small intestine).
A record review of the facility Matrix (a document used to identify pertinent care categories for the last 30 days for all residents) printed on 5/8/24, indicated that Resident 62 was receiving an enteral feeding.
A record review of the Order Summary dated 5/28/24 revealed a diet order which read Regular / NAS (No Added Salt) diet Dysphagia (a medical term for difficulty swallowing) level 1 / Pureed (foods are completely smooth, making them easier to swallow) texture, Regular / Thin consistency, No Straws.
A record review of the Physician's Orders for Resident 62 revealed a note dated 11/17/23 which read oral intake improved enough to sustain caloric intake.
A record review of the Physician's Orders for Resident 62 revealed a note dated 11/28/23 which read removal of gastrostomy tube without problem.
An interview on 05/08/24 at 2:46 PM with Resident 62's POA (Power of Attorney) revealed that Resident 62 had pulled out [gender] G-tube (A gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach.). The POA further revealed that Resident 62 did not receive enteral feedings currently.
An interview on 05/13/24 at 10:31 AM with the facility DM (Dietary Manager), after review of the MDS for Resident 62, dated 2/15/24, Section K, related to enteral feedings, confirmed that the MDS had been coded incorrectly and should not indicate Resident 62 was receiving enteral feedings or had a G-tube in place and confirmed a modification would need to be initiated.
An interview on 05/13/24 at 9:43 AM with Licensed Practical Nurse-L, confirmed that Resident 62 did not receive enteral feedings and did not have a G-tube in place at this time.
An interview on 05/13/24 at 11:46 AM with the facility Director of Nursing, when the facility policy related to MDS completion and accuracy was requested, confirmed that the facility uses the RAI (Resident Assessment Instrument) for the policy.
Licensure Reference 175 NAC 12-006.09B
Based on record review and interviews; the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) for Resident 73 regarding discharge and for Resident 62 regarding the presence and use of a feeding tube. This affected 2 of 19 residents sampled for MDS accuracy. The facility census was 85.
Findings are:
A.
A review of Resident 73's admission Record dated 05/09/2024 revealed the resident was admitted on [DATE] and was discharged on 03/19/2024.
A review of Resident 73's diagnosis list revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), and diagnoses of bone, brain, and lung cancers.
A review of Resident 73's Discharge Return Not Anticipated MDS dated [DATE] revealed that question A2105 Discharge Status, was marked 04 for Short-Term General Hospital.
A review of Resident 73's Progress Notes revealed a note from 03/19/2024 at 11:38 AM that stated, Resident discharged home on current meds and treatments.
During an interview conducted 05/13/2024 at 10:13 AM Registered Nurse (RN) B confirmed that the MDS was incorrect regarding Resident 73's discharge status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C3
Based on record review and interviews; the facility failed to complete a discharge summary including a recapitulation of stay for Resident 73. This affected 1 resident sampled for discharge. The facility census was 85.
Findings are:
A review of Resident 73's admission Record printed 05/09/2024 revealed the resident was admitted on [DATE] and was discharged on 03/19/2024.
A review of Resident 73's diagnosis list revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), and diagnoses of bone, brain, and lung cancers.
A review of the NYE Recapitulation of Stay/Discharge Summary with Effective Date 03/19/2024 revealed that sections A, B, E, and F were not filled out or signed.
During an interview conducted on 05/09/2024 at 2:30 PM, the Social Services Designee (SSD) A confirmed that the discharge summary and recapitulation of stay were not completed at the time of the resident's discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E.
A record review of Resident 27's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] and had a diagnosis of constipation.
A record review of Resident 27's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 04/25/2024 revealed a Brief Interview for Mental Status-(BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]) score of 99. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact. A score of 99 means the interview was not able to be completed, and the Staff Assessment for Mental Status should be completed. Resident 27's Staff Assessment indicated severe cognitive impairment.
A review of Resident 27's Bowel Continence Point of Care (POC) documentation from 04/14/2024 to 05/13/2024 revealed documentation of No Bowel Movement for a five-day time period from 05/04/2024 to 05/08/2024.
A review of Resident 27's Order Summary printed 05/09/2024 revealed orders for the following medications to treat constipation:
-bisacodyl 10 milligram (MG) suppository (a form of medication inserted in the rectum) 1 suppository inserted rectally once daily as needed for constipation,
-Milk of Magnesia (MOM) suspension 400 mg/5 milliliters (ml) take 30 ml by mouth once daily as needed for constipation,
-polyethylene glycol (PEG) 3350 powder mix 17 grams (1 capful) in 4 to 8 ounces (oz) of liquid every day as needed for constipation,
-Senna-time tablet 8.6 mg take 1 tablet by mouth twice daily as needed for constipation.
-The resident also had an order for prune juice 4-8 oz to promote bowel movement as needed for constipation.
A review of Resident 27's Medication Administration Record for May of 2024 printed on 05/13/2024 revealed the resident received bisacodyl on 05/03/2024 and 05/09/2024. Resident 27 did not receive MOM, PEG3350, Senna-time, or prune juice between 05/01/2024 and 05/13/2024.
A review of the facility's undated Bowel Management Guideline revealed that:
All residents are monitored for bowel movements daily, residents may be asked by staff who are able to manage this independently.
Residents who have not had a BM [bowel movement] after 1 day may be offered Prune Juice 4-8oz as tolerated on day 2.
If no BM noted after 2 days resident may be offered 30cc of Milk of Magnesia on day 3.
If no BM noted after 3 days resident may be offered a Dulcolax (a brand name for bisacodyl) suppository on day 4.
If no BM noted after 4 days, nursing staff update MD on day 5 for physician intervention to promote bowel movement.
Review of the resident's Progress Notes for May 2024 revealed no documentation of MD notification of no bowel movements from 05/04/2024 to 05/08/2024.
During an interview conducted on 05/14/2024 at 12:05 PM, the Director of Nursing (DON) confirmed that Resident 27 had not received prune juice on day 2, MOM on day 3, or bisacodyl on day 4, and the MD was not notified on day 5. The DON further confirmed that the resident should not go that long between bowel movements.
Licensure Reference Number 175 NAC 12.006.09D6(7)
Licensure Reference Number 175 NAC 12.006.09D6(5)
Licensure Reference Number 175 NAC 12.006.09D3(5)
Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 32) of 5 sampled resident's physician order was followed to add oxygen to keep oxygen saturations greater than 90%, ensure 1 (Resident 36) of 1 sampled resident's fluid intake restriction was followed per physician's order, failed to prevent constipation for 2 (Residents 7 and 27) of 3 sampled residents, and failed to follow physician orders regarding medication parameters for 1 (Residents 8) of 5 sampled residents. The facility census was 85.
Findings are:
A.
A record review of the facility's Oxygen Administration policy dated 2023 revealed oxygen was administered (given) to resident's who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.
A record of Resident 32's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility on [DATE].
A record review of Resident 32's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Acute Respiratory Failure With Hypoxia (failure breathing with low oxygen), Pneumonia, Unspecified Organism (lung infection), Sepsis, Unspecified Organism (very bad infection), and Multiple and Fractures of Ribs, Right Side, Subsequent Encounter For Fracture With Routine Healing.
A record review of Resident 32's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/05/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) 5 of 15 which indicated the resident was severely cognitively impaired. The MDS revealed Resident 32 was on oxygen while a resident.
A record review of Resident 32's Care Plan with an admission date of 03/29/2024 revealed the resident had a Focus area of the potential for alteration in respiratory status related to possible effects of disease processes. That focus area had interventions of:
-oxygen (o2) at 2 l/m (liters per minute) to keep sats (saturation) > (greater than) 90% (percent) with a date initiated of 02/25/2022,
-administer medications/treatments as ordered. Such as respiratory, cardiac, pain medications, psychotropics (medications for mental behaviors), antibiotics, oxygen as ordered. Observe effectiveness. Labs/tests as ordered, update doctor of results. Doctor visits/order changes as indicated
-monitor for signs and symptoms of respiratory distress: respirations, pulse oximetry, increased heart rate, changes in blood pressure, restlessness, lethargy, confusion, and update doctor
-follow facility practice with oxygen precautions
A record review of the Order Summary Report dated 05/14/2024 revealed Resident 32 had an order of: Oxygen to keep sats greater than 90 every shift with an order date of 12/17/2021.
A record review of Resident 32's Weights & (and) Vitals dated 05/14/2024 revealed Resident 32's oxygen saturation was 89% on room air (not on oxygen) on 05/14/2024 at 6:59 AM.
An observation on 05/13/2024 at 11:02 AM revealed Resident 32 was in the room sleeping in bed with the oxygen nasal cannula on and the oxygen concentrator (a machine that purifies oxygen) set at 2 l/m.
An observation on 05/14/2024 at 7:56 AM revealed Resident 32 was in the room sleeping in bed without oxygen on.
In an interview on 05/14/2024 at 7:58 AM, Medication Aide (MA)-I confirmed MA-I tested Resident 32's oxygen saturation at 6:59 AM and it was 89%. MA-I confirmed MA-I was unsure why the resident was put on oxygen. MA-I confirmed Resident 32's oxygen saturations run low a lot. MA-I confirmed MA-I would recheck the resident's oxygen saturation.
An observation on 05/14/2024 at 7:58 AM with MA-I and Clinical Coordinator (CC)-H revealed Resident 32 was sleeping without oxygen on. MA-I woke up the resident. The resident was very confused but allowed MA-I to check his oxygen saturation. MA-I checked Resident 32's oxygen level. Resident 32's oxygen level was 83% and gradually increased to 86% after MA-I had the resident take several deep breaths. Resident 32 allowed MA-I to apply oxygen to the resident at 2 l/m per nasal cannula (a tubing the runs to the nose to deliver oxygen) and Resident 32's oxygen rapidly increased to 93%.
In an interview on 05/14/2024 at 8:07 AM, CC-H confirmed Resident 32 should have been placed on oxygen anytime the oxygen saturation was below 90% and should have been placed on oxygen at 6:59 AM when MA-I tested the resident and the resident's oxygen saturation was below 90% and was not.
B.
A record review of the facility's Fluid Restriction Guideline dated June 2023 revealed that fluid restrictions would be followed in accordance to providers' orders. The resident would be educated on the risks and benefits of the fluid restriction. The resident has the right to refuse to follow, if refused, documentation should support the reason and the education of risks and benefits.
A record of Resident 36's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility on [DATE].
A record review of Resident 36's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Chronic Diastolic (Congestive) Heart Failure, Edema (swelling caused by fluid building up in the body's tissues), Cardiomyopathy, Unspecified (heart muscle disease), Cellulitis Of Left Lower Limb (bacterial skin infection), Cellulitis, Unspecified, Lymphedema, Not Elsewhere Classified (swelling caused by blockage), Peripheral Vascular Disease, Unspecified (vessel disease in the arms and legs), Venous Insufficiency (Chronic)(Peripheral)(poor blood circulation), Non-Pressure Chronic Ulcer Of Unspecified Part Of Left Lower Leg Limited To Breakdown Of Skin, ), Pulmonary Hypertension, Unspecified (high blood pressure in the lungs), Chronic Kidney Disease, Stage 3, Urge Incontinence (uncontrolled urgent need to urinate), Essential (Primary) Hypertension (high blood pressure), Morbid (Severe) Obesity with Alveolar Hypoventilation (obesity caused low air flow in the lungs), Acute Respiratory Failure With Hypoxia (low oxygen in the blood), Chronic Obstructive Pulmonary Disease (COPD, Obstructive Sleep Apnea (Adult)(Pediatric) (airway closing during sleep), and Sepsis, Unspecified Organism.
A record review of Resident 36's MDS dated 04/05/2024 revealed the resident had BIMS score of 15 of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with upper and lower body dressing, and footwear and needed partial/moderate assistance with personal and oral hygiene and toileting.
A record review of Resident 36's Care Plan with an admission date of 12/01/2023 revealed the resident had a focus area of bladder incontinence and intervention of encourage fluids during the day to promote prompted voiding (urinate) responses. The resident had a focus area of the potential for pressure ulcer development related to decreased mobility and lymphedema to the lower extremities (legs) and interventions of: encourage fluids and intakes by mouth and monitor nutritional status, serve diet as ordered, monitor intake and record. The resident had a focus area of oxygen therapy related to Congestive Heart Failure, COPD, and Acute Respiratory with Hypoxia and an intervention of treat edema as ordered, observe for changes. The resident had a focus area of dehydration or potential fluid deficit (loss) related to diuretic (medication used to decrease excess fluid in the body) use and an indication of invite the resident to activities that promote additional fluid intake, offer drinks during one-to-one visits, ensure all beverages offered comply with diet/fluid restrictions and consistency requirements, offer fluids with medication pass and offer fluids between meals.
An observation on 05/08/2024 at 11:41 AM revealed Resident 36 was seated in the wheelchair in the room with both lower extremities very swollen. The resident had compression dressings on both lower extremities. A large cup of water was located on the counter.
An observation on 05/13/2024 at 07:31 AM revealed the resident was seated in the dining room with legs and feet swollen and compression dressing on both legs. The resident had 3 cups of fluids in front of the resident and then drank the entire cup of a red juice.
A record review of Resident 36's University of Nebraska Medical Center Advanced Heart Failure and Cardiac Transplant Clinic Progress Note dated 02/21/2024 revealed the resident was seen at the clinic and the resident did not have edema to the bilateral lower extremities (BLE)(both lower legs).
A record review of Resident 36's Skilled Nursing Home Provider Rounds dated 5/1/2024 revealed the Physician's Assistant (PA) seen the resident and the resident had 2+ (2 plus)(a grade of the severity of edema from 0 to 4, 4 being the worst) edema in the legs and was using compression wraps to BLE.
A record review of the Order Summary Report dated 05/13/2024 revealed Resident 36 had an order for Bumetanide (a diuretic to decrease fluids in the body) 2 milligram (mg) tablet twice daily for edema and an order for a 2000 milliliter (ml) fluid restriction daily every shift.
A record review of Resident 36's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated March, April, and May 2024 revealed the following days the 2000ml fluid restriction was not followed:
-03/02/2024 - 4000ml,
-03/03/2024 - 4000ml,
-03/04/2024 - 3500ml,
-03/05/2024 - 2380ml,
-03/07/2024 - 2040ml,
-03/09/2024 - 2740ml,
-03/11/2024 - 2920ml,
-03/16/2024 - 3400ml,
-03/17/2024 - 2400ml,
-03/18/2024 - 3480ml,
-03/20/2024 - 3240ml,
-03/23/2024 - 2500ml,
-03/24/2024 - 2360ml,
-03/27/2024 - 3400ml,
-03/30/2024 - 2140ml,
-03/31/2024 - 2500ml,
-04/03/2024 - 2600ml,
-04/05/2024 - 3240ml,
-04/06/2024 - 3200ml,
-04/08/2024 - 3680ml,
-04/10/2024 - 3400ml,
-04/11/2024 - 2360ml,
-04/13/2024 - 3120ml,
-04/14/2024 - 3240ml,
-04/17/2024 - 2160ml,
-04/18/2024 - 2240ml,
-04/19/2024 - 3590ml,
-04/27/2024 - 3240ml,
-04/29/2024 - 3480ml,
-05/05/2024 - 3240ml,
-05/07/2024 - 3200ml,
-05/08/2024 - 4240ml,
-05/10/2024 - 3030ml,
-05/11/2024 - 4000ml,
-05/12/2024 - 2360ml.
A record review of Resident 36's Progress Notes from 02/01/2024 - 05/14/2024 did not reveal the resident refused to follow the ordered fluid restriction or requested more fluids.
In an interview on 05/13/2024 at 9:49 AM, Resident 36 confirmed the [gender] does not refuse to follow the fluid restriction that had been ordered for the resident.
In an interview on 05/13/2024 at 10:07 AM, Nursing Assistant (NA)-N confirmed the resident does not demand more fluids or refuse to follow the fluid restriction ordered.
In an interview on 05.13.2024 at 10:08 AM, Registered Nurse (RN)-O confirmed Resident refused to follow the fluid restriction once in a while. RN-O could not recall the last time the resident refused to follow the fluid restriction or what the resident's reaction was when education was given of why following the fluid restriction was important.
In an interview on 05/14/2024 at 1:04 PM, the DON confirmed that on the above listed days the fluid intake was over the ordered fluid restriction amount of 2000ml and the staff should be trying to keep the resident's fluid intake below 2000ml. The DON confirmed that if the resident refused to follow the fluid restriction, the staff should have educated on the importance of following the fluid restriction and documented it in the progress notes.
C.
A record review of Resident 8's Order Summary Report dated 5/13/24 revealed an order and a diagnosis for the following:
-A diagnosis of Primary Hypertension (a blood pressure that is documented to be higher than 140/90 consistently).
-Carvedilol (Coreg) tab 6.25 milligrams (MG), take 1 tablet by mouth daily. Hold for systolic blood pressure (SBP-the top number of a blood pressure) less than 90, a diastolic blood pressure (DBP- the bottom number of a blood pressure) less than 60, or a heart rate (HR) less than 50. The order was active on 5/1/24.
An observation on 5/13/24 at 8:30 AM of Medication Aide-G (MA-G) and Clinical Coordinator(CC)-H administering medications to Resident 8 revealed:
-No Blood Pressure was taken prior to administering Coreg 6.25mg.
A record review of Resident 8's MAR dated May of 2024 revealed:
-No documentation was located on MAR for Blood Pressure (BP) monitoring 5/1/24-5/13/24 and was documented as administered.
-No documentation was located on MAR for Pulse monitoring 5/1/24-5/13/24 and was documented as administered.
-Carvedilol tab 6.35 MG was to be given at 08:00 AM.
A record review of Resident 8's Blood Pressure Summary Log dated 5/13/24 revealed the following:
-5/1/24 at 8:40AM - BP 145/76,
-5/2/24 at 11:34 AM- BP 124/74,
-5/3/24 at 9:49 AM- BP 129/76,
-5/4/24 at 11:50 AM - BP 110/72,
-5/5/24 at 7:08 PM- BP 90/61,
-5/6/24 at 3:35 PM - 102/66,
-5/7/24 at 10:34 AM-148/70,
-5/8/24 at 9:00 AM-150/73,
-5/9/24 at 10:40 AM-100/83,
-5/11/24 at 10:58 AM-141/98,
-5/12/24 at 5:18 PM-116/65,
-5/13/24 at 8:40 AM-118/73.
A record review of Resident 8's Pulse Summary Log dated 5/13/24 for the dates 5/1/24 through 5/13/24 revealed the following:
-5/1/24 at 08:41 AM -Pulse (P) 88,
-5/2/24 at 11:34 AM-P 80,
-5/3/24 at 09:49 AM - P 78,
-5/4/24 at 11:50 AM- P 99,
-5/5/24 at 7:08 PM - P 86,
-5/6/24 at 3:34 PM-P 68,
-5/7/24 at 10:34 AM- P 91,
-5/8/24 at 09:00 AM- P 88,
-5/9/24 at 10:40 AM- P 107,
-5/11/24 at 10:58 AM- P 78,
-5/12/24 at 5:18 PM- P 83,
-5/13/24 at 8:40 AM-P 88.
An interview on 5/13/24 at 08:40 AM with MA-G confirmed that BP and P were not taken prior to administering Coreg 6.25 MG per physicians' order to Resident 8.
An interview on 5/13/24 at 08:45 AM with CC-H confirmed that MA-G did not take Resident 8's BP prior to administering Coreg 6.25 MG per physician's order to Resident 8.
An interview on 5/14/24 at 10:30 AM with the Director of Nursing (DON) confirmed that no BP's and P 's for the month of May 2024 were located on the MAR for Coreg 6.25 MG order from physician. DON confirmed that the Coreg 6.25 MG order included parameters.
DON then confirmed that the Coreg 6.25MG for Resident 8 was scheduled for 08:00AM (8 AM) and that the time for administration could be an hour prior to 8 AM, or an hour after 8 AM. The DON reviewed BP log for May 2024 and confirmed the following Ps were not within the time frame of 7 AM to 9AM: May 2-7, and 9 -12. The DON also confirmed that the following BPs were not within the time frame 7 AM to 9 AM: May 2nd, 4-7, and 9- 12.
D.
A record review of the facility's undated Bowel Management Guideline revealed:
Residents who have not had a BM after 1 day may be offered Prune Juice 4-8 oz as tolerates on day 2.
If no BM noted after 2 days residents may be offered 30 cc MOM on day 3.
If no BM noted after 3 days may be offered a Dulcolax Suppository on day 4.
If no BM noted after 4 days, nursing staff update MD on day 5 for physician intervention to promote bowel movement.
A record review of Medication Administration Record (MAR) for Resident 7 revealed an order for:
Milk Of Magneisa 30 ml po (per mouth) daily as needed for constipation. Start date: 08/26/2022
No doses administered during month of April 2024.
Resident did receive 1 PRN (when needed) dose on May 3, 2024, at 1344.
Prune Juice 4-8 oz to promote bowel management as needed for
constipation. Start Date: 08/26/2022.
No doses were administered during month of April 2024.
No doses administered from May 1, 2024, through May 9, 2024 at 2:25 PM.
Bisacodyl Suppository 10mg insert 1 suppository per rectum once daily
as needed for constipation. Start date: 8/26/2022.
Resident was administered one dose on April 10, 2024.
No doses administered from May 1, 2024 through May 9, 2024 at
2:25 PM.
Enema ready to use. Use 1 enema per rectum once daily as needed for
constipation. Start Date: 05/05/2024.
No doses administered from May 5, 2024 through May 9, 2024 at 2:25 PM.
Senna-TIME Tab 8.6 mg. Take 1 tablet by mouth twice daily as needed
for constipation. Start date: 02/28/2024.
No doses administered during month of April 2024.
No doses administered from May 1, 2024 through May 9, 2024 at 2:25 PM.
Record review of Resident 7's Facesheet revealed Resident 7 was admitted to facility on 8/26/2022. Current Medical Diagnosis include dementia (loss of cognitive functioning), constipation, and weakness. Resident 7's admission diagnosis further revealed a diagnosis of constipation.
A record review of Resident 7's significant change in status assessment of Minimum Data Set (MDS, a federal assessment utilized to determine a resident's care) dated 3/6/2024 revealed the following:
-A Brief Interview for Mental Status (BIMS, is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of a score of 10, which indicates moderate cognitive impairment.
-Functional Abilities include:
Toileting hygiene - requires Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
Upper body dressing- requires Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
Lower body dressing- Substantial/maximal assistance - Helper does less than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
Personal hygiene - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.
A record review of Resident 7's BIMS completed on 3/22/2024 revealed a BIMS score of 4, which indicates severe cognitive impairment.
A record review of Resident 7's current Care Plan revealed the resident was not identified as having a risk for or actual problem for constipation.
A record review of Progress Notes for Resident 7 dated 5/5/2024 at 4:52 PM revealed; Resident has large hard BM (bowel movement) that [gender] is unable to pass. [Gender] received PRN (as needed) MiraLAX (MiraLAX is classified as an osmotic laxative and works by drawing water into the colon which softens the stool and may naturally stimulate the colon to contract. These actions help ease bowel movements.) this morning. [Gender] now states that [gender] needs to pass BM but isn't strong enough. Will contact hospice and request orders for PRN enema.
A record review of Resident 7's of BM records revealed the following:
-Last BM was on 4.21.24,
-4.25.24 No BM,
-4.26.24 No BM,
-4.27.24 No BM,
-4.28.24 continent of large, formed BM,
-4.29.24 continent of medium, formed BM,
-4.30.24 No BM,
-5.1.24 No BM,
-5.2.24 No BM,
-5.3.24 No BM,
-5.4.24 No BM,
-5.5.24 No BM,
-5.5.24 Large hard BM- unable to self pass.,
-5.6.24 Incontinent of large, formed BM,
-5.7.24 No BM,
-5.8.24 No BM,
-5.9.24 Incontinent x 2 of medium formed BM,
-5.10.24 No BM,
-5.11.24 No BM,
-5.12.24 Continent of large, formed BM.
Resident 7 was without a BM from 4/22/2024 to 4/28/2024 (6 days) and from 4/30/2024 to 05/05/2024 (6 days).
A record review of Medication Administration Record (MAR) for April 2024 revealed routine order for Colace Clear Cap 50 mg- take 3 capsules by mouth twice daily for constipation.
A record review of April 2024 MAR for Resident 7 revealed resident did not receive 24 doses of Colace for reasons of: Absent, sleeping or refused.
A record review of May 2024 MAR for Resident 7 printed on 5/9/24 revealed resident did not receive 6 doses of scheduled Colace for the following reasons: Absent or refused.
An Interview with the Director of Nursing on 5/13/24 at 2:50pm was conducted. DON stated that the facility's bowel care protocol was not followed, and Resident 7 shouldn't have gone 6 days without a bowel movement. DON confirmed that nursing staff did not update Resident 7's physician after 4 days without a bowel movement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E.
A record review of Resident 30's Clinical Census page printed 05/13/2024 revealed the resident was admitted on [DATE].
A record review of Resident 30's Medical Diagnosis list printed 05/09/2024 revealed the resident had diagnoses of obstructive sleep apnea (OSA-a sleep disorder that occurs when throat muscles relax and block the flow of air into your lungs while you sleep), and central cord syndrome (CCS-an incomplete spinal cord injury) at level C2 (C2 is one of the top bones in the spine. Someone with a CCS at this level is at risk of developing breathing problems).
A record review of Resident 30's Medicare Part A Discharge Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 04/26/2024 revealed Brief Interview for Mental Status-(BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]) score of 10. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact.
A record review of Resident 30's Order Summary printed 05/09/2024 revealed an order to Use home CPAP [continuous positive airway pressure-a CPAP machine delivers just enough air pressure to a mask worn over the nose or mouth to keep the upper airway passages open] with home settings. There were no settings listed in the order.
A record review of the initial Physician's Telephone Order dated 02/07/2024 revealed an order for May use home Cpap @ home settings. There were no settings listed in the order.
A review of the website for ResMed (a CPAP machine manufacturer) revealed that Once you've been diagnosed with sleep apnea, you'll receive a prescription from a doctor in order to acquire a CPAP machine and start therapy. The prescription will list a pressure setting, which is determined by the prescribing physician based on the results of your sleep study.
https://www.resmed.com/en-us/sleep-apnea/sleep-blog/diagnosed-with-sleep-apnea/#:~:text=Once%20you've%20been%20diagnosed,results%20of%20your%20sleep%20study
During an interview conducted on 05/08/2024 at 10:15 AM, Resident 30 revealed that they did not have oxygen connected to the CPAP, and that staff washed the mask daily.
During an interview conducted on 05/13/2024 at 11:31 AM Resident 30 confirmed that they did wear the CPAP every night.
During an interview conducted on 05/14/24 at 10:45 AM the Director of Nursing (DON) confirmed that there was no order for the CPAP that included settings.
Licensure Reference Number 175 NAC 12.006.09D6(5)
Based on observation, interview, and record review; the facility failed to ensure 2 (Residents 32 and 36) of 5 sampled residents had a valid oxygen order that included settings, 5 (Residents 6, 26, 30, 36, and 70) of 5 sampled residents had a valid PAP order that included settings, and ensure 1 (Resident 36's) of 5 sampled resident's tubing was not kinked to prevent flow restriction. The facility census was 85.
Findings are:
A.
A record review of the facility's Oxygen Administration policy dated 2023 revealed oxygen was administered (given) to resident's who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen would be administered under orders of a physician.
A record review of Healthcare Quality Association on Accreditation's (HQAA) O2 (oxygen) Orders 101 dated 05/04/2017 revealed that oxygen is a drug, and the orders must include:
-the word oxygen
-the amount - usually expressed in liters per minute (l/m), the duration - such as continuous or 12 hours per day or PRN (as needed)
-delivery device - such as nasal cannula (tubing that goes in the nose), mask, bled into non-invasive ventilator
https://info.hqaa.org/hqaa-blog/o2-orders-101
A record of Resident 32's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility 03/29/2024.
A record review of Resident 32's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Acute Respiratory Failure With Hypoxia (failure breathing with low oxygen), Pneumonia, Unspecified Organism (lung infection), Sepsis, Unspecified Organism (very bad infection), and Multiple and Fractures of Ribs, Right Side, Subsequent Encounter For Fracture With Routine Healing.
A record review of Resident 32's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/05/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) 5 of 15 which indicated the resident was severely cognitively impaired. The resident required substantial/maximal assistance with toileting, lower body dressing, and footwear and needed supervision or setup assistance with oral hygiene (cleaning) and eating. The MDS revealed Resident 32 was on oxygen while a resident.
A record review of Resident 32's Care Plan with an admission date of 03/29/2024 revealed the resident had an intervention of Oxygen (o2) at 2 l/m to keep sats (saturation) > (greater than) 90% (percent) with a date initiated of 02/25/2022.
An observation on 05/13/2024 at 11:02 AM revealed Resident 32 was in the room with the oxygen nasal cannula on and the oxygen concentrator (a machine that purifies oxygen) set at 2 liters per minute (l/m).
An observation on 05/14/2024 at 7:56 AM revealed Resident 32 was in the room without oxygen on.
A record review of the Order Summary Report dated 05/14/2024 revealed Resident 32 had an order of: Oxygen to keep sats greater than 90 every shift with an order date of 12/17/2021.
In an interview on 05/14/2024 at 12:04 PM, the Director of Nursing (DON) confirmed the order on the Order Summary Report dated 05/14/2024 was the only oxygen order the facility had and confirmed it was not a valid oxygen order because it did not contain the setting and other required elements for a valid oxygen order.
B.
A record review of the facility's Oxygen Administration policy dated 2023 revealed oxygen was administered to resident's who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen would be administered under orders of a physician.
A record review of Healthcare Quality Association on Accreditation's (HQAA) O2 (oxygen) Orders 101 dated 05/04/2017 revealed that oxygen is a drug, and the orders must include:
-the word oxygen
-the amount - usually expressed in liters per minute (l/m), the duration - such as continuous or 12 hours per day or PRN
-delivery device - such as nasal cannula, mask, bled into non-invasive ventilator
https://info.hqaa.org/hqaa-blog/o2-orders-101
A record of Resident 36's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility 12/01/2023.
A record review of Resident 36's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity with Alveolar Hypoventilation (obesity caused low air flow in the lungs), Pulmonary Hypertension, Unspecified (high blood pressure in the lungs), Obstructive Sleep Apnea (Adult)(Pediatric) (airway closing during sleep), and Sepsis, Unspecified Organism.
A record review of Resident 36's MDS dated 04/05/2024 revealed the resident had BIMS score of 15 of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with upper and lower body dressing, and footwear and needed partial/moderate assistance with personal and oral hygiene and toileting. The MDS revealed Resident 36 was on oxygen while a resident.
A record review of Resident 36's Care Plan with an admission date of 12/01/2023 revealed the resident had an intervention of oxygen 3 l/m inhalation every shift. Titrate to keep sats > 88%. Do not exceed 4 liters.
An observation on 05/08/2024 at 11:27 AM revealed Resident 36 was seated in the wheelchair in the room with the oxygen nasal cannula on and the oxygen tank regulator (device used to control the flow) was set at 3 l/m, but the tank was empty.
In an interview on 05/08/2024 at 11:27 AM, Resident 36 confirmed the resident was aware the tank was empty, and the resident had to stop and get a new tank on the way to the dining room.
An observation on 05/13/2024 at 7:31 AM revealed Resident 36 was in the dining room with oxygen on at 3 l/m and the tank was full.
A record review of the Order Summary Report dated 05/13/2024 did not reveal an order for Resident 36's oxygen.
A record review of the Order Summary Report dated 12/20/2023 revealed Resident 36 had an order to keep o2 sats >90% but did not reveal a valid order for oxygen.
In an interview on 05/14/2024 at 12:04 PM, the DON confirmed the order on the Order Summary Report dated 12/20/2023 was the only oxygen order the facility had and confirmed it was not a valid oxygen order because it did not contain the setting and other required elements for a valid oxygen order.
C.
A record review of the facility's Noninvasive Ventilation policy dated 2023 revealed the facility would provide noninvasive ventilation as per physician's orders and current standards of practice. The facility would obtain an order for the use of the device.
A record review of ResMed's Diagnosed with sleep apnea? Getting Started on Continuous Positive Airway Pressure (CPAP)(a machine used to treat sleep apnea) dated 02/26/2020 revealed that before starting a CPAP the resident would receive a prescription from a doctor to get a machine and start therapy. The prescription would list a pressure setting which would be determined by the doctor based on the results of a sleep study.
A record of Resident 36's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility 12/01/2023.
A record review of Resident 36's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Obstructive Sleep Apnea (Adult)(Pediatric), Morbid (Severe) Obesity with Alveolar Hypoventilation (obesity caused low air flow in the lungs), Pulmonary Hypertension, Unspecified (high blood pressure in the lungs), Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, and Sepsis, Unspecified Organism.
A record review of Resident 36's MDS dated 04/05/2024 revealed the resident had BIMS score of 15 of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with upper and lower body dressing, and footwear and needed partial/moderate assistance with personal and oral hygiene and toileting. The MDS revealed Resident 36 was on non-invasive mechanical ventilator while a resident, but it did not indicate if it was a CPAP or BiPAP (a machine used to treat sleep apnea with an inspiratory and expiratory setting).
A record review of Resident 36's Care Plan with an admission date of 12/01/2023 revealed the resident had an intervention of CPAP every night (QHS) as ordered.
An observation on 05/08/2024 at 11:29 AM revealed Resident 36 had a Positive Airway Pressure device (PAP) on the table to the left side if the recliner.
An observation on 05/13/2024 at 7:27 AM revealed Resident 36's PAP was on the bedside table with the mask draped over the table.
In an interview on 05/08/2024 at 11:29 AM, Resident 36 confirmed the resident did use a CPAP every night but did not know the settings.
In an interview on 05/13/2024 at 9:49 AM, Resident 36 confirmed the resident used the PAP every night.
A record review of the Order Summary Report dated 05/13/2024 revealed an order of: CPAP/BiPAP setting as at home every evening shift.
In an interview on 05/14/2024 at 12:04 PM, the DON confirmed the order on the Order Summary Report dated 05/13/2024 was the only order the facility had for a PAP device and confirmed it was not a valid order because it did not contain the machine type and settings for a valid noninvasive ventilator order.
D.
A record of Resident 36's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility 12/01/2023.
A record review of Resident 36's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity with Alveolar Hypoventilation, Pulmonary Hypertension, Unspecified, Obstructive Sleep Apnea (Adult)(Pediatric), and Sepsis, Unspecified Organism.
A record review of Resident 36's MDS dated 04/05/2024 revealed the resident had BIMS score of 15 of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with upper and lower body dressing, and footwear and needed partial/moderate assistance with personal and oral hygiene and toileting. The MDS revealed Resident 36 was on oxygen while a resident.
A record review of Resident 36's Care Plan with an admission date of 12/01/2023 revealed the resident had an intervention of oxygen 3 l/m inhalation every shift. Titrate to keep sats > 88%. Do not exceed 4 liters.
An observation on 05/08/2024 at 9:50 AM revealed Resident 36 had an oxygen concentrator (a machine used to purify oxygen) in the room with a humidifier attached. The tubing from the concentrator to the humidifier had a plastic bag attached to it that kinked the tubing at the humidifier attachment.
An observation on 05/13/2024 at 7:27 AM revealed Resident 36 had an oxygen concentrator in the room with a humidifier attached. The tubing from the concentrator to the humidifier had a plastic bag attached to it that kinked the tubing at the humidifier attachment.
An observation on 05/14/2024 at 8:39 AM with the DON revealed Resident 36 had an oxygen concentrator in the room with a humidifier attached. The tubing from the concentrator to the humidifier had a plastic bag attached to it that kinked the tubing at the humidifier attachment.
In an interview on 05/14/2024 at 8:39 AM, the DON confirmed the tubing from the concentrator to the humidifier had a plastic bag attached to it that kinked the tubing at the humidifier attachment which would have restricted the oxygen flow to the resident.
F.
A record of Resident 6's Clinical Census dated 5/9/24 revealed the resident was last admitted to the facility 4/16/24.
A record review of Resident 6's Medical Diagnosis Summary dated 5/9/24 revealed the resident had diagnosis of Chronic Obstructive Pulmonary Disorder (COPD- difficulty or discomfort breathing due to constricting airway), Obstructive Sleep Apnea (pauses in breathing while asleep), and Hypoxemia (decreased blood oxygen).
A record review of Resident 6's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 4/24/24 revealed the resident had a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) 13 of 15 which indicated the resident was cognitively intact.
A record review of Resident's 6's Order Summary Report dated 5/8/24 revealed:
-CPAP setting as at home every evening shift, Active 4/24/24
A record review of Resident 6's Care Plan with an admission 5/9/24 revealed a focus for complications also revealed an intervention of CPAP setting as at home initiated on 4/12/24.
An observation on 5/8/24 at 8:52 AM in Resident 6's room revealed Positive Airway Pressure (PAP) machine and mask on bedside table.
An observation on 5/9/24 at 9:00 AM in Resident 6's room revealed that a PAP mask on the bedside table. No debris or oily substance noted on mask.
An interview on 5/13/24 at 12:37 PM with Registered Nurse-P (RN-P) reveals that Resident 6 refuses water in his CPAP nightly with use.
An interview on 5/14/24 at 9:49 AM with the Director of Nursing (DON) confirmed the order on the Order Summary Report dated 5/8/24 was the only order the facility had for Resident 6's CPAP device and confirmed it was not a valid order without actual machine type and settings for the machine.
G.
A record of Resident 26's Clinical Census dated 5/8/24 revealed the resident was last admitted to the facility 4/12/24.
A record review of Resident 26's Medical Diagnosis Summary dated 5/9/24 revealed the resident had diagnosis of Obstructive Sleep Apnea (pauses in breathing while asleep).
A record review of Resident 26's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 04/20/24 revealed the resident had a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) 14 of 15 which indicated the resident was cognitively intact. The resident required substantial/maximal assistance with toileting, lower body dressing, and footwear and needed supervision or setup assistance with oral hygiene and eating.
A record review of Resident 26's Order Summary Report dated 5/8/24 revealed that no order for CPAP is documented.
An observation on 5/9/24 at 10:00 AM in Resident 26's room revealed Positive Airway Pressure (PAP) machine and mask on bedside table. A small amount of water was in the PAP machines tank.
An observation on 5/13/24 at 9:00 AM in Resident 26's room revealed that a PAP mask on the bedside table and mask was without oily substances or debris.
An interview on 5/13/24 at 9:00 AM with Resident 26 confirmed CPAP was worn nightly.
An interview on 5/14/24 at 12:25 PM with the Director of Nursing (DON) confirmed that the order on the Order Summary Report dated 5/8/24 there was not an order for Resident 26's CPAP machine that was being used.
H.
A record review of Resident 70's Medical Diagnosis summary dated 5/9/24 revealed the resident had diagnosis Sleep Apnea (pauses in breathing while asleep).
A record review of Resident 70's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 4/15/24 revealed the resident had a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) 12 of 15 which indicated the resident was cognitively moderately impaired. Resident 70 had an impaired right arm and left lower leg resulting in set up assistance for eating, oral and personal hygiene. Moderate assistance was needed for upper body dressing. Substantial assistance was needed for showering and lower body dressing. Resident was total dependent for transfers and substantial assist for positioning.
A record review of Resident's 70's Order Summary Report dated 5/9/24 revealed:
-CPAP setting as at home every evening shift was active on 4/8/24
A record review of Resident 70's Care Plan reviewed on 5/9/24 revealed an admission date of 4/8/24. Also, that sleep apnea and CPAP were not on the care plan.
An observation on 5/8/24 at 8:33 AM in Resident 70's room revealed Positive Airway Pressure (PAP) machine on table and the mask on top of machine. No bag for the mask is located.
An observation on 5/9/24 9:00 AM in Resident 70's room revealed Positive Airway Pressure (PAP) machine on bedside table and mask sitting on top of it. Mask is without oily substance or debris.
An interview on 5/13/24 at 12:37 PM with Registered Nurse-P (RN-P) reveals that Resident 70s husband cleans and takes cares for the CPAP machine daily.
An interview on 5/14/24 at 9:29 AM with the Director of Nursing (DON) confirmed the order on the Order Summary Report dated 5/9/24 was the only order the facility had for Resident 70's CPAP device and confirmed it was not a valid order without actual machine type and settings for the machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D
Based on record review and interviews; the facility failed to ensure residents were free from unnecessary medications related to giving acetaminophen (a medication used to treat minor aches and pains and reduce fever) over the recommended daily dosages for 1 (Resident 175) of 5 sampled residents. The facility identified a census of 85.
Findings are:
A record review of the document titled Clinical Resident Profile revealed that Resident 175 had been accepted into the facility on 4/30/24 with a primary diagnosis of coronary artery disease (reduced blood flow to the heart that can cause chest pain and shortness of breath).
A record review of the History and Physical for Resident 175 dated 4/30/24 revealed Resident 175 was Oriented x4 (self, place, time, and situation).
A record review of the MAR (Medication Administration Record) dated May 2024 revealed Resident 175 had the following orders for pain control:
-Acetaminophen (Tylenol) 500 mg (milligrams) 2 tablets (1,000 mg) by mouth every 8 hours, do not exceed 4,000 mg in 24 hours (related diagnosis: pain).
-Acetaminophen 500 mg take 1 tablet by mouth every 6 hours as needed (PRN) for pain/increased temperature, max dose 3,000 mg in 24 hours.
-Acetaminophen 500 mg take 2 tablets (1,000 mg) by mouth every 6 hours as needed for pain/increased temperature, max dose 3,000 mg in 24 hours.
The record review of the acetaminophen orders revealed that the routine order stated not to exceed 4,000 mg in 24 hours while the PRN Acetaminophen order stated not to exceed 3,000 MG in 24 hours.
A record review of Resident 175's May 2024 MAR revealed Resident 175 had received acetaminophen between 05/01/2024 and 05/13/2024. Resident 175 received 3000 mg daily from the routinely scheduled acetaminophen. On 05/02/2024, Resident 175 received one PRN dose of 500 mg, for a 24-hour total of 3500 mg. On 05/05/2024, the resident received one PRN dose of 500 mg at 11:02 AM, and one PRN dose of 1000 mg at 7:14 PM, for a 24-hour total of 4500 mg.
A record review of the document titled [NAME] Legacy admission Orders, which contained the facility standing orders (common orders put into place for all residents), revealed an order which read as follows.
acetaminophen 500 mg 1 to 2 tabs every 6 hours PRN pain/increased temperature dose to not exceed 3 grams in 24 hours.
A record review of the document titled admission Medication Regimen Review dated 4/30/24, completed by the facility pharmacy consultant, revealed a recommendation to the facility which read as follows:
Resident has an order for routine and/or PRN acetaminophen containing products. Please add max dose as indicated by the physician.
During an interview on 5/14/24 at 9:01 AM with Resident 175 revealed that the facility staff were encouraging [gender] to stop taking so much acetaminophen and oxycodone (a narcotic pain reliever) and when [gender] voiced having too much pain to take nothing, staff encouraged [gender] to take more of the PRN acetaminophen and less of the oxycodone.
An interview on 5/13/24 at 9:43 AM with Licensed Practical Nurse-L confirmed awareness that acetaminophen had a recommended max dose in 24 hours and confirmed that the physician should decide what that amount was for each resident.
An interview on 5/13/24 at 10:41 AM with the facility DON (Director of Nursing) after review of the MAR dated May 2024 confirmed that Resident 175 had received over the amount of Tylenol ordered upon admission to the facility as well as over the recommended amount ordered on the facility standing orders and should not have.
A record review of the facility policy titled Pain Management December 2023 revealed it contained no direction or guidance related to ensuring the medications used for pain control were ordered and given at recommended dosages.
A record review of the recommended dosages for Acetaminophen Extra Strength (500mg in each tablet) ingestion, found on the package instructions, read as follows: Directions: Not to exceed 6 tablets in 24 hours, unless directed by a doctor. Total labeled daily dose: 3,000 mg/day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12E1
Based on observation, interviews and record review, the facility failed to secure two medications for 1 (Resident 7) of 4 sampled residents. Facility identified census of 85.
Findings are:
Record review of Resident 7 revealed resident admitted to the facility on [DATE] with diagnoses of: senile degenertation of brain, cerebral infaraction, dementia in other diseases classified elsewhere, unspecified severity, with agitation, pain in left shoulder, unspecified fracture of shaft of humerus.
Record review of Resident 7's significant change in status assessment of Minimum Data Set (MDS a federally mandated assessment utilized to determine a resident's care) dated 3/6/2024 revealed:
-A Brief Interview for Mental Status (BIMS) (An interview utilized to determine cognition) of a score of 10, which indicates moderate cognitive impairment.
Record review of Resident 7's BIMS completed on 03/22/2024 revealed a score of 4, which indicates severe cognitive impairment.
A record review of Resident 7's current Care Plan revealed no focus identified for the resident to self-administer medications.
A record review on 05/09/2024 at 10:30 AM of Resident 7's Physicain orders revealed orders for the following:
-Haloperidol 2 milligrams (mg) per milliliter (ml). Give 2.5 ml (5 mg) by mouth every 8 hours Related Diagnoses: Unspecified Dementia, Unspecified severity, with agitation. Target behaviors: yelling/screaming, increased anxiety. Start Date: 03/27/2024
-Cooling pain gel 4%. Apply topically to bilateral (both) shoulders, bilateral hips and bilateral knees twice daily. Related diagnoses: Pain. Start Date: 01/27/2024
-Halls Cough lozenge. Dissolve 1 lozenge by mouth every two hours as needed for cough. Start Date: 09/18/2023
A record review of Resident 7's Physician Orders confirmed there is no self-administration record noted in the orders.
An observation on 05/08/24 1:45 PM revealed Resident 7 was out of the room and the resident's room door was open. Two separate medications were noted in plastic bags by the sink. In one bag there was a tube of cream with a medication label that stated medication is for Resident 7 and is Cooling Pain Gel 4%. In another bag there is a nearly full bottle with a medication label that stated medication is for Resident 7 and is Haldol 2 mg/ml bottle. The outside package dated 5-5-24. After closing the resident's room door, because of the safety concern of Haldol in the room and other residents on this wing; the Director of Nursing (DON) was immediately brought to the room. The DON quickly picked up the medications and removed them from the room.
An interview with the DON on 05/08/2024 at 1:45 PM confirmed that these medications should not have been left in room.
An observation on 05/08/2024 at 2:53 PM revealed a large hard plastic container with a lid noted on Resident 7's bedside dresser containing approximately 100 Halls Cough Drops.
Interview on 05/13/2024 at 12:25 PM with DON confirmed that there is not a self-administration assessment on Resident 7 and reported, Resident 7 is not appropriate to self-administer any medication and those medications should not have been left in the resident's room.
Record review of the facility's Medication Storage policy dated March 2014 with guideline stating: The facility will ensure all medications housed on our premises will be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.
General Guidelines:
A. All drugs and biologicals will be stored in locked compartments (i.e., medications carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.
B. Only authorized personnel will have access to the keys to locked compartments.
C. During a medication pass, medications must be under the direct observations of the person administering medications or locked in the medication storage area/cart.

Licensure Reference Number 175 NAC 12-006.11E
Based on observations, interviews, and record review; the facility failed to ensure food items were dated upon opening to prevent the potential for food borne illness, this had the potential to affect 85 of 85 residents who ate meals from the kitchen. The facility identified a census of 85.
Findings are:
An observation on 05/08/24 at 8:15 AM of the dry storage room, fridge, and freezer; during the initial kitchen walk-through, while accompanied by the DM (Dietary Manager), revealed that the following items were opened and undated:
1 bag of noodles
1 brown gravy mix packet
1 gallon of milk
1 box of apples
1 stalk of celery, wilted and lying on top of a box, not in baggie or container
1 bag containing cubed cheese
1 bag of sausage undated and out of original packaging
1 bag of roast beef undated and out of original packaging
1 bag of french fries undated and out of original packaging
1 bag of potato wedges undated and out of original packaging
An interview on 05/08/24 at 8:22 AM with the Dietary Manager (DM) confirmed that the items found in the fridge, freezer, and dry storage area all should have been dated upon opening and were not. During the interview, the DM confirmed that the celery should have been in a sealed container and was not.
A record review of the facility policy titled Food Storage and dated 2017 revealed the following guidance;
14. Refrigerated food storage
f. All foods should be covered, labeled, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3(1), 12-006.09D6(7)
Based on observations, record reviews and interviews, the facility failed to ensure indwelling catheter (a tube inserted into the bladder to drain urine) cares were performed in a manner to prevent urinary tract infections (UTIs) for Resident 63, failed to ensure the Continuous Positive Airway Pressure (CPAP-a machine that delivers just enough air pressure to a mask worn over the nose or mouth to keep the upper airway passages open) mask was cleaned daily, and failed to ensure the nasal cannulas (a device that delivers supplemental oxygen through a tube and into the nose) for Residents 36 and 175 were stored when not in use in a manner to prevent cross contamination. This affected 3 of 10 resident sampled for infection control. The facility census was 85.
Findings are:
A.
A review of the facility's Catheter Care policy implemented October 2023 revealed the following information:
6. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine, and
Male:
14. Gently grasp penis, draw foreskin back if applicable.
15. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap.)
16. With a new part of moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis.
17. With a new part of moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter.
A record review of Resident 63's Clinical Census page printed 05/13/2024 revealed the resident was admitted to the facility on [DATE], and admitted to hospice (end of life) services 03/12/2024.
A record review of Resident 63's Medical Diagnosis list printed 05/09/2024 revealed the resident had diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms (a condition in which the prostate becomes enlarged, but not cancerous, and puts pressure on the passage that allows urine to drain from the bladder), urinary tract infection (UTI), and urinary retention (inability to completely empty the bladder).
A record review of Resident 63's Significant Change of Status Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 03/20/2024 revealed a Brief Interview for Mental Status-(BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]) score of 09. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact.
An observation made on 05/14/2024 from 11:08 AM to 11:20 AM of catheter cares done on Resident 63 revealed the following:
Nurse Aide (NA) E and NA F both gathered supplies, performed hand hygiene, and put on a gown and gloves. NA F got a clean washcloth wet in a basin of water, applied a cleanser to the washcloth, and began performing cares. NA F first wiped around the shaft of the penis, then folded the washcloth and wiped the head of the penis around the urethral meatus (the opening in the penis), then folded the cloth again and wiped the catheter tubing from the urethral meatus moving away from the penis, and folded the washcloth again and wiped both sides of the resident's groin. NA F got a new washcloth wet, and used it to rinse the resident's penis and groin by first wiping the shaft of the penis, then the head around the urethral meatus, then down the catheter from the urethral meatus moving away from the penis, and last the groin, using a clean area of the washcloth with each area. Once cares were completed, NA E and NA F assisted Resident 63 to a seated position on the edge of the bed. NA E was holding the dependent drainage bag (the bag urine drains into) above the level of the resident's bladder during the process of repositioning the resident to a seated position.
A record review of Resident 63's discontinued and completed medications revealed the resident had been on the following antibiotics for UTIs:
-ciprofloxacin from 02/23/2024 to 02/25/2024, which was changed to levofloxacin from 02/26/2024 to 03/02/2024 after urine culture results were received;
-levofloxacin from 03/16/2024 to 03/20/2024; and
-cephalexin from 04/01/2024 to 04/06/2024.
A record review of Resident 63's Telephone/Verbal Order dated 04/15/2024 revealed an order for Macrodantin (an antibiotic) for UTI prophylaxis [prevention].
During an interview conducted on 05/14/2024 at 11:22 AM, NA E confirmed that Resident 63's dependent drainage bag should have been kept below the level of the bladder.
During an interview conducted on 05/14/2024 at 11:22 AM NA F confirmed that catheter cares should have been performed starting with the area directly around the urethral meatus.
During an interview conducted on 05/14/2024 at 1:08 PM the Director of Nursing (DON) confirmed that Resident 63's catheter cares should have been done starting at the urethral meatus and moving away from it, and that the dependent drainage bag should have been kept below the level of the bladder. The DON further confirmed that Resident 63 had a history of UTIs.
B.
A record review of the facility's Oxygen Administration policy dated 2023 revealed oxygen was administered to resident's who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen would be administered under orders of a physician. Infection control measure included keeping the delivery devices secured off the floor or bag when not in use.
A record of Resident 36's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility 12/01/2023.
A record review of Resident 36's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity with Alveolar Hypoventilation (obesity caused low air flow in the lungs), Pulmonary Hypertension, Unspecified (high blood pressure in the lungs), Obstructive Sleep Apnea (Adult)(Pediatric) (airway closing during sleep), and Sepsis, Unspecified Organism.
A record review of Resident 36's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/05/2024 revealed the resident had Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) score of 15 of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with upper and lower body dressing, and footwear and needed partial/moderate assistance with personal and oral hygiene and toileting. The MDS revealed Resident 36 was on oxygen while a resident.
A record review of Resident 36's Care Plan with an admission date of 12/01/2023 revealed the resident had an intervention of oxygen 3 l/m (liters per minute) inhalation every shift. Titrate to keep sats (oxygen blood saturation levels) > (greater) 88% (percent). Do not exceed 4 liters.
An observation on 05/13/2024 at 7:27 AM revealed Resident 36's oxygen nasal cannula (tubing used to deliver oxygen to the nose) was curled on a circle and placed on the resident's blanket on the bed with the prongs (the part that is inserted in the nose) touching the blanket. The empty bag was hanging on the oxygen concentrator (a machine used to purify oxygen).
An observation on 05/14/2024 at 7:01 AM revealed Resident 36's oxygen nasal cannula was curled on a circle and placed on the resident's blanket on the bed with the prongs touching the blanket. The empty bag was hanging on the oxygen concentrator.
An observation on 05/14/2024 at 8:39 AM with the Director of Nursing (DON) revealed Resident 36's oxygen nasal cannula was curled on a circle and placed on the resident's blanket on the bed with the prongs touching the blanket. The empty bag was hanging on the oxygen concentrator.
In an interview on 05/14/2024 at 8:39 AM, the DON confirmed the oxygen nasal cannula had been curled up and placed on the resident's blanket on the bed and the prongs were toughing the blanket. The DON confirmed the prongs should not have been touching the blanket and that the tubing should have been placed in the bag on the oxygen concentrator.
C.
A record review of the facility's Noninvasive Ventilation policy dated 2023 revealed the facility would provide noninvasive ventilation as per physician's orders and current standards of practice.
A record review of ResMed's How to clean your Continuous Positive Airway Pressure (CPAP) equipment dated 2024 revealed mask seals (the portion that touched a resident face) should be completed daily. https://www.resmed.com/en-us/sleep-apnea/cpap-parts-support/cleaning-cpap-equipment/
A record of Resident 36's Clinical Census dated 05/14/2024 revealed the resident was last admitted to the facility 12/01/2023.
A record review of Resident 36's Medical Diagnosis dated 05/14/2024 revealed the resident had diagnoses of Obstructive Sleep Apnea (Adult)(Pediatric), Morbid (Severe) Obesity with Alveolar Hypoventilation, Pulmonary Hypertension, Unspecified, Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, and Sepsis, Unspecified Organism.
A record review of Resident 36's MDS dated 04/05/2024 revealed the resident had BIMS score of 15 of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with upper and lower body dressing, and footwear and needed partial/moderate assistance with personal and oral hygiene and toileting. The MDS revealed Resident 36 was on non-invasive mechanical ventilator while a resident, but it did not indicate if it was a CPAP or BiPAP (a machine used to treat sleep apnea with an inspiratory and expiratory setting).
A record review of Resident 36's Care Plan with an admission date of 12/01/2023 revealed the resident had an intervention of CPAP every night (QHS) as ordered.
An observation on 05/08/2024 at 11:29 AM revealed Resident 36 had a Positive Airway Pressure device (PAP) on the table to the left side if the recliner and the mask was draped over the table and had an oily film on the seal.
An observation on 05/13/2024 at 7:27 AM revealed Resident 36's PAP was on the bedside table with the mask draped over the table and an oily film on the resident's mask seal. The PAP's filter had a gray fuzzy substance on it.
An observation on 05/14/2024 at 8:39 AM revealed Resident 36's PAP was on the bedside table with the mask draped over the table and an oily film on the resident's mask seal. The PAP's filter had a gray fuzzy substance on it.
In an interview on 05/08/2024 at 11:29 AM, Resident 36 confirmed the resident did use a CPAP every night and the staff does not clean the PAP mask or supplies.
In an interview on 05/14/2024 at 8:39 AM, the DON confirmed Resident 36's PAP mask was draped over the table to the left of the recliner with an oily film on the seal and the filter had a gray fuzzy substance on it. The DON confirmed that the mask seal and filter were not cleaned and should have been.D.
Record review of Resident 175's medical record revealed the resident admitted to the facility on [DATE] with the medical diagnosis of: heart disease.
Record review of Resident 175's Baseline Care Plan dated 4/30/24 revealed the resident is a one assist with bed mobility, transfers and ambulation. Resident requires setup help only for eating, personal hygiene and bathing support. Resident uses a walker and a wheelchair. Resident is alert and cognitively intact. Resident planning to discharge home after rehabilitation. Oxygen at 2 liters per nasal cannula (NC) at night.
Record review of Resident 175's Order Summary Report revealed physician order for Oxygen at 2 liters per nasal cannula every evening and night shift with start date of 4/30/2024.
Record review Resident 175's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2024 and May 2024 (May 1, 2024 through May 9, 2024 at 2:25 PM) revealed: Order dated 5/15/2024 to change oxygen tubing monthly on night shift every night shift starting on the 15th and ending on the 16th every month. No documentation of oxygen tubing being changed.
Order dated 4/30/2024 for Oxygen at 2 liters per nasal cannula every evening and night shift reveals oxygen administered per order.
An observation on 5/08/24 at 11:06 AM revealed an oxygen concentrator in Resident 175's room not running. Oxygen tubing dated 4/30/24. Oxygen nasal cannula and tubing not bagged. Nasal cannula was touching the oxygen concentrator.
An observation on 5/13/24 at 8:35 AM revealed oxygen concentrator in Resident 175's room not running. Oxygen tubing was not dated. Oxygen nasal cannula and tubing not bagged. Nasal cannula was touching the oxygen concentrator.
An observation on 5/13/24 at 10:02 AM revealed oxygen concentrator in Resident 175's room not running. Oxygen nasal cannula and tubing stored in a clear zipped bag dated 5/13/2024 hanging from the oxygen concentrator.
An interview with Resident 175 on 05/13/2024 at 10:02 AM confirmed that the resident uses 2 liters of oxygen at night every night.
On 05/14/24 12:10 PM an interview with Director of Nursing (DON) confirmed that the oxygen nasal cannula should not be touching anything except for the patient (nares) and the inside of the oxygen storage bag. DON confirmed that facility policy is oxygen nasal cannulas, and the tubing is to be changed on the 15th of the month and is documented on the Treatment Administration Record.
A record review of facilities Oxygen Administration Policy of Date Implemented 2023 revealed:
Guideline: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.
Explanation and Compliance Guidelines include # 5 Infection Control Measures include:
a. Follow manufacturer recommendations for the frequency of cleaning equipment filters.
b. Change oxygen tubing and mask/cannula monthly and as needed if it becomes soiled or contaminated.
c. Change humidifier bottle monthly and as needed. Use only sterile water for humidification.
d. Keep delivery devices secured off the floor or bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
Licensure Reference Number 175 NAC 12-006.04C3a(6)
Based on interview and record review, the facility staff failed to notify 1 (Resident 60) of 3 sampled residents representative of an injury. The facility identified a census of 80.
Findings are:
On 6-14-2023 at 12:35 PM an interview was conducted with Resident 60's representative. During the interview Resident 60's representative reported being notified on 6-11-2023 that Resident 60 had struck a staff member during cares on 6-6-2023.
A record review of facility's incident report dated 6/6/23 revealed Resident 60 received bruises to right hand and to right forearm while being resistive to cares.
A record review of Resident 60's skin observation sheet dated 6/6/23 revealed bruising to back of Resident 60's right hand that measured 6.0 centimeters (cm) in length by 5.0 cm in width and bruising to right forearm measuring 2.0 cm in length by 2.0 cm in width.
A record review of Resident 60's Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 5/15/23 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 9.
A record review of the facility policy titled Notification of Changes, dated 2023, revealed the following:
-Compliance Guidelines: The facility must inform the resident and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances of notification include: 1. Accidents resulting in injury.
Interview on 6/20/23 at 3:41 PM with Director of Clinical Services (DCS) confirmed the resident representative of Resident 60 was not notified of the incident until 6/11/23 and should have been notified when it happened.
Interview on 6/21/23 at 10:54 AM with (Registered Nurse) RN-A confirmed Resident 60's representative was not notified the day of the incident and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7
Based on observation, interview, and record review the facility failed to ensure a non-slip material was placed above and below a pressure relieving cushion in the recliner to prevent a fall for 1 (Resident 47) of 6 sampled residents. Total facility census was 80.
Findings are:
A record review of Resident 47's Clinical Census dated 06/21/2023 revealed the resident was admitted to the facility 09/08/2021, was discharge to the hospital on [DATE], and was re-admitted to the facility on [DATE].
A record review of Resident 47's most recent Minimum Data Set (MDS)(an assessment tool that measures the health status of nursing home residents) dated 04/04/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 5, The resident was a 2 person physical assist with bed mobility (moving), transfers, dressing, toilet use, and personal hygiene (cleaning), and was a 1 person assist with eating. The resident was not on a toileting program and is often frequently incontinent (lack of voluntary control) of urine and occasionally incontinent of bowels. The MDS did reveal the resident had a history of falls and the resident was at risk for developing pressure ulcers injury to the skin or tissues from prolonged pressure on the skin. The resident did have diabetic foot ulcers.
Record review of Resident 47's Progress Notes dated 06/20/2023 revealed Resident 47 had fallen 04/16/2022, 04/24/2022, 11/10/2022, and 06/06/2023.
A record review or Resident 47's Clinical Physician's Orders dated 06/21/2023 revealed the resident had a Fall Intervention (action taken to improve a situation) Nursing order to apply Dycem (a non-slip material) on top and bottom of the cushion in the resident's recliner to prevent sliding. That Fall Intervention was added 04/25/2023.
An observation of the Resident 47's mechanical transfer on 06/15/2023 at 11:06 AM revealed the resident was raised from the recliner, the pressure relieving cushion was in the recliner, but the observation did not reveal Dycem on the bottom or top of the cushion.
An observation of the Resident 47's mechanical transfer on 06/20/2023 at 1:10 PM revealed the resident was raised from the recliner, the pressure relieving cushion was in the recliner, but the observation did not reveal Dycem on the bottom or top of the cushion.
In an interview with the Director of Nursing (DON) on 06/20/2023 at 1:14 PM, the DON confirmed there was not Dycem on the top or bottom of the pressure relieving cushion.
An observation of the Resident 47's mechanical transfer on 06/21/2023 at 11:22 AM revealed the resident was raised from the recliner, the pressure relieving cushion was in the recliner, but the observation did not reveal Dycem on the top of the cushion.
In an interview on 06/21/2023 at 11:22 AM, the DON confirmed there was not Dycem on top of the pressure relieving cushion.

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) pain medication for 1 (Resident 43) of 5 sampled residents. The facility census was 80.
Findings are:
Review of Resident 43's medical diagnosis list, dated 6-15-23, revealed the following diagnoses: Type 2 Diabetes Mellitus with Diabetic Autonomic (Poly)neuropathy, Personal History of Traumatic Fracture, Bilateral Primary Osteoarthritis of Knee, Personal History of Malignant Neoplasm of Breast, Spinal Stenosis, Cervical region, and Age-Related Osteoporosis without Current Pathological Fracture.
Review of Resident 43's active orders, dated 6-15-23, revealed the following PRN pain medication orders:
-Morphine Solution (narcotic medication given to treat moderate to severe pain) 20 milligram(mg)/milliliter (ml), give 0.25ml (5mg) by mouth/sublingually (under the tongue) every 2 hours as needed (Indications for use: pain/dyspnea (difficulty breathing))
-Acetamin (APAP-medication given to treat minor pain) tablet (tab) 500mg, take 2 tablets (1000mg) by mouth every 6 hours as needed for headache *do not exceed 4grams (gm) APAP* (Indications for use: Pain)
-Pain Relievr Tab Plus (medication used to treat pain) take 1 tablet by mouth every 24 hours as needed for headache (Indications for use: headache/migraine)
-Pain Relievr Tab Plus take 2 tablets (500/500/130mg) by mouth every 24 hours as needed *contains 250mg APAP/250mg Aspirin// 65 mg caffeine per tablet*max 4gm APAP/24 hours* (Indications for use: Headache/Migraine)
-Rizatriptan Tab (medication used to treat migraine headaches) 10mg take 1 tablet by mouth at onset of migraine *may repeat once in 2 hours. Maximum of 2 tablets in 24 hours*
Review of Resident 43's Comprehensive Care Plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 6-15-23, revealed the following:
-Focus: Resident 43 has a potential for alteration in comfort due to Osteoarthritis (OA), osteoporosis, spinal stenosis. Other pertinent diagnoses include status post adult hypertrophic pyloric stenosis, atrial fibrillation, reflux, anxiety, depression, hypertension, edema. Resident 43 is alert, usually oriented. Date initiated 8-21-18, Revision on: 12-22-20.
-Intervention: Offer/assist with nonpharmacological interventions PRN: i.e., rest, repositioning, redirection, back rubs, spiritual support, therapy interventions, deep breathing, music, providing for basic needs. Date Initiated 8-21-18, Revision on 12-22-20.
Review of Resident 43's April 2023, May 2023 and June 1-21-2023, Medication Administration Record (MAR) revealed the following related to PRN use of Morphine, APAP, Pain Relievr, and Rizatriptan:
-Morphine: 20 doses
-APAP: 26 doses
-Pain Relievr Tab (one or two tabs): 7 doses
-Rizatriptan: 10 doses
Review of Resident 43's electronic health record and paper chart revealed that nonpharmacological interventions had not been attempted prior to administration of a PRN pain medication from April-June 21-2023.
In an interview on 6-16-23 at 12:45 PM, Medication Aide (MA)-C confirmed that nonpharmacological interventions are to be attempted prior to administration of a PRN pain medication and that the attempted nonpharmacological interventions are to be documented in the progress notes.
In an interview on 6-20-23 at 1:23 PM, the Director of Clinical Services revealed that the facility was unable to find documentation that nonpharmacological interventions had been attempted prior to administration of a PRN pain medication for Resident 43 from April-June 21, 2023.

Licensure Reference Number 175 NAC 12-006.17D
Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (sanitizing) using hand sanitizer or wash hands with soap and water for at least 20 seconds to prevent cross contamination for 1( Residents 47) of 3 sampled residents . The facility census was 80.
Findings are:
A record review of the facility's Hand Hygiene Policy and Procedure with a revised date of 03/06/2020 revealed the staff should have performed hand hygiene:
•
Before and after direct resident care
•
Moving from a contaminated (to make unpure or clean) body site to a clean body site
•
After touching potentially contaminated items
•
Before putting on and after removing gloves
The hand washing procedure was to wet hands and wrists under running water, apply soap, and rub hands together for 20 seconds, then rinse hands.
A. A record review of a hospital Wound Healing Visit Report dated 06/19/2023 revealed Resident 47 had a history of Diabetes Mellitus Type II (a condition that affects the way the body processes blood sugar) and was evaluated and treated for bilateral hand wounds. The resident was found to have a small open skin tear on the back of the left hand near the left wrist, 2 open skin tears on the back of the right hand, and an open skin tear on the left elbow.
A record review of Resident 47's Clinical Physician's Orders Dated 06/21/2023 revealed there was a wound order for staff to apply double layer of Xeroform (a petrolatum-based fine mesh used to treat wounds) to bilateral (right and left) hand wounds and to left elbow, cover with gauze, and secure with rolled gauze and tape daily to be done every day.
An observation of wound care on Resident 47's left hand, right hand, and left elbow on 06/20/2023 at 6:36 AM revealed Registered Nurse (RN)-E moved items and placed supplies on the bedside table without cleaning the surface or placing a barrier. RN-E then put gloves on, without performing hand hygiene, and removed Resident 47's dressing on the left hand, right hand, and left elbow. RN-A then cleaned the wounds with saline (a mixture of salt and water). RN-E then removed the soiled gloves and put new gloves on without performing hand hygiene. RN-E took a folded piece of Xeroform and placed it on the wound on Resident 47's left elbow,covered the Xeroform dressing with a 4-inch by 4-inch dressing (4x4), and wrapped the elbow with Kerlix (a long gauze dressing used to wrap around a body part) then tape the ZKerlix. RN-E then opened another package of Xeroform that was on the resident's bedside table, cut a piece of Xeroform with the scissors that had been laying on the bedside table, folded and placed the Xeroform on the back of Resident 47's left hand without performing hand hygiene or changing the soiled gloves. RN-E placed a 4x4 over the Xeroform on the residents left hand, wrapped with Kerlix, and taped the Kerlex RN-E then opened the package of Xeroform laying on the bedside table and cut 2 pieces of the Xeroform with the scissors from the bedside table. RN-E did not perform hand hygiene or change the soiled gloves. RN-E then folded and placed the Xeroform on the 2 wounds on the back of Resident 47's right hand. RN-E placed a 4x4 over the Xeroform and wrapped with Kerlix and then tape. RN-E then removed gloves and did placed trash in a trash bag and delivered to the soiled utility room where RN-E turned on the water and washed hands for 6 seconds.
In an interview on 06/20/2023 at 10:00 AM, the Director of Nursing (DON) confirmed that RN-E should have performed hand hygiene after removing the gloves and putting a new pair on, and from going from soiled dressings to clean dressings. The DON confirmed that RN-E should have performed hand hygiene and replaced gloves after touching the potentially contaminated Xeroform packaging. The DON confirmed RN-E should have performed hand hygiene and changed gloves between each wound site and should have washed hands with soap and water for at least 20 seconds after removing gloves and disposing of trash following Resident 47's wound care.