Good Shepherd Lutheran Community

Inspectors wroteLicense Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review the facility failed to implement interventions to prevent potential accidents for 3 (Residents 37, 55, and 57) of 3 sample residents. The facility census was 62.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the facility census, the total number of hours worked per discipline per shift and the total number of hours worked for the each shift. This had the potential to affect all residents that resided in the facility. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11 Based on observation, interview, and record review the facility failed to ensure hand hygiene was completed between 2 (Residents 58 and 62) of 2 sampled residents during dining service and failed to perform hand hygiene when indicated during food prep. This had the potential to affect all residents but 1 resident in the facility. The facility census was 62.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the facility assessment included information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff and a contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care. This had the potential to affect all residents that resided in the facility. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews and interviews, the facility failed to ensure staff performed hand hygiene between glove changes and during cares for 4 (Residents 4, 18, 14, and 37) of 5 residents observed, wore gloves during cares on 2 (Residents 37 and 14) of 5 residents observed, ensure staff donned the required Personal Protective Equipment (PPE) before entering 3 (Residents 4, 37 and 14's) 6 EBP rooms observed, ensure respiratory supplies where cleaned and protected on 2 (Residents 4 and 55) of 3 residents observed, and failed to use an applicator during catheter care on 1 (Resident 18) of 1 resident observed, all to prevent cross contamination. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006(F)(i)(5)Based on interview and record review the facility failed to notify the provider of weight change greater than 5 pounds on 1 (Resident 7) of 2 sampled residents. The facility census was 62.

Inspectors wroteLicense Reference Number 175 NAC 12-0060.02(G)(H)Based on interviews and record reviews the facility failed to complete a thorough fall investigation for 1 (Resident 57's) of 1 sample resident. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on interview and record review, the facility failed to add oxygen interventions to 1 (Resident 22) of 2 sampled resident's Comprehensive Care Plan (a detailed roadmap outlining a resident's medical, physical, and daily living needs). The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on observation, record review and interview, the facility failed to follow practitioner orders to obtain a urinalysis for 1 (Resident 41) of 3 residents sampled, failed to follow physician orders to notify provider of oxygen saturation less than 90% for 1 of (Resident 22) of 2 residents sampled, and failed to obtain daily weights and notify the provider of a 5 pound or greater weight gain for 1 (Resident 7) of 2 residents sampled. The facility identified a census of 62.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.10(D)The facility failed to prevent significant medication errors for 2 Residents (2 and 6) of 13 Residents sampled. The facility identified a census of 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S)Based on observation and interview; the facility staff failed to ensure privacy during care for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1)Based on observation, interview and record review the facility failed to ensure two of three medical air mattresses for pressure relief (mattresses designed to prevent and treat bedsores by inflating/deflating air cells to redistribute pressure and improve circulation) were inflated in accordance with the residents' weight (Resident 2 and Resident 3). The facility had a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18Based on observation and interview, the facility failed to ensure that wound care was being provided to residents in a manner that would prevent cross contamination of the wounds for 3 of 3 residents surveyed (Residents 2, 3 and 4). The facility had a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11 E The facility failed to ensure hand hygiene and gloving were performed in a manner to prevent the potential for food borne illness and failed to maintain the cleanliness and condition of shelving units, serving windows, equipment, floors, ventilation systems, and storage carts in the facility kitchen. This had the potential to affect 66 residents in the facility that ate foods prepared in the facility kitchen. The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B) Based on record review observation, and interview, the facility staff failed to implement measures to prevent the potential contamination of resident supplies that affect all residents in the facility, the facility staff failed to change oxygen tubing per practitioner's order for Resident 26, and the facility failed to follow enhanced barrier precautions for Resident 50. The facility identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19A Based on record review, observation and interview, the facility failed to repair leaks in the facility's roof. This had the potential to affect all residents that resided in the facility. The Facility identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04 D Based on observation, record review and interview; the facility failed to ensure a working ventilation system in 20 (302, 303, 304, 305, 306, 307, 308, 310, 311, 400, 401, 402, 404, 405, 406, 407, 408, 409, 410, 411) of 28 occupied resident rooms on the 300 and 400 halls in the facility. The total number of occupied resident rooms in the facility was 52. The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews; the facility failed to notify the medical practitioner and family of 1 (Resident 52) of 5 residents sampled for refusal to take medications. The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on record reviews and interview; the facility failed to ensure a rationale was documented for the continued use of PRN (as needed) antianxiety medication for 1 (Resident 42) of 5 sampled residents. The facility staff identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.02(8) Based on record review and interview; the facility failed to report an allegation of resident-to-resident abuse within the required timeframe to Adult Protective Services (APS) for 1 (Resident 119) of 4 facility self-report investigations reviewed. The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 Based on record review and interview; the facility failed to notify the resident and resident representative in writing of the reason for hospital transfer for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(ii) Based on record review and interview; the facility failed to develop a comprehensive care plan within 7 days of the completion of the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 219) of 21 sampled residents. The facility staff identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications administered revealed two errors resulting in a medication error rate of 8%. The medication errors affected 2 (Resident 39 and Resident 42) of 4 sampled residents. The facility staff identified a census of 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure residents were free of significant medication errors. This affected 1 (Resident 45) of 4 sampled residents.

Inspectors wroteBased on record review and interview; the facility failed to ensure that the designated infection preventionist was certified. This had the ability to affect all residents in the facility. The facility claimed a census of 70.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, interview and record review; the facility failed to position a catheter bag in a manner to prevent the potential for cross contamination for 1 (Resident 20) of 2 residents observed with urinary catheters. The facility census was 70.

Inspectors wroteLicensure reference: 175 NAC 12-006.04C3a(6). Based on record review and interview, the facility failed to notify responsible party of weight loss for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 69 residents.