Mother Hull Home

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(D)Based on observation, interview, and record review the facility failed to follow approved recipes when preparing resident foods and failed to ensure food temperature was maintained for hot food at or above 135 degrees Fahrenheit. This had the potential to affect all the residents receiving food items from the kitchen. The facility census was 45.

Inspectors wroteLicensure Refrence Number 175 NAC 12-006.11 Based on observation, record review, and interview, the facility failed to complete hand hygiene using the approved technique during meal preparation. This had the potential to affect all of the residents receiving food stuff from the kitchen. The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on record reviews, observations and interviews, the facility failed to provide adequate indications for use consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals and a documented clinical rationale for administering an antipsychotic medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any safer treatments have been deemed clinically contraindicated for 2 of 5 sampled residents (Resident 5 and Resident 11). The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(3)Based on record review, and interview the facility failed to evaluate and monitor resident skin issues for 2 (Resident 4, and Resident 7) of 2 sampled residents. The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (H)(iii)(1) and (2)Based on observation, record review, and interview the facility failed to assess and monitor pressure related skin issues to ensure documentation of wound healing or decline for 2 residents (Resident 1 and Resident 6) of 2 sampled residents, failed to ensure the settings for a specialty low air loss mattress were at the correct setting to promote healing of a pressure related wound for 1 resident (Resident 6) of 2 sampled residents and failed to cleanse pressure related wounds per professional standards of practice to promote healing for 1 resident (Resident 6) of 2 sampled residents. The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to ensure a medication error rate of less than 5% with an observed medication error rate of 8% (25 medication administration observations and 2 errors). This affected 2 of 7 residents observed (Residents 28 and 53). The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to ensure that residents were free of significant medication errors for 2 of 7 residents observed (Residents 28 and 53). The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 1-005.06(F)Based on observation, record review, and interview the facility failed to ensure that staff disinfected medication administration equipment as required for 1 of 2 residents observed (Resident 28); and the facility failed to ensure that hand hygiene was performed between glove changes during wound care for 1 resident (Resident 6) to prevent the potential for cross contamination. The facility census was 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19 Based on observation and interview, the facility failed to ensure a clean and sanitary environment in resident's bathrooms for 5 (rooms 9, 11, 16, 18, and 23 ) of 12 sampled rooms and failed to ensure hand sanitizer dispenser was working for 1 (Resident 23) of 49 sampled residents with a facility census of 49.

Inspectors wroteLicensure Reference Number 12-006.09(H)(iii) Based on record reviews, interviews, and observations, the facility failed to ensure interventions for constipation were put into place to promote bowel movements for 2 (Residents 6, and Resident 12) of 5 sampled residents, and the facility failed to provide wound care that prevented cross contamination for 1 (Resident 14) of 1 sampled residents. The facility census was 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the 5 rights of medicaiton administration for 4 residents, (Resident 14, 199, 26, and 34) of 8 sampled residents. This made an error rate of 16.13 %. The facility census was 49. A. Record review of Resident 14's Physician Orders dated 12/16/24 revealed Resident 14 had a physician order to apply Diclofenac Sodium which is a topical pain relief or analgesic cream. Directions to apply 2 grams to both resident's knees and lower back three times a day. In an observation on 12/17/24 at 11:30 AM with Registered Nurse-B(RN-B) revealed RN-B with a gloved hand used their fingers to scrape a clear thick gel like substance from a clear medication cup that was sitting on Resident 14's bed side table. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that resident assessments were coded incorrectly for hypoglycemic and antiplatelet on the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes to create individualized care plans based on their specific needs) . This affected 2 residents (Residents 6 and 12) of 3 sampled residents. The facility census was 49.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(E) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review, and interview, the facility failed to ensure that staff wore both a gown and gloves during resident care as required for Enhanced Barrier Precautions (An infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6(7) The facility failed to ensure respiratory equipment was cleaned and stored in a manner to prevent the potential for cross contamination related to oxygen tubing when not in use for 3 residents (Residents 2, 6, and 22) of 4 sampled residents and related to the CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask for 1 resident (Resident 36) of 1 sampled residents. The facility identified a census of 46. Findings Are: A record review of the undated facility policy titled Oxygen Safety read as follows: 7. Oxygen tubing shall be monitored for cleanliness, monitored to assure tubing is not kinked, that it does not touch the floor, and is properly stored when not in use. Tubing is change weekly by nursing staff. A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure that dietary sanitizer solution (a substance or preparation for killing germs on food-processing surfaces and equipment) was at the required concentration (The amount of the sanitizer (chemical) in the water. Too high of a concentration is toxic, and too little will not ensure sanitation) to prevent the potential for foodborne illness. This affected all 46 residents that ate food prepared by the facility kitchen. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview, the facility failed to perform hand hygiene to prevent the potential for food borne illness during meal service, which had the potential to affect 46 residents; and failed to ensure a resident had a cleanable sleeping surface for infection prevention for 1 resident (Resident 6). Facility stated census of 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D3(1) Based on observation, record review, and interview, the facility failed to provide perineal care (which is cleansing of the genatalia of a resident) in a manner to prevent cross contamination of 2 sampled residents (Resident #5 and Resident #14). The facility census was 46.