Every finding on record at Ambassador Health of Lincoln

The facility failed to wear appropriate Personal Protective Equipment (PPE) during gastric-tube medication administration for Resident 24 and gastric-tube feeding for Resident 98; and the facility failed to ensure oxygen tubing was appropriately stored for Resident 47, nebulizer mask, chamber and tubing were cleaned and stored in a manner to prevent cross contamination for Resident 16 and Resident 77; and the facility failed to ensure the laundry cart was covered during delivery; and the facility failed to ensure clean water pitchers were provided.Nebraska Licensure Reference Number 175 NAC 12-006.18 and 175 NAC 1-005.06 The findings are: A. Record review of facility policy on Infection Control Guidelines for All Nursing Procedures with the effective date of 08/2025 revealed Enhanced Barrier (Based) Precautions (EBP) including gowns will be utilized during high contact activity. Record review of facility policy on Infection Control & Isolation Guidelines for All Departments dated 8/2025 revealed Enhanced Barrier Precautions (EBP) are to be used in conjunction with standard precautions and expands the use of PPE (Personal Protective Equipment, undefined in facility procedure) to donning (putting on) of gown and gloves during high-contact activities, which includes cares related to a feeding tubes. Record review revealed a facility document entitled EBP Residents lists Resident 89. Observation on 5/11/2026 at 12:15 PM reveals that Resident 89 resides in a single room and had the EBP sign (enhanced barrier precautions) on the door frame leading into Resident 89's room. Observation on 05/11/2026 at 12:28 PM with LPN-I administering Resident 89's feeding via gastric tube without wearing a gown. Interview with LPN-I on 05/11/2026 at 12:40 PM confirmed that a gown should have been worn while administering Resident 89 feeding through a gastric tube. B. During an observation on 05/07/2026 at 9:00 AM Medication aide (MA-A) administered gastric tube (g-tube-a flexible medical device inserted through the abdomen into the stomach to deliver nutrition, fluids, and medication directly used for patients unable to swallow or eat enough food safely) medications to Resident 24 without wearing a gown. Record review of the facility's Infection control and Isolation guidelines for all departments with effective date of 08/2025 stated that EBP is indicated for residents with any of the following: wounds include but not limited to chronic wounds, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. Indwelling medical devices that require use of EBP during high contact resident care activities include urinary catheters, central lines, feeding tubes, and tracheostomies. During an interview on 05/07/2026 at 3:15 PM MA-A confirmed that MA-A should have worn a gown when administering medications through the G-tube for Resident 24. During an interview on 05/07/2026 at 3:25 PM Rehab nurse (RN-C) confirmed that when administering G-tube medications that a gown should be worn. Observation on 05/06/2026 at 11:37 AM revealed Resident 16's dated oxygen and nebulizer tubing laying over Resident 16's bed side nightstand with fluid observed in the nebulizer chamber. Nebulizer mask and tubing remained attached to the nebulizer machine. Observation on 05/07/2026 at 6:56 AM revealed Resident 16's nebulizer tubing, mask and chamber remain connected to nebulizer machine with fluid observed in the nebulizer chamber. C. Observation on 05/07/2026 at 9:00 AM revealed Resident 16 working with a speech therapist with their oxygen on. Further observation revealed Resident 16's nebulizer tubing, mask and chamber remain connected to nebulizer machine with fluid observed in the nebulizer chamber. Observation on 05/11/2026 at 8:42 AM revealed Resident 16's nebulizer tubing, mask and chamber remain connected to nebulizer machine with fluid observed in the nebulizer chamber. Record review of the facility's Departmental (Respiratory Therapy)-Equipment Storage Policy last reviewed on 06/2025 revealed that nebulizer equipment should store the circuit (nebulizer equipment) in a plastic bag between uses and to mark the bag with the date and resident's name. Interview on 05/11/2026 at 2:30 PM RN-B confirmed that the chamber mask for Resident 16 should have been rinsed after use and stored in a plastic storage bag and wasn't. In an interview on 05/11/2026 at 2:55 PM Rehab nurse (RN-C) confirmed that the nurses on the floor are to ensure the residents complete the breathing treatment and properly rinse the mask and chamber and allow them to dry on a paper towel. D. Record review of the Medication: Aerosol Administration (Nebulizer Treatment) policy dated 08/2025 revealed that once the treatment was completed, the nebulizer should be dismantled, rinsed with tap water and placed in a clean place to air dry. Record review of the Departmental (Respiratory Therapy)- Equipment Storage Policy dated 06/2025 revealed nebulizers circuit should be stored in a plastic bag between uses, with date and resident's name. Record review of the Treatment Administration History with treatment dates of 04/12/2026-05/11/2026 revealed that Resident 77 had a scheduled dose of albuterol sulfate for nebulization 1.25mg/3ml vial that they received twice daily with 12 documented refusals. There were special instructions within the order to empty any remaining medication, rinse nebulizer canister with water and let air dry after every use. The administration record revealed that the nebulizer treatments had been administered throughout the observation period, indicating that the nebulizer should have been cleaned and stored to prevent contamination. An observation on 05/06/2026 at 7:52 AM revealed Resident 77 in their room having just completed their nebulizer treatment and the nebulizer tubing and chamber (assembled) placed by housekeeping in the recliner upon exit of the room. The nebulizer machine was stored in the recliner. No bag noted. An observation on 05/06/2026 at 12:55 PM, Resident 77 was lying in their bed, the nebulizer machine with the tubing and chamber (assembled) continued to lay uncontained and exposed to contaminated surfaces in the recliner. The nebulizer chamber and tubing had been moved from the last observation. There was a plastic bag noted, but nothing inside the bag. An observation on 05/07/2026 at 7:19 AM, Resident 77 was in bed, revealed the nebulizer machine, with the tubing loose, and chamber (assembled) uncontained sitting in the recliner on top of a bag. An observation on 05/11/2026 at 9:18 AM, Resident 77 was in bed, revealed the nebulizer machine, tubing laid across the recliner, and chamber (assembled) uncontained in the recliner, with no bag noted. An interview on 05/11/26 at 12:35 PM with the Interim Director of Nursing (IDON) confirmed that the expectation of nebulizer storage would be to refer to the policy, but it should be cleaned out and stored in a clean place. E. An observation on 05/06/2026 at 8:16 AM of laundry cart not covered on station 2 while laundry staff was passing out clean laundry to residents. During an interview on 05/06/2026 at 8:17 AM Laundry aide (L) – J confirmed that the laundry cart should be covered. Record review of the facility policy titled Laundry Storage, Collection and Transportation dated 2/2024 revealed that all laundry transported throughout the facility will be done in an approved cart and covered to ensure cleanliness and to protect from dust and soil during transport and unloading. F. During an interview on 05/06/2026 at 10:48 AM Resident 47 revealed the staff just refill the water pitchers and cups, they never change them out for clean ones. They are gross and smell. An observation on 05/06/2026 at 10:49 AM revealed a dirty water pitcher (visibly dirty) on Resident 47's tray table. During an interview on 05/11/2026 at 9:39 AM Resident 47 confirmed that (gender) wrote the room number on the cup about a year ago and it was the same cup and there was only a little bit of water in their cup last night and that was the same water in the cup this morning. Record review of the facility policy titled Water Distribution dated 2018 revealed: -changing of water pitchers will be completed every 24 hours -and fresh water shall be provided at least every 24 hours -nursing staff staff shall ensure personal cups are emptied, cleaned and refilled as needed. If a resident's personal cup is unavailable, soiled or not suitable for use a clean facility cup shall be provided During an interview on 05/12/2026 at 7:16 AM the Dietary Manager (DM) confirmed that the resident's water pitchers are not changed out and washed in the kitchen routinely. During an interview on 05/12/2026 at 7:27 AM the Infection Preventionist (IP) was unaware if the resident's water pitchers get changed out and cleaned everyday. G. An observation on 05/06/2026 at 11:00 AM revealed an oxygen tank in Resident 47's room on 4 wheeled walker with tubing hanging off the handle. An observation on 05/7/2026 at 8:42 AM revealed an oxygen tank in Resident 47's room with tubing hanging over walker handle. Review of the facility policy titled Equipment Storage Policy dated June 2025 revealed to keep oxygen cannula and tubing in a plastic bag when not in use. During an interview on 05/12/2026 at 7:28 AM the Infection Preventionist (IP) confirmed that oxygen tubing and nasal cannulas must be in a plastic bag when not in use.

Licensure Reference Number 175 NAC 12-006.11E Based on record review, observation, and interview, the facility failed to ensure kitchen staff wore hair restraints to contain all head and facial hair, failed to perform hand hygiene prior to food service and between contact with contaminated surfaces, failed to distribute beverages under sanitary conditions, and failed to have hair restrained during food distribution from the dining room in order to prevent the potential for food born illness for 69 of 83 residents that were served out of the kitchen. The facility census was 83. Findings are:Record review of the U.S. Food and Drug Administration Food Code 2022 Hair Restraint 2-402.1 food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.Record review of facility Responsibilities for Meal Service policy dated 10/2025 revealed that dietary personnel assemble each tray or place setting using sanitary food handling techniques.Record review of the U.S. Food and Drug Administration Food Code 2022 When to Wash 2-301.14 food employees shall clean their hands as specified immediately before engaging in food preparation with exposed food and:-after touching bare human body parts other than clean hands and clean, exposed portions of arms-as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks-before donning (applying) gloves to initiate a task that involved working with food-after engaging in other activities that contaminated the hand An observation on 05/07/2026 at 11:47 AM in the kitchen revealed Dietary Aide (DA) during the food preparation with their hair on their shoulders out of their hat and not contained.An observation on 05/07/2026 at 11:49 AM was in the kitchen revealed [NAME] without a beard net in place and visible facial hair was noted.An observation on 05/07/2026 at 12:01 PM was in the kitchen of the [NAME] with a beard net on but not in place and below the chin not covering the facial hair.An observation on 05/07/2026 at 12:04 PM of the [NAME] doffing (removing) gloves, picked up an item off the floor, did not perform hand hygiene, and donned (put on) new gloves.An observation on 05/07/2026 at 12:14 PM of Medication Aide-E (MA-E) in the dining room noted with a coffee cup held by the rim of the cup with bare hands, filled the cup with hot water and placed a tea bag, then served it to a resident.An observation on 05/07/2026 at 12:24 PM of MA-G who stood by the serving window in the dining room and coughed into their jacket, then touched their face, and noted having had their hair hanging down over their face during meal service. There was no hand hygiene completed.An observation on 05/07/2026 at 12:29 PM of MA-E, MA-F, MA-G, and Nurse Aide-H (NA-H) all served meal trays in the dining room and did not complete hand hygiene prior to meal service.An observation on 05/07/2026 at 12:31 PM, NA-H moved a resident wheelchair and set up a meal tray for that resident. NA-H did not complete hand hygiene after that task and continued to serve meal trays.An observation on 05/07/2026 at 12:36 PM was of MA-F with their hair down beyond the middle of their back and not contained. MA-F touched their own face and clothes and did not perform hand hygiene and continued meal service, and during that time, their hair touched the resident meal tray as it was being served.An interview on 05/07/2026 at 11:50 AM with the DA confirmed that they were to make sure that hair was to be contained and they should have worn a hairnet as their hair was visible on their shoulders.An interview on 05/07/2026 at 11:50 AM with the Dietary Manager (DM) confirmed that the expectation was to wear a hairnet or to be sure hair was fully contained in a hat. They confirmed that a beard net was to be worn with visible facial hair longer than a quarter of an inch. They confirmed that the [NAME] was to be wearing a beard net and they were not. An interview on 05/07/2026 at 11:56 AM with the [NAME] confirmed that would normally wear a beard net but did not on that day. An interview on 05/07/2026 at 12:16 PM with MA-E confirmed that the coffee cup should have been held by the handle and not by the rim of the glass. They confirmed that the cup was held by the rim of the glass. An interview on 05/07/2026 at 12:41 PM with MA-F confirmed that hand hygiene should be completed before serving and between trays. They were unaware of what the dress code policy was for uncontained hair. An interview on 05/07/2026 at 12:45 PM with MA-G and NA-H confirmed that the expectation was that hand hygiene should be completed prior to serving meal trays and between every three meal trays and that it was not completed when they started meal service.

Licensure Reference Number 175 NAC 12-007.04DBased on observation, record review, and interview, the facility failed to ensure that the ventilation systems were operational in 10 resident bathrooms (Rooms 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122). The facility census was 83 at the time of survey.Findings are:During a facility tour on 05/06/2026 from 7:02 AM until 10:09 AM an observation of Rooms 113, 114, 115, 116,117, 118, 119, 120, 121, and 122 revealed the bathroom vents did not suck up one ply square of toilet paper (were not working).An observation on 05/11/2026 from 7:04 AM until 7:17 AM revealed Rooms 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122 the bathroom vents did not suck up one ply square of toilet paper.An observation on 05/11/2026 at 7:24 AM with the Maintenance Staff (MS) revealed the bathroom vents in resident rooms 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122 were not working.During an interview on 5/11/52 at 7:44 AM the MS confirmed that bathroom vents in resident rooms 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122 were not working and MS was unaware of the problem and was unable to provide resident bathroom vent check logs.Record review of the facility's policy titled Ventilation System Check and Auditing, dated 3/8/2023 revealed ventilation system audits will be maintained.

Licensed Reference Number 175 NAC 12-006.12(D)(i) Based on observations, interviews, and record review, the facility failed to ensure medications were stored and secured for three residents (Resident 10,16, and Resident 30), and to lock the medication cart while unattended. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 83. Findings are: A. A record review of Resident 30's Minimum Data Set (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 4.2.2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A record review of the Care Plan (a mandatory, individualized document detailing a resident's medical, physical, and emotional needs, along with specific interventions to address them) with an admission date of 6.6.2025 for Resident 30 revealed: Resident will self-administer medications safely, appropriately, timely, and will keep medications in room and locked up when Resident 30 is out of the room. A record review of the facility policy Storage of Medications dated 6.2025 revealed that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner, and to never leave the medication unattended. An observation on 5.6.2026 at 8:19 AM of Resident 30's room revealed a medication pack located on the bedside stand. During an interview on 5.6.2026 at 8:19 AM with Resident 30 confirmed self-administration of all medications. Resident 30 stated the nurses fill the medication pack with the medications and leave them at the bedside for self-medication administration. Resident 30 also confirmed that the medication pack is left on the bedside stand while out of the room. During an interview on 5.11.2026 at 7:00 AM with Resident 30 confirmed leaving the room with the medication pack unattended. During an interview on 5.11.2026 at 10:06 AM with LPN-K confirmed Resident 30 leaves the room with the medication pack unattended. Also confirmed that it is okay since there are no other residents walking around. An observation on 5.11.2026 at 11 AM revealed Resident 30's medication pack was at the bedside and unattended while Resident 30 was out of the room. During an interview on 5.11.2026 at 1:00 PM with the Director of Nursing (DON) confirmed that medications should not be left unattended when Resident 30 is out of the room, and the care plan and policy should be followed. B. During an observation on 05/06/2026 at 8:50 AM a Bretzi inhaler was on Resident 16's bedside table. During an observation on 05/07/2026 at 9:00 AM Resident 16 is working with speech therapy and Resident 16's Bretzi inhaler is at bedside. During an observation on 05/11/2026 at 7:10 AM revealed Resident 16's Breztri inhaler (combines 3 medicines typically used to help manage COPD (chronic obstructive pulmonary disease) on Resident 16's bedside table. Record review on 5/11/2026 at 12:37 PM of Resident 16's self-medication administration assessment revealed that Resident 16 can have an Albuterol inhaler at bedside. In an interview on 5/11/2026 at 1:00 PM that Rehab nurse (RN-C) confirmed that Breztri inhaler should not have been at bedside. Record review of Resident 16's order summary revealed Resident 16 had a order for a Breztri Inhaler to be used twice a day but revealed no order that Breztri can be self administered or left at the bedside. C. During an observation on 05/07/2026 at 11:20 AM revealed a medication cart on unit 3 is unlocked with 2 baskets sitting on top of cart with glucometer, lancets, alcohol pads and cotton balls in basket. During an observation on 05/07/2026 at 11:47 AM Registered nurse (RN-D) locked the medication cart. In an interview on 05/07/2026 at 11:55 AM RN-D confirmed that the medication cart should have been locked. D. Review of facility Medication Administration Policy dated 07/2025 states under #15 You must observe the act of swallowing and NEVER leave medication with the resident/patient to be taken later. Record review of Resident 10's Continuity of Care Document and Physician Orders revealed that Resident 10 has the following oral medications ordered for administration in the morning: Wellbutrin SR (for diagnosis of Depression), taurine (for diagnosis of Vitamin deficiency) docusate sodium (for diagnosis of Constipation) oxybutynin (for diagnosis of Overactive bladder) modafinil (for diagnosis of Multiple sclerosis) magnesium (for diagnosis of hypomagnesemia [low magnesium levels]) loratadine (for diagnosis of Allergies) gabapentin (for diagnosis of Other disorders of peripheral nervous system) duloxetine (for diagnosis of Other chronic pain) dalfampridine (for diagnosis of Multiple sclerosis) lactobacillus rhamnosus (for diagnosis of Vitamin deficiency) baclofen (for diagnosis of pain) alpha lipoic acid (for diagnosis of Vitamin deficiency) miralax powder (for diagnosis of constipation) Record review of Resident 10's Electronic Medical Record reveals no documentation regarding assessment for self-administration of medications. During interview with Resident 10 on 05/06/2026 at 9:45 AM, it was observed that Resident 10 had a medication cup on bedside table with many pills in it. Resident 10 indicated that facility staff had the cup of pills for the resident to take after breakfast. Resident 10 was observed to swallow the many pills all at once. There was no staff member present to verify that Resident 10 had taken these medications. An observation on 5/7/2026 from 11:30 to 11:47 AM revealed that treatment cart on Station 3 was left unlocked with containers of needles left unattended on top of the cart and insulin pens and other unidentified items observed in the top drawer. Direct observation that treatment cart was locked at 11:47 by RN-D. The containers of needles were moved into the cart by RN-D and relocked it at 11:55 AM. Interview of RN-D confirmed that the medication and treatments carts should be locked.

Licensed Reference Number 175 NAC 12-006.06 Based on interviews and record review, the facility failed to provide prompt follow-up and communication regarding complaints and grievances brought to the Resident Council meetings. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 83. Findings are: A record review of the facility policy Grievances with a review date of 7.2023 revealed:All grievances and recommendations stemming from resident councils concerning issues of resident care in the facility will be considered. Actions on such issues will be discussed with the resident/family group and the facility's response, and rationale will be documented in writing. During the initial tour on 5.6.2026 at 10:15 AM, Resident 14 stated a complaint was filed regarding a missing military book, but nothing ever happened. During the initial tour on 5.6.2026 at 10:56 AM, Resident 47 stated a complaint was filed regarding housekeeping and nothing ever happened. During an interview on 5.11.2026 at 11:35 AM with the Administrator (ADM), it was confirmed the facility would schedule a resident council meeting with residents that are cognitively capable of participating in the discussion. During an interview on 5.11.2026 at 12:56 PM, Resident 14 confirmed many issues are discussed during the resident council meetings, but the residents never hear back what the facility has done to resolve the issues. During a resident council meeting held on 5.11.2026 at 11:15 AM, there were six residents (Resident 25, 30, 38, 49, 65, and Resident 67) present, information shared revealed: Housekeeping depends on who is working, often the housekeeper will enter the room, look around and then leave, somedays housekeeping never enters the room, Sundays are the worst. The residents stated they often must ask for something to be done. Residents report the call lights are often not answered for over an hour and are told the facility is short on staff. Activity calendars are not delivered to their rooms routinely. Residents have asked for more activities relating to the younger population, such as outings or age-appropriate movies. Residents have asked for additional outside seating towards the back of the building with no follow-up. All residents in the group confirmed a lack of follow-up to their concerns and never received feedback. The residents confirmed talking about the concerns to leaders but then it does not go anywhere. During an interview on 5.12.2026 at 9:00 AM with the ADM confirmed that the facility Quality Assurance and Performance Improvement (QAPI) meetings address issues identified in the resident council meetings, and through the complaint and grievance process. During a record review of the facility policy Quality Assurance and Performance Improvement with an effective date of 4.28.205 revealed in the policy statement that the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life, and will regularly review and analyze data and act on available data to make improvements. A record review of the resident council meeting minutes revealed: 4.2025- Short staffed, medications late, call lights turned off and staff do not return, request for furniture in the courtyard, staff not knocking before entering the rooms. No corrective action or follow-up indicated. 5.2025- Request for tables in the courtyard, staff do not knock before entering the rooms, call lights shut off and staff do not return, long call light times. No corrective action or follow-up indicated. 6.2025- Staff phone use on the floor, staff entering resident rooms without knocking, call lights shut off and staff do not return, requesting a table in the courtyard. No corrective action or follow-up indicated. 7.2025- Staff do not knock before entering rooms, call lights shut off and staff do not return. No corrective action or follow-up indicated. 8.2025- Night staff telling residents to wait to use the bathroom due to being short staffed, housekeeping looks into the room but does not always clean it or just takes the trash and does not clean, bathrooms not getting wiped down. No corrective action or follow-up indicated. 9.2025- Nurse aides sitting at the desk unless a light is on, left for long periods of time on the commode/toilet, continued and unresolved issues, request to go to the Lied Center in December. No corrective action or follow-up indicated. 10.2025- Call lights turned off and staff do not return, excessive staff leaving the building. No corrective action or follow-up indicated. 11.2025- Staff not knocking on doors prior to entering, staff on phones at nurses' station when call lights are on, request for computer/printer to be available for resident use, resident lounge needs cleaned up. Residents were advised to speak with upper management regarding on-going concerns in any department. No corrective action or follow-up indicated. 12.2025- Long wait times for help. request to go to the [NAME] the spring. Residents were advised of the grievance process if issues continued with no resolution. No corrective action or follow-up indicated. 1.2026- Concern regarding on-going education for staff, call light times are worse at night. No corrective action or follow-up indicated. 2.2026- Long call light times are on-going with no improvement, requested to attend a salt dog outing. No corrective action or follow-up indicated. 3.2026- Long call light times are worse during the day, bathroom trash is not being taken out, need more help in the bathhouse. No corrective action or follow-up indicated.

Licensure Reference Number 175 NAC 12-006.09(H)(vii)(2)Based on observation, record review, and interview, the facility failed to ensure activities were provided to meet the physical, mental, and psychosocial well-being for 3 (Residents 14, 47, and 66) out of 3 sampled residents. The facility census was 83 at the time of survey. Findings are: Review of facility policy titled Activity Program dated 7/26/2016 revealed the facilities activity program is designed to meet the interests and the physical, mental, and psychosocial well being of each resident. Review of March, April, and May 2026 activity calendars revealed there was one music activity scheduled on the weekends and no evening activities scheduled for each month. A. During an interview on 05/06/2026 at 10:11 AM Resident 14 revealed they only have activities for the old people here. Record review of Resident 14's Quarterly MDS dated [DATE] revealed a BIMS of 15 (indicates cognitively intact), no behaviors exhibited and no rejection of cares noted. Record review of Resident 14's Annual MDS dated [DATE] revealed it was very important for Resident 14 to do things with groups of people. Record review of Resident 14's Comprehensive Care Plan (CCP) revealed a problem dated 1/13/2025 revealed that the resident will attend group activities of choice. Record review of Resident 14's activity participation documentation for March of 2026 revealed that the resident attended 4 group activities. Record review of activity progress note dated 4/27/26 revealed that Resident 14 attended 1 group activity during the last week. B. During an interview on 05/06/2026 at 10:39 AM Resident 47 revealed that they don't have any activities in the evenings or on weekends. Record review of Resident 47's annual MDS dated [DATE] revealed a BIMS of 15 (indicates cognitively intact) resident, no behaviors and no rejection of cares, and that it was very important for the resident to do things with groups of people. Record review of Resident 47's CCP with a start dated 11/30/22 revealed that the resident can get to and from activities of choice. Record review of Resident 47's activities progress note dated 3/6/26 revealed the resident attended 5 group activities this week and is active, out and about most days throughout the facility. The resident continues to direct own leisure and decide which activities to attend. Record review of Resident 47's progress notes dated 2/20/26 revealed the resident attended 5 group activities this week. During an interview on 05/11/2026 at 12:33 PM with the Activities Director (AD) it was confirmed there are not enough activities in the evenings or the weekends. During an interview on 05/11/2026 1:50 PM the AD confirmed that they would like to do more activities in the evenings and on the weekends but has not implemented them yet. C. Record review of facility's Activity Program policy (undated) reveals that the facility's activity program is designed to meet the interests and well-being of each resident. Record review of facility's posted Activity Calendar for May 2026 reveals that the only scheduled activities for residents on the weekends are Indian Hills Church Service on Sunday's at 3:00 PM and Live Music With [NAME] which is offered only on Saturday, May 16th at 2:30 PM. There are no other scheduled opportunities for activity participation on the weekends. The calendar does list Independent Activities as options for all Saturdays and Sundays in May. Record review of Resident 66's electronic medical record reveals they were admitted on [DATE]. Further record review of Resident 66's reveals a Brief Interview of Mental Status (BIMS, a tool to evaluate cognitive function) score of 15, which indicates intact cognition. Interview with Resident 66 on 5/12/26 at 7:15 AM revealed that this resident was able to keep busy in the evenings but feels that there is nothing to do on the weekends and time passes very slowly. Resident 66 was asked about the Independent Activities that are listed on the Activity Calendar. Resident 66 replied that the independent activities refers to a cart of books and things located outside of the Activity Director's office door. Resident 66 reported that they had used items from this cart in the evenings to fill free time but did not want to have only independent activities on the weekends, stating having planned activities available on the weekends would be great.

Licensure Reference Number 175 NAC 12-006.02 (H) Based on interviews and record reviews, the facility failed to report an adverse event which involved violating resident rights of one resident (Resident 1) by performing Cardiopulmonary resuscitation (CPR) when the resident was a Do Not Resuscitate (DNR), out of four residents sampled. The facility census was 87 at the time of the survey. Findings are: A record review of Resident 1's Minimum Data Set (MDS) (this comprehensive assessment evaluates each resident's functional capabilities) dated 3.4.2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A record review on 3.11.2026 of Resident 1's current physician order report dated 2.11.2026 revealed a Do Not Resuscitate (DNR) order, which is a legally binding medical document signed by a physician, instructing healthcare providers not to perform Cardiopulmonary Resuscitation (CPR) if the heart stops or respirations cease. A record review of Resident 1's nursing progress note dated 2.23.2026 at 9:47 AM revealed the resident was found to be unresponsive, without a pulse, and CPR was initiated. In a record review of the facility's undated Code Blue- Resident 1 event documentation revealed: Resident 1 was in the dining room at approximately 8:50 AM and went unresponsive and CPR was initiated During the CPR, the facility staff noted that Resident 1 had a DNR status, but CPR continued Resident 1 was ultimately transferred to acute care at approximately 9:30 AM In a record review of the facility's 2026 Reportable Events revealed the event involving Resident 1 on 2.23.2026, including the investigation was not reported to Adult Protective Services (APS). During an interview on 3.11.2026 at 10:00 AM with the Administrator (ADM), it was confirmed that CPR was initiated on Resident 1 on 2.23 2026, that Resident 1 was a DNR, and CPR should not have been initiated due to the resident's wishes to be DNR. It was also confirmed that a full investigation was completed into this event, including training with all staff, but was not reported to APS. During an interview on 3.11.2026 at 11:20 AM with Resident 1, it was confirmed the facility initiated CPR on 2.23.2026 against physician orders and resident wishes. Resident 1 confirmed being happy to be alive but would not want CPR to be initiated again and continues to be a DNR.

Licensure Reference Number 175 NAC 12-006.05(F) Based on interviews and record reviews, the facility failed to honor the resident rights of one resident (Resident 1) by performing Cardiopulmonary resuscitation (CPR) when the resident was a Do Not Resuscitate (DNR), out of four residents sampled. The facility census was 87 at the time of the survey. Findings are: A record review of Resident 1's Minimum Data Set (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 3.4.2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A record review on 3.11.2025 of Resident 1's current physician order report dated 2.11.2026 revealed a Do Not Resuscitate (DNR) order, which is a legally binding medical document signed by a physician, instructing healthcare providers not to perform Cardiopulmonary Resuscitation (CPR) if the heart stops or respirations cease. A record review of Resident 1's nursing progress note dated 2.23.2026 at 9:47 AM revealed the resident was found to be unresponsive, without a pulse, and CPR was initiated by facility staff. During an interview on 3.11.2026 at 10:00 AM with the Administrator (ADM), it was confirmed that CPR was initiated on Resident 1 on 2.23.2026, that Resident 1 was a DNR, and CPR should not have been initiated due to the residents wishes to be a DNR . During an interview on 3.11.2026 at 11:20 AM with Resident 1, it was confirmed the facility initiated CPR on 2.23.2026 against physician orders and resident wishes. Resident 1 confirmed being happy to be alive but would not want CPR to be initiated again, and continues to be a DNR.

Licensure reference number 175 NAC 12-006.11C Based on observation, interview and record review, the facility failed to perform hand hygiene and wear a beard net in the kitchen to prevent food-borne illness. And failed to ensure food items were sealed, labeled, and dated. This had the ability to affect 65 of 71 residents who eat out of the kitchen. The census of the facility was 72. Findings are: Initial kitchen tour on 11/6/24 at 7:05 AM revealed: Jello in their individual containers without labels or dated in the walk-in refrigerator. Carrot cake in their individual containers without labels or dated in the walk-in refrigerator. A box of rainbow sprinkles, with the sack not sealed and not dated. Rice Krispies and raisin bran cereal opened and sealed, but not labeled or dated. Vanilla instant pudding sack was not sealed or dated. Brown sugar was opened, but not sealed or dated. Natural Cocoa powder package was open, but not sealed. Interview with CDM (Certified Dietary Manager) on 10/6/24 at 7:20 AM revealed the food items listed above should be sealed, labeled, and dated. Observation on 11/6/24 at 7:30 AM Cook-E was preparing breakfast without a beard net on. [NAME] length was 1/2 to 3/4 inch in length. Observation on 11/7/24 at 10:05 AM Cook-E was prepping food without a beard net on. [NAME] length was 1/2 to 3/4 inch in length. Interview on 11/7/24 at 10:05 AM with Cook-E revealed [gender's] supervisor told Cook-E that if shaves beard 2 x a week and it is like a shadow beard then [gender] would not have to wear a mask. Interview with CDM on 11/7/24 at 10:31 AM confirmed that Cook-E's beard is not a shadow beard, and [gender] needs to wear a mask over it. On 11/12/24 at 9:04 AM observed food prep by Cook-F. [Gender] had a cap, mask over beard and an apron on. At 9:08 AM Cook-F washed hands with soap and water x 12 seconds. Cook-F the opened 2 cans of V8 juice and 2 cans of diced tomatoes and poured into pan. At 9:18 AM Cook-F preformed hand washing for 8 seconds, then put in basil, rosemary, and thyme in pan and stirred. Cook-F put the frozen meatballs in same pan and stirred again. Cook-F placed a pan of frozen tomato basil soup and pan meatball/saucepan in oven after covering. At 9:29 am Cook-F washed hands for 6 seconds, donned gloves, and placed hoagie buns in pan and covered. Cook-F placed 4 tilapia in a pan, and beef franks with water in another pan, then placed into the oven. At 9:47 AM Cook-F washed hands for 12 seconds. Interview on 11/12/24 at 9:40 AM with CDM revealed there was 65 out of 72 residents who consumed foods from the kitchen. Interview on 11/12/24 at 9:52 am interview with CDM revealed that hand washing should be performed for 20 seconds. Corporate Dietary Hand washing Policy dated 7/1/09 revealed: Procedure: Clean hands immediately before engaging in food preparation including working with exposed food. -Wet hands with warm water and apply soap -Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to finger and fingertips. Wash hands for a minimum of 20 seconds. -Apply vigorous friction between fingers and fingertips. Rinse with clean, running warm water. -Dry hands thoroughly with single use towel, turn off faucets with towel and discard. Record review of Food Receiving and Storage Policy dated 12/21/23 revealed: Policy Statement: Foods shall be received and stored in a manner that complies with safe Handling practices. Refrigerated/Frozen Storage: -All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). -Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded. Record review of Food Preparation and Services Policy dated 12/21/23 revealed: -Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Record review of Nebraska Food Code dated 9/6/23 revealed the following: Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment. utensils, and linens; and unwrapped single service, and single use articles.

Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.19(C)i Based on observation, interview, and record review, the facility failed to ensure the area was kept clean behind the washing machines, a fan was not blowing from the dirty to clean side, and ensure a gown was worn during sorting contaminated (dirty or used) laundry in the laundry room to prevent cross contamination (transfer of bacteria). This had the ability to affect all residents in the facility. The facility failed to ensure staff handled clean laundry away from the staff's clothing, ensure hand hygiene (cleaning) was completed between glove changes during medication administration (provide medications) for 2 (Residents 11 and 30) of 2 sampled residents and perform handwashing greater than 20 seconds during wound care for 1 (Resident 28) of 1 sampled resident to prevent cross contamination. The total facility census was 72. Findings are: A. A record review of the facility's Laundry Department Procedures dated 08/2024 revealed proper hand hygiene (cleaning), safety practices, and the appropriate use of Personal Protective Equipment (PPE) are essential to the physical safety of the facility's associates, as well as minimizing the contribution of contaminated laundry to the incident of healthcare associated illness and infections. Gloves should be worn any time laundry is being handled. Fluid resistant protective gowns (and gloves) should be used any time soiled laundry is being sorted to protect the associate from contaminants on the laundry. [NAME] associates must wear gloves, fluid resistant gown, and optional mask, hair net, foot covers, goggles while sorting soiled laundry. An observation on 11/06/2024 at 12:00 PM revealed Laundry Aide (LA)-B delivered cleaned personal laundry to resident rooms [ROOM NUMBERS] after holding the laundry between LA-B's left arm and chest, touching LA-B's clothing. An observation on 11/12/2024 at 9:10 AM with the Director of Maintenance (DOM) revealed a large amount of a gray fuzzy substance, debris, and a hanger was behind the washing machines. The observation revealed a fan was located just to the left of the wall opening separating the dirty side from the clean side of the laundry room with the airflow going from the dirty side to the clean side. The observation revealed LA-A was wearing gloves on the dirty side, but not a gown. At the time LA-A was not sorting laundry. In an interview on 11/12/2024 at 9:10 AM, LA-A confirmed the staff only wore gloves when opening the soiled bags of laundry and linens. LA-A confirmed the staff did not wear a gown when sorting soiled laundry and linens. In an interview on 11/12/2024 at 9:21 AM, DOM confirmed the staff should have wore a gown and gloves when sorting laundry, it should have been clean behind the wash machines, and the fan in the laundry room should not have blown from the dirty side to the clean side of the laundry room. 42861 B. An observation on 11/12/24 at 7:11 AM revealed Medication Aide (MA)-G had been in the process of preparing medications for a resident when MA-G dropped a pill on the top of the medication cart then picked up the pill with ungloved hands and placed it into the medication cup containing other medications. When questioned of the facility process for dropped medications, MA-G confirmed that (gender) should not have picked the pill up with ungloved hands or picked the pill out of the medication cup which contained other pills, with ungloved hands and placed the pill into the sharps container (a safe, disposable container for needles, syringes, lancets, and often used as a safe container to dispose of medications). MA-G then donned gloves, replaced the pill, and then placed the cup of pills into the pocket of (gender) scrub top and grabbed a cup of water and the blood pressure machine and proceeded to the resident room. The following medication administration was observed: MA-G adminstered Resident 30's medications at 7:14 AM. The observation further revealed that MA-G did change gloves at this time but did no handwashing or sanitization. Then MA-G prepared and administered Resident 11's medications as 7:22 AM. An interview on 11/12/24 at 7:23 AM with MA-G, when questioned about the availability of hand sanitizer, as there was no dispenser on the cart. MA-G stated, well there are some there that we're supposed to use, pointing to a container of Virex wipes (disinfectant cleaner wipes) hanging from a dispenser on the wall behind the nurse's desk. An interview on 11/12/24 at 10:17 AM with the DON (Director of Nursing) confirmed that the facility expectation was that hand hygiene would be performed between each resident when passing medications. The DON also confirmed that hand sanitizer was available to be placed on the medication cart or carried in staff pockets. A record review of the facility policy titled Medications: Administration-General Principles, dated 09/2019, contained the following guidance related to medication administration: -Wash hands. -Apply personal protective equipment as applicable per the exposure control plan. Although the medication is not to be touched, the work area should be as free of bacteria as possible. -Administer the medication. Allow the resident/patient to be as independent as possible, NEVER touch the medications with your hand. Give an adequate amount of fluid to ensure all medication is swallowed. You must observe the act of swallowing and NEVER leave medication with the resident/patient to be taken later. -Wash hands and/or use hand sanitizer and remove any personal protective equipment as applicable before procced to the next resident/patient. This must be done between each resident/patient. 47406 C. Record review of Resident 28's Continuity of Care Document dated 11/7/24 revealed admission to facility was 12/28/2017. Record review of Resident 28's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 9/24/24 revealed: Section M: Risk for Pressure Ulcer - indicated yes. Does this resident have one or more unhealed pressure ulcers/injuries - indicated no. Other Ulcers, Wounds and Skin Problems: MASD (Moisture Associated Skin Damage) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage) - indicated yes. Record review of Physician Orders dated 11/7/24 revealed: Right buttock crease: Clean wound with mild soap and water. Apply skin prep to periwound. Apply therabond over wound and secure with tegaderm daily. Once A Day. Observation of wound care on 11/12/24 at 10:07 AM by Licsensed Practical Nurse (LPN)-D. LPN-D had supplies in room on a bedside table. LPN-D performed hand washing with soap and water for 12 seconds. LPN-D donned (put on) gown and gloves. The Therabond and tagaderm dressing had fallen off and was on chux. LPN-D removed and threw away the dressing in the trash. LPN-D doffed (took off) gloves, performed hand hygiene using hand sanitizer gel, then donned new gloves. LPN-D cleansed right buttock wound with soap and water and patted dry with clean dry gauze. LPN-D performed hand hygiene using hand sanitizer gel and applied new gloves, then applied skin prep to periwound. LPN-D then applied therabond dressing over the wound and secured it with Tegaderm dressing. Interview on 11/12/24 at 10:19 AM with LPN confirmed that hand washing should be done for 20 seconds. Interview on 11/12/24 at 3:38 pm with DON revealed that hand washing is to be for 20 seconds. Record review of Hand washing policy dated 12/2019 revealed: Policy Statement - It is the policy of the facility to prevent the spread of infection through the use of hand washing and hand sanitizing gel in accordance with professionally accepted standards. Antiseptic Hand Wash Procedure: -Completely wet your hands and the area above the wrist by 2-3 inches under the running water. Keep your fingertips pointed downward. -Apply antimicrobial soap. -Hold your hands lower than your elbows while washing. -Work up a good lather. Spread it over the entire area of your hands and 2-3 inches above the wrist. Get soap under nails and between your fingers. -Clean under the nails by rubbing your nails across the palms of your hands. Use a rotating and rubbing (frictional) motion for a minimum of 20 seconds.

Licensure Reference Number 175 NAC 12-006.09(D) Based on observation, interview and record review, the facility failed to ensure the accuracy of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) related to the BiPap use for one (Resident 14) of two sampled residents. The facility identified a census of 72. Findings Are: A record review conducted on 11/7/24 of the face sheet printed on 6/6/24 revealed Resident 14 had been accepted into the facility on [DATE] with a primary diagnosis of COPD (a term for lung and airway diseases that restrict your breathing) and hypotension (a blood pressure that is lower than normal). A record review conducted on 11/7/24 of the MDS dated [DATE] revealed Resident 14 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 15. During an interview on 11/06/24 at 10:20 AM Resident 14, an observation revealed a BiPAP (a noninvasive ventilation) nasal pillows (a mask that is smaller and easy to wear), still connected to the tubing and hanging from a hook on the wall behind the machine with the nasal pillows touching the wall and not stored in a bag and tubing was undated. Resident 14 also revealed being on 4 liters per mineute l/m of o2 continuously. An observation on 11/7/24 at 09:34 AM revealed Resident 14's nasal pillows to be connected to the tubing and hanging from a hook on the wall. An interview on 11/7/24 at 9:46 AM with LPN-D revealed that Resident 14 requests that the tubing and nasal pillows be hung from hook on the wall. An interview on 11/12/24 at 10:22 AM with Resident 14 confirmed (gender) request to have nasal pillows and tubing hanging on the hook on the wall. Resident 14 confirmed staff had educated (gender) on best practice of keeping tubing and nasal pillows in a bag to prevent the potential for cross contamination. A record review on 11/7/24 at 5:15 PM of the MDS dated [DATE], Section O, did not indicate Resident 14 used a BiPAP. An interview on 11/13/24 at 8:27 AM with the facility MDS Nurse, after review of the MDS dated [DATE], Section O, confirmed it did not reflect the BiPAP use for Resident 14. The interview revealed that the facility follows the RAI (Resident Assessment Instrument) Manual related to guidance when completing an MDS. A record review conducted on 11/13/24 at 2:22 PM of the RAI Manual related to completing section O of an MDS revealed the following instructions: O0110. Special Treatments, Procedures, and Programs Check all of the following treatments, procedures, and programs that were performed. O0110G2, BiPAP Check if the non-invasive mechanical ventilator support was BiPAP.

Licensure Reference Number 175 NAC 12-006.05(S) Based on interview and record review, the facility failed to ensure the staff explained procedures and provide privacy during resident cares for 1 (Resident 15) of 3 sampled residents. The total facility census was 72. Findings are: A record review of the facility's Dignity policy dated 02/05/2024 revealed residents were treated with dignity and respect at all times. Procedures were explained before they were performed. Staff would promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Staff were expected to treat cognitively impaired (confused) residents with dignity and sensitivity. A record review of Resident 15's Resident Census dated 11/13/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 15's SNF (Skilled Nursing Facility) Continuity of Care Document (CCD) dated 11/13/2024 revealed the resident had diagnoses of Anoxic Brain Injury (an injury that cut off oxygen to the brain), Tracheostomy status (trach)(a tube inserted in the neck for breathing), Acute and Chronic Respiratory Failure with hypoxia (breathing problem with low oxygen), and Dependance on respirator (ventilator)(breathing machine). A record review of Resident 15's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 09/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 99 that indicated the resident is rarely/never understood. The resident was dependent on staff for all activities of daily living (ADLs). The resident was on oxygen, needed tracheostomy care, and was on a ventilator. A record review of Resident 15's Care Plan with last reviewed/revised date of 09/10/2024 revealed an intervention for Respiratory to provide trach care as ordered and as needed (PRN). A record review of Resident 15's Podiatry Exam dated 11/06/2024 revealed the Podiatrist (foot doctor) trimmed and debrided (removed damaged tissue) on both of the resident's feet 11/06/2024. A record review of Resident 15's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated 11/01/2024 - 11/13/2024 revealed Respiratory Therapist (RT)-C done the resident trach care the morning of 11/12/2024. An observation on 11/06/2024 at 8:52 AM revealed the Podiatrist was trimming Resident 15's left toenails with the room door open all of the way and the procedure was visible from the hall. An observation on 11/12/2024 at 08:08 AM revealed RT-C entered Resident 15's room and performed trach care on the resident, but did not explain what RT-C was going to do to the resident before or during trach care. In an interview on 11/13/2025 at 7:05 AM, the Director of Nursing (DON) confirmed the Podiatrist should have closed the door while trimming Resident 15's toenails and RT-C should have told Resident 15 what RT-C was going to do prior to starting trach care regardless of the resident cognitive ability (ability to understand).

Licensure reference number 175 NAC 12-006.09D6(7) Based on observation, interview and record review; the facility failed to follow the physician's order for administration of Oxygen for Resident 28. Findings are: Record review of O2 Therapy - General Principles Policy dated 10/2011 revealed: It is the policy of this facility to treat or prevent symptoms of hypoxia. Adjust liter flow/FI)2 per physician's order. An SaO2 reading on the prescribed liter flow must be documented. Record review of Resident 28's Continuity of Care Document dated 11/7/24 revealed admission was 12/28/2017. Record review of Resident 28's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 9/24/24 revealed in Section C having 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) scored 15 and in Section O receiving O2. Record review of Resident 28's Diagnoses in Continuity of Care Document dated 11/7/24 revealed Acute respiratory failure with hypoxia. Record review of Physician Orders dated 11/7/24 revealed Oxygen: O2 @ 1 LPM Continuous. Special Instructions: Update PCP if needing more than 1L. *Document Minutes of O2 use: Continuous for 12 hours would be 720 Minutes Every Shift. Record review of August 2024 Medication Administration Record revealed O2 2 L administered 29 times. Record review of September 2024 Medication Administration Record revealed O2 2 L administered 13 times. Record review of October 2024 Medication Administration Record revealed O2 2 L administered 7 times. Record review of November 2024 Medication Administration Record revealed O2 2 L administered 0 times. Observation on 11/6/24 at 2:00 PM Resident 28 with O2 (Oxygen) 2 L (liter) per nasal cannula on via oxygen concentrator. Observation on 11/7/24 at 8:20 AM Resident 28's O2 on at 1.5 L per nasal cannula via oxygen concentrator. Observation of Liscenced Practical Nnurse (LPN)-D on 11/7/24 at 2:35 PM revealed LPN changed Resident 28's O2 from 1.5 L to 1 L. Interview on 11/7/24 at 2:36 PM wit LPN-D revealed that there was no documentation for the increase of O2. Interview with Resident 28 on 11/12/24 at 9:56 AM revealed resident has not asked for the oxygen to be increased and has been short of breath. Record review of O2 saturation (Oxygen saturation which is a measurement of the percentage of how much oxygenation is in the blood) documented 2-3 times a day from 8/1/24 to 11/13/24 revealed O2 saturations were not lower than 91%. Interview on 11/13/24 at 7:24 AM with the Director of Nursing (DON) revealed that there was no documentation of reason for increasing the O2 from 1 liter and the physician was not notified.

Licensure Reference 175 NAC 12-006.09B1(2) Based on record review and interviews, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities. An SCSA is required when a resident has a major improvement or decline in condition that will not resolve itself.) was completed after a significant change in condition for 1 (Resident 52) of 18 sampled residents. The facility census was 66. Findings are: A record review of Resident 52's Continuity of Care Document (CCD) created 12-19-2023 revealed, that the resident was admitted to the facility on [DATE] with a fractured right femur (thigh bone), multiple rib fractures on the left side, and a fractured vertebra after a fall at home. The resident also had diagnoses of chronic kidney disease, osteoporosis (a disease that weakens the bones), and macular degeneration (a disease of the eye that cause blurred or reduced central vision). A record review of Resident 52's Quarterly MDS dated [DATE] revealed, that Resident 52 was independent with bed mobility, and required supervision with transfers, eating, and toilet use. A record review of Resident 52's Quarterly MDS dated [DATE] revealed, that Resident 52 required substantial to maximal assistance with eating, and was dependent on staff for bed mobility, transfers, and toileting hygiene. A record review of the MDS 3.0 Resident Assessments list printed 12-19-2023 revealed, there were no other MDS assessments completed for Resident 52 between 09-15-2023 and 11-28-2023. An interview with Licensed Practical Nurse (LPN)-A on 12-21-2023 at 10:51 AM revealed, that the resident had a significant decline in condition, and should have had a SCSA MDS done.

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 spread of infection and prevent cross contamination during morning cares for 1 resident (Resident 34) of 1 sampled residents. The facility census was 66. Findings are: An observation on 12/20/2023 at 6:50 AM of morning cares were completed on Resident 34 by Restorative Aide (RA)-B Medication Aide (MA)-C revealed the following: RA-B and MA-C were in Resident 34's room with gloves applied. Resident 34 was lying in bed with [gender] TED (thrombo-embolic deterrent stockings to prevent blood clots) hose, pants and shoes already on. RA-B performed peri-care with incontinence wipes to the front of Resident 34's genitalia. The resident was rolled to their side with the assist of MA-C who then washed Resident 34's buttocks with incontinence wipes. RA-B and MA-C then applied a clean brief. RA-B and MA-C did not perform hand hygiene or change their gloves. Then, RA-B and MA-C removed their soiled gloves and applied new gloves without performing hand hygiene. RA-B assisted the resident in getting their legs over side of bed and feet onto floor. RA-B then applied deodorant, put a t-shirt on, and applied tuba-grip (a sleeve that provides support for swelling) to Resident 34. MA-C put a sweater on resident. Then, RA-B applied a gait belt (a belt applied to resident to assist with transferring) around the resident's waist. Resident 34's feet were placed on a pivot stand, and transferred to wheelchair by RA-B and MA-C. MA-C then put Resident 34's dirty gown and incontinence pad from the bed into the garbage bag. MA-C then removed their gloves. RA-B made the resident's bed while MA-C replaced the garbage bags and the cleaned the resident's room. MA-C then performed hand hygiene at the sink with soap and water for 20 seconds. RA-B removed their gloves and applied new gloves and set the resident up to brush their teeth. RA-B washed Resident 34's face then removed their soiled gloves and applied new gloves. RA-B rinsed Resident 34's toothbrush and put it away. Then, RA-B removed their soiled gloves and left the resident's room. In an interview on 12/20/2023 at 7:08 AM with RA-B revealed [gender] did not complete hand hygiene between the removal of dirty gloves and the application of new gloves when performing cares to Resident 34. RA-B further revealed [gender] did not perform hand hygiene prior to leaving Resident 34's room. RA-B confirmed hand hygiene should have been performed during cares and prior to leaving the resident's room. In an interview on 12/20/2023 at 7:09 AM with MA-C revealed [gender] did not complete hand hygiene between the removal of dirty gloves and the application of new gloves while performing cares to Resident 34. MA-C confirmed this should have been done. In an interview on 12/20/2023 at 8:55 AM with the DON (Director of Nursing) revealed hand hygiene should be completed after the removal of dirty gloves and before proceeding with other cares. The DON revealed hand hygiene should be completed prior to staff leaving a resident's room. A record review of the facility policy Hand Washing dated 12/2019 under Indications for Hand Antisepsis and Alcohol-based Hand Rub revealed: -Antiseptic Hand Wash: (hand washing with antimicrobial soap and water) a. whenever gloved hands are visibly soiled with blood or body fluids including urine and feces. -Alcohol-based hand rub: b. when entering or leaving a patient's room, e. when going from dirty to clean function on the same patient. A record review of the facility policy Infection Control Guidelines for All Nursing Procedures dated 6/2/2023 under General Guidelines revealed: -Employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: - before and after direct contact with residents, - after contact with blood, body fluids, secretions, mucous membranes or non-intact skin, and - after removing gloves.

Licensure Reference Number175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to code anti-anxiety medication for Resident 50, and a fall for Resident 52 on the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) . This affected 2 of 17 residents sampled. The facility census was 66. Findings are: A. A record review of Resident 50's Continuity of Care Document (CCD) created 12-19-2023 revealed, that Resident 50 was admitted to the facility on [DATE] with diagnoses of: acute respiratory failure and generalized anxiety disorder. Further record review of Resident 50's CCD revealed, the resident had an order for buspirone (an anti-anxiety medication) 15 milligrams (mg) three times a day with a start date of 09-23-2022. A record review of Resident 50's Quarterly MDS dated [DATE] revealed, that in Section N-Medications, question N0415B was not checked to indicate that the resident was taking an anti-anxiety medication. A record review of Resident 50's Medication Administration Record and Treatment Administration Record (MAR/TAR) for November 2023 revealed, the resident received buspirone during the assessment time frame for the 11/13/23 MDS, which was 11-07-2023 to 11-13-2023. An interview with Licensed Practical Nurse (LPN)-A on 12-21-2023 at 10:51 AM revealed, that the buspirone was not coded on the 11-13-23 MDS as an antianxiety medication. B. A record review of Resident 52's Continuity of Care Document (CCD) created 12-19-2023 revealed, that Resident 52 was admitted to the facility on [DATE] with a fractured right femur (thigh bone), multiple rib fractures on the left side, and a fractured vertebra after a fall at home. The resident also had diagnoses of chronic kidney disease, osteoporosis (a disease that weakens the bones), and macular degeneration (a disease of the eye that cause blurred or reduced central vision). A record review of Resident 52's Progress Notes from 10-01-2023 to 12-21-2023 revealed, that the resident had a fall on 11-16-2023. Further record review of the Progress Notes revealed, that an X-ray was done on 11-19-2023 which revealed, a fractured left collarbone. A record review of the resident's quarterly MDS dated [DATE] revealed, that in Section J-Health Conditions, question J1800 regarding falls since last admission or re-entry or since the most recent assessment was coded no, indicating no falls. A record review of the MDS 3.0 Resident Assessments list printed 12-19-2023 revealed, that there were no other MDSs completed for the resident between 09-15-2023 and 11-28-2023. An interview with LPN-A on 12-21-2023 at 2:20 PM revealed, that the fall from 11-16-2023 should have been captured on the 11-28-2023 MDS as a fall with major injury.

LICENSURE REFERRENCE NUMBER 175 NAC 12-006.17B Based on observation, record review and interview, the facility failed to ensure respiratory equipment was cleaned and stored in a manner to prevent potential cross contamination when not in use for 4 of 5 sampled residents (Resident 49, 55, 68, and 226). The facility census was 73. Findings are: A. On 01/17/2023 at 02:40 PM an observation revealed an oxygen concentrator in Resident 226's room to have the tubing connected and draped over the machine with the nasal cannula touching the outside of the concentrator. On 1/18/23 at 12:44 PM an observation revealed Resident 226's oxygen tubing remained draped over the concentrator with the nasal cannula touching the machine. On 1/19/23 at 11:52 AM an observation revealed Resident 226's oxygen tubing remained draped over the concentrator with the nasal cannula touching the machine. B. On 01/17/23 at 03:30 PM an observation revealed a nebulizer (a device used for producing a fine spray of liquid, used for getting medications into the lungs) equipment (tubing, mask or mouthpiece and medication chamber) to be intact, coiled up and setting on the counter near the sink in Resident 49's room. On 1/18/23 at 12:44 PM an observation revealed Resident 49's nebulizer kit to be intact and resting on nightstand. On 1/19/23 at 11:52 AM an observation revealed Resident 49's nebulizer kit to be intact and resting on nightstand C. On 01/17/2023 at 02:40 PM an observation revealed an oxygen concentrator in Resident 55's room to have the tubing connected and draped over the machine with the nasal cannula touching the outside of the concentrator. On 1/18/23 at 12:44 PM an observation revealed Resident 55's oxygen tubing remained draped over the concentrator with the nasal cannula touching the machine. On 1/19/23 at 11:52 AM an observation revealed Resident 55's oxygen tubing remained draped over the concentrator with the nasal cannula touching the machine. An interview on 1/19/23 at 01:45 PM with the DON (Director of Nursing) confirmed that the facility expectation was that respiratory equipment be stored in a baggie when not in use. Record review of the facility policy titled Medication: Aerosol Administration (Nebulizer Treatment) dated 08/2011 revealed the following direction for the nebulizer kits: 11. Once the treatment is completed, the nebulizer should be dismantled, rinsed with tap water and placed in a clean place to air dry. Record review of the facility policy titles Oxygen Therapy - General Principle dated 10/2011 revealed no direction as to how to store oxygen tubing when not in use to prevent the potential for cross contamination. 45641 D. An observation on 01/17/2023 at 03:30 PM revealed Resident 68's nebulizer kit had been placed on top of the nebulizer machine with a residual amount of medication left in it. An observation on 01/18/2023 at 02:32 PM revealed Resident 68's nebulizer kit had been placed on top of the nebulizer machine with a residual amount of medication left in it. An observation on 01/19/2023 at 07:57 AM revealed Resident 68's nebulizer kit was standing on top of the nebulizer machine with a residual amount of medication left in it. In an interview on 01/19/2023 at 12:00 PM, Registered Nurse (RN)-A confirmed that the nurses are responsible for Resident 68's nebulizer medication treatments and that they do not clean the nebulizer kit after the treatment is completed or at the end of the day. In an interview on 01/23/2023 at 08:58 AM, the Director of Nursing confirmed that Resident 68's nebulizer kit had not been cleaned after the nebulizer treatment and should have been, and was not stored in a clean dry place and should have been.

Licensure Reference Number 175 NAC 12-006.05 Based on record review and interview, the facility failed to notify the State Office of the Ombudsman (a state official appointed to investigate resident complaints) of the emergent hospital transfer for 1 (Resident 61) of 1 sampled resident. The facility staff identified a census of 73. Findings are: A record review of Resident 61's Progress Notes dated 6/22/22 at 01:14 PM revealed the resident was admitted to the facility on [DATE]. A record review of Resident 61's Progress Note dated 12/19/22 revealed the resident was adjusted in bed on 12/19/22 at 03:14 PM when staff heard a pop. A Physician Assistant was present in the building and saw the resident. Resident 61 was transferred to [NAME] West Hospital for left femur (bone in upper leg that attaches to the hip) evaluation and treatment. A record review of Resident 61's Progress Note dated 12/22/22 at 03:46 PM revealed that Resident 61 returned to the facility on [DATE]. A record review of the facility's Electronic Medical Record did not reveal documentation that the Ombudsman had been notified that Resident 61 had been hospitalized for a leg fracture (break) on 12/19/22. An interview on 01/24/23 at 08:50 AM with the Director of Nursing confirmed that the Ombudsman was not notified about Resident 61's hospitalization . An interview on 01/24/23 at 10:17 AM with Social Services-H confirmed that the Ombudsman was not notified of Resident 61's hospitalization . A record review of Emergent Transfer or Discharge Policy dated 01/27/22 revealed that the Ombudsman was to be notified of emergency transfers on a monthly basis. A record review of the Admission/Leave/Discharge Tracking Report dated 12/01/2022 - 12/31/2022 did not reveal that Resident 61's name was listed on the emergency discharge to the hospital. In an interview on 01/24/23 at 11:30 AM the Administrator confirmed that Resident 61's name was not on the Admission/Leave/Discharge Tracking Report dated 12/01/2022 - 12/31/2022 that was faxed to Ombudsman on 12/31/22. Resident #61

LICENSURE REFERRENCE NUMBER 175 NAC 12-00609D Based on record review and interview, the facility failed to follow physician's orders related to a fluid restriction ordered for Resident 16. The sample size was 1. The facility census was 73. Findings are: On 01/24/23 at 11:10 AM a record review of the Active Orders list for Resident 16 revealed the following order: Diet: Dysphagia 2 Diet with 2000ml (Milliliters) a day fluid restriction dated 2/18/2020. On 01/24/23 at 11:17 AM a record review of the vitals charting titled Intakes/Fluids revealed the following fluid intakes charted by the Nurse Aides in the last 90 days for Resident 16, which were in excess of the 2000 cc fluid (cubic centimeter or millimiter) restriction ordered for Resident 16: -2220 cc total on 11/15/22 -2265 cc total on 11/19/22 -2190 cc total on 12/17/22 On 01/22/23 at 11:17 AM a record review of the vitals charting titled Intakes/Fluids for the last 90 days for Resident 16 revealed no documentation of fluids on the following dates and times: -12/1/22 only documented in the evening shift, not day shift or night shift -12/2/23 two entries at 3 pm, no other shifts. -12/3/22 one documented entry at 06:24 PM -12/4/22 two entries at 6:00 PM and 8:00 PM, no meal intakes documented -12/10/22 no day shift fluid documentation -12/16/22 no evening shift fluid documentation -12/20/22 documented as 4,880 and 2,440 intakes for the 24-hour period. -12/31/22 single entry at 7:43 PM, no other entries -1/4/23 no evening shift documentation -1/13/23 no evening shift documentation An interview on 01/24/23 at 12:02 PM with the DON (Director of Nursing), after review of the fluid restriction documentation for Resident 16, confirmed that the documentation was incomplete. On 01/22/23 at 11:17 AM a record review of the facility policy titled Encouraging and Restricting Fluids dated 09/2015, revealed the following directions related to fluid restrictions: General Guidelines 2. Follow physician's orders concerning fluid intake or restrictions.

LICENSURE REFERRENCE NUMBER 175 NAC 12-006.12A Based on record review and interview, the facility failed to ensure residents were free of duplicate medications related to the use of 4 hypoglycemic medications (medications used to lower blood glucose levels) for Resident 16. The sample size was 5. The facility census was 73. Findings are: Record review of the Active Orders list revealed Resident 16 to be taking the following medications for diabetes: -Actos for diabetes -Metformin for diabetes -Levemir Insulin for diabetes -Humulog insulin for diabetes An interview on 1/19/23 at 1:45 PM with the DON (Director of Nursing), after review of the medication list for Resident 16, confirmed that duplicate medications were present and had not been addressed with the physician prior to today. A record review of the facility policy titled Blood Glucose Monitoring dated 01/2015 revealed that the policy did not address hypoglycemic medication use or duplicate medication use. A record review of the facility policy titled Medications: Administration-General Principles dated 09/2019 revealed it did not address hypoglycemic medication use or duplicate medication use.

Licensure Reference: 175 NAC 12-006.09D6 Based on interviews and record reviews, the facility failed to ensure an Oximeter (oxygen saturation monitoring device) was turned 'on' and functioning to alert staff of the declining oxygen saturation level for Resident 1. Facility census was 76. Findings are: A. Review of Admission report in the Medical Record for Resident 1 revealed an admission to the [MEDICAL CONDITION] Unit on 2/8/16. Resident 1's code status was changed to Do Not Resuscitate on 2/11/16 per Resident 1 Power of Attorney. Resident 1 had medical [DIAGNOSES REDACTED]. - Pneumonia, - Extreme [MEDICAL CONDITION], - Hypoventilatio[DIAGNOSES REDACTED] with severe obstructive sleep apnea, - History of Chronic [MEDICAL CONDITION] (an incision in the windpipe for artificial opening through the neck to allow passage of air or evacuate secretions), - History of Motor Vehicle Accident with chronic disability. - [MEDICAL CONDITION] requiring mechanical ventilation,(an appliance for artificial respiration/ breathing) - weaning protocol, guarded prognosis given the obesity hypoventilation history and [MEDICAL CONDITION] (without oxygen) [MEDICAL CONDITION], - previous [MEDICAL CONDITION] ( [MEDICAL CONDITION]), - Heart Failure, and - [MEDICAL CONDITION]. A Facsimile (FAX) communication report dated 2/16/16 to Resident 1's Pulmonologist (Respiratory tract/Lung disease specialist) revealed a request, May we [MEDICAL CONDITION] (administration of air or oxygen through cannula tube in the patients neck opening) trials daytime. The Physician ordered that the facility would advance [MEDICAL CONDITION] trial for Resident 1 for daytime only but the resident required the [MEDICAL CONDITION] (machine for non-invasive form of mechanical ventilation therapy for sleep apnea) at night. Review of facility investigation report for Resident 1 from the incident on 2/20/16 revealed an unexpected death of Resident 1 when found at respiration check to be without pulse or lung sounds and oximeter machine was not on at time of Resident 1 being found. Interview with Director of Nursing on 2/29/16 at 10:45am revealed that Resident 1 was very sweaty and the pulse oximeter device kept slipping off of Resident 1 on 2/20/16 which was a common occurrence. The oximeter monitor device was applied to Resident 1's ear lobe as Resident 1 did not tolerate the device when applied to fingers. Review of nursing notes for Resident 1 on 2/29/16 of entries recorded on 2/22/16 revealed: - 12:30pm facial area moist, oximetry ear probe kept sliding off ear, ear was dried and probe put back on several times during the shift. The room temperature was lowered for Resident 1's comfort. - 4:00pm resident was repositioned and secretions suctioned. The Sa02 (oxygen level) monitor read 92 - 97% with FI02 (forced air with ratio of blood oxygen and inspired (breathed in) oxygen through a tube) @ at 35% [MEDICAL CONDITION]. - 5:00pm Resident 1 restless and received a pain pill and repositioning. - 5:40pm Resident 1 checked and sleeping comfortably. Review of Resident 1 medical record for treatment note charting by Respiratory Therapist from 2/20/16 revealed: - 6:20pm went to provide breathing treatment scheduled and found (Resident 1) was laying on the ear probe for the oximeter, which was turned off. Put the ear probe on ear and turned on the oximeter. While waiting for the oximeter to read SA02 (saturation of oxygen level in blood) noted was blue in the lips and not responding when change stoma pad (dressing over [MEDICAL CONDITION]). Tried to feel for a radial (arm) or carotid (neck) pulse and listened for breath sounds. Didn't hear any or feel a pulse. Quickly went to get the nurses down at the nursing station. We all went back down to room. Turned O2 (oxygen) up to 100% (was at 35% via [MEDICAL CONDITION] mask for ventilator weaning). Still not getting respirations. Pupils were fixed and dilated. Was on the cool mist Nebulizer 35% 02 since 6:55 am. The facility policy for Ventilator weaning dated May 2014 required non -invasive monitoring including: oximetry for Sp02 (saturation of oxygen available in the blood to support respiratory function) and heart rate with the level of Sp02 to be greater than 90%. B. Review of the Facility Systems with Director of Nursing and [MEDICAL CONDITION] Unit Manager (Respiratory Therapist) on 2/29/16 between 1:30 pm and 2:45 pm revealed that the facility took the following actions to review systems to correct the immediacy of care concerns on the evening of 2/22/16 and 2/23/16 - 1. Checked all oximetry machines the evening of 2/20/16. Signed documents recorded that the facility Respiratory Therapist on the evening/night shift (6:00 pm - 6:00 am) went to each room, checked all the oximeters in all the patient's rooms, and determined all were on and in working condition including the oximeter used for Resident 1. 2. All staff including Nursing staff and Respiratory Therapists, were provided education on 2/23/16 including: Pulse Oximetry Protocols review with staff and discussion of Treatment Record recording of oximetry, Respiratory Therapy orders, exception reports and obtaining clarification orders from physicians and review of Ventilator Weaning Protocol. 3. A second inservice on Medication Errors (including oxygen) was conducted for all staff at the facility on 2/26/16. The meeting also included further information and updating on Respiratory Care Protocols. 4. Internal Investigation of Resident 1's death and resultant staff disciplinary action was given to the two professional/licensed nurses working the day shift of 2/20/16. The personnel files of Nursing Staff J and K were reviewed for this disciplinary action. 5. Facility staff obtained specific physician orders [REDACTED]. for all six residents residing on the [MEDICAL CONDITION] unit requiring ongoing oximetry. These orders included: check Oxygen Saturations twice daily and record; change oxygen site monitoring every morning; Keep Oxygen saturation greater than 90%. The newly obtained clarification orders for the oximetry readings were audited by the Respiratory Manager and also an outside Respiratory Therapist over a three week time period. 6. The Respiratory Unit staff were conducting change of shift rounds in each resident's room to review that resident specific assignment sheet criteria were in place. 7. Staff Interview with Respiratory Therapist (RT) - D on 2/29/16 at 2:58 pm revealed that the oximetry monitors were always positioned in the open metal basket above the residents' bed so the monitor readings could easily be visualized each time staff walk by the rooms. This compilation of correction methods placed the facility in compliance with correction as of 2/23/16 when all staff re-education was provided for Respiratory protocols.