Every finding on record at Ambassador Health of Omaha

Licensure Reference Number 175 NAC 12.006.11(D)Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure that all food stored in the facility's dry storage, refrigerators (fridge) and freezer were labeled, dated, and sealed, the low-temperature dish machine was reaching 120 degrees Fahrenheit (F)(a temperature scale) during every wash cycle, items were tested for the temperature (temped) after being reheated in the microwave to prevent foodborne illness, failed to follow recipes, and failed to ensure the kitchen shelving and equipment were clean to prevent cross contamination. This had the potential to affect 32 residents that consumed food from the kitchen. The total facility census was 78.Findings are: A.A record review of the facility's Food Receiving and Storage dated 12/21/2025 revealed that dry foods that were stored in bins are removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerators 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. An observation on 07/07/2025 at 7:04 AM - 7:45 AM revealed:The True 3-door fridge contained: 1 each 5-pound (lb) container of [NAME] Cottage Cheese that was opened but not dated and expired 07/01/2025. 1 each 5-lb [NAME] Sour Cream that was opened, not dated. 2 bags of a leafy green substance that were opened, not labeled or dated. 1 partial, long, round object sealed in plastic wrap not labeled or dated.The walk-in fridge contained: 1 each cube of a white substance wrapped in plastic wrap, not labeled or dated. 1 plastic bag of slices of a white substance that was opened, not labeled or dated. 3 plastic bags of a shredded and grated white substance, 1 bag not labeled or dated, 1 bag not labeled, and 1 bag not dated. 1 small black container with a clear lid with 2 peeled eggs inside, not labeled or dated. 1 open bag of mixed vegetables, not sealed or dated. 1 large clear container with a red lid that contained a red liquid, not labeled. 1 gallon of [NAME] Mayo that had been opened, not dated. 1 gallon of Imperial Honey Mustard Dressing that had been opened, not dated. 1 gallon Casa [NAME] Enchilada Sauce that had been opened, not dated. 1 gallon Marzetti Buttermilk Ranch Dressing that had been opened, not dated. 2 each Grove Apple concentrate that had been opened and dated 05/19. 1 each Grove Pineapple concentrate that had been opened and dated 05/19. 1 each 25 lb container of Chef Grade Hard Cooked Peeled Eggs opened, not sealed or datedThe walk-in freezer contained: 1 bag of round bread items that had been opened, not labeled or dated. 1 bag of long, brown sticks that had been opened, not sealed, labeled or dated. 1 bag of long, brown sticks that had been opened, not labeled or dated. 1 bag of small, tan sticks that had been opened, not labeled or dated. 1 bag of brown, breaded strips that had been opened, not labeled or dated.The dry storage room contained: 1 large clear container with a blue lid that contained a white powder substance that was not sealed, labeled, or dated. 1 bag of a brown powder substance in a box that had been opened, not labeled or dated. 1 opened bag of small marshmallows that had been opened, not sealed or dated. 1 bag of small chunks that had been opened, not sealed and dated 3/21. 1 bag of Dark Roast Gravy Mix wrapped in plastic wrap that had been opened, not dated. 1 silver bag labeled croutons that had been opened, not dated. 1 6-quart plastic container with a red lid labeled corn meal that had 1 label dated 9/19 and another label was dated 4-10. In an observation on 07/07/2025 at 7:45 AM with the Kitchen Manager (KM) revealed The True 3-door fridge contained 1 each 5-pound (lb) container of [NAME] Cottage Cheese that was opened but not dated and expired 07/01/2025. 1 each 5-lb [NAME] Sour Cream that was opened, not dated. 2 bags of a leafy green substance that were opened, not labeled or dated. 1 partial, long, round object sealed in plastic wrap not labeled or dated.The walk-in fridge contained: 1 each cube of a white substance wrapped in plastic wrap, not labeled or dated. 1 plastic bag of slices of a white substance that was opened, not labeled or dated. 3 plastic bags of a shredded and grated white substance, 1 bag not labeled or dated, 1 bag not labeled, and 1 bag not dated. 1 small black container with a clear lid with 2 peeled eggs inside, not labeled or dated. 1 open bag of mixed vegetables, not sealed or dated. 1 large clear container with a red lid that contained a red liquid, not labeled. 1 gallon of [NAME] Mayo that had been opened, not dated. 1 gallon of Imperial Honey Mustard Dressing that had been opened, not dated. 1 gallon Casa [NAME] Enchilada Sauce that had been opened, not dated. 1 gallon Marzetti Buttermilk Ranch Dressing that had been opened, not dated. 2 each Grove Apple concentrate that had been opened and dated 05/19. 1 each Grove Pineapple concentrate that had been opened and dated 05/19. 1 each 25 lb container of Chef Grade Hard Cooked Peeled Eggs opened, not sealed or dated.The walk-in freezer contained: 1 bag of round bread items that had been opened, not labeled or dated. 1 bag of long, brown sticks that had been opened, not sealed, labeled or dated. 1 bag of long, brown sticks that had been opened, not labeled or dated. 1 bag of small, tan sticks that had been opened, not labeled or dated. 1 bag of brown, breaded strips that had been opened, not labeled or dated.The dry storage room contained: 1 large clear container with a blue lid that contained a white powder substance that was not sealed, labeled, or dated. 1 bag of a brown powder substance in a box that had been opened, not labeled or dated. 1 opened bag of small marshmallows that had been opened, not sealed or dated. 1 bag of small chunks that had been opened, not sealed and dated 3/21. 1 bag of Dark Roast Gravy Mix wrapped in plastic wrap that had been opened, not dated. 1 silver bag labeled croutons that had been opened, not dated. 1 6-quart plastic container with a red lid labeled corn meal that had 1 label dated 9/19 and another label was dated 4-10. In an interview on 07/07/2025 at 7:45 AM, KM confirmed all the above items were not sealed, labeled, or dated and should have been. In an interview on 07/08/2025 at 2:40 AM, the facility's Medical Nutrition Therapist (MNT) confirmed the above items were not sealed, labeled, or dated and should have been. B.A record review of the facility's Sanitization policy dated 12/26/2023 revealed the dishwashing machines are operated to manufacturer instructions. Low temperature dishwasher (chemical sanitization) wash temperature should be 120 degrees F. Stop machine and notify supervisor if low-temperature dishwasher is below 50 ppm or if temperature is below specified temperature range. An observation on 07/08/2025 at 8:26 AM revealed the facility's cook (Cook)-B loaded, started, and walked away from the main kitchen's EcoLabs XL2000/4000 low-temperature dish machine and both the wash and rinse temperatures were 106 degrees F on both the upper and lower thermometers. The observation did not reveal the potential of hydrogen (pH) was tested following the cycle, but did reveal the dishes that were washed were put away. An observation on 07/08/2025 at 10:52 AM revealed Cook-C loaded, started and walked away from the main kitchen's EcoLabs XL2000/4000 low-temperature dish machine and both the wash and rinse temperatures were 82 degrees F on both the upper and lower thermometers. The observation did not reveal the potential of hydrogen (pH) was tested following the cycle, but did reveal the dishes that were washed were put away. An observation on 07/08/2025 at 11:07 AM with the KM revealed the KM ran emptied he water from the kitchen's EcoLabs XL2000/4000 low-temperature dish machine, ran it again empty and the upper thermometer read 115 degrees F and the lower thermometer read 117 degrees F, and the KM walked away. An observation on 07/08/2025 at 11:23 AM revealed Cook-B loaded, started and walked away from the main kitchen's EcoLabs XL2000/4000 low-temperature dish machine and both the wash and rinse temperatures were 106 degrees F on the upper thermometer and 102 degrees F on the lower thermometer. The observation did not reveal the potential of hydrogen (pH) was tested following the cycle, but did reveal the dishes that were washed were put away. In an interview on 07/08/2025 at 11:07 AM, the facility's KM confirmed the main kitchen's EcoLabs XL2000/4000 low-temperature dish machine cools down and takes a while to heat back up if it sits for a while. In an interview on 07/08/2025 at 2:40 PM. The facility's MNT confirmed that the main kitchen's EcoLabs XL2000/4000 low-temperature dish machine should have reached 120 degrees F for all wash cycles. C.A record review of the facility's Food Preparation and Service policy dated 12/21/2023 revealed ready to eat foods that require reheating are taken directly from the sealed container and cooked to at least 135 degrees for holding for hot service. An observation on 07/08/2025 at 11:34 AM revealed that Cook-C placed a cup of milk in the microwave for 1 minute, then added 30 seconds, and left it in the microwave. At 11:42 AM Cook-C added 30 seconds to the microwave and pressed start. Cook-C then handed the cup to the Nursing Assistant (NA) and the NA mixed the microwaved milk and a packet of Chocolate Cocoa mix and handed it to Resident 24. The observation did not reveal the milk was temped following the microwaving process. An observation on 07/08/2025 at 11:54 AM revealed Cook-C opened a can of Tomato Soup and poured it into a cup. Cook-C placed the cup of Tomato soup in the microwave and heated for 30 seconds, then added another 30 seconds while the soup was cooking. Cook-C then removed the cup of Tomato Soup from the microwave and handed the cup to the NA that placed it in front of Resident 24. The observation did not reveal Cook-C temped the Tomato Soup following being microwaved. In an interview on 07/08/2025 at 12:08 PM, the facility's MNT confirmed Cook-C should have temped food following being microwaved. D.A record review of the facility's Standardized Recipes policy dated 12/21/23 revealed standardized recipes shall be developed and used in the preparation of foods. Clear concise directions are given for making the product. A record review of the facility's Orange Chicken recipe dated 2025 revealed:The ingredients for 50 servings were: 11 lbs, 2 ounces (oz) skinless, boneless, chicken breasted thawed and cut into bite sized pieces. 1 cup, 6 tablespoons (Tbsp) all-purpose flour. 8 and 1/4 oz margarine, 2 quarts (qt). 3 cups Orange (Asian) sauce. The directions were: 1. Dredge chicken pieces in flour. 2. Place coated chicken in a single layer on sheet pan sprayed with nonstick cooking spray and drizzle with melted margarine. 3.Bake 20-25 minutes at 350 degrees F until desired internal temperature was reached. 4. Heat orange sauce over medium heat until desired internal temperature is reached, stirring frequently. 5. Spray steam table pans with nonstick cooking spray, add chicken and heated orange sauce. Cover and return to oven for 8-10 minutes until desired internal temp is reached. A record review of the facility's Steamed [NAME] recipe dated 2025 revealed:The ingredients for 50 servings were: 2 qts. long grain rice. 1 gallon, 3 cups water. 9 and 1/2 oz magarine.The directions were: 1. Rinse rice in a colander to remove some of the starch. 2. Stray steam atble pan with nonstick cooking spray. 3. Add rice and water to pan. Stir to distribute evenly. 4. Cover pan tightly with foil. Bake 1 hour at 350 degrees F or until desired internal temp is reached. Final internal cook temp of 135 degrees F. 5. Remove from oven and fluff rice with a fork. 6. Stir in margarine. A record review of the facility's Broccoli recipe dated 2025 revealed:The ingredients for 50 servings were: 2 qt water. 12 and 1/2 lbs broccoli florets (tops). 1/2 lb margarine. 2 teaspoons (tsp) iodized salt.The directions were: 1. Tap frozen vegetables in package to loosen. 2. Bring water to a boil in saucepan, stockpot, or steam jacketed kettle; add broccoli and cook until fork tender and desired temperature of 135 degrees F was reached. 3. Drain broccoli slightly, leaving enough broccoli in pan to retain heat. Add margarine and salt. 4. Transfer to steam table pans. Cover and hold until ready to serve. An observation on 07/08/2025 at 8:26 AM - 11:26 AM of Cook-A prepare facility's Orange Chicken did not reveal that Cook-A cut chicken breast into bite size pieces and dredge chicken in flour prior to cooking, drizzle chicken with melted margarine prior to cooking, heat the orange sauce over medium heat, or measure the ingredients. The observation of Cook-A prepare the Steamed [NAME] did not reveal Cook-A rinsed rice to remove starch, stir in margarine after cooking, it was done before cooking, or measure the ingredients. The observation of Cook-A prepare the Broccoli did not reveal Cook-A followed instructions such as cooking in saucepan, stockpot, or steam jacketed kettle and margarine and salt were not added. An observation on 07/08/2025 at 11:31 AM of the second-floor kitchen steam table revealed the first pan of Orange Chicken was dry with very little sauce. Cook-C called down to the main kitchen to get another pan of Orange Chicken more Kikkoman's Orange Sauce and served from the second pan until it was gone, then poured an un-measured amount of Kikkoman's Orange Sauce into the first pan of Orange Chicken before serving. The observation did not reveal the Orange Chicken was temped following adding the sauce. In an interview on 07/08/2025 at 8:48 AM, Cook-A confirmed Cook-A did not cut or flour the chicken breast prior to cooking and Cook-A put about 2 Tbsp soy sauce and teriyaki sauce and sprinkled with an un-measured amount of black pepper prior to placing in the oven. Cook-A confirmed Cook-A did not follow the recipes or measure ingredients, Cook-A just done what KM told Cook-A to do. In an interview on 07/08/2025 at 2:40 PM, the facility's MNT confirmed the facility's cooks should have followed the recipes when preparing all menu items. E.A record review of the facility's Sanitization policy dated 12/26/2023 revealed all utensils, counters, shelves, and equipment were to be kept clean, maintained in good repair, and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Nonfood contact surfaces of all other equipment including, but not limited to tables, counters, etc. shall be cleaned and sanitized as frequently as necessary in order to prevent accumulation of dust, dirt, food particles, and other soil or debris. An observation on 07/07/2025 at 7:04 AM - 7:45 AM revealed all the shelves below the prep tables contained food spills and food debris. The shelves above the prep table on the South wall were sticky and contained food debris. The exterior front of the Cres Cor double warmer contained food splatters, and the drip pan on the bottom contained food debris. An observation on 07/07/2025 at 7:45 AM with KM revealed all the shelves below the prep tables contained food spills and food debris. The shelves above the prep table on the South wall were sticky and contained food debris. The exterior front of the Cres Cor double warmer contained food splatters, and the drip pan on the bottom contained food debris. In an interview on 07/07/2025 at 7:45 AM, KM confirmed that all the shelves below the prep tables contained food spills and food debris. The shelves above the prep table on the South wall were sticky and contained food debris. The exterior front of the Cres Cor double warmer contained food splatters, and the drip pan on the bottom contained food debris and should have been clean.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(a)Based on observation, interview and record review the facility failed to ensure resident's receiving a continuous tube feeding had a head of bed elevation of at least 30 degrees for 1 (Resident 18) of 2 residents sampled. The facility census was 78.The findings are:Record review of Resident 18's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-12-2025 revealed the facility staff assessed the following about the resident:-had a diagnosis of an anoxic brain injury (an injury that completely deprives the brain of oxygen).-had a gastric tube (a tube inserted into the stomach for the delivery of nutrition).-was ventilator (a medical device that helps a person breathe) dependent.-required total assistance with hygiene, toileting, dressing, bathing, bed mobility and transfers. Record review of Resident 18's orders revealed an order for a continuous tube feeding at 55 milliliters (ml) per hour continuously and to elevate the Head of Bed (HOB) 30 degrees every shift, day and night.Record review of Resident 18's Comprehensive Care Plan (CCP) revealed a problem of potential altered nutrition and hydration related to total dependence on tube feedings for nutrition and hydration. The CCP also revealed the goal was to meet the nutritional needs of Resident 18, without signs of dehydration or tube feeding rejection. Under approaches for the staff to use revealed the HOB was to be elevated no less than 30 degrees. An observation on 07-08-2025 at 8:52 AM revealed Resident 18 was lying in bed with the tube feeding running and the HOB was elevated 15 degrees according to the gauge on the side of the bed. An observation on 07-09-2025 at 6:20 AM revealed Resident 18 was lying in bed with the tube feeding running and the HOB was elevated 15 degrees according to the gauge on the side of the bed.An observation on 07-10-2025 at 9:16 AM revealed Resident 18 was lying in bed with the tube feeding running and the HOB was elevated 15 degrees according to the gauge on the side of the bed. An interview with the Registered Nurse (RN) D at 9:20 AM confirmed the bed was not elevated 30 degrees but it was close. An observation on 07-22-2025 at 12:00 PM with the Administrator (ADM) and Director of Nursing (DON) measuring the angle of the HOB with a cell phone app which revealed when the gauge on the bed reads 15 the angle of the HOB was 18 degrees. Record review of the facility's policy titled Tube Feeding: Continuous dated 06-2025 revealed the following:-it is the policy of this facility to provide continuous enteral feedings for the resident when it is indicated and prescribed by the physician. Under the procedure section, the policy directs the staff to elevate the head of bed 30-45 degrees unless contraindicated.

Based on interview and record review, the facility failed to ensure that the ordered parameters were followed prior to Carvedilol (a medication used to treat heart failure and high blood pressure) administration for 1 (Resident 40) of 5 sampled residents. The facility census was 78.Findings are: A record review of the facility's Medications: Administration-General Principles dated 09/2019 revealed it was the policy of the facility to administer medications as prescribed by the physician. A special preparation for the medication administration procedure was to take any required vital signs prior to administration for medications with parameters for administration. A record review of Resident 40's Face Sheet dated 07/10/2025 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses of Hypertension (high blood pressure), Congestive Heart Failure (CHF), Duchenne or [NAME] muscular Dystrophy (genetic disorder characterized by the progressive loss of muscle), Chronic Respiratory Failure, Dependence on a Respirator (breathing machine), Tracheostomy (trach)(tube inserted in neck to assist with breathing), and Gastronomy (G-tube)(tube in the stomach to allow feeding). A record review of Resident 40's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/27/2025 revealed the resident was admitted to the facility 08/20/2024. The resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware. The resident was dependent on staff for all activities of daily living (ADLs). The resident required a trach, G-tube, and an invasive mechanical ventilator (breathing machine). The resident had Hypertension. A record review of Resident 40's Care Plan with an admission date of 08/20/2024 revealed the resident was on a Beta Blocker (medicines that lower blood pressure). A record review of Resident 40's Orders dated 07/08/2025 revealed Resident 40's practitioner ordered the following: -Carvedilol tablet; 12.5 milligram (mg): 1 tablet in the evening; Once an evening, decrease evening carvedilol to 12.5 mg if Systolic Blood Pressure (SBP)(top number of the reading which represented the arteries) below 100 re-check in 60 minutes and call the provider prior to holding. Start date 04/22/2024.- Carvedilol tablet; 25 mg: 1 tablet in the morning; Once a morning Carvedilol 25 mg if SBP below 100 recheck in 60 minutes call the provider prior to holding medication. Star date 04/22/2024. A record review of Resident 40's Medication Administration History (MAR) dated 05/01/2025 - 05/31/2025 and the resident's Vitals Report dated 05/01/2025 - 05/31/2025 revealed the following: -On 05/04/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/05/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/08/2025 the morning dose of Carvedilol was administered and the SBP was 97 -On 05/13/2025 the evening dose of Carvedilol was administered and the SBP was 95 -On 05/17/2025 the evening dose of Carvedilol was administered and the SBP was 95. -On 05/18/2025 the evening dose of Carvedilol was administered and the SBP was 90. -On 05/04/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/20/2025 the evening dose of Carvedilol was administered and the SBP was 90. -On 05/21/2025 the evening dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/20/2025 the evening dose of Carvedilol was administered and the SBP was 97. -On 05/22/2025 the evening dose of Carvedilol was administered and the SBP was 96. -On 05/2/2025 the morning dose of Carvedilol was administered and the SBP was 98. -On 05/24/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/25/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/26/2025 the evening dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/28/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/22/2025 the evening dose of Carvedilol was administered and the SBP was 98. -On 05/30/2025 the evening dose of Carvedilol was administered but the blood pressure had not been taken. -On 05/22/2025 the evening dose of Carvedilol was administered and the SBP was 94 A record review of Resident 40's MAR dated 06/01/2025 - 06/30/2025 and the resident's Vitals Report dated 06/01/2025 - 06/30/2025 revealed that: -On 06/02/2025 the morning dose of Carvedilol was administered and the SBP was 88. -On 06/03/2025 the evening dose of Carvedilol was administered and the SBP was 95. -On 06/04/2025 the evening dose of Carvedilol was administered but the blood pressure had not been taken. -On 06/05/2025 the evening dose of Carvedilol was administered and the SBP was 90. -On 06/07/2025 the evening dose of Carvedilol was administered but the blood pressure had not been taken. -On 06/08/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. - On 06/12/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. - On 06/14/2025 the evening dose of Carvedilol was administered and the SBP was 98. -On 06/15/2025 the evening dose of Carvedilol was administered and the SBP was 90. -On 06/18/2025 the evening dose of Carvedilol was administered and the SBP was 93. -On 06/20/2025 the evening dose of Carvedilol was administered and the SBP was 94. -On 06/22/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 06/20/2025 the evening dose of Carvedilol was administered and the SBP was 94. -On 06/22/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 06/22/2025 the evening dose of Carvedilol was administered and the SBP was 92. -On 06/26/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 06/27/2025 the evening dose of Carvedilol was administered but the blood pressure had not been taken. -On 06/30/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken A record review of Resident 40's MAR dated 07/01/2025 - 07/08/2025 and the resident's Vitals Report dated 07/01/2025 - 07/07/2025 revealed that: - On 07/01/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. -On 07/04/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. - On 07/05/2025 the morning dose of Carvedilol was administered but the blood pressure had not been taken. A record review of Resident 40's MAR dated 07/01/2025 - 07/10/2025 with a run date of 07/10/2025 revealed the Carvedilol administration records now had an associated blood pressure line. A record review of Resident 40's Progress Notes dated 05/01/2025 - 07/01/2025 did not reveal a blood pressure had been rechecked or the provider notified of an SBP of less than 100 except on 07/02/2025 at 8:34 AM. In an interview on 07/08/2025 at 10:27 AM, the Director of Nursing (DON) confirmed that Resident 40's Carvedilol was administered with an SBP of less than 100 and should not have been and re-checks should have been completed.

License Reference Number 175 NAC 12-006.12B Based on interviews and record review, the facility failed to ensure a documented rationale was provided by the physician for an as needed psychotropic medication for an order of longer duration than two-week period for 1 (Resident 29) of 5 sampled resident. The facility identified a census of 83. The findings are: A record review of the Resident 29's census sheet revealed an admitted [DATE]. A record review of Resident 29's undated Diagnosis Sheet listed the following diagnoses: Mitochondrial metabolism disorder, unspecified, chromosomal abnormality, cyclical vomiting, congenital insufficiency of aortic valve-Bicuspid aortic valve, respiratory disorder, anemia, hypertension, diaphragmatic hernia with obstruction, pneumonitis, due to inhalation of food and vomit, obstructive sleep apnea, atrial septal defect, constipation, disturbances of salivary secretion, and insomnia. A record review of Resident 29's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 2/20/24 revealed the resident to be [AGE] years old. Resident had short- and long-term memory problems. Resident's ability to make daily decisions was identified as severely impaired. Resident 29 had no physical or verbal behaviors, nor any rejection of care issues. The resident did routinely take an antipsychotic (a medication used to reduce or relive symptoms of psychosis), antidepressant and an anticoagulant (a blood thinner). A record review of Resident 29's Physician's Order revealed an order for Lorazepam (psychotropic medication in the class of anti-anxiety medication, used to treat anxiety) 2 milligrams (mg) per milliliter (ml) intravenous (IV medication given in the vein), dilute in minimum of 1:1 with normal saline every 6 hours as needed for excessive drooling and retching. The start date for the Lorazepam was 07/21/2023 with no stop date. A record review of Resident 29's Pharmacy Consults since July of 2023 throught April of 2024 revealed no review for the use of the as needed Lorazepam for cyclic vomiting was mentioned. An interview with the Director of Nursing (DON) on 05/13/24 at 1:31 PM revealed there was no documented rationale for the use of the as needed Lorazepam for longer than 2-week was available. An interview on 05/14/24 12:18 PM with the IV Medication Pharmacist confirmed the pharmacy did not have a documented rationale for the use of the as needed Lorazepam for longer than 2 weeks. An interview on 05/14/24 at 12:19 PM to the Pharmacy Consultant confirmed the facility did not have a documented rationale for the use of the as needed Lorazepam longer than a 2-week period.

Licensure Reference Number NAC 175 12.006.17B Based on observation, interview and record review; the facility staff failed to wear a gown during wound care for 1 resident (Resident 19) of 1 sampled residents who was on contact precautions. The facility census was 83. Findings are: Record Review of Resident 19's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 04-10-2024 revealed Resident 19 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 indicating intact cognition. The MDS also revealed Resident 19 had diagnoses of respiratory failure and was ventilator (Ventilators are machines used to move air in and out of a patient's lungs when lung capacity decreases or stops altogether) dependent and was receiving wound care and treatments for a surgical wound. Record Review of Resident 19's Electronic Health Record (EHR, a digital version of a patient's paper chart) revealed Resident 19 had a surgical wound on the left thigh and a culture (a sample of body fluid or tissue is added to a substance that promotes the growth of germs) and sensitivity (sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) lab test was collected on 05-02-2024 that revealed growth of Methicillin Resistant Staphylococcus Aureus (MRSA, a multidrug resistant organism) and Methicillin Sensitive Staphylococcus Aureus (MSSA)organisms. The EHR also revealed Resident 19's physician had ordered on 01-30-2024 daily dressing changes for the surgical wound on the left thigh and on 05-08-2024 Bactrim DS (an antibiotic) was ordered twice a day for 7 days to treat the MRSA and MSSA in the left thigh wound. An observation on 05-09-2024 at 10:40 AM of Resident 19's bathroom door revealed a sign that instructed staff that Resident 19 was on Contact Precautions (Contact Precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment). The sign indicated that staff should always wear a gown and gloves. An observation on 05-09-2024 at 10:45 AM of the Wound Nurse (WN) B without a gown on performing wound care to Resident 19's left thigh wound. An interview on 05-09-2024 at 11:10 AM revealed WN-B was aware that Resident 19 was on contact precautions and should have worn a gown during wound care. An interview conducted on 05-09-2024 at 1:31 PM with the Unit Coordinator (UC) A confirmed that Resident 19 was on contact precautions and gown and gloves should be used when providing care. According to the recommendations from the Centers of Disease Control (CDC) to prevent the spread Multi Drug Resistant Organisms (MDRO) in Long Term Care Facilities (LTCF) for ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living, ventilator-dependent) and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure the range hood had been maintained in a clean and safe operating condition to prevent the potential for food-borne illness. This had the potential to affect the 26 residents that consumed food from the kitchen. Total census was 78. Findings are: According to the National Fire Protection Association's (NFPA) Kitchen Hood Cleaning Requirements, NFPA 96-section 11.6.2 states hoods, grease removal devices, fans, ducts, and other items shall be cleaned to remove combustible (able to catch fire) contaminates (unclean materials) prior to surfaces becoming heavily contaminated with grease or oily sludge. Observation on 01/12/2022 at 8:10 AM revealed the black coating used on the facility's kitchen range hood was peeled off in multiple locations. Observation on 01/13/2022 at 09:42 AM revealed the black coating on the facility's kitchen range hood was peeled off in multiple locations. Observation on 01/13/2022 at 11:20 AM revealed the black coating used on of the facility's kitchen range hood peeled off in multiple locations. Observation on 01/18/2022 at 08:25 AM revealed the black coating on the facility's kitchen range hood was peeled off in multiple locations. Interview with the Administrator on 01/18/2022 at 9:01 AM confirmed the range hood coating was peeled off in multiple locations and created a potential hazard for the debris to fall into food being prepared on the stove below. Interview with the Dietary Manager on 01/18/2022 at 09:01 AM confirmed the range hood's coating was peeled off in multiple locations.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview and record review, the facility failed to complete hand hygiene and glove changes and cleanse scissors during a treatment in a manner to prevent the potential for cross contamination for 1 (Resident 66) of 3 residents reviewed. The facility census was 78. Findings are: Record review of a facility policy entitled Hand Washing dated 12/2019 revealed the following information: Indications for use: Alcohol based Hand Rub: - to be used when going from dirty to clean function on the same resident. Record review of Resident 66's Readmission Face Sheet revealed a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 66's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 01/18/22 between 09:06 AM and 9:20 AM with Registered Nurse [RN] A revealed the following observation: - Licensed Practical Nurse [LPN] B performed hand hygiene, donned gown and gloves outside of Resident 66's room. LPN B had on a N 95 mask and face shield. With gloved hands, LPN B touched the door to knock, entered the room and touched the handles of the cupboards and gathered towels. LPN B entered the bathroom and touched the faucet to turn on and prepared soapy water in a basin. LPN B took the supplies and soapy to the bed, unzipped the exterior of the bed and placed the supplies on a towel barrier on the bed. - With the same gloved hands, LPN B repositioned Resident 66 into the bed by touching the resident 's body and night clothing in order to expose the stomach area. LPN B placed a wash cloth into the warm soapy water and proceeded to cleanse the skin surrounding the G tube and changed the surface of the cloth with each swipe onto the skin. LPN B dried the area with a towel. - With the same soiled gloves and no hand hygiene performed, LPN B touched the dresser drawer, opened the drawer and took out a new box of [MEDICATION(S)] dressings, opened the box and removed a 4x4 dressing. - With the same soiled gloves and no hand hygiene performed, LPN B took a scissors out of [gender] right pocket. - Without wiping the scissors with cleanser and wearing the same soiled gloves with no hand hygiene performed, LPN B cut out a small portion of the [MEDICATION(S)] dressing, placed the remainder of the dressing back into the box and back into the drawer. - Wearing the same soiled gloves and with no hand hygiene performed, LPN B placed the small piece of [MEDICATION(S)] dressing on the skin to surround the G tube site. - LPN B took off the soiled gloves and (with no hand hygiene performed) proceeded to cleanse the CT site with a new warm wash cloth, changed the surfaces of the cloth with each swipe and then dried the area with a towel. - Wearing the same soiled gloves, LPN B touched the dresser drawer, opened the drawer and took out a 2 x 2 piece of gauze and placed it on the skin so it surrounded the CT site. - Wearing the same soiled gloves and with no hand hygiene performed, LPN B took the remainder of the [MEDICATION(S)] dressing from the box inside the drawer. - Without wiping the scissors with cleanser and wearing the same soiled gloves with no hand hygiene performed, LPN B cut out a small portion of the [MEDICATION(S)] dressing, placed the remainder of the dressing back into the box and back into the drawer. - Wearing the same soiled gloves and with no hand hygiene performed, LPN B placed the small piece of [MEDICATION(S)] dressing on top of the gauze to surround the CT site. - Wearing the same soiled gloves and with no hand hygiene performed, LPN B removed the soiled towels and the soapy water and zipped the exterior of the bed. LPN B took the soiled supplies into the bathroom, rinsed the basin, removed the soiled gloves and gown and performed hand hygiene. Interview with RN A on 01/18/22 at 10:01 AM confirmed the following: - LPN B touched several contaminated surfaces in the room and did not change the soiled gloves prior to beginning GT site care for Resident 66. LPN B should have gathered all the supplies necessary for the GT and CT site care and then performed hand hygiene and donned clean gloves prior to touching the resident and starting the site care. - After cleansing the G tube site, LPN B should have removed the soiled gloves, used hand sanitizer and put on clean gloves. LPN B should have wiped off the scissors with sanitizer prior to cutting the dressing and placing it onto the CT site and should not have placed the dressing back into the box and drawer. RN A confirmed that the interior of pockets are considered contaminated. - LPN B should have changed gloves and using hand sanitizer prior to beginning the CT site care. LPN B should have wiped off the scissors with sanitizer prior to cutting the dressing and placing it onto the CT site and should not have placed the dressing back into the box and drawer. Interview on 01/18/22 at 10:50 AM with the Director of Nursing confirmed that all supplies should have been gathered prior to beginning site care, gloves should have been changed and hand hygiene performed between cares and the scissors should have been cleaned before cutting the dressing.

Based on record review and interview, the facility failed to provide written notice of transfer for 3 residents (Residents 20, 54 and 77) of 3 residents reviewed for transfer/discharge requirements. Findings are: A. Record review of a Bed Hold Notice sheet dated 10-12-2021 revealed Resident 20 was discharged to the hospital on 10-12-2021. Record review of Resident 20's medical record revealed there was no evidence the facility staff provided a written notice of transfer to the hospital or the reason for transfer to the hospital to Resident 20's responsible party. An interview on 1-19-2022 at 085:56 AM with the Director of Nursing confirmed there was not a written notice of transfer to the hospital or a written reason for transfer given to Resident 20's responsible party. B. Record review of a Bed Hold Notice sheet dated 12-28-2021 revealed Resident 54 was discharged to the hospital on 12-25-2021. Record review of Resident 54's medical record revealed there was no evidence the facility staff provided a written notice of transfer to the hospital or the reason for transfer to the hospital to Resident 54's responsible party. An interview on 1-19-2022 at 08:56 AM with the Director of Nursing confirmed there was not a written notice of transfer to the hospital or a written reason for transfer given to Resident 54's responsible party C. Record review of a Bed Hold Notice sheet dated 11-18-2021 revealed Resident 77 discharged to the hospital on 11-18-2021. Record review of Resident 77's medical record revealed there was not evidence the facility staff provided a written notice to Resident 77 or Resident 77's responsible party of the reason Resident 77 was transferred to the hospital. On 1-18-2022 at 9:05 AM an interview was conducted with the Social Services Director (SSD). During the interview the SSD confirmed a written notice was not provided to Resident 77 or Resident 77's Responsible party for the reason of the transfer to the hospital.

Based on observation, interview, and record review, the facility failed to implement CMS and CDC recommendations in order to prepare for COVID-19. The facility failed to thoroughly screen visitors, when the Federal surveyor entered the facility and was not screened by staff. Additionally, the facility failed to screen staff, when the facility failed to ask CDC-recommended screening questions prior to staff caring for residents. The facility failed to ensure that staff correctly wore facemasks at all times while in the facility, and while within six feet of residents. Findings included: - On 6/2/20 at 11:30am, Registered Nurse (RN1) and RN2 sat at the 3R, or pediatric floor, nursing station. RN1 and RN2 wore disposable surgical facemasks, but failed to wear the masks appropriately. RN1 and RN2 each had their mask beneath their nose, leaving their noses exposed. Upon seeing the Federal surveyor, RN1 and RN2 pulled their facemasks over their noses. On 6/2/20 at 12:03pm, the Pediatrics Supervisor indicated that facemasks must be worn over the mouth and nose. The Pediatric Supervisor indicated that she was not aware of any issues with staff wearing facemasks inappropriately. On 6/2/20 at 12:17pm, RN1 and RN2 indicated that their facemasks had slipped beneath their noses. On 6/2/20 at 12:37pm, a housekeeper (H1) cleaned R1's room while R1 watched TV in the common area. H1 wore a disposable surgical facemask, however, H1's mask was pulled beneath her chin, leaving her mouth and nose exposed while she cleaned the room. On 6/2/20 at 12:47pm, H1 indicated that she was too hot, so she pulled her mask down beneath her chin. H1 indicated that this was not appropriate mask wearing, and fixed her mask. On 6/2/20 at 12:58pm, H1 swept R2's room, while R2 was present. H1 stood directly next to R2 and looked in the direction of R2's television, which played cartoons. H1's facemask was again pulled beneath her chin, leaving her mouth and nose exposed. H1 then exited the room and retrieved a dustpan, collected some floor debris, then exited R2's room. H1 failed to sanitize her hands after leaving the room and beginning to vacuum the hallway. On 6/2/20 at 1:05pm, RN3 stood in R3's room and talked with the resident. RN3 wore a disposable surgical facemask, however, the mask was pulled down, leaving R3's nose exposed. Upon seeing the Federal surveyor, RN3 pulled her facemask over her nose. On 6/2/20 at 1:22pm, RN3 indicated that her mask had slipped down, and that she had not fixed it yet. RN3 indicated that masks must be worn over the mouth and nose. On 6/2/20 at 2:30pm, Licensed Practical Nurse (LPN1) indicated that facemasks must be worn over the mouth and nose at all times. LPN1 indicated that in the past, she had observed staff not wearing facemasks appropriately. This happened occasionally, and LPN1 would complete on-the-spot education for staff who did not correctly wear their masks. - Review of CMS guidance, dated 3/4/20, documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019- ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19. The guidance then stated: How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). On 6/2/20 at 11:15am, the Federal surveyor entered the facility. A receptionist sat at the desk. The Federal surveyor gave the reason and purpose for the visit, and the receptionist called the Director of Nursing (DON). The receptionist failed to screen the Federal surveyor. Approximately five minutes later, the DON arrived, and escorted the Federal surveyor to floor 3R. The DON failed to screen the Federal surveyor. On 6/2/20 at 12:17pm, RN2 indicated that the facility screening process consisted of staff taking their own temperatures and logging the result. There were no screening questions to complete. On 6/2/20 at 12:28pm, the DON indicated that all floors in the facility were locked, so staff were either screened there or at the nursing stations, which were directly by the entry doors. Facility staff were to take their own temperatures and log them. The DON indicated that there were also screening questions staff were to complete. On 6/2/20 at 1:22pm, RN3 indicated that the facility screening process consisted of staff taking their temperatures and logging the result. Staff were asked if they had signs or symptoms of COVID-19, but there were no further screening questions. Review of staff screening sheets, dated 3/15/20 through the recent ones, documented facility staff had their temperatures taken, and answered a single question as to if they had signs or symptoms of a respiratory infection. There were no other screening questions present. The facility failed to provide any staff screening forms prior to 3/15/20.

Licensure Reference Number 12-006.11E Based on observation, record review and interviews the facility failed to ensure hand washing was performed for a minimum of 20 seconds per facility policy, failed to ensure hot foods on the steam table were held at 135 degrees Fahrenheit or above and cold foods were below 41 degrees Fahrenheit and failed to change gloves during meal services to prevent potential for food Bourne illness. This had the potential to affect all residents that eat foods served in units 2 and 3 dining rooms. The facility census was 86. [NAME] An observation on 02/06/20 at 11:40AM in Unit 2 dining room revealed DA (Dietary Aide)-A removed gloves, turned faucet on applied soap then water, washed hands for 8 seconds, drying hands with paper towel. An observation on 02/10/20 at 11:30AM revealed DA - C turn on water faucet, applied soap to hands and then water, washed hands for 5 seconds, turned faucet off with the same paper towel that was used to dry hands. Record review of policy titled Hand Washing Dated 07/01/09 revealed staff will wash hands frequently as needed throughout the day following proper hands washing procedures. Hand washing facilities should be readily accessible and equipped with paper towels and soap. Section 2 - How to wash hands bullet 2 wash hands for a minimum of 20 seconds. An interview on 02/11/20 at 12:20PM with dietary manager confirmed hand washing is to be done for 20 seconds or longer per facility policy. B. An observation on 02/10/20 at 11:10AM revealed the following food temperatures on unit 2 steam table were: Chicken 146 degrees Fahrenheit. Veggies - 173 degrees Fahrenheit. Rice- 187 degrees Fahrenheit. Dinner rolls- 149 degrees Fahrenheit. Cup of Italian salad dressing - 66.3 Degrees Fahrenheit. An interview on 02/10/20 at 11:15 AM with DA-A revealed that if food is not at the correct temperature food can be warmed up in the microwave and food that is cold can be placed back in fridge to be cooled down. An observation on 02/10/20 at 11:30AM revealed the following food temperatures on unit 3 steam table were: Rice- 185 Degrees Fahrenheit Chicken- 145- degrees Fahrenheit Mashed Potatoes- 159 Degrees Gravy 190 Degrees Fahrenheit Pureed Chicken - 192 degrees Fahrenheit Pureed Plate - on top of steam table Veggies- 175 degrees Fahrenheit Pureed Chicken- 177 Fahrenheit Mechanical Soft - Cups on top of steam table Cup of ground Hot Dog- 93.7 Degrees Fahrenheit Package of pureed Cauliflower- 44.0 Degrees Fahrenheit. An interview on 02/10/20 at 11:30AM with DA- C revealed that the correct temperature for food on the steam table is to be 150 degrees Fahrenheit. DA-C stated that if food is not the correct temperatures it is sent back down to the kitchen. An interview on 02/10/20 at 11:34 AM with Dietician confirmed food not at the appropriate temperatures are returned to the kitchen- if it's a large pan, if its pureed or mechanical soft the items are reheated in the unit kitchen microwave. Record review of policy titled Proper Food Storage not dated revealed in section 14. Foods are kept hot, above 140 Degrees F or cold, below 41 degrees F and are not kept at in-between temperatures during preparation and service longer than is necessary. An interview on 02/10/20 at 1:29PM with Dietician confirmed cold foods that have a temperature above 41 degrees Fahrenheit are to be discarded and hot foods that have a temperature below 135 degrees Fahrenheit. The facility failed to ensure hand washing was performed for a minimum of 20 seconds per facility policy, failed to ensure hot foods on the steam table were held at 135 degrees Fahrenheit and cold foods were below 41 degrees and failed to change gloves during meal services to prevent potential for food Bourne illness . This had the potential to affect all residents that eat foods served in units 2 and 3 dining rooms. Findings are: Dining Observation 02/05/20 11:30 AM Observation of lunch being served on 3 rd floor,Dietary Aide while serving food from the steam table was wearing gloves. While serving resident food the Dietary Aide went from serving to opening the refrigerator to the microwave, then back to serving. At one point the Dietary Aide picked up a piece of bread on the residents food tray with her gloved hand that had just touch several different pieaces of equipment in the area. 02/06/20 01:00 PM Interview with Dietary manager ,confirmed that the use of gloves when serving the food from the dietary steam table and going from steam table to refregiator to microwave has the potenial to cause food bourne illness.

Licensure Reference Number 175 NAC 12-006.18 A Based on observation and interview, the facility staff failed to maintain the cleanliness and condition of ceiling tiles, doors, lighting fixtures, and ensure nurse equipment was clean and in good repair on the [MEDICAL CONDITION] Unit. The facility census was 88. Findings are: [NAME] Observation on 2/11/20 between 10:20 AM and 10:50 AM with the Maintenance director (MD) and Environmental Services Director (ESD) revealed the following environmental concerns: - Ceiling lights in the nurse's station on the [MEDICAL CONDITION] floor were littered with dead bugs, and the bathroom light in room [ROOM NUMBER] had no cover for the bulbs. The nurse's station between [MEDICAL CONDITION] floor North and South had no cover for the bulbs. Ceiling tiles on the [MEDICAL CONDITION] floor were stained with a brown substance and had holes in them. - Equipment which was in the [MEDICAL CONDITION] Department hallways, including lifts, vitals machines. Nurse computer carts, were littered with brown and grey debris. - Bathroom door in room [ROOM NUMBER] had 2 holes in it, one with attempted repair and one completely open. Interview on 2/20/19 between 10:20 AM and 10:50 AM with the ESD and MD confirmed the bathroom light having no cover, dead bugs in the ceiling light, no cover over the bulbs in the nurses station, the stained ceiling tile and the holes in the ceiling tile, and the holes in the bathroom door of room [ROOM NUMBER].

LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview and record review, the facility staff failed to maintain the cleanliness and condition of the ventilation system for 9 rooms (215, 216, 220, 227, 231, 232, 315, 328, and 333). The facility cencus was 88. Findings are: A -Observation on 2/11/20 between 10:20 AM and 10:50 AM during an environmental tour with the Maintenance director (MD) and Environmental Services Director (ESD) revealed the ventilation covers were coated with a dusty gray substance on the interior and exterior of the system in resident bathrooms in rooms 317, 328 and 333. - The environmental tour revealed that the MD stated housekeeping was to clean the vents. The MD stated that they may have to take the metal grates off now so that the vents can be cleaned. - Record review of the maintenance tasks reveals that the bathroom vents do not appear on the maintenance tasks and the ESD produced policies which do not address the bathroom ventilation system. B. An observation on 02/5/20 at 3:10PM revealed in rooms 220, 216, 215,232, 231 and 227 the vents were covered in furry gray substance and not working as evident by using a 2x2 square sheet of 1 ply toliet paper and holding against vent - toliet paper was not drawn into vent. See photos on CD. An interview on 02/10/20 at 10:18AM with Head of maintenance department confirmed vents are to be cleaned by house keeping and aware that vents were not working; a belt for ventilation sytem was just replaced to fix the issue.

Licensure Reference Number 175 NAC 12-006.05 (4) Based on interviews, record review and observations the facility failed to ensure Residents food choices and preferences were honored for 3 Residents (Resident's 290,289 and 58). The facility census was 86. [NAME] An interview on 02/05/20 at 10:00AM with Resident 290 revealed that resident does not get to choose food choices and is not served what is circled on menu. An observation on 02/05/20 at 11:30AM revealed resident 290 in the dining room, resident was given the standard meal, resident looked at plate and stated (gender) did not want cabbage, DA( Dietary Aide) -A served resident potatoes and did not offer other alternatives for the meal. Record review of menu revealed A la carte (Lunch & Dinner) Please notify dietary the day before. An interview on 02/06/20 at 12:17PM with Cook - B confirmed that nursing staff hand out menus on Fridays and must be returned by Monday. In each units kitchenette soups, peanut butter & jelly sandwiches, ice cream, puddings and cereal are all available. An observation on 02/06/20 at 11:30AM revealed Resident 290 received a BLT sandwich; resident tapped toast on plate and toast was hard, resident showed everyone (gender) top teeth are loose and cannot eat tough foods. Dietary staff did not offer Resident 290 any alternative to hard toast or additional alternatives. Record review of Resident 290's Care Plan (a written document that specifies how to take care of residents, reflecting their preferences and choices) dated 02/06/20 revealed the following problem- Problem Start Date: 02/06/2020 -Potential for altered nutrition, hydration, and weight status related to use of therapeutic diet (CCHO), use of laxatives. Goal Target Date: 05/06/2020 Resident 290 will consume 75-100% of meals and supplements. Intervention Start Date: 02/06/2020 Honor res food preferences, and choice of dining location. Intervention Start Date: 02/06/2020 Offer replacement food, Determine food likes, R.D. consult, PRN, record food intake if resident eats in dining room, Provide diet appropriate snacks. B. An observation on 02/05/20 at 11:34AM revealed Resident 289 was wheeled up to table in dining room, DA-A then pointed at Resident 289 and asked who is this? Nursing staff replied it's a new person. Resident 289 was not asked what he would like for lunch as was served the standard meal. An interview on 02/06/20 at 7:00AM with Resident 289 revealed food is not very good, not many options are available and just get what your serviced. Resident 289 also mention has had issues with thrush (fungal infection) in mouth and throat that makes swallowing very painful. Facility has tried some normal soft foods but has not asked resident what (gender) would prefer. Record review of Resident 289 Care Plan (a written document that specifies how to take care of residents, reflecting their preferences and choices) dated 02/07/20 revealed the following information Problem Start Date: 02/07/2020 Problems: - Inadequate oral intake r/t painful swallowing due to thrush as evidenced by frequent poor Intakes. Interventions: Honor resident's food preferences, and choice of dining location. Provide ordered diet, Monitor calorie intake, Monitor Intake and output, as ordered, Offer replacement foods, Determine resident's food likes. An interview on 02/06/20 from 12:34PM- 12:49PM with Dietary Manager and Dietician confirmed residents are given menus for 1 week on Fridays and have until Monday to turn it in. Resident also have option to turn in 1 day at a time. Residents are able to choice any al a carte item any time if they do not like what is on their tray. Dietary staff and nursing staff are to help resident's complete menus and write down any alternatives. C. An interview on 02/06/20 at 7:45AM with Resident 58 revealed that meal menus are passed out 1-2 weeks in advance and you must fill out the menu for the week and return it. Resident 58 says (gender) does not receive what he orders and is given the standard meal. Resident 58 often eats food family has brought in due to the facility food being mushy and not being served what (gender) ordered. Record review of Resident 58's Care Plan (a written document that specifies how to take care of residents; reflecting their preferences and choices) dated 02/07/20 revealed the following Problems- Potential for altered nutrition, hydration, and weight change related dependence on tube feed for nutrition and hydration needs, history of weight loss. Goal Target Date: 12/11/2019 1) Resident 58 will consume 75-100% food with meals. 2) Resident 58 will consume average of 240-360ml fluid with meals. Approach Start Date: 09/11/2019 Honor resident's food preferences, and choice of dining location.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on record review and interview; the facility pharmacist failed to notify the facility of a discrepancy on the method of medication administration for 1 ( Resident 3) of 4 residents. The facility staff identified a census of 91. Findings are: Record review of Resident 3's Comprehensive Care Plan (CCP) dated 7-09-2018 revealed Resident 3 was dependent on a tube for feedings, hydration needs and medication use. Record review of Resident 3's Physicians Order Report (POR) sheet from 7-29-2019 through 8-29-2019 revealed Resident 3 had a Gastric Tube ( Tube placed through the abdomen into the stomach). Further review of the POR dated 7-29-2019 through 8-29-2019 revealed orders for medications that included the following: -Milk of Magnesia 30 milliliters (ml) as needed to be taken orally with an order dated of 6-27-2018. -Multivitamin, give 1 tablet daily to be taken orally with an order date of 6-27-2018. -[MEDICATION NAME] -[MEDICATION NAME], give 5 ml's orally with a order date of 7-14-2018. -Carvedilol 3.125 milligrams (mg) 1 table orally with an order date of 5-21-2019. -Narco( pain medication) 5-325 mg to be given orally as needed with an order date of 5-21-2019. Observation on 8-29-2019 at 7:55 AM revealed Registered Nurse (RN) A administered all medication through the gastric tube. On 8-29-2019 at 8:05 AM an interview was conducted with RN [NAME] During the interview RN A confirmed Resident 3 was Nothing by Mouth (NPO). On 8-29-2019 at 1:30 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not being notified by the facility pharmacist of Resident's 3's discrepancy of orders for medications to be taken orally. The DON confirmed Resident 3 was NPO.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on record review and interview; the facility failed to obtain medications for 1 (Resident 5) of 4 sampled residents. The facility staff identified a census of 91. Findings are: Record review of a Doctor's Orders and Progress Notes sheet dated 6-15-2019 revealed Resident 5's practitioner [MEDICATION NAME](an antibiotic medication) drops to both eyes every 2 hours while awake for 5 days related to pink eye. Record review of Resident 5's Medication Administration Record [REDACTED]. Record review of Resident 5 Progress Notes (PN) dated 6-16-2019 revealed the Charge Nurse followed up with the facility Pharmacy at 10:34 AM related to when the antibiotic medication would be delivered. Further review of Resident 5's PN dated 6-16-2019 revealed the pharmacy reported being notified of the antibiotic order on 6-15-2019 and would be delivering it on 6-16-2019. On 8-29-2019 at 1:15 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed resident 5 had not received the antibiotic eye drops as the medication was not available.

Licensure Reference Number: 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to ensure the kitchen staff wore hair nets to cover all of their hair while preparing food for the residents. This had the potential to affect 45 residents in the facility. The facility census was 92. Findings are: Observation on 10/09/18 at 10:31 AM revealed Staff (A)'s hair net was not covering all of hair. Observation on 10/11/18 at 9:30 AM revealed Staff (A)'s hair net was not covering all of hair. Interview with Dietary Manager on 10/11/18 at 11:30 AM confirmed that Staff (A)'s hairnet had not covered all of hair. Record review of the facility hair net policy revealed Hair must be restrained and hairnets must be worn. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for the food service sanitation practices, revealed the following regarding 2-402.11(A) 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 effectively keep their hair from contacting exposed food: clean equipment, utensils, and Linens.

Licensure Reference Number: 175 NAC 12-006.18A (1) Based on observation and interview, the facility failed to ensure that the light fixtures in the second floor dining room were free of dead insects. This had the potential to affect the residents on the second floor. The facility census was 92. Findings are: Observation of the second floor dining room on 10/09/18 at 12:05 PM revealed dead insects in overhead lights. Observation of the second floor dining room on 10/11/18 at 10:05 AM revealed dead insects in overhead lights. Interview with the Administrator and the Head of Maintenance on 10/11/18 at 1:50 PM confirmed that there were dead insects in overhead lights in the second floor dining room.

Based on observation, record review and interview, the facility failed to safely store medications by not discarding expired medications and supplies in 2 of 10 medications storage areas, and leaving a respiratory cart unlocked and unattended. The findings are: Record review of policy and procedure, Storage of Medications dated 12/2016 revealed, Policy: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Procedure .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On 9/11/17 at 8:40 a.m. during an observation on the 3rd floor, near the elevator, a treatment cart with respiratory medications in the cart was unattended, in the hallway and unlocked. Licensed Practical Nurse (LPN) C walked by as the cart drawer was opened, and was asked if the cart should be unlocked. LPN C stated, probably not and proceeded to walk past the cart. The Respiratory Therapist (RT) came to the cart, and when asked if the cart should be unlocked while unattended, he verified that it should not be. He confirmed that he was in a resident's room down the hall and was coming and going in between residents. On 9/13/17 at 7:55 a.m. during an observation in central supply, 10 Airlife Disposable facemasks (medium adult) with the expiration date of 9/2016 were found on the shelf. Central Supply (CP) employee verified that there were 10 masks, they were expired, and should be disposed of. On 9/13/17 at 8:25 a.m. during an observation of the 3rd floor Pediatric medication storage room, six packages of Levalbuterol Inhalation Solution 0.63 mg (milligrams)/3 ml (milliliters) were found in an unmarked cabinet with expiration dates of 8/2017. At this time, Registered Nurse (RN) B was asked to verify the dates, and confirmed that the medication was expired. RN B was asked to do what the facility does when they find expired medications and she stated, I will take them, and removed the medications. On 9/13/17 at 10:06 a.m. during an interview with the Director of Nursing (DON), when asked if medication/treatment carts should be unlocked and unattended, she stated, No, they shouldn't. When asked if expired medications and supplies should be removed from use, she verified that they should.

Based on observation, record review and interview; the faciilty Quality Assurance committee failed to re-evaluate prior plans of correction to maintain correction for previously cited deficient practice related to assuring storage areas were free from expired medicaiton and supplies. The facility census was 91. Findings are: Review of the facilities prior survey results revealed the facility has had repeat deficiencies for Federal Regulation F431 for having expired medication and supplies available for resident use in 2015, 2016 and 2017. Interview with the Director of Nursing (DON) on [DATE] at 8:21 AM revealed follow up is completed on the results of the completed project to assure maintained compliance. Interview on [DATE] at 1:45 PM revealed the Administrator was in agreement that the correction had not been maintained.

Based on observation, record review and interview, the facility failed to maintain a medication error rate under 5%, with 17 errors of 29 medications observed, by not staying in the dining room with 1 Resident (R) R # 68 of 3 residents observed for medication administration, to verify that he took his medications. The findings are: Record review of policy Medication-Self Administration dated 08/2010 revealed, Residents/patients will not be permitted to administer or retain medications in their rooms unless so ordered by the attending physician, an assessment has been completed . On 09/12/17 at 7:42 a.m. during an observation of medication pass, Licensed Practical Nurse (LPN) A pulled the following 17 medications for R #68 and placed them in a cup for administration: [MEDICATION NAME] (blood pressure medication) 2.5 mg (milligram), [MEDICATION NAME] (vitamin D3) 4000 mg, [MEDICATION NAME] (dietary supplement/similar to a vitamin), [MEDICATION NAME] (vitamin B12) 100 mcg (microgram), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] (nerve pain medication) 300 mg, [MEDICATION NAME] (heart medication) ER (extended release) 30 mg, [MEDICATION NAME] (blood pressure medication) 2.5 mg, magnesium oxide (mineral) 800 mg, [MEDICATION NAME] (medication to stimulate stomach motility) 10 mg, [MEDICATION NAME] (blood pressure medication) ER 25 mg, [MEDICATION NAME] (prevents organ rejection) 500 mg, [MEDICATION NAME] (steroid for inflammation) 5 mg, [MEDICATION NAME] (prevents organ rejection) 1mg, aspirin (blood thinner) 81 mg, iron (mineral) 325 mg, and multivitamin 1 tablet. LPN A took the pills to the dining room where R # 68 was eating his breakfast. LPN A asked R #68, did you want to take your pills now, or are you waiting until you are done with breakfast? R # 68 replied, after I am finished. LPN A left the pills at the table and walked out of the room. On 09/12/17 at 7:55 a.m. during an interview with LPN A, when asked if it is policy to leave the pills at the dining room table while unattended by a nurse, she stated, as long as they are alert and oriented. When asked how she knows if the resident took his pills, she stated, He tells me. He is alert and oriented. On 09/12/17 at 8:03 a.m. during an interview with the charge nurse for the unit, LPN B, when asked if it is part of the facility policy to leave medications with a resident to take unobserved by the nurse, she stated, If the resident is alert and oriented. If they don't have any mental deficits, yes. When asked how the nurse can ensure that a resident took the medication if a nurse is not there to observe them, she stated, If you're not watching? You can't. If you're not standing there you can't. On 9/13/17 at 10:06 a.m. during an interview with the Director of Nursing (DON), when asked the policy on medication administration, leaving medications at the bedside or with a resident in the dining room, unattended by the nurse, she stated, If we leave the meds, we would like to see that there have been self-administering medications assessments done to know that they are cognitively able. When asked if R #68 had been assessed for self-administration before the medications were given to him, and left unattended by LPN A on 9/12/17 at 7:55 a.m., she confirmed that he had not been assessed. When asked if it was ok to leave the medications with R #68 to take without nursing supervision, she verified that this was not ok to do.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D9 Based on record review and interview; the facility staff failed to evaluate fluid intake and implement interventions to prevent dehydration for 1 (Resident 11). The facility staff identified a census of 93. Findings are: Record review of an Admitting and Discharge Record sheet dated 7-23-2013 revealed Resident 11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Narrative Nursing Note dated 7-11-2013 revealed Resident 11 had arrived at the facility with Resident 11's daughter. According to the documentation, Resident 11 had a history of [REDACTED]. Record review of a Nursing Narrative Note dated 7-11-2013 at 4:09 PM revealed Resident 11's nutrition was "adequate, eats 1/2 (of) most meals". "Usually takes (a) supplement". Mental Status was "alert/oriented x's 3". Record review of a Resident 11 information flow record dated 7-11-2013 revealed Resident 11 was identified as having "swallowing problems. difficult at times". Record review of Resident 11's intake flow record revealed the following documented fluid intake: -7-12-2013,120 ml (milliliters) for the day. -7-13-2013,480 ml for the day. -7-14-2013,240 ml for the day. -7-15-2013, no fluid intake recorded. -7-16-2013, no fluid intake and Resident 11 was having "difficulty swallowing". -7-17-2013, 360 ml for the day. -7-18-2013, 120 ml for the day. -7-19-2013, 240 ml for the day. -7-20-2013, no fluid intake recorded. -7-21-2013, Resident 11 not eating or drinking, skin condition hot, did not void. Record review of a Patient Transfer Form dated 7-21-2013 revealed Resident 11 was sent to the hospital due being unresponsive and had an elevated temperature. An interview on 7-23-2013 at 1:30 PM was conducted with the Director of Nursing (DON). During the interview, Resident 11's fluid intake was reviewed with the DON. When asked if an evaluation of Resident 11's fluid intake had been completed, the DON stated "no". An interview was conducted on 7-23-2013 at 2:40 PM with Physician A. During the interview Physician A reported laboratory test had been obtained on Resident 11. According to Physician A, Resident 11 had [MEDICAL CONDITION] (infection) and secondary severe dehydration. Physician A reported that if Resident 11 was not receiving enough fluids at the facility "this could be a factor". Physician A reported Resident 11 had multi systems failure related to the [MEDICAL CONDITION] and dehydration. A follow up phone interview was conducted on 7-24-2013 at 7:45 AM with the facility Registered Dietician (RD). During the interview, the facility RD calculated Resident 11's estimated daily needs for fluids as 1500 to 1850 ml per day and 1470 to 1840 calories per day. Review of Resident 11's fluid intake was conducted with the facility RD. When asked if Resident 11 had enough fluid intake, the facility RD stated "no". When asked what would happen if there was not enough fluid intake, the facility RD stated "...dehydration". The facility RD reported interventions "should have been started earlier".

Licensure Reference: 175 NAC 12-006.09D7b Based on record review and interviews, the facility failed to evaluate changes in blood pressure related to risk for falls and implement interventions to decrease risk for falls for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 102 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] according to admission information. History and Physical for Resident 1 dated 6/5/11 listed a [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 5/27/11 identified Resident 1 as scoring 10 out of 15 on Brief Interview for Mental Status. Resident 1 is identified as requiring limited assist of one person for transfer, walking, and toilet use. Resident 1's Care Plan dated 6/1/11 identified Resident 1 as being at risk for falls and injuries. The following approaches were listed for Resident 1: -"Transfers with 1 assist, gait belt, and walker or cane." -"Ambulates with 1 assist, gait belt, and walker or cane." -"Monitor for adverse effects of meds-hypotension, dizziness, daytime drowsiness, change in usual mental status, dry mouth." -"Encourage/cue resident to request assist as needed" -"Cue/remind to change positions slowly" -"Notify MD (physician) as needed." -"Bedrails up and used for bed mobility and transfers." -"Physical Therapy per Plan of Care" -"2 assist for transfers in bathhouse" intervention dated 5/23 -"Cut bracelets off from hospital" intervention dated 5/26 -"Nonskid foot wear & landing pads" intervention dated 5/28 -"Do not leave unattended in bathroom" intervention dated 6/2 Undated therapy recommendations for Resident 1 regarding activities of daily living and transfers stated Resident 1 required contact guard assistance and forward wheeled walker for transfers. Therapy recommendations stated Resident 1 may need assist with lower body dressing clothing management, management for toileting, transfer, and bed mobility. A review of admission Nurses' Notes dated 5/20/11 at 5:04 PM listed the following blood pressures for Resident 1: Lying-107/52; sitting 90/56; and standing 85/50. Event Report dated 5/23/11 for Resident 1 revealed Bath Aide A stepped on Resident 1's right foot after a shower in bathhouse. Interview with Bath Aide A on 6/7/11 at 1:02 PM revealed Resident 1 stood up from shower chair and started to fall back. Bath Aide A reported grabbing Resident 1 to keep Resident 1 from falling and stepping on Resident 1's foot. The Event Report listed Resident 1's blood pressure as 110/60. The Event Report stated Resident 1 was to be a 2 assist transfer in the bath house to prevent further incidents. Event Report dated 5/28/11 stated Resident1's knees buckled during a transfer and Resident 1 slipped to the floor with Resident 1 hitting head on bedside table. Interview with Nurse Aide B revealed Resident 1 stood up while Nurse Aide B was positioning the shower chair in order for Nurse Aide B to transfer Resident 1 into the chair. Nurse Aide B reported grabbing the gait belt that was on Resident 1 and lowering Resident 1 to the floor. The Event Report listed Resident 1's blood pressure as 89/53. The Event Report stated landing pads and non skid foot wear should be put in place to prevent further incidents. Nurses Note dated 5/30/11 at 4:02 AM as a late entry for 5/29/11 at 9:30 PM documented a blood pressure of 79/51 and stated Resident 1's blood pressure had been running low all day. Note stated Resident 1's physician was called and order received for IV Fluids D5W with 1/2 normal saline to run at 100 ml/hour for 24 hours. Nurses Notes for Resident 1dated 5/31/11 at 2:21 PM stated therapy brought Resident 1 back down and placed Resident 1 in bed after Resident 1 had a heart rate of 160. Nurse's Note stated a recheck at 11:10 AM revealed a heart rate of 116 and a blood pressure of 75/48. Resident 1's physician was contacted and orders received for lab tests and to start Resident 1 on IV fluids of 5% dextrose at 75cc/hour for 48 hours. Nurses Notes listed the following blood pressures for Resident 1: -5/31/11 at 5:30 PM 76/50 -6/1/11 at 1:19 AM 85/49 -6/1/11 at 9:50 AM 80/51 -6/2/11 at 5:10 AM 93/50 -6/2/11 at 8 AM 89/54 Physical Therapy Daily Treatment Note dated 5/31/11 revealed Resident 1 received therapy in bed at nurse request due to Resident 1's low blood pressure. Therapy Note documented Resident 1's blood pressure as 80/50 supine, 82/52 seated at edge of bed and 88/54 supine during therapy. Event Report dated 6/2/11 stated Resident 1 was found lying on the bathroom floor with laceration above right eye and Resident 1 was transported to the emergency room via ambulance. In an interview on 6/7/11 at 10:40 AM, Nurse Aide C reported assisting Resident 1 to transfer to the toilet and leaving Resident 1's room. Nurse Aide C got a few feet from the room and heard noise. Nurse Aide C reported finding Resident 1 on the floor. Nurse Aide C reported Nurse Aide C had not been told that Resident 1 could not be left on the toilet alone. A review of the Event Report dated 6/2/11 revealed Resident 1 was not to be left unattended in the restroom as a new safety measures to be put in place to prevent reoccurrences. Nurses Notes dated 6/2/11 at 4:12 PM as a late entry for 6/2/11 at 12:30 PM stated Resident 1 sustained a laceration hematoma on head above right eye from fall to floor and bleeding was stopped with pressure. According to Nurses Note, Resident was transferred to emergency room . Interview with Registered Nurse D on 6/7/11 between 10:50-11:14 AM revealed Resident 1 had not been identified as a falling star. A review of facility documentation regarding fall program dated 5/11 revealed residents who are assessed as being at risk for falls are provided with a green wrist band and a falling star placed outside of the resident's room. In an interview on 6/7/11 between 3:09-4 PM, the DON (Director of Nursing) reported changes in interventions had not been documented. The DON confirmed orthostatic blood pressure should have been evaluated. Staying with the resident may be an intervention used when a resident has a low blood pressure according to the DON.