Every finding on record at Beaver City Manor

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview the facility failed to ensure that the facility dishwasher operated in the required temperature range to sanitize dishware. This affected all facility residents. The facility census was 23. Findings are: Record review of the Nebraska Food Code, effective date 7/21/16, section 4-501.110(B) revealed that the temperature of the wash solution in spray-type dishwashers that use chemicals to sanitize may not be less than 120° Fahrenheit (F). Record review of the facility dishwasher manufacturer product guide dated 2009 revealed that the facility dishwasher is a low temperature chemical sanitization washer. The product guide revealed that the wash operating temperature is required to be 120 degrees F minimum. Observation on 6/10/25 at 8:43 AM in the facility kitchen revealed that the dishwasher temperature log was taped on the front of the dishwasher. The log had spaces to document the AM and PM temperatures of the dishwasher water daily. The log noted that the temperature is to be 120 degrees F or above. Staff are to notify maintenance if the temperature is not 120 degrees F or above. Observation on 6/10/25 at 9:07 AM in the facility kitchen revealed that Dietary Aide (DA)-I was rinsing dishware and placing it into the dishwasher. DA-I started the dishwasher. The water temperature during the wash cycle was 96 degrees F. The rinse cycle temperature reached 133 degrees F. Observation on 6/10/25 in the facility kitchen at 10:54 AM revealed that Dietary [NAME] (DC)-C placed a load of dishes in the dishwasher. The wash cycle water temperature reached 104 degrees F and a rinse temperature of 140 degrees F. This surveyor asked DC-C what the wash temperature was required to be. DC-C revealed that DC-C had just started and was not sure. Observation on 6/10/25 at 1:35 PM in the facility kitchen with the Dietary Supervisor (DS) observed a dish wash cycle for the dishwasher. The wash temperature reached 104 degrees F and fluctuated between 103 degrees F and 104 degrees F. The DS confirmed that the facility dishwasher is a low temperature chemical sanitizing dishwasher. The DS confirmed that the wash temperature was only 104 degrees F and did not reach the required temperature of 120 degrees F or above. Interview on 6/10/25 at 2:19 PM with the Facility Administrator (FA) revealed that the representative from the company that maintains and services the facility dishwasher was in the facility in May 2025. The FA noted that the representative revealed that the wash cycle temperature of the dishwasher was 125 degrees F and the rinse cycle water temperature was 140 degrees F. The FA revealed that the FA talked with the representative per phone and that it is likely that a booster for heating water is out. The FA revealed a plumber would be in to take a look at the situation today or first thing in the morning. Interview on 6/10/25 at 4:47 PM with the FA revealed the facility would use paper products for food service tonight and at breakfast as the plumber would be in the facility in the morning. FA revealed that they are using the 3 compartment sink to wash cookware to ensure sanitization. Observation on 6/11/25 at 8:02 AM in the facility dining room revealed that DA-I and DC-C served resident breakfast meals to residents in the dining room. The meals were being served on the regular facility orange plates. Beverages were served in the usual facility reusable plastic coffee cups and beverage glasses. Interview on 6/11/25 at 8:07 AM with DC-B revealed that DC-B was told yesterday that they would be using paper plates and paper ware for meals until the dishwasher was fixed. DC-B revealed that DC-B got a call around 9:30 PM last night letting them know that the dishwasher was fixed. DC-B revealed that they had to run the dishwasher and record both the wash and rinse cycle temperatures. DC-B revealed that the wash temperature was 134 degrees F or something. Observation on 6/11/25 at 9:23 AM in the facility kitchen revealed that DA-I rinsed dishware and placed a rack of dishware in the dishwasher. The wash cycle temperature reached a high of 84 degrees F. The rinse cycle water temperature was 142 degrees F. This surveyor asked DA-I to run the load through the dishwasher again. The wash cycle temperature topped at 110 degrees F. This surveyor notified DC-B of the dishwasher wash cycle not reaching 120 degrees F or above. DC-B had DA-I run the load through the dishwasher again. The wash temperature topped at 112 degrees F. Observation on 6/11/23 at 9:29 AM with the Facility Administrator (FA) in the kitchen revealed that DA-I started a load of dishware in the dishwasher. The wash temperature reached a high of 112 degrees F. The FA stopped the cycle and instructed dietary staff to resume the use of paper products for meals until the dishwasher can be looked at again. The FA confirmed that the wash temperature was not at the required temperature of 120 degrees F or above to ensure sanitation of the dishware. Interview on 6/12/25 at 8:19 AM with the FA confirmed that the facility does not have a policy for use and monitoring of the dishwasher. The FA confirmed that the facility follows the dishwasher manufacturer product guide. The FA confirmed that the dishwasher is required to operate the wash cycle with a temperature of 120 degrees F or above to ensure sanitation.

Licensure Reference Number 175 NAC 12-006.04(A)(ii) Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, record review, and interview the facility failed to ensure that pre-employment health history screens were completed to prevent the potential for the spread of infectious diseases for 5 of 5 staff reviewed. This had the potential to affect all facility residents. The facility failed to ensure that staff performed hand sanitization (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) as required to prevent the potential for cross contamination during delivery of room meals. This affected 1 resident (Resident 18) of 3 residents observed. The facility census was 23. Findings are: A. Record review of the undated facility Orientation Checklist revealed that it contained tasks and record requirements to be completed for new employees. The checklist included the requirement for the completion of the Pre-Employment Questionnaire (pre-employment health screen). Interview on 6/11/25 at 1:37 PM with the facility Business Office Manager (BOM) confirmed that the Pre-Employment Questionnaire on the Orientation Checklist is the Pre-Employment Health Screen. The BOM confirmed that on hire the new employee was to fill out the facility Pre-Employment Health Screen (a 2 page form). The BOM revealed that the employee fills out the front side (page 1) of the form and the back side of the form (page 2). The BOM confirmed that page 2 of the form is where the employee signs and dates the form to confirm that the information is correct. The BOM confirmed that the BOM reviews the information on the form. The BOM confirmed that the Pre-Employment Health Screen has a line for the supervisor to sign and date that the form was reviewed on page 2 of the form. The BOM confirmed that the Pre-Employment Health Screen is to be completed before the employee begins working in the facility. Record review of the undated and untitled list of facility employees revealed that Nurse Aide (NA)-E had a hire date of 3/18/25. Record review of the employee file for NA-E revealed that it contained a Pre-Employment Health Screen for NA-E. The health screen did not have page 2 of the form. There was no signature and no date documenting the date the health screen was completed. There was no page 2 for the BOM to document the review of the health screen. Interview on 6/11/25 at 1:37 PM with the facility BOM confirmed that the Pre-Employment Health Screen for NA-E did not contain page 2 and was not dated or signed by NA-E as required. The BOM confirmed that that there was no supervisor review of the health screen as required. B. Record review of the undated and untitled list of facility employees revealed that NA-F had a hire date of 3/22/25. Record review of the employee file for NA-F revealed that it contained a Pre-Employment Health Screen for NA-F. The health screen did not have page 2 of the form. There was no signature and no date documenting the date the health screen was completed. There was no page 2 for the BOM to document the review of the health screen. Interview on 6/11/25 at 1:37 PM with the facility BOM confirmed that the Pre-Employment Health Screen for NA-F did not contain page 2 and was not dated or signed by NA-F as required. The BOM confirmed that that there was no supervisor review of the health screen as required. C. Record review of the undated and untitled list of facility employees revealed that Laundry Aide (LA)-G had a hire date of 4/1/25. Record review of the employee file for LA-G revealed that it contained a Pre-Employment Health Screen for LA-G. The health screen was signed on page 2 by LA-G with a date of 6/6/25 (2 months and 5 days after hire). The line for the Signature of Supervisor and date on page 2 were blank. Interview on 6/11/25 at 1:37 PM with the facility BOM confirmed that the Pre-Employment Health Screen for LA-G did not contain the supervisor signature and had no documentation that the health screen had been reviewed. The BOM confirmed that that there was no supervisor review of the health screen as required. D. Record review of the undated and untitled list of facility employees revealed that Activity Aide (AA)-H had a hire date of 4/1/25. Record review of the employee file for AA-H revealed that it contained a Pre-Employment Health Screen for AA-H. The health screen was signed on page 2 by AA-H with a date of 6/2/25 (2 months and 1 day after hire). The line for the supervisor Signature of Supervisor and date on page 2 were blank. Interview on 6/11/25 at 1:37 PM with the facility BOM confirmed that the Pre-Employment Health Screen for AA-H did not contain the supervisor signature and had no documentation that the health screen had been reviewed. The BOM confirmed that that there was no supervisor review of the health screen as required. E. Record review of the undated and untitled list of facility employees revealed that Medication Aide (MA)-D had a hire date of 6/4/25. Record review of the employee file for MA-D revealed that it contained a Pre-Employment Health Screen for MA-D. The health screen was signed on page 2 by MA-D with a date of 6/4/25. The line for the supervisor Signature of Supervisor and date on page 2 were blank. Interview on 6/11/25 at 1:37 PM with the facility BOM confirmed that the Pre-Employment Health Screen for MA-D did not contain the supervisor signature and had no documentation that the health screen had been reviewed. The BOM confirmed that that there was no supervisor review of the health screen as required. F. Record review of the facility policy titled Hand Hygiene dated 2/4/25 revealed that all staff will perform proper hand hygiene (hand sanitization) to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed when entering and exiting a resident room, between resident contacts, and after handling contaminated objects. Observation on 6/9/25 at 12:27 PM at the facility dining room revealed that Dietary Aide (DA)-A pushed a 3 shelf cart containing 3 resident room meals down the west hall to the room of Resident 2. DA-A removed a covered plate from the 3 shelf cart and carried it into the room of Resident 2. DA-A used the bare hands to rearrange items on the over bed table next to Resident 2. Resident 2 was in the recliner and refused the meal. DA-A asked Resident 2 if they wanted the tea left in the room. DA-A picked up the plate of food and carried it out of the room and placed it back onto the 3 shelf cart. DA-A pushed the cart down the hall past 2 resident rooms and applied hand sanitizer from a dispenser in the hall. DA-A rubbed their hands together and then continued to push the 3 shelf cart to the room of Resident 16 on the east hall. DA-A picked up a covered plate and beverages from the cart and carried them into the room of Resident 16. DA-A used the bare left hand to move items on the over bed table to make room for the plate of food. DA-A sat the plate on the over bed table and encouraged Resident 16 to eat what they could. DA-A used the bare hands to reposition the over bed table over the lap of Resident 16. DA-A exited the room of Resident 16 and pushed the 3 shelf cart to the room of Resident 18. DA-A did not perform hand sanitization. DA-A picked up a covered plate of food from the 3 shelf cart and carried it into the room of Resident 18. The room was dark and DA-A asked Resident 18 if they wanted them to turn the light on. DA-A used the bare right hand to turn the light on. DA-A sat the plate of food on the edge of the over bed table. DA-A used the bare hands to pick up the podium mirror from the over bed table and sat the mirror on the floor by the room heating unit. DA-A used the bare hands to move other items on the over bed table and positioned the plate of food in the middle of the over bed table. DA-A repositioned the over bed table for Resident 18 to begin eating. DA-A exited the room of Resident 18 and pushed the 3 shelf cart to the facility dining room. DA-A did not perform hand sanitization. DA-A walked over to the kitchen meal service window and picked up a carafe of coffee with the bare right hand and moved it to a different location in the service window. DA-A entered the kitchen and walked past the sink. The facility Dining Supervisor was washing their hands at the sink. DA-A continued through the door towards the employee lounge. DA-A re-entered the kitchen through the door near the sink and stopped and began to wash the hands. DA-A washed the hands for a total of 11 seconds. Interview on 6/12/25 with the facility Infection Preventionist (IP) confirmed that staff are required to perform hand hygiene on exit from a resident room. IP confirmed that this includes dietary staff delivering meals into resident rooms.

Licensure Reference Number 175 NAC 1-005.06(C) Based on Record Review and Interview; the facility failed to have an effective antibiotic stewardship program. This had the potential to affect all residents in the facility. The facility identified a census of 23. Findings are: Record Review of the facility policy Antibiotic Stewardship Program dated 05/09/2025 revealed: 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR form (a structured communication format used to convey information including situation, background, assessment, and recommendation) prior to notifying the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the (CDC's NHSN Surveillance Definitions) to define infections. iv. The Loeb Minimum Criteria are used to determine whether to treat and infection with antibiotics. v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. vi. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. vii. Whenever possible, narrow spectrum antibiotics that are appropriate for the condition being treatment shall be utilized. b. Monitoring antibiotic use: i. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. ii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iii. Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). IV. Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy). v. At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include Clostridioides difficile infections (a bacterial infections that can cause severe diarrhea common in healthcare settings often associated with recent antibiotic use), antibiotic resistance, adverse drug events related to antibiotic use, or [NAME] related to antibiotic use. vi. A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices. 5. At least annually, feedback shall be provided on the facility's antibiotic stewardship use data in the form of a written report shared with administration, medical and nursing staff, resident and family council, and the QAA committee. Record review of an admission Record dated 06/10/2025 for Resident 18 revealed an admission date of 09/28/2023. Record review of an Order Summary dated 06/10/2025 for Resident 18 revealed an order for Clarithromycin (Biaxin) Oral Tablet 250 milligram (MG) for chronic UTI (urinary tract infections; bacteria (most commonly E. coli) enter the urinary tract and multiply, causing an infection)), order date 01/15/2024. An interview with the IP and the DON on 06/11/2025 at 11:00 AM revealed that Resident 18 had not encountered a UTI since admission to the facility on [DATE]. Record review of a physician fax dated 06/11/2025 revealed Biaxin was ordered on 10/23/2023 for history of UTI. Since being on Biaxin, resident has had no noted further UIT's. Do you feel this medication should be continued as the benefits out weight the risks associated? Yes was physically circled. Physician response revealed antibiotic prophylaxis for chronic recurrent symptomatic UTI and multiple allergies to antibiotics. Prescribed by a Urologist (medical doctor who specializes in diagnosing and treating conditions of the urinary tract) for this purpose. An interview with the IP and the DON on 06/11/2025 at 11:00 AM revealed that Resident 18 does not have an established Urologist currently and the medication Biaxin is currently being managed by the primary physician. An interview on 06/11/2025 at 11:00 AM the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that reassessments, lab testing, and tracking and trending for residents on long term use antibiotics had not been performed. During an interview on 06/11/2025 at 4:30 PM the Administrator and the DON indicated they do not have an effective management of antibiotics within the facility.

Licensure Reference Number 175 NAC 12-006.05(D) Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview the facility failed to ensure that the resident/resident representative received education and provided informed consent for use of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) as required for 5 of 5 residents reviewed (Residents 13, 20, 23, 1, and 18). The facility census was 23. Findings are: Record review of the facility policy titled Use of Psychotropic Drugs dated 8/1/24 revealed that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication. Residents and /or representatives shall be educated on the risks and benefits of psychotropic drug use as well as alternative treatments/non-pharmacological interventions. A. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 13 dated 3/19/25 revealed that Resident 13 had a diagnosis of depression. The MDS revealed that Resident 13 received an antidepressant (a psychotropic medication) 7 days of the 7 day MDS lookback period. Record review of the current care plan for Resident 13 dated 6/9/25 revealed that Resident 13 used antidepressant medication for depression. Interventions included monitoring for adverse reactions to antidepressant therapy including change in behavior, hallucinations, social isolation, decline in activities of daily living ability, rigid muscles, dizziness, falls, and weight loss. Record review of the Order Summary (a listing of all physician orders for a resident) for Resident 13 dated 6/9/25 revealed that Resident 13 had an order for Lexapro (an antidepressant medication) 20 milligrams (mg) daily for depression. The order date was 4/23/25. Record review of the medical record for Resident 13 revealed no evidence of a consent for use of psychotropic medications. Interview on 6/11/25 at 12:58 PM with the facility Director of Nursing (DON) revealed that the DON was not sure if the facility had any informed consent for the use of psychotropic medication for Resident 13. Interview on 6/11/25 at 2:48 PM with the DON confirmed that the facility did not have a psychotropic consent form for the resident as required. B. Record review of the MDS for Resident 20 dated 4/30/25 revealed that Resident 20 had a diagnosis of dementia. Resident 20 had no psychiatric or mood disorder diagnoses. The MDS revealed that Resident 20 received an antipsychotic medication (a class of psychotropic medication used to manage psychotic disorders such as schizophrenia) 7 days of the 7 day MDS lookback period. Record review of the current care plan for Resident 20 dated 6/9/25 revealed that Resident 20 used psychotropic medications due to dementia. Interventions included monitoring for side effects and effectiveness. It also stated to monitor and report any unsteady gait (a person's manner of walking), tardive dyskinesia (involuntary repetitive uncontrolled movements that are a side effect of the use of antipsychotic medications), frequent falls, difficulty swallowing, loss of appetite, and weight loss. Record review of the Order Summary for Resident 20 dated 6/9/25 revealed that Resident 20 had an order for Zyprexa 2.5 mg (an antipsychotic medication) one time a day for dementia with agitation. The order date was 5/30/25. Record review of the medical record for Resident 20 revealed no evidence of a consent for use of psychotropic medications. Interview on 6/11/25 at 12:58 PM with the facility Director of Nursing (DON) revealed that the DON was not sure if the facility had any informed consent for the use of psychotropic medication for Resident 20. Interview on 6/11/25 at 2:48 PM with the DON confirmed that the facility did not have a psychotropic consent form for the resident as required. C. Record review of the MDS for Resident 23 dated 3/12/25 revealed that Resident 23 had a diagnosis of depression. The MDS revealed that Resident 23 received an antidepressant 7 days of the 7 day MDS lookback period. Record review of the current care plan for Resident 23 dated 6/9/23 revealed that Resident 23 felt down and depressed. Interventions included to administer antidepressant medication as ordered and to monitor for side effects and effectiveness. Record review of the Order Summary for Resident 23 dated 6/9/25 revealed that Resident 23 had an order for Sertraline 50 mg (an antidepressant medication) at bedtime for depression. The order date was 9/5/24. Record review of the medical record for Resident 23 revealed no evidence of a consent for use of psychotropic medications. Interview on 6/11/25 at 12:58 PM with the facility Director of Nursing (DON) revealed that the DON was not sure if the facility had any informed consent for the use of psychotropic medication for Resident 23. Interview on 6/11/25 at 2:48 PM with the DON confirmed that the facility did not have a psychotropic consent form for the resident as required. D. Record review of Resident 1's quarterly MDS dated [DATE] revealed an admission date of 12/18/2009. Active diagnoses included depression, psychotic disorder, and schizophrenia. Antipsychotic, and antidepressant medications were received 7 days of the 7-day MDS look back period. Review of Resident 1's Physician Orders dated 06/10/2025 revealed Resident 1 had orders for the following medications: Sertraline 100 mg by mouth (PO) every day one time a day (QD) for depression with an order date of 12/06/2021 Zyprexa (Olanzapine) 10 mg PO QD for paranoid schizophrenia with an order date of 04/20/2022. Review of Resident 1's Medication Administration Record for April, May, June 2025 revealed documentation the Sertraline and Zyprexa were administered to Resident 1 as ordered. Review of Resident 1's Consent for Use of Psychoactive Medication revealed no consent for use of the Sertraline and Zyprexa or education of adverse side effects and other alternatives. During an interview on 06/11/2025 at 2:05 PM the Director of Nursing (DON) indicated no consent for use, rather a treatment contract for Ambience Counseling dated 09/10/2024, none referring to the medications Sertraline and Zyprexa being administered for Resident 1, education of adverse side effects and/or other alternatives. E. Record review of Resident 18's quarterly MDS dated [DATE] revealed an admission date of 09/28/2023. Active diagnoses included Parkinson's disease, anxiety disorder, and depression. Antianxiety, and antidepressant medications were received 7 days of the 7-day MDS look back period. Review of Resident 18's Physician Orders dated 06/10/2025 revealed Resident 18 had orders for the following medications: Duloxetine 60 mg PO every day one time a day (QD) for depression with an order date of 12/27/2023, and Lorazepam 0.5 mg PO QD with an order date of 3/13/2024. Review of Resident 18's Medication Administration Record for April, May, June 2025 revealed documentation the Sertraline and Zyprexa were administered to Resident 18 as ordered. Review of Resident 18's Consent for Use of Psychoactive Medication revealed no consent for use of the Duloxetine and Zyprexa or education of adverse side effects and other alternatives. During an interview on 06/11/2025 at 2:05 PM the DON indicated no consent for use, rather a treatment contract for Ambience Counseling dated 08/19/2024, none referring to the medications Duloxetine and Zyprexa being administered for Resident 18, education of adverse side effects and/or other alternatives.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to ensure that investigations of potential abuse or neglect were submitted to the state agency within 5 working days as required for 2 residents (Residents 6 and 2) of 3 residents reviewed. The facility census was 21. Findings are: A. Record review of the facility policy titled Abuse, Neglect, and Exploitation dated 2/1/24 revealed that it is the facility policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation occur. Record review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 2/1/24 revealed it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. The Facility Administrator or designee will report sufficient information to describe the result of the investigation and any corrective actions taken within 5 working days of the incident. Record review of the Admission Record dated 7/8/24 for Resident 6 revealed that Resident 6 admitted into the facility on [DATE]. Record review of the Care Plan dated 7/8/24 for Resident 6 revealed that Resident 6 is at risk for falls. The care plan revealed that Resident 6 had falls in the facility on 10/8/23, 10/14/23, and 4/24/24. Record review of the progress note for Resident 6 dated 4/24/24 at 8:07 AM revealed that Resident was laying on the floor of the resident's room just outside of the bathroom doorway. When staff began to assist Resident 6, Resident 6 stated ooow with facial grimacing noted. Resident 6 complained of pain in the left mid-thigh and right hip and buttock. Record review of the progress note for Resident 6 dated 4/24/24 at 9:15 AM revealed that an ambulance was requested. Resident 6 was transferred to the emergency room . Record review of the progress note for Resident 6 dated 4/24/24 at 12:15 PM revealed that the report from the hospital revealed that Resident 6 had a fracture of the cervical spine C1 (one of 7 stacked spinal bones that start at the top of the shoulders and continue up to support the skull). Record review of the email dated 5/1/24 at 3:43 PM from the Facility Administrator (FA) to the state agency revealed that it was the investigation report for Resident 6 (This was the 6th business day after Resident 6's fall with injury on 4/24/24). Interview on 7/10/24 at 11:05 AM with the FA confirmed that the email dated 5/1/24 at 3:43 PM was the investigation report submitted to the state agency for Resident 6's fall with injury on 4/24/24. The FA confirmed that the facility had not counted the day of occurrence as day 1 when calculating the 5 days. The FA confirmed the facility had not submitted the investigation to the state agency within 5 business days. B. Record review of the Admission Record dated 7/9/24 for Resident 2 revealed that Resident 2 admitted into the facility on [DATE]. Record review of the progress note for Resident 2 dated 5/14/24 at 11:54 AM revealed that Resident 2 requested that their Social Security check be deposited into their resident trust account and that the resident's bank account be closed. Resident 2 revealed they no longer wanted their child to have access to their finances. The facility notified the Social Security Office of the change requested by Resident 2. The facility contacted the bank to have the money in the bank account of Resident 2 mailed to Resident 2 in the facility. Record review of the progress note for Resident 2 dated 5/24/24 at 3:06 PM revealed that the child of Resident 2 called and requested that the facility send transfer information for Resident 2 to another long-term care facility. The facility faxed the information to the other facility as requested. Record review of the progress note for Resident 2 dated 5/25/24 at 12:19 AM revealed Resident 2 was having difficulty falling asleep. Resident 2 revealed that the resident was still upset about what went on earlier in the day. Record review of the progress note for Resident 2 dated 5/30/24 at 11:34 AM revealed that the child of Resident 2 contacted the facility to send referral information to another long-term care facility. This is the second facility the child requested information be sent to. Resident 2 feels their child wants the resident moved to another facility in order to regain access to Resident 2's bank account. Record review of the progress note for Resident 2 dated 6/4/24 at 2:44 PM revealed that Resident 2 is feeling somewhat indifferent to their child misappropriating the resident's finances. Record review of the facility misappropriation investigation dated 6/3/24 revealed that Adult Protective Services (APS) was notified on 5/24/24 at 11:37 AM to notify them of the misappropriation of Resident 2's finances. Record review of the email dated 6/3/24 at 5:00 PM from the Facility Administrator (FA) to the state agency revealed that it was the investigation report for Resident 2 (This was the 7th business day after the misappropriation of Resident 2's finances was reported to APS on 5/24/24). Interview on 7/10/24 at 11:05 AM with the FA confirmed that the email dated 6/3/24 at 5:00 PM was the investigation report submitted to the state agency for Resident 2's misappropriation of finances for the 5/24/24 report to APS. The FA confirmed that the facility had not submitted the investigation to the state agency within 5 business days for Resident 2.

Licensure Reference Number 175 NAC 12-006.09(H) Based on observation, record review, and interview the facility failed to ensure that residents receiving antipsychotic medications (a psychotropic medication that affects behavior, mood, thoughts, or perception and is used to manage psychotic disorders) were monitored for adverse reactions for 2 of 5 residents reviewed (Residents 6 and 5) and failed to ensure that PRN (as needed) psychotropic medications had a documented rationale and determined duration for use for 1 of 5 residents reviewed (Resident 5). The facility census was 21. Findings are: A. Record review of the facility policy titled Use of Psychotropic Drugs dated 1/13/23 revealed that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Residents who receive psychotropic medications at regular intervals shall be evaluated on an ongoing basis for the effects of the psychotropic medications on their physical, mental, and psychosocial well-being during Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) review (quarterly, annually, significant change) and in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. Record review of the MDS assessment dated [DATE] for Resident 6 revealed that Resident 6 admitted into the facility on [DATE]. The MDS revealed that Resident 6 is [AGE] years old. The MDS revealed that Resident 6 had a diagnosis of Dementia, Anxiety, and a diagnosis of Psychotic Disorder other than schizophrenia (a severe mental disorder that causes abnormal thinking and perceptions). The MDS revealed that Resident 6 took an antipsychotic medication during the MDS assessment lookback period. Record review of the Order Summary dated 7/9/24 for Resident 6 revealed that Resident 6 had a physician's order to take Seroquel 25 milligrams (an antipsychotic medication) daily. Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) dated December 2023 revealed that Resident 6 received Seroquel 25 milligrams daily every day in December 2023 (12/1/23-12/31/23). Record review of the MAR dated January 2024 revealed that Resident 6 received Seroquel 25 milligrams daily every day in January 2024 (1/1/24-1/31/24). Record review of the MAR dated February 2024 revealed that Resident 6 received Seroquel 25 milligrams daily on 27 of 29 days in February 2024 (2/1/24-2/27/24). Record review of the MAR dated March 2024 revealed that Resident 6 received no Seroquel 25 milligrams daily during March 2024 (3/1/24-3/31/24). Record review of the MAR dated April 2024 revealed that Resident 6 received Seroquel 25 milligrams daily on 7 of 30 days in April 2024 (4/27/24-4/30/24). Record review of the MAR dated May 2024 revealed that Resident 6 received Seroquel 25 milligrams daily every day in May 2024 (5/1/24-5/31/24). Record review of the MAR dated June 2024 revealed that Resident 6 received Seroquel 25 milligrams daily every day in June 2024 (6/1/24-6/30/24). Record review of the MAR dated July 2024 for the dates of 7/1/24-7/9/24 revealed that Resident 6 received Seroquel 25 milligrams daily every day as of 7/9/24 (7/1/24-7/9/24). Record review of the Nursing 2018 Drug Handbook revealed that Seroquel is in the therapeutic class of antipsychotics (Seroquel is an antipsychotic medication). Seroquel has a Black Box Warning specifying that Seroquel is not indicated for use in elderly patients with dementia-related psychosis because of increased risk of death from cardiovascular disease or infection. Adverse reactions include extrapyramidal reaction (involuntary movements that you cannot control caused by antipsychotic medications). Monitor patient for tardive dyskinesia (an extrapyramidal reaction where your face, body or both make sudden, irregular movements which you cannot control. It can develop as a side effect of medication, most commonly antipsychotic drugs). Observation on 7/9/24 at 7:30 AM in the facility dining room revealed that Resident 6 sat at a table. An unidentified Dietary staff delivered the breakfast meal to Resident 6. Resident 6 slowly picked up a weighted fork with the right hand. Resident 6's right arm did not bend beyond approximately 20 degrees per visual measurement and appeared stiff. Resident 6 began to feed themselves. Resident 6 struggled to lift the fork to their mouth. Observation on 7/10/24 at 8:05 AM in the facility dining room revealed that Resident 6 sat at a dining room table. A plate of food was on the table in front of the resident. Nurse Aide-C (NA-C) sat to the left of Resident 6 and used the silverware to feed Resident 6. Record review of the Care Plan dated 7/8/24 for Resident 6 revealed that Resident 6 uses psychotropic medications (Seroquel) related to hallucinations. Interventions included monitor/document/report any adverse reactions of psychotropic medications: unsteady gait (a person's manner of walking), tardive dyskinesia, EPS (Extrapyramidal Symptoms) (shuffling gait, rigid muscles, shaking). Record review of the medical record for Resident 6 revealed that one Abnormal Involuntary Movement Assessment (AIMS) (an assessment used to assess for abnormal irregular, involuntary movements most commonly in areas of the face, around the eyes, and of the mouth, including the jaw, tongue, and lips) was completed for Resident 6 on 12/1/23. The medical record revealed no other completed assessments to monitor Resident 6 for adverse extrapyramidal reactions. Record review of the AIMS assessment dated [DATE] for Resident 6 revealed that there was no rigidity of either the right or left arm of Resident 6. The resident was scored as 0.0 meaning no observed abnormal movements or impact of movements on the resident. Interview on 7/10/24 at 12:17 PM with the facility Infection Preventionist (IP) confirmed that Resident 6 takes an antipsychotic medication that requires monitoring for extrapyramidal symptoms. The IP confirmed that the expectation is for an Abnormal Involuntary Movement (AIMS) assessment to be performed quarterly for residents taking antipsychotic medications. The IP confirmed that quarterly AIMS assessments were not completed for Resident 6 as required. 50105 B. Record review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment used to develop the resident care plan) dated 05/01/2024 revealed the following: -diagnosis of unspecified dementia, hallucinations, unspecified severity with psychotic disturbance, abnormal weight loss, anxiety disorder unspecified, (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and the presence of cardiac pacemaker -Cognitive score of 1/15, indicating severe cognitive impairment. -behaviors were not indicated in the MDS -the resident received the following high risk drug class medications: antianxiety, antidepressants, antipsychotics, anticoagulants, and diuretics. Record review of Resident 5's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) with a revision date of 06/05/2024 revealed the following: -the resident uses an antidepressant medication -the resident uses an antianxiety medication -the resident uses a psychotropic medication -the resident has behaviors related to dementia evidenced by ineffective coping skills, poor impulse control, hallucinating, and anxiety -the resident has impaired cognitive and communication functions related to dementia, and anxiety, evidenced by hallucinating thoughts -monitor/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, extrapyramidal symptoms (EPS). Record review of Resident 5's order summary report of physician orders revealed the following psychotropic (any medication that affects behavior, mood, thoughts, or perception) medications: -Zoloft (antianxiety) 50 milligram (mg) one time daily for the treatment of anxiety, with a start date of 08/11/2022 -Buspirone (antianxiety) 5 mg one time daily for the treatment of anxiety, with a start date of 8/11/2022 -Lorazepam (antianxiety) 0.5 mg every 6 hours PRN for anxiety or agitation with a start date of 07/28/2022. Record review of Resident 5's order summary report of physician orders revealed the following ordered antipsychotic (a psychotropic medication used to manage psychotic disorders) medications: -Haloperidol (antipsychotic) 0.5 milliliters (mL) every 6 hours PRN for agitation with a start date of 11/12/2023 and a discontinuation date of 06/19/2024 Record review of Resident 5's order summary report of physician orders revealed the following orders: -admission to hospice services with a start date of 11/06/2023 and a discontinuation date of 04/24/2024 Record review of Resident #5's medical record revealed no assessments for abnormal involuntary movement scale (AIMS) for the medication Haloperidol. The medical record revealed no assessments completed for the duration of the active PRN medication ordered. Interview with IP on 07/09/2024 at 2:20 PM revealed no AIMS assessment or other assessments were completed for the ordered and duration of use for the as needed antipsychotic medication Haloperidol. C. Record review of facility policy titled Use of Psychotropic Drugs with a revised date of 01/12/2024 reveals: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnoses and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 8. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN medication order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. b. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. 10. The resident's response to the medications(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 11. Use of psychotropic medications in specific circumstances: a. Acute or emergency situations (i.e., acute onset or exacerbation of symptoms or immediate threat to health or safety or resident or others): ii. Use of the psychotropic medication shall be consistent with #8 above, regarding PRN orders. Record review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment used to develop the resident care plan) dated 05/01/2024 revealed the following: -diagnosis of unspecified dementia, hallucinations, unspecified severity with psychotic disturbance, abnormal weight loss, anxiety disorder unspecified, (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and the presence of cardiac pacemaker -cognitive score of 1/15, indicating severe cognitive impairment. -behaviors were not indicated in the MDS -the resident received the following high risk drug class medications: antianxiety, antidepressants, antipsychotics, anticoagulants, and diuretics. Record review of Resident 5's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) with a revision date of 06/05/2024 revealed the following: -the resident uses an antidepressant medication -the resident uses an antianxiety medication -the resident uses a psychotropic medication -the resident has behaviors related to dementia evidenced by ineffective coping skills, poor impulse control, hallucinating, and anxiety -the resident has impaired cognitive and communication functions related to dementia, and anxiety, evidenced by hallucinating thoughts Record review of Resident 5's order summary report of physician orders revealed the following psychotropic (any medication that affects behavior, mood, thoughts, or perception) medications: -Zoloft (antianxiety) 50 milligram (mg) one time daily for the treatment of anxiety, with a start date of 08/11/2022 -Buspirone (antianxiety) 5 mg one time daily for the treatment of anxiety, with a start date of 08/11/2022 -Lorazepam (antianxiety) 0.5 mg every 6 hours as needed for anxiety or agitation with a start date of 07/28/2022. Record review of Resident 5's order summary report of physician orders revealed the following ordered antipsychotic (a psychotropic medication used to manage psychotic disorders) medications: -Haloperidol (antipsychotic) 0.5 milliliters (mL) every 6 hours as needed for agitation with a start date of 11/12/2023 and a discontinuation date of 06/19/2024 Record review of psychotropic and antipsychotic medications ordered as needed did not contain a documented rationale and did not contain a determined duration of use date. Interview with the DON on 07/09/2024 at 11:29 PM revealed there was no physician documented rationale or determined duration of use for the as needed ordered antianxiety medication Lorazepam.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to ensure a medication error rate of less than 5% with an observed medication error rate of 7.14% (28 medication administrations with 2 errors). The facility census was 21. Findings are: A. Record review of the facility policy titled Insulin Pen dated 2/1/24 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing. The section titled Policy Explanation and Compliance Guidelines revealed that insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The section titled Procedure revealed the step to attach the pen needle. The procedure steps continued to prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. The procedure steps continued to set the insulin dose: Turn the dose selector to the ordered dose. A click will be heard for each unit dialed. Check dose a second time. Record review of the Admission Record dated 7/9/24 for Resident 2 revealed that Resident 2 admitted into the facility on [DATE]. Resident 2 had diagnosis of Diabetes Mellitus (a chronic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves). Record review of the Medication Administration Record (MAR) dated 7/9/24 for Resident 2 revealed that Resident 2 had an order to receive 28 units of Novolog insulin (a mealtime insulin injected under the skin made to help control blood sugar spikes in adults with diabetes) three times daily at 7:30 AM, 11:00 AM, and 5:00 PM. Observation on 7/09/24 at 11:32 AM at the medication cart revealed that Licensed Practical Nurse-A (LPN-A) reviewed the insulin order for Resident 2. LPN-A confirmed that Resident 2 has an order for Novolog insulin (a rapid-acting Insulin to help control blood sugar spikes in adults with diabetes) 28 units subcutaneously (under the skin) three times a day before each meal. LPN-A removed the Novolog insulin pen from inside the medication cart. LPN-A removed the cap from the insulin pen and wiped the top of the pen with an alcohol prep pad. LPN-A dialed the pen dose to 28 units. LPN-A applied a needle to the top of the insulin pen. (LPN-A did not dial the pen to 2 units and prime the needle prior to dialing the ordered dose of 28 units). LPN-A entered the room of Resident 2 with the insulin pen. LPN-A asked Resident 2 which arm they would like the insulin administered in. LPN-A wiped the upper right arm of Resident 2 with an alcohol prep pad. LPN-A placed the insulin pen against the skin of Resident 2's right upper arm and administered the insulin. LPN-A removed the needle from the insulin pen and discarded it into the sharp's container in the resident's room. LPN-A returned to the medication cart and documented the insulin administration. Interview on 7/10/24 at 2:52 PM with the facility Director of Nursing (DON) confirmed that staff are expected to prime the insulin pen prior to dialing the ordered insulin dose on the insulin pen to ensure the resident received the correct dose of insulin per the physician's order. The DON confirmed that not priming the insulin pen was a medication error. B. Observation on 7/10/24 at 11:49 AM at the medication cart outside the room of Resident 2 revealed that Licensed Practical Nurse-B (LPN-B) reviewed the insulin order for Resident 2. LPN-B confirmed that Resident 2 has an order for Novolog insulin (a rapid-acting Insulin to help control blood sugar spikes in adults with diabetes) 28 units subcutaneously three times a day before each meal. LPN-B carried the insulin pen and supplies into the room of Resident 2. LPN-B picked up the Novolog insulin pen and removed the cap from the insulin pen. LPN-B opened a needle and attached the needle to the insulin pen. LPN-B dialed the pen dose to 28 units. (LPN-B did not dial the pen to 2 units and prime the needle prior to dialing the ordered dose of 28 units). LPN-B wiped the upper right arm of Resident 2 with an alcohol prep pad. LPN-B placed the insulin pen against the skin of Resident 2's right upper arm and administered the insulin. LPN-B removed the needle from the insulin pen and discarded the needle into the sharp's container in the resident bathroom. LPN-B returned to the medication cart. Interview on 7/10/24 at 2:52 PM with the DON confirmed that staff are expected to prime the insulin pen prior to dialing the ordered insulin dose on the insulin pen to ensure the resident received the correct dose of insulin per the physician's order. The DON confirmed that not priming the insulin pen was a medication error.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to prevent significant medication errors (a medication error which causes the resident discomfort or jeopardizes his or her health and safety) for 1 of 4 residents observed (Resident 2). The facility census was 21. Findings are: A. Record review of the facility policy titled Insulin Pen dated 2/1/24 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing. The section titled Policy Explanation and Compliance Guidelines revealed that insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The section titled Procedure revealed the step to attach the pen needle. The procedure steps continued to prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. The procedure steps continued to set the insulin dose: Turn the dose selector to the ordered dose. A click will be heard for each unit dialed. Check dose a second time. Record review of the Admission Record dated 7/9/24 for Resident 2 revealed that Resident 2 admitted into the facility on [DATE]. Resident 2 had a diagnosis of Diabetes Mellitus (a chronic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves). Record review of the Medication Administration Record (MAR) dated 7/9/24 for Resident 2 revealed that Resident 2 had an order to receive 28 units of Novolog insulin (a mealtime insulin injected under the skin made to help control blood sugar spikes in adults with diabetes) three times daily at 7:30 AM, 11:00 AM, and 5:00 PM. Observation on 7/09/24 at 11:32 AM at the medication cart revealed that Licensed Practical Nurse-A (LPN-A) reviewed the insulin order for Resident 2. LPN-A confirmed that Resident 2 has an order for Novolog insulin (a rapid-acting Insulin to help control blood sugar spikes in adults with diabetes) 28 units subcutaneously (under the skin) three times a day before each meal. LPN-A removed the Novolog insulin pen from inside the medication cart. LPN-A removed the cap from the insulin pen and wiped the top of the pen with an alcohol prep pad. LPN-A dialed the pen dose to 28 units. LPN-A applied a needle to the top of the insulin pen. (LPN-A did not dial the pen to 2 units and prime the needle prior to dialing the ordered dose of 28 units). LPN-A entered the room of Resident 2 with the insulin pen. LPN-A asked Resident 2 which arm they would like the insulin administered in. LPN-A wiped the upper right arm of Resident 2 with an alcohol prep pad. LPN-A placed the insulin pen against the skin of Resident 2's right upper arm and administered the insulin. LPN-A removed the needle from the insulin pen and discarded it into the sharp's container in the resident's room. LPN-A returned to the medication cart and documented the insulin administration. Interview on 7/10/24 at 2:52 PM with the facility Director of Nursing (DON) confirmed that staff are expected to prime the insulin pen prior to dialing the ordered insulin dose on the insulin pen to ensure the resident received the correct dose of insulin per the physician's order. The DON confirmed that not priming the insulin pen was a significant medication error. B. Observation on 7/10/24 at 11:49 AM at the medication cart outside the room of Resident 2 revealed that Licensed Practical Nurse-B (LPN-B) reviewed the insulin order for Resident 2. LPN-B confirmed that Resident 2 has an order for Novolog insulin (a rapid-acting Insulin to help control blood sugar spikes in adults with diabetes) 28 units subcutaneously three times a day before each meal. LPN-B carried the insulin pen and supplies into the room of Resident 2. LPN-B picked up the Novolog insulin pen and removed the cap from the insulin pen. LPN-B opened a needle and attached the needle to the insulin pen. LPN-B dialed the pen dose to 28 units. (LPN-B did not dial the pen to 2 units and prime the needle prior to dialing the ordered dose of 28 units). LPN-B wiped the upper right arm of Resident 2 with an alcohol prep pad. LPN-B placed the insulin pen against the skin of Resident 2's right upper arm and administered the insulin. LPN-B removed the needle from the insulin pen and discarded the needle into the sharp's container in the resident bathroom. LPN-B returned to the medication cart. Interview on 7/10/24 at 2:52 PM with the DON confirmed that staff are expected to prime the insulin pen prior to dialing the ordered insulin dose on the insulin pen to ensure the resident received the correct dose of insulin per the physician's order. The DON confirmed that not priming the insulin pen was a significant medication error.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to wear hair restraints while preparing resident food and failed to test the sanitizer solution used to clean the resident dining, meal preparation, and eating surfaces. This had the potential to affect all of the facility residents. The facility identified a census of 23 at the time of survey. Findings are: Observation of the DM (Dietary Manager) on 6/26/23 at 06:55 AM revealed the DM was wearing a ball cap with no hairnet. The DM's hair was visible approximately two inches below ball cap, and their hair was dripping with sweat. The DM was preparing and serving food and drinks to the facility residents who were seated in the dining room. Interview on 6/27/23 at 3:11 PM with the DM revealed a hairnet was not worn under the ball cap. The DM revealed that hair restraints are to be worn to cover all hair. Record review of the Food Code 2-402.11-Effectiveness revealed that 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. B. Observation on 6/27/23 at 9:44 AM of the facility kitchen revealed a bucket was filled with sanitizer used for cleaning of tables and surfaces. Interview on 6/27/23 at 10:00 AM with DA-A (Dietary Aide) revealed the water in the sanitizer bucket was changed 6-7 times a day and was used for cleaning surfaces/tables. DA-A revealed they did not test the bucket of sanitizer fluid to determine if the concentration of sanitizer was at the level it needed to be in order to sanitize the meal preparation and dining surfaces. Interview on 6/27/23 at 10:01 AM with DC-B (Dietary Cook) revealed the dietary staff should test the bucket of sanitizer fluid prior to use. Interview on 6/27/23 at 10:14 AM with the FA (Facility Administrator) revealed the FA was unaware of a policy to test the sanitizer in the water bucket. Interview on 6/27/23 at 2:40 PM with the FA revealed the ECO lab representative confirmed the bucket with sanitizer should have been tested prior to cleaning the tables. The FA revealed test strips were not present in the facility but have been ordered on this date. Record review of the Food Code 4-302.14 Sanitizing Solutions, Testing Devices revealed that a test kit or other device that accurately measures the concentration in mg/L of sanitizing solutions shall be provided.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to prevent potential cross contamination during meal preparation and meal service by handling the eating surface of plates, cups/mugs, and touching prepared food with bare hands, failing to clean food preparation equipment, failing to perform hand hygiene during meal prep and meal service; and failed to prevent potential cross contamination by failing to wash hands when contaminated in the dining room. This had the potential to affect all of the facility residents. The facility identified a census of 21 at the time of survey. Findings are: A. Observation of the facility dining room on 4/25/22 at 11:51 AM revealed DC-A (Dietary Cook) was observed serving plates of food to residents in the facility dining room. DC-A had visible perspiration on their face. DC-A touched their face with their bare hand then picked up a plate of food from the service window and took the plate of food to Resident 15. DC-A then handled 2 glasses of drinks and placed them in front of Resident 21 who then proceeded to drink from the glasses by handling the same surface DC-A had handled. At 11:53 AM, DC-A touched the handle of Resident 21's walker with their bare hand to move it and tied Resident 21's clothing protector around their neck then handled 2 glasses of drinks and took then to Resident 16 who then handled the glasses by the surface DC-A had handled and proceeded to drink from the glasses. At 11:54 AM, DC-A poured coffee in a mug and put a lid on it. DC-A touched the opening/drink hole with their hands. DC-A then poured milk into a mug and put the lid on and touched the opening of the mug and the drinking hole by placing their thumbs on the drinking surface of the mug to push the lid onto the mug. DC-A then took the mugs to Resident 5 who then picked up the mugs and proceeded to drink from them. At 11:56 AM DC-A handled 2 glasses and poured ice water and tea into the glasses for Resident 9 and then took the glasses and a plate of food to Resident 9. Resident 9 was then observed eating and drinking from the items. At 11:58 AM, DC-A poured coffee into a cup and tea into a glass by handling the cup/glass by the drinking rims and took them to Resident 11 who then proceeded to handle the items and drink from them. DC-A then took a plate of food to Resident 11 who then ate the food from the plate DC-A had touched with their soiled hands. At 12:02 PM, DC-A got a wet rag from the kitchen and used it to clean the counter in front on the service window. DC-A used their bare hand to handle the rag then DC-A put the rag back in the kitchen. DC-A then handled a cup and a glass and poured milk and tea for Resident 18 and then took them to Resident 18. Resident 18 was then observed drinking from the items. DC-A did not do hand hygiene after their hands were contaminated by touching their face, resident personal items, and the cleaning rag while serving food and drinks to the residents. Interview with the FA (Facility Administrator) on 5/2/22 at 4:34 PM revealed the facility staff were expected to handle resident tableware without touching the eating/drinking surface or putting their fingers in the food. The FA revealed the facility staff were expected to perform hand hygiene during meal prep/meal service. B. Observation of the facility kitchen on 4/25/22 at 11:20 AM revealed DC-B failed to wash all parts of the food blender between each food item during the preparation of the pureed meal. DC-B placed pieces of pork into the blender, pureed it, and emptied the pork into a container. Without cleaning the lid of the blender, DC-B placed mixed vegetables into the blender, put the lid on the blender, pureed the vegetables, and placed them into a container. The vegetables splashed onto the lid while they were being pureed and got mixed with the pork. Without cleaning the lid of the blender, DC-B then placed peach cobbler into the blender, put the lid on the blender, and pureed the peach cobbler. Pieces of the peach cobbler were observed being mixed with the pork and vegetable residue which was on the lid of the blender. DC-B also failed to wash their hands between handling each of the containers of the food items and the soiled blender. DC-B then served the pureed meal to the residents. C. Observation of the facility kitchen on 4/25/22 at 12:00 PM revealed DC-B touched the top of the plate with thumb and fingers. The plate was filled with potatoes and pork and gravy mixture. DC-B placed their thumb into the food and brushed it off on their pants. The plate of food was then served to an unidentified resident in the dining room. DC-B then went to the refrigerator to get items out for residents and did not complete hand hygiene at any time. D. Observation of the facility dining room on 4/25/22 at 12:00 PM revealed DA-A (Dietary Aide) failed to complete hand hygiene between residents when passing trays and assisting residents with meal setup at the residents' table. DA-A would stop and pull their face mask up, and continue serving trays, and did not do any hand hygiene. At 12:05 PM, DA-E served plates of food to the residents and prepared meal trays and did not do any hand hygiene between residents. DA-E was observed within 6 feet of each resident when they put the plates of food in front of them and the residents did not have a face covering. At 12:15 PM, DA-A had their fingers and thumb on top of the eating surface of the plates and their hand was covering the tops of cups and glasses when DA-A was delivering them to the residents. DA-A had their thumb in potatoes on the plate, removed their thumb and wiped it on their pants, and continued delivering meals to residents in the dining room without doing any hand hygiene. E. Observation of the facility kitchen on 4/25/22 at 12:20 PM revealed DC-B went to the freezer, obtained ice cream for a resident, opened the container, handed the ice cream across and through the service window and did not do hand hygiene. F. Observation of the facility kitchen on 4/26/22 at 08:33 AM revealed DC-C failed to perform hand hygiene while preparing resident food and while serving breakfast to the residents from the kitchen. At 10:20 AM, DC-C did not use hand hygiene after they placed a dirty jar and lid used for blending foods in the dirty dish water, then placed in the dish washer by handling the machine with their bare hands. DC-C then continued to prepare resident food without doing hand hygiene. At 10:55 AM, DC-B did not do hand hygiene between tasks while preparing pureed food for the lunch menu. DC-B prepared the pureed food by putting asparagus in the blender container and the lid to the blender had not been cleaned from meat, and pureed food particles on the blender blades contaminated the equipment and food. The blueberry dessert was on the blades and DC-B put broccoli in to puree next, and they were pureed together. At 11:20 AM DC-C failed to wash all parts of the blender which was the blade and jar of the small blender during the preparation of pureed chicken and potato, gravy, blueberry dessert, and carrots. DC-C did not clean the inside of the lid with blades for pureeing foods, and then started to puree the next item when the lid had not been washed and cleaned. Bits of the food from the lid were observed being mixed with the item that was being pureed. DC-C also failed to perform hand hygiene during meal preparation. G. Observation of the facility dining room on 5/2/22 at 11:50 AM revealed DC-D and DC-B were in the dining room serving and assisting residents. DC-D and DC-B served plates of food to all of the residents in the dining room and prepared the meal and room trays without doing hand hygiene in between residents. The residents were observed sitting in the dining room without face coverings and the dietary staff were within 6 feet of the residents. Interview with DC-B on 4/25/22 at 12:55 PM revealed the expectation was that hand hygiene should be completed when hands become soiled and after assisting residents. Interview with DC-B on 4/27/22 at 12:45 PM revealed the expectation would be to do hand hygiene each time staff had soiled hands and between food items and residents; when leaving the steam table area to put items in the dishwasher; or to get other food items for residents in the kitchen. Interview with the FA on 5/02/22 at 2:40 PM revealed the expectation of the dietary staff was to use hand hygiene while working in the kitchen to prevent cross contamination. Interview with DC-B on 4/27/22 at 4 PM revealed the expectation of the staff was to complete hand hygiene between residents and anytime hands were soiled or if they had been away from the dining room. Interview with the FA on 5/02/22 at 4:04 PM confirmed the expectation of hand hygiene would be to wash hands between each resident or when hands were soiled. 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 2-301.14. When to Wash your hands after handling soiled equipment or utensils, and During Food preparation, and as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility staff failed to prevent potential disease transmission including Covid-19 by failing to wear face masks in resident care areas which had the potential to affect all of the facility residents; failed to perform hand hygiene during the distribution of resident clothing which affected 4 of 5 residents observed, Resident 5, 10, 19, and 3; and failed to store oxygen cannulas to prevent potential cross contamination for 2 of 2 sampled residents, Resident 11 and 20. The facility identified a census of 21 at the time of survey. Findings are: A. Observation of the facility dining room on 4/25/22 at 11:51 AM revealed DC-B (Dietary Cook) and NA-F (Nurse Aide) had surgical masks on. Their masks were down under their noses which left their noses exposed. DC-B was observed in the kitchen and served the entire dining room and the room trays with their mask down under their nose. 21 residents were served food by DC-B. NA-F was observed sitting next to Resident 10 and helping Resident 10 put the food on their spoon. Resident 10 was eating and was not wearing a face mask. B. Observation of the facility dining room on 4/26/22 at 9:16 AM revealed DC-B was observed in the dining room walking around the residents. DC-B was observed with a surgical mask that was down under their nose and their nose was not covered. 16 residents were observed in the dining room with no face covering. C. Observation of the facility dining room on 4/27/22 at 8:00 AM revealed DC-B was observed in the kitchen serving food to the residents. DC-B was observed wearing a surgical mask that was down under their nose and their nose was exposed/uncovered. DC-B was then observed in the dining room helping the residents and refilling drinks and their nose was also not covered with the surgical mask. 17 residents were in the dining room. All of the facility residents were observed being served food from the dining room/kitchen either present in the dining room or per room trays which were observed being prepared by DC-B. D. Observation of the facility dining room on 4/27/22 at 12:18 PM revealed DA-I (Dietary Aide) had a surgical mask on that was under their nose and their nose was uncovered. DA-I walked through the dining room with the coffee carafe and poured Resident 3 some coffee then walked back to the front of the dining room to put the coffee carafe back on the counter. 17 residents were observed seated in the dining room without masks on. At 12:21 PM NA-G was observed standing in the dining room talking to Resident 9 who was seated at the dining room table eating lunch and was not wearing a face mask. NA-G was within 6 feet of Resident 9 and the surgical mask NA-G was wearing was down and their nose was not covered. E. Observation of the facility on 4/26/22 at 11:52 AM revealed LS-H (Laundry Staff) was distributing resident clothing on the unit. LS-H took hangers of clothes off the cart in the hall into Resident 9's room, opened the closet door with their bare hands, put the clothes in the closet, took the empty hangers out of the closet with their bare hands and brought the empty hangers from the closet out to the cart in the hall and hung them up on the same cart. LS-H did not do hand hygiene then got more clothes off the cart that were on hangers and took them in to Resident 5's room, opened the closet door, put the clothes in the closet, took the empty hangers out of the closet and put them on the cart in the hall, and without doing hand hygiene LS-H took hangers of clothes into Resident 10's room, opened the closet door, hung up the clothes, took the empty hangers out of the closet to the cart, and without doing hand hygiene took clothes off the cart that were on hangers into Resident 19's room. LS-H opened the closet door with their bare hands, put the clothes on hangers in the closet, removed the empty hangers and took them out to the cart. Without doing hand hygiene, LS-H took clothes on hangers off the cart into Resident 3's room, opened the closet door, put the clean hangers in the closet, took the empty hangers out, brought them out of the room and put them on the cart. F. Observation of the facility on 4/26/22 at 1:58 PM revealed NA-F was observed standing at the nurses' station without a mask covering their nose and mouth. NA-F had a surgical mask on that was down under their chin and their nose and mouth were uncovered. NA-F was observed drinking out of a mug. The nurses' station was not enclosed and was open to the living room. Resident 16, Resident 9, Resident 21, and Resident 1 were observed sitting in the living room with no face covering on. Interview with the DON (Director of Nursing) on 5/02/22 at 11:31 AM revealed the facility staff were expected to wear a face mask that covered the nose and mouth and the staff were expected to wear a face mask in the facility at all times including in the resident care areas, the nurses' station, and the dining room. Review of the facility Covid-19 Vaccination Residents Tracking Log received 4/25/2022 revealed Resident 6 was not up to date with their Covid-19 vaccinations. Review of the facility Covid-19 Staff Vaccination Matrix dated 4/18/2022 revealed NA-F and NA-G were unvaccinated for Covid-19. Interview with the FA on 5/2/22 at 4:34 PM revealed the facility staff were expected to perform hand hygiene while distributing clothing. The FA revealed the facility staff were expected to wear face masks while they were in the facility and their noses and mouths were to be covered. Review of the facility policy Hand Hygiene dated 10/15/2020 revealed the following: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Either soap and water or Alcohol Based Hand Rub (ABHR is preferred): When entering and exiting a resident room, between resident contacts, after handling contaminated objects, before and after handling clean or soiled dressing, linens, etc.; after handling items potentially contaminated with blood, body fluids, secretions, or excretions; when, during resident care, moving from a contaminated body site to a clean body site; after assistance with personal body functions, (e.g. elimination, hair grooming, smoking); when in doubt. Review of the facility policy Handling Clean Linen dated 5/21/2020 revealed the following: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. Carry clean linen with clean hands away from your body. Review of the facility policy LTC Covid-19 Emergency Response Plan dated 6/29/2020 revealed the following: All employees are required to wear a mask, procedure or surgical, if in direct contract with residents or cloth face covering for non-direct care employees. G. Observation of Resident 11's room on 4/26/22 at 8:48 AM and 5/2/22 at 11:02 AM revealed the oxygen tubing was coiled up and stored under the handle on the concentrator and the oxygen nasal cannula (a tube placed into the nose for the administration of oxygen) was hanging down the front of the machine touching the concentrator and was not contained. Review of Resident 11's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) date 3/1/22 revealed oxygen was used while a resident. Review of Resident 11's Order Summary Report dated 4/26/2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 20's room on 5/2/22 at 11:02 AM and 11:24 AM revealed the oxygen nasal cannula was draped over the side of the concentrator and was touching the concentrator. Review of Resident 20's Significant Change in Status MDS dated [DATE] revealed oxygen was used while a resident. Review of Resident 20's Order Summary Report dated 4/26/2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DON (Director of Nursing) on 5/02/22 at 11:33 AM revealed the expectation was for oxygen cannulas to be stored in a bag on the concentrator. Observation of the oxygen concentrators in Resident 11's room and Resident 20's room with the DON at this time revealed the oxygen cannulas were hanging over the edges of the concentrators touching the concentrators and there were no storage bags on the concentrators. The DON confirmed the oxygen cannulas were supposed to be stored in bags. The DON revealed they were supposed to have bags on the concentrators to store the cannulas when they were not in use. Review of the undated facility policy Medication Administration-Oxygen revealed no documentation of a storage procedure to prevent cross contamination for the oxygen cannulas. H. Observation of the facility dining room on 4/25/22 at 12:00 PM revealed DA-A's mask was below their nose through the meal service. DA-A served the residents in the dining room and prepared the room trays with their mask below their nose. All of the residents were observed eating after being served and were not wearing face coverings. DA-A was within 6 feet of the residents when they served the residents their plates of food and their drinks. I. Observation of the facility kitchen on 4/25/22 at 12:20 PM revealed DC-B was serving plates of food to the residents and their mask was below their nose. DC-B plated food for all of the facility residents. Interview with DC-B on 4/25/22 at 12:55 PM revealed the expectation was for all dietary staff to wear masks above their nose at all times and when working around in the nursing home with residents. Interview with the FA (Facility Administrator) on 5/02/22 at 4:04 PM revealed face masks should be worn at all times in the facility, for protection of all staff and residents

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure resident care equipment was maintained to prevent a potential accident hazard. This had the potential to affect 1 of 5 sampled residents, Resident 11. The facility identified a census of 21 at the time of survey. Findings are: Observation of Resident 11's bathroom on 4/26/22 at 8:48 AM revealed there was a toilet riser on the toilet that was not secured to the toilet and could be tipped forward or to the side when a hand was placed onto the toilet riser. The toilet riser had a twist type lock on the front of it that was not secured. Interview with the FA (Facility Administrator) on 4/26/22 at 10:35 AM revealed there was no documentation the toilet risers were being checked to ensure they were secured to the toilet and did not create an accident hazard. The FA revealed the facility did not have a formal program or procedure in place to check the toilet risers. The FA revealed maintenance and housekeeping were expected to check the rooms for any accident hazards. The FA revealed that if the nursing staff noticed any issues with resident care equipment, they were expected to document it in the maintenance book at the nurses' station to alert the maintenance staff of needed repairs. The FA confirmed Resident 11 did use the toilet in their bathroom.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility failed to ensure resident beds were monitored for potential entrapment hazards. This affected 1 of 16 resident beds reviewed, Resident 10. The facility identified a census of 21 at the time of survey. Findings are: Observation of Resident 10's bed on 4/26/22 at 8:37 AM revealed the mattress was not secured to the bed. The bed was against the wall and the mattress could be slid off the bed frame which created a gap between the mattress and the wall, which placed Resident 10 at risk for entrapment. Interview with the FA (Facility Administrator) on 4/26/22 at 10:35 AM revealed the facility did not have documentation the beds were being checked for potential entrapment and the facility did not have a formal monitoring program for the beds to check them for safety hazards. The FA revealed maintenance and housekeeping were expected to check the resident rooms for accident hazards. The FA revealed if nursing staff observed any issues they were expected to document in the maintenance book at the nurses' station to alert maintenance staff of needed repairs. The FA confirmed Resident 10 slept in the bed.

Licensure Reference Number: 175 NAC 12-006.09D7a Based on record reviews and interviews, the facility failed to assess the safety of an electric recliner for one closed record sampled (Resident 1) to reduce the risk of accidents. The facility census was 21 with two current sampled residents and one closed record reviewed. Findings are: Review of Resident 1's Progress Notes, dated 2/19/22 at 1:29 PM revealed that the resident used a lift for transfers and had intermittent confusion on this shift. Further review revealed that at 3:25 PM, the resident was found on the floor and had arm pain. The resident's recliner was found positioned upright and forward. The resident was sitting in the recliner prior to the fall, was having intermittent confusion and staff reported that the resident said was able to walk. The staff reminded the resident not to use the remote for the recliner and placed it where the resident's arm wouldn't move it and within reach. The resident was transferred to the hospital for evaluation at 4:05 PM. Review of the care plan, target date 3/14/22, revealed that the resident required a full lift and two staff assistance with transfers, had impaired thought processes related to dementia, forgetfulness and memory loss, had hearing loss and communication problems. Further review revealed that the resident was a low risk for falls related to confusion, unaware of safety needs and decreased mobility. Interview with the Director of Nursing on 3/1/22 at 3:15 PM confirmed that the resident was having intermittent confusion and hallucinations prior to the fall and was left with access to the remote for the electric recliner. Further interview confirmed that an assessment of the electric recliner was not completed to ensure that the resident could safely use the remote.

Licensure Reference Number 175 NAC 12-006.04C1 Based on record review and interview the facility failed to provide 8 hours of RN (Registered Nurse) coverage for every 24 hour period. This had the potential to affect all the residents at the facility. The facility census was 21. Findings are: Record review of the facility nursing staff schedule revealed that the nursing staff schedule did not reflect 8 hours RN coverage for September 20, 2020. Interview on 9/22/2020 at 2:00 PM with the Director of Nursing confirmed there was not any RN coverage on that date in the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to store food containers in a manner to prevent potential cross contamination and failed to serve drinks to prevent potential cross contamination. This had the potential to affect all of the facility residents. The facility identified a census of 21 at the time of survey. Findings are: Interview with the facility Administrator on 09/16/20 8:15 AM revealed all of the facility residents were being served their meals on disposable dishes and containers in their rooms. A. Observation of the kitchen on 9/16/2020 at 8:20 AM revealed Cook-D was dishing food into square Styrofoam containers and pouring cereal into Styrofoam bowls. The square Styrofoam containers and Styrofoam bowls. DA-H (Dietary Aide) then took the containers on a cart out to the residents. DA-H took a square container into each residents' room and the residents were observed eating food from the containers. Observation of the kitchen on 9/16/2020 at 12:06 PM revealed Cook-D dished food into square Styrofoam containers. DA-H then took the containers of food to the facility residents. The square Styrofoam containers and Styrofoam bowls were sitting on the floor in a bag. DA-H took a square container into each residents' room and the residents were observed eating food from the containers. Interview with the FSS (Food Service Supervisor) on 9/22/2020 at 9:05 AM revealed the Styrofoam box containers and the bowls were not to be stored on the floor. Review of the facility policy Sanitation and Infection Control effective March 23, 2017 revealed the following: It is the policy of this facility that Dietary Employees follow all areas of sanitation and infection control as stated is USFDA Food Code 2013. Employees will practice good personal hygiene to be in compliance with infection control. All employees are to follow use of gloves and handwashing policy. B. Observation on 09/16/2020 at 12:15 PM residents were eating meals in their rooms, the dietary staff brought out drinks for the residents on a three tiered cart. The dietary staff provided drinks for all residents, no hand hygiene was observed as the dietary staff went up and down each hallway, pouring drinks and moving personal items on the residents' over bed tables. Observation on 09/22/20 at 08:05 AM revealed the nursing and dietary staff were delivering breakfast trays, from one to another resident without hand hygiene between setting residents up with their meals. A bottle of hand sanitizer liquid was on the top of the cart that held the residents food. On 09/22/2020 at 09:07 AM interview with the Food Service Supervisor revealed their expectation was the staff did not need to sanitize their hands if they were just delivering food to the residents. Record review of undated facility policy on Handwashing revealed the following: Employees will use proper handwashing techniques that will aid in the prevention of the transmission of infection. Guidelines When to Wash Hands: whenever hands are obviously soiled.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility staff failed to prevent potential cross contamination by failing to perform hand hygiene during meal preparation and during meal service which affected all of the facility residents; failed to prevent potential cross contamination by failing to change gloves and perform hand hygiene during cares which affected 1 sampled resident (Resident 21);failed to prevent potential cross contamination by failing to clean the lift after use which had the potential to affect all of the residents who used the lifts (Residents 21, 6, 22, 20, 14, 13 and 24) ; failed to prevent potential cross contamination by failing to store an indwelling catheter bag off the floor for 1 of 2 residents with a catheter (Resident 6); and failed to prevent potential cross contamination by failing to perform hand hygiene during a dressing change for 1 of 3 sampled residents (Resident 6). The facility identified a census of 21 at the time of survey. Findings are: A. Observation of the facility kitchen on 9/16/2020 at 8:20 AM revealed Cook-D putting food into square Styrofoam containers. DA-H (Dietary Aide) then took the boxes out into the halls on a cart to the residents who were dining in their rooms. DA-H took food to Resident 14 in their room then to Resident 10; then to Resident 9; then took food to Resident 2 by handling the Styrofoam containers and placing them in front of the residents. DA-H touched Resident 2's Styrofoam cup to move it as it was sitting on the tray table and then DA-H sat the container of food in front of Resident 2. DA-H did not do hand hygiene between residents or when they touched Resident 2's cup. At 8:37 AM DA-H took the cart back to kitchen area and picked up 3 more food boxes. DA-H did not do any hand hygiene. DA-H then took food to Resident 12, Resident 3, and Resident 11. DA-H then pushed the cart back to the kitchen and touched the rims of Styrofoam coffee cups then put coffee in them from an urn with a spigot. DA-H then put creamer in one of them the put lids on both of the cups. At 8:43 AM DA-H took the coffee to Resident 8 and Resident 22. DA-H did not do any hand hygiene. All of the residents were observed feeding themselves and handling the cups and food. Resident 2 was observed drinking from the glass DA-H touched then did not perform hand hygiene prior to serving food to the other residents. Observation of the facility kitchen on 9/16/2020 at 9:48 AM revealed Cook-D washed their hands at the sink. After Cook-D washed their hands, they turned the water off with their bare hand then got paper towels and dried their hands. Cook-D then poured tater tots into 2 pans. Cook-D then poured diced chicken onto the tater tots. Cook-D then placed peas and carrots onto the tater tots and chicken then poured milk and cream of chicken soup mixture over all. Cook-D then put foil on the pans and placed them into the oven. Cook-D touched the food prep items in the kitchen and used their un-gloved hands which they had touched the faucet with to prepare the foods. Observation of the facility kitchen on 9/16/2020 at 11:53 AM revealed Cook-D washed their hands. Cook-D shut the faucet off with their bare hand then dried their hands with paper towels. Cook-D then prepared pureed food in a blender for Resident 17 then placed it into a square Styrofoam container. At 12:06 PM, Cook-D then dished the regular food for the other facility residents into the square Styrofoam containers. Cook-D had bare hands and handled the containers while filling them with food. DA-H then took the food to the facility residents. The residents were observed eating the food from the Styrofoam containers. B. Observation of the facility on 9/17/20 at 8:12 AM revealed DA-H took a cart with square Styrofoam containers down the hall. DA-H took the food boxes into each residents room. DA-H did not perform any hand hygiene after DA-H took the food boxes in to each resident. DA-H was directly observed taking food to Resident 22, Resident 13, Resident 5, Resident 16, Resident 14, Resident 19, and Resident 8. The residents were observed eating the food from the Styrofoam containers. Interview the FSS (Food Service Supervisor) on 9/22/2020 at 9:05 AM if the dietary staff touched the tables or the glasses/cups, they were supposed to do hand hygiene. The FSS expressed they did not realize the staff had to do hand hygiene between each resident but the FSS agreed they probably should since the DA was taking food in to residents who were not always wearing a mask and there was potential for cross contamination as the DA was in close proximity to the residents when they were delivering the food containers. The FSS revealed the staff were not supposed to touch the handles on the faucets with their bare hands after they had washed their hands; they were supposed to get the towel, dry their hands, then use a towel to shut the faucet off and also use a towel to open the door. Review of the undated facility policy Handwashing revealed the following: Employees will use proper handwashing techniques that will aid in the prevention of the transmission of infection. Guidelines When to Wash Hands: whenever hands are obviously soiled. Before preparing or handling food or medications. After handling items or work surfaces potentially contaminated with blood, excretions, or secretions. Whenever in doubt. C. Observation of Resident 21 on 9/21/20 at 2:35 PM revealed the following: MA-B (Medication Aide) and MA-C assisted Resident 21 with peri care. MA-B and MA-C both donned gloves. MA-B lowered Resident 21's brief and Resident 21 started to urinate so MA-C pulled the brief back up to cover Resident 21. MA-C then pulled the brief back down then touched Resident 21's clothing and face and asked Resident 21 to roll over. MA-C touched Resident 21's clothing and face wearing the same gloves MA-C was wearing when they had touched Resident 21's brief. MA-B did not have wipes so MA-B touched the lift with the gloved hands MA-B had touched Resident 21's clothing and brief with and moved the lift so MA-B could get to the bathroom to get wipe. MA-B then got the wipes out of the bathroom and returned to Resident 21's bedside. MA-B then used pre-moistened wipes to wipe Resident 21's perineum (bottom). MA-B removed the soiled brief and discarded it into the trash then MA-B then used the same gloved hands and put clean brief under Resident 21. MA-B then removed their gloves. MA-B did not do hand hygiene after they removed the gloves. MA-C then fastened the brief. MA-B and MA-C then handled Resident 21's blanket and covered Resident 21 with it. MA-C then removed the gloves and then used their bare hands to take Resident 21's shoes off. MA-C then handled the oxygen tubing and cannula (the tube used to administer oxygen into the nose) and placed it on Resident 21's face. MA-C had not done hand hygiene after MA-C removed the gloves and handled Resident 21's shoes. MA-C then went and washed their hands. MA-B pulled the trash bag out of the can with the soiled brief and wipes in it and used both hands to tie it. MA-B was holding it in their hand. MA-B then took the call light box off of Resident 21's rolling table then gave Resident 21 their call light box. MA-B opened the door by grabbing the handle and took the lift out and the trash bag out of the room. MA-B put the trash in the utility room then came back out and used hand sanitizer to do hand hygiene. MA-C put the lift back into the store room and did not clean it. MA-C then left the store room and did hand hygiene with hand sanitizer. 1 full lift in the store room was placed between 2 sit to stand lifts. Interview with LPN-E (Licensed Practical Nurse) on 9/22/20 at 10:18 AM revealed these resident used the facility lifts: Resident 22, Resident 6, Resident 14, Resident 20, Resident 21, and Resident 24 used the full lift. Resident 13 and Resident 24 used the sit to stand lift. LPN-E revealed Resident 24 used both lifts. D. Review of Resident 6's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/11/2020 revealed an admission date of [DATE]. Resident 6 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 6 was cognitively intact. Resident 6 required extensive assistance of 2 staff for bed mobility, transfer, and toilet use. Resident 6 had a pressure ulcer/injury Stage 3 unhealed pressure ulcer not present upon admission. Pressure reducing device for chair or bed, pressure ulcer/injury care and application of non-surgical dressings (with or without topical medications) other than to feet were used. Interview with Resident 6 on 9/16/20 at 3:21 PM revealed they had a pressure ulcer on their coccyx (tailbone). Observation of Resident 6 on 9/17/20 at 8:12 AM revealed Resident 6 was in bed. Resident 6 had an indwelling urinary catheter (a tube inserted into and left in the bladder to drain urine). The catheter bag was uncovered and lying on the floor. Observation of Resident 6 on 9/17/20 at 2:24 PM revealed Resident 6 was in bed. Resident 6's catheter bag was uncovered and lying on the floor. Observation of Resident 6 on 9/21/2020 at 10:56 AM revealed LPN-A (Licensed Practical Nurse) and LPN-G completing a dressing change for Resident 6. LPN-A and LPN-G washed their hands and donned gloves. At 11:00 AM LPN-A picked the trash can up with the gloved hand and moved it closer to the work area. LPN-A then removed their gloves and put new gloves on. LPN-A did not do hand hygiene after between glove changes. LPN-A helped Resident 6 roll over in bed by touching Resident 6's skin and clothing. LPN-A revealed the old dressing had already been removed as Resident 6 had gotten a bath. The area to coccyx was observed to be about a cm in diameter and was a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). Using the same gloved hands, LPN-A cleaned the open area with wound wash and a gauze pad and discarded the gauze pad into the trash can. Resident 6 had stooled so LPN-A cleaned that with a cleansing wipe then discarded it into the trash can. LPN-A changed gloves but did not perform hand hygiene. LPN-A put gel into the wound using their gloved finger then applied skin prep to the area around the wound. LPN-A put a gauze pad into the wound and placed an adhesive bordered dressing over the gauze pad. LPN-A removed their gloves and washed their hands. At 11:06 AM LPN-A touched the trash can and picked it up so Resident 6 could discard something into the trash can. LPN-A put the trash can back on the floor, put the table close to Resident 6, then picked up Resident 6's cell phone off the bedside stand and handed it to Resident 6. LPN-A then picked up the tub of supplies then touched the door knob to open it and left the room. LPN-A then opened the medication room door with the same hands and took the tub of Resident 6's dressing supplies into the medication room. LPN-A did not do hand hygiene after handling the trash can before handling Resident 6's personal items and touching the table and the door knobs. Interview with NA-F (Nurse Aide) on 9/22/2020 at 8:57 AM revealed the staff were expected to make sure the catheter bags were not lying on the floor. Interview with the DON (Director of Nursing) on 9/22/2020 at 9:31 AM revealed the staff were expected to perform hand hygiene between residents; when the staff were switching cares from one task to another and when the gloves were contaminated they were expected to change their gloves. The staff person would be expected to do hand hygiene after they touched the dirty trash can. It was the expectation the staff would change their gloves and be prepared and have their supplies ready so they didn't have opportunities to contaminate the gloves. The staff were expected to clean the lifts between residents. The DON confirmed the facility lifts were used for multiple residents. Review of the undated facility policy Use of Gloves revealed the following: Gloves must never be used in place of hand washing. Gloves should be changed: as soon as they become soiled or torn; before beginning a different task. Review of the undated facility policy Mechanical Lift Cleaning revealed the following: Mechanical Lift devices will be cleaned after each usage with the germicidal wipes utilized by the facility. The mechanical lift will not be used on another resident until the recommended time frame has elapsed for the maximal effect of the germicidal cleansing wipes. Review of the undated facility policy Catheter Care revealed the following: Check the following items: Catheter is not lying on floor. Review of the undated facility policy Handwashing revealed the following: Employees will use proper handwashing techniques that will aid in the prevention of the transmission of infection. Guidelines When to Wash Hands: Whenever hands are obviously soiled. After handling used dressings, specimen containers, contaminated tissues, linen, etc. After contact with blood, oral secretions, mucous membranes, broken skin, etc. After handling items or work surfaces potentially contaminated with blood, excretions, or secretions. Whenever in doubt. E. Observation on 09/16/20 at 08:10 AM revealed MA-B observed taking the cart down 100 with the food boxes for resident meals. MA-B took the food boxes into each resident's room on 100 and did not perform any hand hygiene; MA-B was directly observed taking food to Resident 1, Resident 13, Resident 15, and Resident 16. MA-B went into each room, moving and helping get over bed tray clear for meals, no hand hygiene was performed. On 09/22/20 at 11:36 AM an interview with the Director of Nursing revealed expectations of all staff would be to use hand hygiene before, between and after each tray passed to residents. Record review of undated facility policy on Handwashing revealed the following: Employees will use proper handwashing techniques that will aid in the prevention of the transmission of infection. Guidelines When to Wash Hands: whenever hands are obviously soiled.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review; the facility failed to submit a written summary of the baseline care plan to the resident or resident PR (Personal Representative) for 5 of 7 sampled residents (Resident 7, 8, 19, 21, and 10). The facility identified a census of 21 at the time of survey. Findings are: A. Review of Resident 7's Quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 7 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 7 was cognitively intact. Review of Resident 7's Baseline Care Plan dated 9/20/2019 revealed no documentation a written summary was provided to Resident 7. The Resident and/or Representative signature line was blank. Review of Resident 7's Progress Notes revealed no documentation a written summary of their baseline care plan was given to them. B. Review of Resident 8's quarterly MDS dated [DATE] revealed an admitted on 1/20/2020. Resident 8 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of Resident 8's Baseline Care Plan dated 1/20/2020 revealed no documentation a written summary was provided to Resident 8. The Resident and/or Representative signature line was blank. Review of Resident 8's Progress Notes revealed no documentation a written summary of their baseline care plan was given to them or their PR. C. Review of Resident 19's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 19 had a BIMS score of 14 which indicated Resident 19 was cognitively intact. Review of Resident 19's Baseline Care Plan dated 10/22/2019 revealed no documentation a written summary was provided to Resident 19. The Resident and/or Representative signature line was blank. Review of Resident 19's Progress Notes revealed no documentation a written summary of their baseline care plan was given to them. D. Review of Resident 21's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 21 had a BIMS score of 9 which indicated moderate cognitive impairment. Review of Resident 21's Baseline Care Plan dated 10/22/2019 revealed no documentation a written summary was provided to Resident 21. The Resident and/or Representative signature line was blank. Review of Resident 21's Progress Notes revealed no documentation a written summary of their baseline care plan was given to them or their PR. Interview with the DON (Director of Nursing) on 09/21/20 at 4:09 PM. The written summary of the baseline care plan was not given to the resident/PR. The DON confirmed if there was no signature on the page then it wasn't done. The DON revealed they have been going over the care plan with the resident/PR at the initial care plan meeting but not before. Review of the facility policy Baseline Care Plan dated 1/10/2018 revealed the following: Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders [REDACTED] ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASRR recommendation, if applicable. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. E. Record review of Resident 10's admission record revealed the resident was admitted [DATE]. There was no documentation the family for Resident 10 received or acknowledged the baseline care plan. Record review of Resident 10's SSD (Social Services Director) progress notes revealed the resident had been in the hospital and returned on 4/30/2020 and the baseline care plan had not been completed. The comprehensive care plan had been reviewed on 5/13/20. On 09/22/20 at 12:00 PM an interview with the Director of Nursing confirmed that there was no documentation on the Resident 10's baseline care plan that the family had received or acknowledged written receipt of the baseline care plan.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, interview, and record review; the facility failed to revise the care plan after falls with new interventions for Resident 4 and Resident 8; failed to document interventions to prevent complications from the use of an indwelling urinary catheter (a tube inserted into and left in the bladder to drain urine) for Resident 6; and failed to implement interventions for a UTI (Urinary Tract Infection) for Resident 21. This affected 4 of 13 sampled residents. The facility identified a census of 21 at the time of survey. Findings are: A. Review of Resident 4's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/11/2020 revealed an admission date of [DATE]. Resident 4 had a BIMS (Brief Interview for Mental Status) of 5 which indicated severe cognitive impairment. Resident 4 required extensive assistance of 2 staff for bed mobility, transfer, walk in room and corridor, and locomotion on and off unit. Resident 4 had 1 fall with no injury since prior assessment. Observation of Resident 4 on 9/16/20 at 9:50 AM revealed they were walking in the hall without assistance or an assistive device; an unidentified NA got up to Resident 4, held onto Resident 4, and called another staff person for a gait belt and Resident 4's walker. Review of Resident 4's Progress Notes dated 9/16/2020 at 3:14 AM revealed Resident 4 was found lying on the floor on their back next to their bed. A skin tear was observed to Resident 4's right elbow. Resident 4 was assessed and neurological checks were initiated. On 9/16/20 at 2:50 PM it was documented that Resident 4 continued to be anxious and was attempting several times to get up on their own. A call was placed to family to see if a temporary personal alarm would be ok. It was documented the family granted permission for the use of the personal alarm temporarily. Review of Resident 4's Care Plan dated 6/15/2018 revealed no documentation the care plan was revised and a new intervention was implemented after Resident 4 fell on [DATE] including the temporary use of the alarm. B. Review of Resident 6's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 6 had a BIMS score of 15 which indicated Resident 6 was cognitively intact. Resident 6 required extensive assisting of 2 staff for bed mobility, transfers, and toilet use. Observation of Resident 6 on 9/17/20 at 8:12 AM revealed Resident 6 had an indwelling urinary catheter. Review of Resident 6's Progress Notes dated 8/25/2020 revealed they returned to the facility from the hospital with an indwelling urinary catheter that was to remain in place until Resident 6 was seen by the urologist in September. It was documented the catheter continued to be in place on 8/29/2020 and 9/19/2020. Review of Resident 6's Care Plan dated 9/13/2018 revealed no documentation of the indwelling urinary catheter or interventions to prevent complications from the use of the catheter. C. Review of Resident 8's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 8 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident 8 had 2 or more falls with no injury since prior assessment. Interview with Resident 8 on 09/16/20 at 2:12 PM revealed Resident 8 had a history of [REDACTED]. Review of Resident 8's Progress Notes dated 9/5/2020 revealed documentation that Resident 8 fell to a sitting position on the floor near their bed. Review of Resident 8's Care Plan dated 2/4/2020 revealed no documentation of interventions implemented after Resident 8 fell on [DATE]. D. Review of Resident 21's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/21/2020 revealed an admission date of [DATE]. Resident 21 had a BIMS (Brief Interview for Mental Status) score of 9 which indicated moderate cognitive impairment. Antibiotic medication was administered to Resident 21 on 7 days of the 7 day look back period. Interview with Resident 21's family member on 9/16/20 at 10:37 AM revealed Resident 21 was being treated for [REDACTED]. Review of Resident 21's Order Summary Report dated 9/21/2020 revealed an order for [REDACTED]. Review of Resident 21's Progress Notes 9/2/2020 revealed orders were received from the medical provider to start [MEDICATION NAME] (antibiotic) for 10 days for a UTI. On 9/11/2020 it was documented that orders were received to discontinue the [MEDICATION NAME] and start [MEDICATION NAME]. Review of Resident 21's MAR (Medication Administration Record) for September 2020 revealed documentation the [MEDICATION NAME] Capsule 100 MG (Milligrams) ([MEDICATION NAME] Macro) Give 1 capsule by mouth two times a day for UTI for 10 Days -Start Date-09/02/2020 -D/C (discontinue) Date-09/11/2020 was administered to Resident 21 on 9/2/2020 through 9/11/2020; [MEDICATION NAME] Tablet 500 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day for UTI -Start Date-09/12/2020-D/C Date-9/21/2020 was administered to Resident 21 from 9/12/2020 through 9/21/2020 and [MEDICATION NAME] Capsule 500 MG Give 500 mg by mouth two times a day for Urinary Tract Infection -Start Date-10/22/2019 was administered to Resident 21 twice a day from 9/1/2020 to 9/21/2020. Review of Resident 21's Care Plan dated 12/3/2019 revealed no documentation of interventions for the UTI. Interview with the DON (Director of Nursing) on 9/22/2020 at 9:31 revealed the care plans were to be updated in the computer. The nurses all had access to the care plans and they were supposed to be updating them as things changed, like falls, and things like that. The DON revealed the care plans were reviewed quarterly and the expectation was the care plans would reflect what was going on with the resident. The DON revealed if the staff missed putting something on the care plan it was expected they would catch it on the quarterly care plan review. The DON confirmed they were a little behind on updating the care plans. Interview with NA-F (Nurse Aide) on 9/22/2020 at 8:57 AM revealed they got the information they needed to care for the residents from their care plans.

LICENSE REFERENCE NUMBER 175 NAC 12-006.10B1 Based on observation, interview, and record review; the facility staff failed to ensure 4 residents (1, 11, 14, 15) were monitored to ensure the resident swallowed their medications during medication administration. This affected 4 of 4 residents observed. The facility census was 21. Findings are: Observation on 09/16/2020 at 08:13 AM in resident (1, 11, 14, 15) rooms, revealed medications sitting on resident's overbed tables, without a nurse or medication aide present to observe the residents swallow their medications. Interview on 9/16/20 at 2:20 PM with LPN-A revealed the residents preferred to take their medications left at bedside; so the residents can take their medications with the resident meals and at their own pace. Observation on 9/22/20 at 08:30 am revealed Resident 11 had cup of medications on an overbed tray and the nurse was not with the resident to observe them taking the medications. Review of Medication Administration: NCLEX-RN, National Council Licensure Examination-Registered Nurse is a nationwide examination of areas to test for to obtain a nursing license revealed the proper procedure for giving oral (by the mouth) medication was to give the patient the medication, Remain with the patient until the medication is swallowed, some patients may pocket (hold) medications in their cheeks rather than swallow them. Medication Administration procedure for the facility revealed for the medication pass #18 remain with the resident until all medications have been taken. Interview with Director of Nursing on 09/22/2020 at 11:00 AM confirmed the nursing staff person who passed the medications should stay with the resident and observe the resident swallow the medications.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on interview and record review, the facility failed to implement measures to prevent weight loss for Resident 6. This affected 1 of 3 sampled residents. The facility identified a census of 20 at the time of survey. Findings are: A. Review of Resident 6's face sheet revealed an admission date of [DATE]. Review of Resident 6's Dietary Notes by the RD (Registered Dietitian) dated 2/17/2015 revealed Resident 6 had an admission weight of 130 pounds. Review of Resident 6's weights revealed the following: -1/2/17 - 123.5 pounds, -1/4/2017 - 124.5 pounds, -1/13/2017 - 123 pounds, -1/18/17 - 124.5 pounds, -1/30/17 - 118.0 pounds, -2/1/17 - 118.5 pounds, and -2/6/2017 - 118 pounds. Review of Resident 6's weights revealed a 5% weight loss from 124.5 pounds on 1/18/17 to 118 pounds on 1/30/17 which is a period of 12 days. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument User's Manual Version 3.0 revealed that significant weight loss was indicated by a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. If the resident is losing a significant amount of weight, the facility should not wait for the 30 or 180 day time frame to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Interview with the DON (Director of Nursing) on 2/07/2017 at 9:45 AM revealed the dietitian was to be notified if a resident had significant weight loss. Interview with the DON on 2/07/2017 at 11:52 AM confirmed the dietitian was not notified of the weight loss from 1/18/17 of 124.5 pounds to 1/30/2017 at 118 pounds. The DON revealed the dietitian was notified of resident weight loss when they visited the facility once a month. Interview with the DON on 2/07/2017 at 12:09 PM revealed that Resident 6 had visited the medical provider 1/20/2017 but there was no documentation addressing weight loss. The DON confirmed there was no documentation the medical provider had been notified of Resident 6's weight loss. Review of Resident 6's Dietary Notes by the RD (Registered Dietitian) dated 1/26/2017 revealed Resident 6's weight was 124.5 lbs. There was no documentation by the RD regarding Resident 6's weight after 1/26/2017. Interview with the RD on 2/07/2017 on 4:15 PM confirmed they were not notified about Resident 6's weight loss from their last visit on 1/26/2017 when resident weighed 124.5 pounds to Resident 6's weight of 118 pounds on 1/30/2017. B. Review of Resident 6's Medication and Treatments List, identified by the DON as Resident 6's admission orders [REDACTED]. Review of Resident 6's care plan dated 12/20/2016 revealed Resident 6 had a potential for alteration in nutritional status and staff were to administer Boost Breeze 4 ounces twice a day. Review of Resident 6's Meal Intake with supplement documentation for 1/1/2017-2/7/2017 revealed the supplement was administered 1 time per day on January 3, 4, 6, 7, 10, 11, 12, 13, 15, 17, 18, 19, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31 and no documentation the supplement was administered at all on January 1, 2, 8, 16, and February 5th. Interview with the DON on 2/07/2017 at 9:09 AM confirmed Resident 6 was to be receiving the supplement twice a day as ordered and per care plan and there was incomplete documentation the supplement was administered. Interview with the DON on 2/07/2017 at 9:35 AM revealed that, when Resident 6 was admitted to the facility, they were given Carnation Instant Breakfast but Resident 6 didn't like it. The DON revealed they switched the supplement to Boost Breeze on 5/5/2015 and it didn't get put on the MAR (Medication Administration Record). Other than the Meal Intake charting, it was not being documented anywhere else.

Licensure Reference Number: 175 NAC ,[DATE].07 Based on record review and interviews; the facility failed to re-evaluate prior plans of correction to correct and maintain correction for previously cited deficient practice related to: environmental issues of fixing marred doors and walls, changing the tile in the resident rooms once marred, cracked or missing, covering the bottom of the light bulbs for safety of the residents, notification of the dietician of a weight loss, the lack of documentation of supplements to prevent weight loss, hand hygiene while preparing and serving meals, outdated supplies available for use, and the failure of acting on irregularities of unnecessary medications for residents. The facility census was 20 at the time of the survey. Findings are: Record review of the previous complaints, and annual survey deficiencies for the facility revealed the following: -F253 The facility failed to ensure a clean, comfortable environment for the residents. -F282 The facility failed to implement measures to prevent weight loss for a resident. -F325 The facility failed to prevent weight loss for a resident due lack of documentation of supplements ordered and monitoring of constipation. -F371 The facility failed to assure food was prepared and served in a manner to prevent cross contamination. -F428 The facility failed to ensure the Pharmacist's recommendations for a GDR (gradual dose reduction) was completed by the Physician. -F431 The facility staff failed to ensure expired medical supplies were not available for resident use. Additional tags cited this survey include: F 312, F 327, and F 329. Interview on [DATE] at 1:31 PM Interview with the Quality Assurance Coordinator/Provisional Administrator and the Director of Nursing revealed the facility had not corrected the issues of environmental issues of fixing marred doors and walls, changing the tile in the resident rooms once marred, cracked or missing, covering the bottom of the light bulbs for safety of the residents, notification of the dietician of a weight loss, the lack of documentation of supplements to prevent weight loss, hand hygiene while preparing and serving meals, outdated supplies available for use, and the failure of acting on irregularities of unnecessary medications for residents.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on interviews and record review, the facility failed to implement measures to prevent pressure sores for Resident 1. The facility census was 17 at the time of survey. Findings are: Review of Resident 1's face sheet revealed an admission date of [DATE] and a discharge date of [DATE]. Confidential interview on 7/27/2016 at 12:40 PM revealed that Resident 1 had pressure sores on both buttocks that were discovered when Resident 1 was transferred to the hospital from the facility on 4/27/2016. These pressure sores were not present when Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Departmental Notes dated 4/14/2016 revealed no documentation that pressure sores were present on Resident 1's buttocks upon admission to the facility. Review of Resident 1's Admission MDS (Minimum Data Set) dated 4/21/2016 revealed that Resident 1 required assistance from staff for bed mobility, transfer, and locomotion and there was no documentation that Resident 1 had pressure sores present upon admission. Review of Resident 1's Daily Skilled Nurses Notes dated 4/23/2016 revealed documentation that Resident 1 had a 2.5 cm (centimeter) by 1 cm open area to the right buttock and a 2 cm by 1 cm open area to the left buttock. A dressing was applied to the areas. Review of Resident 1's Daily Skilled Nurses Notes for 4/14/2016 to 4/27/2016 revealed no documentation that Resident 1's health care provider or responsible party were notified about the open areas to Resident 1's buttocks, that the areas were being monitored, and there was no documentation that further treatment was applied to heal the areas after they were initially treated on 4/23/2016. Review of Resident 1's physician's orders [REDACTED]. Review of Resident 1's eMAR (Medication Administration Record) revealed no documentation of treatment to the open areas on Resident 1's buttocks. Review of Resident 1's Care Plan dated 4/14/2016 revealed no documentation of interventions implemented to prevent or heal the open areas on Resident 1's buttocks. Interview with RN-A (Registered Nurse) on 7/27/2016 at 3:27 PM revealed the facility did not have a formal procedure for monitoring residents for skin breakdown. RN-A revealed the nurse aides were to let the charge nurses know if they found any issues. RN-A confirmed that if skin breakdown was found, the charge nurses were to document it, notify the provider and family. RN-A revealed they were to record the area in the resident's medical record so that it was monitored and interventions were to be implemented if needed. Interview with the facility Administrator on 7/27/2016 at 4:45 PM revealed the facility did not have a policy or procedure in place for monitoring residents for potential skin issues.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observation, interviews, and record review; the facility failed to implement interventions to prevent dehydration to Resident 1. The facility census was 17 at the time of survey. Findings are: Review of Resident 1's face sheet revealed that Resident 1 was admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident 1's face sheet revealed that Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's admission MDS (Minimum Data Set-a comprehensive assessment tool used for developing a resident's care plan) dated 4/21/2016 revealed that Resident 1 required assistance from staff for bed mobility, transfer, locomotion, dressing, personal hygiene, toileting, bathing, and eating. Resident 1 also had a urinary catheter (a tube placed in the bladder to drain urine) and no dehydration. Confidential interview on 7/27/2016 at 12:40 PM revealed that Resident 1 had a transplanted kidney and required plenty of fluids to keep from getting dehydrated. The interview further revealed that Resident 1 was showing signs of dehydration with decreased urinary output and staff having difficulty obtaining blood samples while Resident 1 was still residing in the facility. Review of Resident 1's Dietary Note dated 4/19/2016 revealed that Resident 1's fluid needs were 2897 cc's (cubic centimeters-or approximately 96 ounces) per day. Review of Resident 1's Intake and Output Roster for 4/14/2016 to 4/27/2016 revealed the following daily amounts of fluid intake: 4/14/2016- 580 cc 4/15/2016-2310 cc 4/16/2016-1310 cc 4/17/2016-1100 cc 4/18/2016-1960 cc 4/19/2016-3180 cc 4/20/2016-2360 cc 4/21/2016-1560 cc 4/22/2016-2850 cc 4/23/2016-2370 cc 4/24/2016-2800 cc 4/25/2016-2850 cc 4/26/2016-1240 cc Review of Resident 1's Intake and Output Roster for 4/14/2016 to 4/27/2016 revealed that Resident 1's daily fluid needs were met only once during the time Resident 1 was in the facility. Observation of Resident 2, Resident 3, and Resident 4 on 7/27/2016 at 2:15 PM revealed all 3 residents were in their rooms in their recliners and did not have anything to drink within reach. Observation of Resident 2, Resident 3, and Resident 4 on 7/27/2016 at 4:17 PM revealed all 3 resident were in their rooms in their recliners and did not have anything to drink within reach. Interview with Resident 2 and Resident 4 on 7/27/2016 at 4:17 PM revealed they were able to drink on their own, however, they were not able to get up to get something to drink without assistance so the fluids needed to be within reach. Review of Resident 1's Departmental Notes dated 4/22/2016 revealed documentation that Resident 1's spouse was in the facility and expressed concern about poor urinary output from Resident 1's catheter and that Resident 1 had a temperature of 99.5 F (Fahrenheit) and was complaining of nausea. Review of Resident 1's eMAR (Medication Administration Record) for April 2016 revealed that Resident 1 was administered milk of magnesia and a [MEDICATION NAME] suppository (laxatives) on 4/24/2016 and magnesium [MEDICATION NAME] (a laxative) on 4/26/2016 for constipation. Review of Resident 1's 'Daily Skilled Nurses Notes dated 4/26/2016 revealed Resident 1 did not have any results from the laxatives administered. and that bowel tones were very hypoactive (slow) and almost not present. Review of Resident 1's Daily Skilled Nurses Notes dated 4/25/2016 revealed documentation that Resident 1's urine was slightly dark in color. Review of Resident 1's Daily Skilled Nurses Notes dated 4/24/2016 revealed documentation that Resident 1's urine was dark yellow. Review of Resident 1's Daily Skilled Nurses Notes dated 4/23/2016 revealed that Resident 1's urine was amber (dark yellow to tan) colored. Review of Resident 1's Daily Skilled Nurses Notes dated 4/21/2016 revealed that Resident 1's urine was amber colored. Review of Resident 1's Daily Skilled Nurses Notes dated 4/17/2016 revealed that Resident 1's urine was amber colored. Review of Resident 1's Daily Skilled Nurses Notes dated 4/16/2016 revealed that Resident 1's urine was dark yellow colored. Review of Resident 1's Intake and Output Roster for 4/14/2016 to 4/27/2016 revealed the following daily urinary outputs: 4/14/2016-2200 cc 4/15/2016-2400 cc 4/17/2016-1000 cc 4/18/2016-1350 cc 4/19/2016-3825 cc 4/20/2016-1375 cc 4/21/2016-625 cc 4/22/2106-1400 cc 4/23/2106-2300 cc 4/24/2106-1150 cc 4/25/2016-775 cc 4/26/2016-1075 cc Review of the Mayo Clinic Kidney transplant Diet and Nutrition guidelines copyright date 1998-2016, revealed that kidney transplant patients were to stay hydrated by drinking adequate water and other fluids each day. Review of the Mayo Clinic Dehydration Symptoms copyright date 1998-2016 revealed that mild to moderate dehydration is likely to cause decreased urine output. A better indicator of the body's need for water is urine color. Clear or light-colored urine means you're well hydrated, whereas a dark yellow or amber color usually signals dehydration. Mild to moderate dehydration is likely to cause decreased urine output and constipation. Severe dehydration can cause fever. Review of the facility's policy and procedure Fluid Offered for Hydration dated 8/2/2007 revealed that it was the policy of the facility to ensure all residents were provided with sufficient fluid intake to maintain proper hydration and health. Drinking water would be made available at all resident bedsides, staff were to offer fluids to residents whenever entering resident rooms, or at least every 2 hours and if an individual resident required extra fluids, staff were to offer extra per resident likes and dislikes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on interviews and record reviews, the facility staff failed to implement interventions to correct a significant weight loss for Resident 21. Facility census was 21 at the time of survey. Findings are: Review of Resident 21's Admission MDS (Minimum Data Set - a federally mandated assessment tool used for Care Planning) dated 12/25/2015 revealed an admission date of [DATE]. Review of Resident 21's weights revealed the following: -2/17/2015: 169.5 pounds; -12/18/2015: 169.9 pounds; -12/31/2015: 165.0 pounds; -1/4/2016: 147.0 pounds; -1/13/2016: 148.0 pounds; -1/18/2016: 145.0 pounds; -1/25/2016: 145.5 pounds; -2/1/2016: 146.0 pounds; and -2/8/2016: 146 pounds. Review of Resident 21's Physician's Visit Sheet dated 1/8/2016 revealed an order to increase CIB(Carnation Instant Breakfast-a nutritional supplement) to TID (3 times a day) and malts as needed. Interview with DA (Dietary Aide)-F on 2/11/2016 at 7:54 AM revealed the dietary staff were administering the CIB to Resident 21 twice a day. Interview with Cook-A on 02/11/2016 9:16:54 AM revealed supplement orders were written down on the Drink List so dietary staff knew what the residents were to be receiving. Review of the undated facility Drink List for each meal revealed Resident 21 was documented to receive CIB twice a day. Interview with the facility Administrator on 2/09/2016 at 4:36 PM revealed the dietary staff administered the supplements as documented on the Drink List and the supplement intakes were not documented anywhere. Review of Resident 21's care plan dated 11/26/2013 revealed supplements provided. Review of Resident 21's dietary notes dated 1/26/2016 revealed the following: Current weight 145.5 pounds. Since (gender) hospitalization in December, (gender) has had little or no appetite We have seen significant weight loss during this period of time. December weights ranged from 167 to 165, however, January weights are 147 to 145.5. On 12/28/2015 (gender) was started on CIB BID (twice a day) to prevent weight loss. On 1/8/2016, (gender) CIB was increased to TID (three times a day) along with a shake in the afternoon .Will proceed with current approaches and will monitor (gender) weight. Will provide and encourage. By. RD (Registered Dietitian). Interview with the facility Administrator on 2/11/2016 at 9:43 AM confirmed that Resident 21 was to be receiving the CIB 3 times a day and not 2 times a day. The Administrator confirmed Residents 21's CIB order was not updated on the Drink List so the dietary staff were unaware they were supposed to be administering the CIB 3 times a day. The Administrator confirmed that Resident 21 was not receiving the CIB 3 times a day as ordered. The Administrator also confirmed there was no documentation the facility staff had notified the Dietitian about Resident 21's weight loss before 1/26/2016 even though Resident 21 had a significant weight loss from 12/31/2015 to 1/4/2016. The Administrator confirmed that the Dietician should have been notified about Resident 21's weight loss on 1/4/2016. The Administrator also confirmed there was no other weight monitoring system in place other than quarterly when MDS assessments were completed. The Administrator confirmed that Resident 21 had a weight loss that could not be attributed to anything other than inadequate intake as the facility staff had evaluated scale fluctuation and/or malfunction and changes in fluid distribution. Interview with the DON (Director of Nursing) on 2/11/2016 at 9:43 AM revealed the bath aides monitored the resident's weights and were to notify the charge nurse when they noticed a weight loss. The DON revealed there was no other weight monitoring process in place. Interview with the RD on 2/11/2016 at 11:32 AM confirmed that Resident 21 had significant weight loss and was to be receiving CIB TID and a shake as needed. Interview with the RD on 2/11/2016 on 4:29 PM revealed the RD was unaware the CIB was not being administered to Resident 21 as ordered and should have been. The RD confirmed that the RD had not been made aware of Resident 21's weight loss until 1/26/2016 and it was the RD's expectation that the facility staff were to bring it to the RD's attention if a resident had a drastic weight loss like that.

Licensure Reference Number 175 NAC 12-006.07C Based on interview and document review; the facility's Quality Assurance Committee (QA) failed to develop and implement plan of actions to correct multiple issues of deficient practice relevant to resident care and services. The facility failed to implement effective plans of action to maintain correction for previously cited areas of deficient practice identified at F253, F280, F282, F431. This had the potential to affect all residents that resided in the facility. The facility census was 21. Findings are: Record review of the facility Statement of Deficiencies for the annual survey completed on 1/19/15 revealed citations at F253, F280, F282 and F431. The facility was also cited at F253 and F280 in 2/2014. Record review of the deficiencies for the survey 2/11/16 revealed: -F253 The facility failed to clean the linoleum floors in the bathrooms,repair the room entrance doors and bathroom door frames, clean the heating units, to anchor the full length mirror to the door of the bathroom clean or polish the water faucets in the bathrooms and fix the wall behind the recliner. -F280 The facility failed to revise care plan with interventions and follow up monitoring for bruising. -F282 The facility staff failed to notify the dietitian of a significant weight loss and failed to administer dietary supplements as ordered and failed to monitor for high risk medication . -F431 The facility failed to remove a discontinued medication from the medication cart to ensure that it was not available for resident use. Interview with the Administrator and the Business Office Manager on 2/11/2016 at 5:28 PM revealed an agenda was followed each meeting and the committee worked to come up with plans for a correction if issues were identified. .