Every finding on record at Garden County Hospital & Nursing Home

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interview, the facility failed to ensure 4 of 5 sampled nurse aides (NA) completed 12 hours of ongoing training annually and failed to ensure 5 of 5 sampled staff completed the required 4 hours of Alzheimer's care and dementia care training annually. This had the potential to affect all residents. The facility census was 21. Findings Are: A record review of the Facility assessment dated [DATE] revealed in Section 3.4 that staff training/education and competencies are maintained through the Relias Learning platform and the modules are completed upon hire and annually. A record review of an undated and untitled facility document revealed the following:-NA-E was hired on 8/5/2024,-NA-F was hired on 4/7/2023,-NA-G was hired on 6/26/2023,-NA-H was hired on 1/31/2024, and -NA-I was hired on 8/3/2020. A.A record review of an undated facility provided document NA-F's Relias Transcript revealed there were no completed assignments. A record review of a facility provided document Training Hours dated 8/21/2025 revealed that between the dates of 6/26/2024-6/26/2025, NA-G had completed 10.69 hours of ongoing training. A record review of an undated facility provided document Course Completion History revealed that between the dates of 1/31/2024-1/31/2025, NA-H had not completed any trainings. A record review of a facility provided document Training Hours dated 8/21/2025 revealed that between the dates of 8/3/2024-8/3/2025, NA-I completed 10.84 hours of ongoing training. A interview on 8/21/25 at 2:40 PM with Human Resources (HR) confirmed NA-F, NA-G, NA-H, and NA-I had not completed the required 12 hours of annual ongoing training. B.A record review of a facility provided document Training Hours dated 8/21/2025 revealed that between the dates of 8/5/2024-8/5/2025, NA-E had completed 0.5 hours of dementia care training. A record review of an undated facility provided document NA-F's Relias Transcript revealed there were no completed assignments. A record review of a facility provided document Training Hours dated 8/21/2025 revealed that between the dates of 6/26/2024-6/26/2025, NA-G had completed 0.5 hours of dementia care training. A record review of an undated facility provided document Course Completion History revealed that between the dates of 1/31/2024-1/31/2025, NA-H had not completed any trainings. A record review of a facility provided document Training Hours dated 8/21/2025 revealed that between the dates of 8/3/2024-8/3/2025, NA-I had completed 0.5 hours of dementia care training. An interview on 8/21/25 at 11:36 AM with Registered Nurse (RN)-A revealed the facility had begun assigning Alzheimer's and dementia care training to staff via their training platform but it was less 4 total hours per year. RN-A confirmed none of the 5 sampled staff had completed the required 4 hours of annual Alzheimer's care and dementia care training.

Licensure Reference Number 175 NAC 12-006.18(D)Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to A) transport and then use visibly soiled utensils in a manner to prevent the potential for cross contamination B) sanitize counters and thermometers, C) have expiration or best used by dates on canned goods, and D) failed to ensure staff performed hand hygiene as required during meal delivery. This had the potential to affect all residents. The facility census was 21. A. An Observation on 8/21/2025 at 11:30 AM revealed [NAME] K removed covered food-from oven and placed the food on a Hot/Cold serving cart. Further observations revealed serving utensils that were soiled with food debris were placed on a serving tray and placed on to the serving cart Cook-K transported the food from the kitchen through the hospital hallway and into the nursing facility. The Hot/Cold serving cart was placed against the wall in nursing home hallway outside the dining room. Visibly soiled utensils remain uncovered on top of the cart as cart sat in hallway. [NAME] K moved covered food bins individually into a serving room where the steam table was located and moved visibly soiled utensils into the steam room. [NAME] K after placing the food bins onto the steam table place the soiled utensils placed into the food for serving. An Interview on 8/21/2025 at 12:30 with PM [NAME] -J gave a confirming statement kitchen utensil should not have been transported through the hallway uncovered. Cook-J reported utensils should have been covered or clean prior to using and the serving cart should not be placed against the wall of the dining room in the hallway and left uncovered. B. An observation on 8/21/2025 at 9:50 AM Cook-K removed a rag from sanitizing solution and wiped down the counter with liquid solution. After wiping the counter Cook-K walked over to the paper towel rack grabbing a paper towels and dried the counter within 1- 2 seconds of sanitizing solution on the counter. An Interview on 8/21/2025 at 2:50 PM with Cook- J confirmed sanitizer was not left on the counter for the required amount of time and let dry. [NAME] -K Confirmed Sanitizer should not be wiped off with paper towels. A record review of facility Sanitation-General policy dated 9/2013 revealed all food contact surfaces should be sanitized according to sanitation instruction with a concentrated sanitizer solution. The concentrated sanitizer solution should be allowed to air dry and not be wiped off. C. A record review of an undated facility provided document, Dry Foods/Staples University of Nebraska: Food Storage Recommendations revealed commercially canned fruits, juices and Tomato Soup stored at room temperature should be used within 12 to 18 months of receiving and within 5 to 7 days after opening. An observation on 8/20/2025 at 9:00 AM during the initial tour of the kitchen revealed the following: - World Horizons 6 lb. can -Pineapple Tidbits bits -no expiration date - Mandarin Orange Segments in light syrup – 6 lb. cans 10 oz. expired 12/01/2023. - Harvest Of [NAME] sliced pears 6 lb. can 10 oz. -no expiration date. - Harvest Value Apple Pie Filling, 7 lb. can No expiration date An Interview on 8/20/2025 at 11:00 AM with Cook- J confirmed the canned foods on the shelf did not have expiration dates on canned foods and should have been discarded. D. A record review of facility policy Handwashing/Hand Hygiene dated 2001 revealed a policy statement of This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy revealed all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. The policy stated hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, and after touching a resident. A continuous observation on 08/20/2025 from 12:05 PM until 12:20 PM in the dining room revealed Cook-J performing the following: -Carried plates of food to two residents, set the plates in front of those residents, then returned to the serving area and leaned with their hands and arms on the shelf above the steam table. -Picked up a plate from the serving shelf, placed in front of a resident, then returned to the serving area, then placed their hands on the lower shelf in front of the steamtable on the dining room side of the glass partition. -Picked up a plate from the serving shelf, placed the plate in front of a resident, returned to the serving area, then Cook-J left the dining area. -At 12:10 PM Cook-J returned to the dining room with a bottle containing a white substance in it. Cook-J placed the bottle on the shelf above the steamtable, then performed Hand Hygiene (HH) with soap and water. -Obtained a white bowl from a metal cart just outside the dining room and placed it on top of the shelf above the steam table. Cook-J picked up a plate from the shelf and placed it in front of a resident then returned to the serving area, leaned on the shelf with their arms and hands, then picked up the bowl and a plate and placed in front of two residents. -Returned to the serving area and picked up two plates with hot pads under them and took the plates to two residents, placed the plates in front of the residents and carried the hot pads back to the serving area. -Obtained a bottle of ketchup from inside the fridge in the serving area, then carried the ketchup and a plate to a resident. Placed the plate in front of the resident, opened the ketchup and poured on plate, then returned to serving area and placed the ketchup on the shelf above the steamtable. -Performed HH using soap and water, then picked up a plate and placed it in front of a resident. Cook-J returned to the serving area and obtained a paper towel and used it to wipe up a liquid substance on a resident's table, then threw the paper towel in the trash can. -Picked up ketchup bottle and put in the fridge, then picked up a plate from the serving area and placed in front of resident. -Returned to serving area and leaned on shelf with hands touching shelf, then put hands on lower shelf. Picked up plate and placed in front of a resident, put their left hand onto the resident's table, then returned to the serving area and leaned hands on the lower shelf. -Picked up a plate and set it in front of a resident, then walked back to the serving area, opened the fridge, removed a pitcher, then handed the pitcher to nursing staff, then closed the fridge. -Exited the serving area then picked up a plate and took it to a resident's table.

Licensure Reference Number 175 NAC 12-006.04(B)(i) Based on record review and interview, the facility failed to ensure 3 of 4 sampled employees completed initial orientation as required. The facility census was 21.Findings Are: A record review conducted on 8/21/2025 of an undated and untitled facility staff list revealed the following:-Nurse Aide (NA)-B was hired on 8/1/2025.-Housekeeper (HSK)-C was hired on 4/7/2025.-Cook-D was hired on 8/11/2025. A record review of facility provided employee file for NA-B revealed no evidence that initial orientation had been completed. A record review of facility provided employee file for HSK-C revealed no evidence that initial orientation had been completed. A record review of facility provided employee file for Cook-D revealed no evidence that initial orientation had been completed. An interview on 8/25/2025 at 9:02 AM with the Director of Nursing confirmed that initial orientation had not been completed for NA-B, HSK-C, or Cook-D.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to submit accurate Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) data related to weight loss for 1 (Resident 2) of 1 sampled residents. The facility identified a census of 21 residents. Findings are:A. Record review of Resident 2's annual MDS assessment dated [DATE], Section K, item K0200 revealed the Resident's most recent weight was given as 103 pounds and height of 60 inches. Item K0300 of Resident 2's MDS was marked for weight loss and was not on physician-prescribed weight-loss regimen. Weight loss coding was further defined in MDS Item K0300 as 5% or more in the last month or 10% or more in the last six months.Record review of Resident's weights as documented in the facility's electronic medical record (EMR) showed Resident 2 weighed 105.4 pounds on 5/8/25.Record review of Resident's weights as documented in the facility's EMR showed Resident 2 weighed 103.8 pounds on 4/9/25, which is a 1.5% weight gain over one month.Record review of Resident's weights as documented in the facility's EMR showed Resident 2 weighed 100 pounds on 11/7/24, which is a 5.4% weight gain over six months. B.Record review of MDS data for Resident 2's quarterly MDS assessment dated [DATE], Section K, item K0200 identified Resident 2's most recent weight as 100 pounds and height of 60 inches. Item K0300 of Resident 2's MDS was marked for weight loss and not on physician-prescribed weight-loss regimen. Record review of Resident's weights as documented in the facility's electronic medical record (EMR) showed Resident 2 weighed 100 pounds on 2/6/25.Record review of Resident's weights as documented in the facility's EMR showed Resident 2 weighed 99.1 pounds on 1/9/25, which is a 0.9% weight loss over one month.Record review of Resident's weights as documented in the facility's EMR showed Resident 2 weighed 103 pounds on 8/5/24, which is a 2.9% weight loss over six months.An interview on 8/21/25 at 1:25 PM with Registered Nurse (RN) -A revealed they were the MDS coordinator for the facility. During the interview RN-A confirmed the weights for the resident were representative of the resident's actual weights, and that the MDS submitted 5/13/25 and 2/11/25 should not have been marked with a Yes for weight loss on those two occasions.

Licensure Reference Number 175 NAC 12-006.09(J) Based on observations, record reviews, and interviews; the facility failed to evaluate and implement interventions for 2 (Residents 11 and 8) of 13 sampled residents to prevent significant weight loss. The facility census was 26. The Findings Are: A. A record review of Resident 11's Minimum Data Set (MDS,a federally mandated comprehensive assessment tool used in care planning), dated 5/14/24, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 6/15, which indicated the resident had severe cognitive impairment. The MDS also revealed in Section K revealed Resident 11 had a weight loss of 5% or more in the last month or of 10% or more in the last six months and was not on a prescribed weight loss plan. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 revealed that 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 and that if significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication, or changed fluid volume status. Record review of Resident 11's weights documented in their Electronic Health Record (EHR) revealed Resident 11 weighted 120 pound on 4-1-2024 and weighed 110 pounds on 5-07-2024, a loss of 10 pounds or 8.3%. Record review of an annual chart review conducted by the Dietitian on 4/17/2024 revealed Resident 11 was on a regular diet with increased protein. The review also identifed Resident 11 was receiving Pro-stat daily and the House supplement TID. The Dietitian wrote a recommendation to increase Resident 11's Pro-stat to twice a day (BID) as each ounce of the Pro-stat provided 100 calories and 15 grams of protein. Record review of Resident 11's EHR and Paper heath Record, that included Medication Administration Record, Progress Notes, Dietary Notes, Practitioners Orders and Care Plan revealed there was no indications the facility staff had followed up on the facility RD recommendation dated 4-17-2024. Record review of Resident 11's weights documents in Resident 11 HER revealed Resident 11 weight on 6-04-2024 was 101 pounds a loss of an additional 9 pound or 8.18% from Residents 11's weight on 5-07-2024. According to Resident 11's record, Resident 11 lost 19 pound or 15.83% of their weight from 4-01-2024 to 6-04-2024. A record review of Resident 11's undated care plan revealed the resident was at risk for nutritional decline and had the following interventions: -2/29/2024: 4 ounces of the house supplement three times a day (TID). -4/9/2021: Meals and fluids to be charted after each meal. -4/9/2021: Offer the resident assistance as needed for better meal and fluid intake. -4/9/2021: Regular diet as ordered. -4/9/2021: Snacks or fluids to be offered to the resident at AM (morning) and PM (evening) snack time. -4/9/2021: Weekly weights checked for gain or loss. A record review of Resident 11's meal intakes from 6/1/24 through the morning of 7/23/24 revealed Resident 11 consumed 50% or less of their meal for 90 out of 157 meals. There were also 26 mealtimes that had no documentation of intake. A record review of Resident 11's physician's orders revealed an order with a start date of 3/23/23 that stated Increase protein at meals. 4 ounces of the house supplement TID. A record review of Resident 11's supplement intakes from 6/1/24 through the morning of 7/23/24 revealed there was no documentation for 55 doses of the supplement. Resident 11 consumed 50% or less of 19 of the remaining 102 doses. A record review of Resident 11's snack documentation from 6/1/24 through the morning of 7/23/24 revealed the resident was offered a snack 13 times and consumed 3 of the 13 snacks offered. A record review of an annual chart review conducted by the dietitian on 4/17/2024 revealed Resident 11 was on a regular diet with increased protein. The review also stated that the resident was receiving Pro-stat daily and the House supplement TID. The dietitian wrote a recommendation to increase Resident 11's Pro-stat to twice a day (BID) as each ounce of the Pro-stat provided 100 calories and 15 grams of protein. A record review of Resident 11's physician's orders revealed an order dated 9/26/23 that stated Pro-stat 30 milliliters (ML) once a day. There was no evidence that the facility had implemented the dietitian's recommendation to increase the Pro-stat to twice a day. An interview on 7/23/24 at 10:25 AM with the MDS Coordinator confirmed Resident 11 had not been assessed by the dietitian since 4/17/24. A record review of Resident 11's electronic health records and of their paper health records revealed no evidence of Resident 11's primary care provider (PCP) being notified of the resident's significant weight loss. An interview on 7/23/24 at 12:15 PM with the Director of Nursing (DON) confirmed Resident 11's weight loss and that there was no evidence of their PCP being notified of the weight loss. 49766 B. A record review of a facility policy Resident Assessments with a review date of 11/2017 revealed Dietary assessments of a Nutrition Risk Assessment would be completed annually and with significant change and a Quarterly Nutrition Assessment would be completed quarterly within 14 days of the MDS Assessment Reference Date. An interview on 7/23/2024 at 10:50 AM with the MDS Coordinator revealed the facility did not have a nutrition or weight loss policy that could be located. A record review of a Resident Face Sheet indicated the facility admitted Resident 8 on 3/2/2020 with diagnoses of Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease. A record review of Resident 8's Significant Change MDS with an Assessment Reference Date of 5/14/2024 revealed Resident 8 had a BIMs score of 9/15, which indicated Resident 8 had moderate cognitive impairment. It also indicated Resident 8 required substantial assistance with eating. A record review of Resident 8's Vitals revealed Resident 8 weighed 120.8 pounds on 1/12/2024. A record review of Resident 8's Vitals revealed Resident 8 weighed 104.5 pounds on 7/8/2024, which is a 13.5% severe weight loss in six months. A record review of Resident 8's Care Plan with a last edited date of 7/11/2024 revealed Resident 8 was at risk for impaired nutrition. A record review of Resident 8's Observations revealed the Dietician had not completed a Nutrition Risk Assessment or a quarterly nutrition assessment with the Significant Change MDS or with the most recent quarterly MDS. A record review of Resident 8's Progress Notes revealed the last Dietician quarterly review was completed on 10/11/2023. A record review of Resident 8's medical record did not reveal any evidence that Resident 8's physician was aware of their severe weight loss. An interview on 7/23/2024 at 10:25 AM with the MDS Coordinator confirmed there was no evidence that the Dietician had assessed Resident 8 since October 2023 or that the physician had been notified of Resident 8's severe weight loss.

Licensure Reference 175 NAC 12- 006.11(E) Based on observations, interviews, and record reviews; the facility failed to a) ensure foods were disposed of prior to the expiration date and to label open food items, b) ensure beard restraints were in use, c) implement hand hygiene as required during meal preparation and meal service and d) ensure sanitation of the kitchen environment. This had the potential to affect all 26 residents who resided within the facility. A. A record review of a facility policy Food Handling - Storage with a last revised date of [DATE] revealed foods which have been opened or prepared will be enclosed container, dated and labeled. Expiration dates will be checked on a regular basis and foods which have expired will be discarded. A record review of a facility policy Food - Handling - Leftovers with a last revised date of [DATE] revealed refrigerated leftovers will be utilized within 72 hours. Items which do not have a planned use within 72 hours should be dated, labeled and placed within the freezer within 24 hours. A record review of 2017 Nebraska Food Code, under section ,d+[DATE].17 revealed food should be clearly marked to indicate the date or day by which food should be consumed or discarded. An observation during an initial kitchen tour on [DATE] at 8:50 AM revealed the outside freezers contained cream cheese cookies with a use by date of ,d+[DATE], Traditional Cinnamon Roll dough with a use by date of [DATE], a bag of meat that was ,d+[DATE] used without a date or being sealed, and beef pot roast in a plastic bag that was opened and not sealed off. In the reach-in refrigerator, a box of Danimals cups with a best by date of [DATE]. In another reach-in refrigerator, a container of beets with a preparation date of [DATE], cream cheese with a best by date of [DATE], and a container of baked beans with a use by date of [DATE]. In a reach-in freezer, a bag of butterscotch chips that were ,d+[DATE] used with a date of [DATE]. In the dry storage refrigerator, a bottle of Italian dressing with a use by date of [DATE], bottles of barbecue sauce, [NAME] Lynch, and ranch without preparation dates or use by dates, and a container of pickle spears with a preparation date of [DATE] and no use by date. In the dry storage freezer, 2 loaves of Soft Wheat Bread with best by [DATE], and 2 loaves of [NAME] Texas Toast with best by dates of [DATE]. In the kitchen, under the food preparation table, flour and sugar were in bins without preparation or use by dates. An interview on [DATE] at 9:19 AM with the Dietary Manager (DM) confirmed items should be disposed of after preparation or opening within 7 days, on expiration dates, and stored in an enclosed container once prepared or opened. B. A record review of a facility policy Dietary Dress Code / Hygiene with a last revised date of [DATE] revealed hair and beard must be covered with a hair/beard restraint but did not provide information of when the hair and beard restraints are required to be worn. A record review of 2017 Nebraska Food Code, under section ,d+[DATE].11 revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-use articles. An observation on [DATE] at 9:20 AM revealed the DM had a beard and had entered the kitchen without a beard restraint. An observation on [DATE] at 10:50 AM revealed Dietary Aide (DA) - F was preparing fruit in a bowl for residents. DA-F had a goatee and was not wearing a beard restraint. An interview on [DATE] at 11:03 AM with the DM revealed the DM believed beard covers were only required when serving or preparing foods. C. A record review of facility policy Hand Washing and the Use of Gloves with a last revised date of ,d+[DATE] revealed hand hygiene should be completed before and after glove use and between contacts with different residents. It also revealed gloves should never be reused. An observation on [DATE] at 12:14 PM revealed Medication Aide (MA) - D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it while assisting another resident. An observation on [DATE] at 12:28 PM revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An observation on [DATE] at 12:29 PM revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An observation on [DATE] at 12:30 PM revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An observation on [DATE] at 12:36 revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An interview on [DATE] at 1:45 with MA-D revealed they had been wearing a glove on their right hand while assisting a resident with eating due to having a band aid on their thumb and was unaware of whether they should be sanitizing their gloves or changing the glove. An observation on [DATE] at 9:53 AM revealed Cook-B removed a glove from their right hand, then opened a bag of raw Chicken Cordon Bleu, then applied a new glove to their right hand without the benefit of hand hygiene prior to application of the new glove. An interview of [DATE] at 11:00 AM with Cook-B confirmed hand hygiene should be completed before and after changing their gloves. An observation on [DATE] at 12:19 PM revealed DA-F delivered a plate of food to a resident, touched the resident's back, then delivered another plate of food to another resident without the benefit of hand hygiene in between residents. An interview on [DATE] at 12:33 PM with DA-F revealed DA-F was only aware of the requirement to perform hand hygiene upon entering the kitchen. D. A record review of 2017 Nebraska Food Code, under section ,d+[DATE].111 revealed the premise shall be maintained free of insects. A record review of 2017 Nebraska Food Code, under section ,d+[DATE].11 revealed employees shall eat or drink only in designated areas where the contamination of exposed food, clean equipment, utensils, and linens cannot occur. An observation during an initial kitchen tour on [DATE] at 8:50 AM revealed several flies around the kitchen, two dead flies on a window seal above where Styrofoam food containers were being stored, and a coffee cup with coffee on the shelf above a kitchen preparation table. An interview on [DATE] at 9:19 AM with the Dietary Manager (DM) confirmed there were several flies, stating the feedlot nearby attracted the flies and it got worse in the summer. The interview also confirmed the need for sanitation of the window and that food/drinks were not allowed in the kitchen to be consumed by employees. A record review of the facility policy Sanitation -- General with a last revised date of ,d+[DATE] revealed all food contact surfaces should be sanitized when beginning to work with another type of food and care shall be taken to minimize hand contact with food surfaces. A continuous observation on [DATE] from 9:43 AM to 10:13 AM revealed Cook-B used scissors to cut open bags of uncooked pork, causing juices from the meat to contaminate the preparation table. Cook-B later prepared carrots and corn on the contaminated table. Cook-B had also set utensils down on the countertop, then stirred the vegetables with these utensils. An interview on [DATE] at 11:00 AM with Cook-B confirmed the table should be sanitized any time a new task or food is began to be prepared.

Licensure Reference 175 NAC 12- 006.18(B) Based on observations, interviews, and record reviews; the facility failed to provide wound care for 1 (Resident 26) and failed to distribute laundry throughout the nursing unit in a manner that prevented the potential for cross contamination. The facility census was 26. Findings are: A. A record review of the Center for Disease Control's Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) with a date of 4/2/2024 indicated Enhanced Barrier Precautions, including donning a gown and gloves, should be implemented during all wound care or any skin opening that requires a dressing. A record review of the facility's policy Pressure Ulcers Treatment with a last reviewed date of 1/20/2023, under section Steps in the Procedure, indicated directions to maintain sterility. The policy did not include directions to implement Enhanced Barrier Precautions. A record review of Resident 26's admission Minimum Data Set (MDS), a standardized assessment tool that measures health status in nursing home residents, with an Assessment Reference Date of 5/21/2024 revealed Resident 26 had a Brief Interview for Mental Status score of 9/15, which indicated Resident 26 had moderate cognitive impairment. The MDS also indicated Resident 26 had a stage 2 pressure ulcer requiring pressure injury care. A record review of Resident 26's Orders revealed an order for a dressing change with instructions to apply Thera honey to wound bed, then cover with an Opti foam dressing. An observation on 7/18/2024 at 1:22 PM revealed Licensed Practical Nurse (LPN) - H performing wound care for Resident 26. During the wound care, LPN-H did not don a gown as required. LPN-H also opened the Thera honey cream and applied directly onto the Opti foam and had touched the tip of the tube on the Opti Foam. When completed, LPN-H put the unused remainder of Opti Foam back into the package with Resident 26's name on it and stored it on a counter with other residents' open treatment supplies. An interview on 7/18/2024 at 2:42 PM with LPN-H confirmed these practices were in violation of infection control practices. 49263 B. An observation on 7/23/24 beginning at 8:08 AM revealed Laundry Aide (LA)-G was distributing personal laundry to the residents. The laundry cart was parked on Lane 2 of the nursing unit outside resident room [ROOM NUMBER], the cart covering had been left open and no one was in the hallway at that time. At 8:09 AM, LA-G exited a resident room, performed hand hygiene (HH) via Alcohol Based Hand Rub (ABHR), obtained clothing from the laundry cart, and carried them into resident room [ROOM NUMBER], leaving the cover to the laundry cart open. LA-G then exited room [ROOM NUMBER], performed HH via ABHR, obtained hanging clothes and folded clothes from the laundry cart, and walked toward resident room [ROOM NUMBER]. LA-G stopped outside room [ROOM NUMBER], put the hanging clothes between their legs, and performed HH via ABHR, then grabbed the clothes from between their legs and carried them into resident room [ROOM NUMBER]. LA-G continued obtained laundry from the laundry cart, and carrying them into resident rooms [ROOM NUMBERS], performing HH via ABHR between rooms but leaving the cover open to the laundry cart throughout distribution of clothes to each room. LA-G then closed the cover to the laundry cart, pulled the cart to Lane 3 of the nursing unit, and parked it outside resident room [ROOM NUMBER]. LA-G proceeded to distribute resident clothing to rooms [ROOM NUMBER], performing HH via ABHR between each room but left the cover of the laundry cart open throughout the distribution of resident laundry to each room. After LA-G distributed clothing to the last room, LA-G performed HH via ABHR, closed the cover to the laundry cart, and returned the cart to the laundry area. An interview on 7/23/24 at 8:39 AM with Laundry Aide (LA)-G confirmed that LA-G had left the laundry cart cover open throughout their laundry distribution on Lanes 2 & 3, and that LA-G had placed the laundry for resident room [ROOM NUMBER] between their legs while they performed HH outside room [ROOM NUMBER].

Licensure Reference 175 NAC 12-006.5(R) Based on observation, interview, and record review the facility failed to ensure private medical information was protected for 4 (Resident 2, 15, 22, and 23) of 4 sampled residents. The facility census was 26. Findings are: A record review of the facility policy Resident Rights Policy with a last reviewed date of 3/13, under section 3.25 revealed that privacy will be provided for residents' medical information to assure confidentially. An observation on 7/18/2024 at 2:30 PM of a medication room from a public hallway window revealed the ability to see Resident 2's name on a bottle of calmoseptine, Resident 15's name on an inhaler device, Resident 22's name on a bottle of glucose testing strips, and Resident 23's name on a bottle of MiraLAX. An interview on 7/18/2024 at 2:42 PM with Licensed Practical Nurse - H confirmed the medications were in public sight and was a violation of the resident's privacy.

Licensure Reference 175 NAC 12- 006.05(S) Based on observations, interviews, and record review; the facility failed to provide meal service that enhanced dignity by ensuring all residents were served at a table before serving the next table for 1 (Resident 5) of 1 sampled resident. The facility census was 26. Findings are: An observation on 7/22/2024 at 12:09 PM revealed Resident 5's four other table mates were served lunch meals. Resident 5 had been watching their other table mates eat. An observation on 7/22/2024 at 12:14 PM revealed a table of three seated behind Resident 5 were served lunch meals. Resident 5 had began to look around and continue to watch other residents eat. An observation on 7/22/2024 at 12:17 PM revealed Resident 5 was served their lunch meal. An interview on 7/22/2024 at 12:22 PM with Cook-B confirmed all residents should be served at one table at the same time.

Licensure Reference 175 NAC 12-006.04(F)(i)(5) Based on interviews and record review; the facility failed to notify the physician of significant weight loss for 2 (Residents 8 and Resident 11) of 2 sampled residents. The facility census was 26. Findings are: A. A record review of a facility policy Notification of Change in Resident Condition with a last revised date of 1/2019 revealed all licensed personnel will notify the attending physician of any significant change in condition. A record review of Resident 8's Vitals record revealed Resident 8 weighed 120.8 pounds on 1/12/2024 and on 7/8/2024 Resident 8 weight was 104.5 pounds, a loss of 16.3 pounds or 13.5% since the weight on 1/12/2024. A record review of Resident 8's medical record did not reveal any evidence that Resident 8's physician was aware of the severe weight loss. An interview on 7/23/2024 at 10:25 AM with the Minimum Data Set (MDS, a federally mandated assessment tool used for care planning)) Coordinator confirmed there was no information Resident 8's physician had been notified of Resident 8's severe weight loss. The MDS Coordinator further confirmed the physician should have been notified of Resident 8's severe weight loss. 49263 B. A record review of Resident 11's MDS, dated [DATE] revealed Resident 11 had had a weight loss of 5% or more in the last month or of 10% or more in the last six months and was not on a prescribed weight loss plan. A record review of Resident 11's weights documented in their electronic health record revealed the resident weighed 120 pounds on 4/1/24 and 110 pounds on 5/7/24, which was an 8.3% weight loss in one month. The resident also had a weight of 101 pounds on 6/4/24, which indicated the resident had lost an additional 8.2% during the month of May 2024. A record review of Resident 11's Electronic Health Records and of their paper health records revealed no evidence of Resident 11's primary care provider (PCP) being notified of the resident's severe weight loss. An interview on 7/23/24 at 12:15 PM with the Director of Nursing (DON) confirmed Resident 11's weight loss and there was no evidence of their PCP being notified of the weight loss. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 revealed that 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 and that if significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication, or changed fluid volume status.

Licensure Reference Number 175 NAC 12-006.05(G) Based on observation, record review, and interviews; the facility failed to evaluate 1 (Resident 13) of 2 sampled residents of a potential use of a physical restraints. The facility census was 26. The Findings Are: A record review of facility policy Restraints with revised date of 9-99 revealed that restraints would only be used as a last resort to prevent a patient from injuring self or others and only when alternatives to restraints are not effective. The policy also stated that restraints were to have a physician's order except in the case of an emergency. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed a physical restraint was defined as Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. A record review of Resident 13's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 5/7/24 revealed documentation that there were no restraints in use for Resident 13. A record review of Resident 13's Care Plan revealed an intervention dated 3/3/23 that stated: May use a gait belt (a safety device used by a caregiver to help transfer a person from one surface to another) on the legs for positioning. Resident 13 is able to remove. A record review of Resident 13's electronic health records and paper health records revealed no evidence of Resident 13 being assessed for their ability to remove the gait belt from [gender] legs on [gender] own. An observation on 7/17/24 at 9:24 AM revealed Resident 13 sitting upright in their wheelchair in [gender] room. There was a gait belt secured around Resident 13's thighs, holding the legs together. An observation on 7/17/24 at 12:30 PM revealed Resident 13 sitting in their wheelchair near the nurse's station. There continued to be a gait belt secured around Resident 13's thighs, holding the legs together. An interview on 7/22/24 at 1:42 PM with Medication Aide (MA)-D confirmed that the facility utilized a gait belt around Resident 13's legs for positioning. An interview on 7/23/24 at 9:20 AM with the Director of Nursing (DON) confirmed that Resident 13 was never assessed for their ability to remove the gait belt from their legs independently prior to or during the use of the gait belt around their legs as a positioning device. The DON revealed the DON had applied the gait belt to Resident 13's legs that morning and Resident 13 was not able to remove it from their own legs.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record reviews and interview; the facility failed to revise a care plan when the current interventions were ineffective for preventing significant weight loss for 1 (Resident 8) of 13 sampled residents. Findings are: A record review of a Resident Face Sheet indicated the facility admitted Resident 8 on 3/2/2020 with diagnoses of Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease. A record review of Resident 8's Significant Change Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) with an Assessment Reference Date of 5/14/2024 revealed Resident 8 had a Brief Interview for Mental Status score of 9/15, which indicated Resident 8 had moderate cognitive impairment. A record review of Resident 8's Vitals revealed Resident 8 weighed 120.8 pounds on 1/12/2024. A record review of Resident 8's Vitals revealed Resident 8 weighed 103 pounds on 7/08/2024, which is a 13.5% significant weight loss in six months. A record review of a Care Conference Report with a date of 5/20/2024 revealed dietician's recommendation to start Ensure Clear supplements. A record review of Resident 8's Care Plan revealed no evidence of the intervention regarding starting a supplement drink. An interview on 7/23/2024 at 10:50 AM with the MDS Coordinator confirmed the care plan was not revised to reflect the dietician's recommendation of starting a supplement drink.

Licensure Reference Number 175 NAC 12-006.09(H) Based on observations, record review, and interviews; the facility failed to implement a physician ordered treatment for 1 (Resident 25) of 1 sampled resident's edema and failed to ensure a hypertension medication was administered in accordance with the Prescribers' orders for 1 (Resident 6) of 5 sampled residents. The facility census was 26. The Findings Are: A. A record review of Resident 25's progress note dated 7/8/2024 revealed that Resident 25's left arm was swollen, and that the resident had been seen by a provider two days prior. A record review of Resident 25's progress note dated 7/16/24 revealed that Resident 25's provider had seen the resident that day for a follow up appointment related to their left arm swelling. The progress note stated there had been new order put into place for blood work, Tylenol, x-rays of the resident's left arm, and for an ACE wrap to the left arm. A record review of Resident 25's paper chart revealed an order from their provider dated 7/16/24 for OT (Occupational Therapy) evaluate and treat. Diagnosis (Dx): Left arm pain. Ace Wrap on during day and off at night & PRN (as needed). Dx: Left arm swelling. The paper chart also revealed orders dated 7/16/24 for an x-ray of the resident's left hand, wrist, and forearm, blood work, and routine Tylenol. An observation on 7/17/24 at 11:54 AM revealed Resident 25's left arm had swelling from the resident's shoulder to their hand. Resident 25's left arm was elevated on a pillow and there was no ACE wrap on their left arm. An observation on 7/18/24 at 8:57 AM revealed Resident 25 sitting in their recliner in their room. Resident 25's left arm continued to be swollen and was elevated on a pillow. There was no ACE wrap on Resident 25's left arm. An observation on 7/18/24 at 12:16 PM revealed Resident 25 sitting upright in their wheelchair in the dining room eating lunch. Resident 25's left arm continued to be swollen and was elevated on a pillow with no ACE wrap on the arm. An observation on 7/22/24 at 9:47 AM revealed Resident 25 sitting upright in their recliner with their left arm elevated slightly on a pillow. There was no ACE wrap on Resident 25's left arm. A record review conducted on 7/22/24 of Resident 25's current physician's orders in their electronic health record revealed no evidence of an order for Resident 25 to wear an ACE wrap around their left arm. An interview on 7/23/24 at 9:21 AM with the Director of Nursing (DON) confirmed the order for Resident 25's ACE wrap to their left arm was never implemented as the staff who entered the other orders written by the provider from that day did not enter this order in Resident 25's electronic health records. 49766 B. A record review of a Resident Face Sheet indicated the facility admitted Resident 6 on 4/9/2021 with diagnoses of stroke, Congestive Heart Failure, Dementia, and high blood pressure. A record review of Resident 6's Orders revealed an order for Coreg, a high blood pressure medication, to be given twice a day. The order included special Prescribers instruction to hold the medication if Resident 6's systolic (the first number in a blood pressure reading) blood pressure was under 110. A record review of Resident 6's Medication Administration Record with a date of 4/23/2024 to 5/23/2024 revealed Resident 6 had been administered Coreg at the following blood pressures: -4/24/2024 AM - 106/69 -5/6/2024 PM - 106/72 -5/14/2024 AM - 89/50 -5/14/2024 PM - 99/62 -5/17/2024 PM - 109/64 A record review of Resident 6's Medication Administration Record with a date of 5/24/2024 to 6/23/2024 revealed Resident 6 had been administered Coreg at the following blood pressures: -5/24/2024 PM - 101/60 -5/26/2024 AM - 103/74 -6/3/2024 PM - 109/61 -6/10/2024 PM - 109/62 -6/11/2024 PM - 108/72 -6/12/2024 AM - 95/55 -6/17/2024 PM - 106/63 -6/22/2024 AM - 109/76 -6/23/2024 PM - 106/70 A record review of Resident 6's Medication Administration Record with a date of 6/23/2024 to 7/23/2024 revealed Resident 6 had been administered Coreg at the following blood pressures: -6/23/2024 PM - 106/70 -6/30/2024 PM - 107/65 -7/1/2024 PM - 98/60 -7/2/2024 PM - 105/63 -7/20/2024 PM - 107/66 An interview on 7/23/2024 at 1:40 PM with the DON confirmed Resident 6's Coreg was administered in error and not according to the Prescribers' order on 4/24/2024, 5/6/2024, 5/14/2024, 5/17/2024, 5/24/2024, 5/26/2024, 6/3/2024, 6/10/2024, 6/11/2024, 6/12/2024, 6/17/2024, 6/22/2024, 6/23/2024, 6/30/2024, 7/1/2024, 7/2/2024, and 7/20/2024.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, record review, and interview; the facility failed to ensure 1 (Resident 12) of 2 sampled residents' oxygen concentrator was not left on when unattended. The facility census was 26. The Findings Are: A record review of website www.inogen.com revealed that oxygen itself is not a flammable gas, but it does support combustion. This means that fires ignite and burn more easily, and hotter, in an oxygen-rich environment. In order to maintain a safe environment while using supplemental oxygen, it is important to adhere to safe practices. The website also listed a safe oxygen storage guideline of Turn off your oxygen when you're not using it. Don't set the cannula or mask on the bed or a chair if the oxygen is turned on. A record review of facility policy Oxygen Administration with review date of 11/23/13 revealed no guidance related to turning off the oxygen administration devices when not in use. A record review of Resident 12's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 4/16/24 revealed Resident 12 had a diagnosis of chronic respiratory failure with hypoxia, an absence of enough oxygen in the tissues to sustain bodily functions, and that the resident was receiving oxygen therapy. A record review of Resident 12's physician's orders revealed an order with a start date of 2/16/23 that stated oxygen 1-3 liters per minute (LPM) per nasal cannula to keep oxygen saturation at 88%-92%. Oxygen must be turned off when not in use and cannula and tubing stored in IP (infection prevention) bag. An observation on 7/17/24 at 10:23 AM revealed Resident 12 was not in their room. Resident 12's oxygen concentrator was turned on and running at 3 LPM. An interview on 7/17/24 at 10:26 AM with the MDS Coordinator confirmed that there was no one in Resident 12's room at that time and that Resident 12's oxygen concentrator had been left on.

Based on record review and interview, the facility failed to ensure an antibiotic had a stop date for 1 (Resident 13) of 1 sampled residents. The facility census was 26. The Findings Are: A record review of facility policy Antimicrobial Stewardship Program Committee with revised date of 7/24, revealed the goal of the Antimicrobial Stewardship Program was to ensure proper use and duration of antimicrobials within the entire facility. The policy stated that this would help reduce antimicrobial resistance and adverse reactions to antimicrobials. A record review of Center for Disease Control's (CDC) document The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use revealed Surveys of antibiotic use have shown that (Urinary Tract Infection) UTI prophylaxis accounts for a significant proportion of antibiotic prescriptions. Very few studies support antibiotic use for UTI prophylaxis, especially in older adults, and many studies have shown this antibiotic exposure increases risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure and improve resident outcomes.' A record review of Resident 13's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 5/7/24 revealed Resident 13 had a personal history of urinary tract infections (UTI), had an indwelling urinary catheter and was taking an antibiotic. A record review of Resident 13's care plan revealed an evaluation note dated 2/15/2024 revealing the resident was received an antibiotic(Cephalexin) prophylactically. A record review of Resident 13's physician's orders revealed the resident had been taking Cephalexin (an antibiotic medication used to treat infections) daily since 11/10/2021 for a diagnosis of personal history of urinary tract infections and that the order did not have a stop date. An interview on 7/23/24 at 1:05 PM with Registered Nurse (RN)-C confirmed that they were aware of Resident 13's long term use of Cephalexin and that the facility had not attempted to have Resident 13's medical provider discontinue the Cephalexin. RN-C stated that the pharmacist reviews each resident's medications monthly, and each resident's primary care provider (PCP) reviews the resident's medications every 60 days, so if either the pharmacist or the PCP felt the medication was unnecessary they would have taken action to discontinue it.

Licensure Reference 175 NAC 12-006.09(E) Based on record reviews and interview; the facility failed to develop a comprehensive care plan regarding Activities of Daily Living (ADL) for 2 (Resident 1 and Resident 8) of 13 sampled residents. The facility census was 26. Findings are: A record review of the facility's policy Activities of Daily Living Policy with a last review date of 12/2023 revealed an individual care plan is completed by the interdisciplinary team which specifies the direction and/or assistance needed for the activities of daily living for each resident. A. A record review of a Resident Face Sheet indicated the facility admitted Resident 1 on 1/04/2018 with diagnoses of: Multiple Sclerosis, Dementia, a contractures, and abnormal involuntary movements. A record review of Resident 1's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 4/16/2024 revealed Resident 1 had severe cognitive impairment. The MDS also revealed Resident 1 required total assistance for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A record review of Resident 1's Care Plan under ADLs Functional, with a last edited date of 4/25/2024 revealed staff were to document assistance with bed mobility, dressing, eating, personal hygiene, and toileting. The care plan did not include specific information regarding the level of assistance needed for eating, dressing, bathing, or personal hygiene. B. A record review of a Resident Face Sheet indicated the facility admitted Resident 8 on 3/2/2020 with diagnoses of: Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease. A record review of Resident 8's Significant Change MDS with an ARD of 5/14/2024 revealed Resident 8 had a Brief Interview for Mental Status score of 9/15, which indicated Resident 8 had moderate cognitive impairment. The MDS also revealed Resident 8 required substantial assistance with eating and oral hygiene and required total assistance for toileting, bathing, dressing, and personal hygiene. A record review of Resident 8's Care Plan under ADLs Functional, with a last edited date of 3/6/2024 revealed staff were to document assistance with bed mobility, dressing, eating, personal hygiene, and toileting. The care plan did not include specific information regarding the level of assistance needed for eating, dressing, bathing, or personal hygiene. An interview on 7/22/2024 at 3:33 PM with the MDS Coordinator confirmed the care plans were not comprehensive or person-centered for Resident 1 and 8.

License Reference Number NAC 175 12-006.11E Based on observations, record reviews, and interviews, the facility failed to 1) follow recipes during meal preparation, 2) failed to change gloves as required, and 3) failed to perform hand hygiene as required during meal preparation. This had the potential to affect all the residents who resided at the facility. The facility identified a census of 29 residents at the time of the survey. Findings are: Observation on 6/27/2023 of the facility's kitchen from 10:00 AM to 11:33 AM revealed the following; - The Food Service Coordinator (FSC) had donned gloves and on both hands and placed hamburger in a skillet on the stove. The FSC then doffed the gloves without performing hand hygiene and donned a new glove on their left hand. The FSC then opened the refrigerator with the left gloved hand and retrieved an onion and [NAME] Sauce. The FSC did not perform hand hygiene and immediately went and placed the onion on a cutting board, held the onion with the gloved hand, and diced it. The FSC then spread the diced donions over the hamburger and poured an unmeasured amount of [NAME] Sauce into the hamburger on the stove. -At 10:07 AM, the FSC doffed the left hand glove and did not perform hand hygiene. The FSC then moved dishes, a rag, and scooped out an unmeasured amount of dill relish from a plastic gallon container and placed it in a small bowl to make the sauce for sloppy joes. The FSC utilized their bare hand to reach into a brown sugar bag and scooped brown sugar with a portion cup. The FSC did not measure the amount of brown sugar placed into the sauce mixture. -At 10:12 AM, the FSC performed hand hygiene with soap and water for 12 seconds. The FSC then retrieved french fries from the freezer, touched their mouth, and went over to the stove to mix and chop the hamburger into smaller pieces. The FSC then went to the storage shed outside and retrieved chicken, peas, and french fries. The FSC did not perform hand hygiene. - At 10:27 AM, the FSC donned a pair of gloves, placed the chicken on a baking pan, poured the bag of peas into a pan, and placed them on the stovetop. - At 10:33 AM, the FSC had not performed hand hygiene or change gloves and placed additional french fries on a baking pan with the gloved hands. FSC then doffed their gloves but did not perform hand hygiene. - At 10:39 AM, the FSC mixed the cooking hamburger then grabbed two packages of buns, drained the hamburger, took the skillet to the dirty dish room, washed the skillet, put supplies away, wiped the food preparation counter,and placed an unmeasured amount of butter into the peas. The FSC then placed the hamburger into a pan, adjusted their glassess with their bare hands, and then poured the sloppy [NAME] sauce over the hamburger. The FSC then wrote on a piece of paper, touched their right side of the neck, retrieved a package of gravy, filled a pot with water, and retreived a whisk and cutting board from a shelf. The FSC then performed hand hygiene with soap and water for 14 seconds. -At 10:56 AM, the FSC adjusted the left side of their glasses with their bare left hand. The FSC then removed a pan of chicken from the oven. The FSC then donned gloves, diced the chicken, removed their gloves, and placed the gloves on a cutting board. The FSC poured a powder gravy mix into the water and did not measure the gravy mix. The FSC had poured the chicken into the gravy and cleaned the preparation counter with a rag and took the dishes into the dish room and rinsed them. The FSC did not perform hand hygiene. - At 11:11 AM, the FSC had donned gloves and placed a piece of chicken on a cutting board where there was a pair of used gloves laying. The FSC grabbed the knife and diced the chicken on the cutting board next to the used gloves. The FSC then adjusted the left side of their glasses with their left hand and retrieved a thermometer from a drawer. The FSC did not perform hand hygiene. - At 11:19 AM, the FSC donned a pair of gloves, sprayed a blender and two plates with Vegalene food release oil spray. The FSC placed french fries, cream of celery soup, and butter into the blender and blended the food. The butter and cream of celery soup were not measured. The mixture was poured onto plates. -At 11:25 AM, the FSC doffed their gloves and performed hand hygiene with soap and water for 12 seconds. The FSC had put peas into the blender with the left-over potatoes and blended them. - At 11:29 AM, the FSC had rinsed the blender in the dish room and had not performed hand hygiene. The FSC then opened a package of bread and removed two slices with bare hands, and placed them into the blender with chicken gravy. The pureed food was placed onto the two pureed plates. Interview on 6/27/23 at 11:34 AM with the FSC revealed [gender] had not washed their hands with soap and water long enough, had not washed their hands after glove use, and did not change their gloves after touching items prior to handling food. The FSC further revealed they did not measure ingredients for the food they were preparing and did not follow recipes as [gender] had been cooking for a long time. The FSC revealed temperatures of the puree food were not taken prior to serving residents. Interview on 6/27/23 at 11:45 AM with the Food Service Manager (FSM) revealed hand hygeine is expected prior to starting meal preparation, anytime one touches their hair, clothing, or personal items, and after removing gloves. The FSM said facility staff are expected to wash their hands for 20-30 seconds with soap and water. The FSM revealed dietary staff are to follow recipes and ingredients should be measured. The FSM revealed FSC did not follow a recipie or measure ingreidents while preparing the sloppy [NAME] meal. Record review of the undated Sloppy [NAME], Lutheran Ladies Bar B-Q recipe revealed it called for the following ingredients: 5 pounds of hamburger; 2 medium onions, chopped; 1 1/4 t garlic powder; 2 1/2 t salt; 1/2 cup + 2T brown sugar; one 12 ounce tomato paste; 2 1/2 T mustard; 1 quart of catsup; 1/2 cup + 2 T vinegar; and 3 C tomato soup. Bake 350 degrees for 3 hours. Record review of the undated Pureed Vegetables recipe revealed starchy (root-type) vegetable preparation (potatoes/yams/carrots/squash/beats/turnips/parsnips, 1) Use 1/2 c. portions per serving. 2) To each portion, add 1 tsp. margarine. 3) If the consistency is too stiff, add 1 T. broth, gravy, sauce, or hot milk. Watery (leaf, stem, flower-type) vegetable preparation- green beans/tomatoes/spinach/greens/cabbage/broccoli/peas, 1) Use 1/ c. portions per serving. 2) To each portion, add 1 tsp. margarine and 1 to 2 tsp. broth or hot water and puree. 3) Add 1 to 32 tsp. commercial thickener per portion if too thin. Record review of the Dietary Department's Food Handling-Temperatures policy with a last reviewed date of 11/2007, revealed food temperatures will be taken and recorded prior to each meal service. Record review of the facility's Hand Hygiene and Surgical Antisepsis policy with a revised date of 5/2022, revealed under the section, Procedural Notes Hand Hygiene-How to do it, handwashing (soap and water), wet hands and apply the product. Do not use hot water; repeated exposure to hot water may increase the risk of dermatitis. Rub hands vigorously for at least 15 seconds, covering all surfaces. Rinse hands with water and dry with a disposable towel. Use a towel to turn off the faucet to prevent re-contamination of hands. Hand hygiene- When to do it: Hand washing is to be done before eating and after using the restroom. After removing gloves. More About Gloves to Maintain Hand Hygiene: Gloves do not take the place of hand hygiene measures.

Reference Number 175-NAC 12-006.09B Based on record review and interview; the facility failed to ensure the MDS (Minimum Data Set, a comprehensive assessment tool used to develop a resident's care plan) reflected the current status of 1 (Resident 12) of 1 sampled residents related to a Serious Mental Illness diagnosis. The facility identified a census of 29. Findings are: Record review of Resident 12's Face Sheet revealed the resident had been admitted to the facility on [DATE]. Record review of Resident 12's Level 1 PASSR dated 4/1/2022 revealed a PASRR (a federally mandated evaluation used to identify Mental Disorders (MD), Intellectual Disability (ID), or Related Disorders (RD) and to ensure appropriate facility placement with appropriate services) Level II Evaluation and Determination was not required at that time. Resident 12's PASRR did not identify any diagnoses or suspicion of serious mental illness (SMI), or intellectual disability or related condition. Record review of Resident 12's Banner Health History of Present Illness (H & P) dated 3/25/2022 revealed under Problems List, Resident 12 did not have a diagnosis of bipolar disorder. Record review of Resident 12 's diagnosis history revealed a diagnosis of bipolar disordered that was entered on 4/4/2022 and deleted on 6/6/2023. Record review of Resident 12's MDS dated [DATE] revealed Section I Active Diagnoses under the section Psychiatric/Mood Disorder, the resident had a diagnosis of bipolar disorder. Record review of Resident 12's Regional [NAME] Garden County Provider Order Sheet with a date of 4/4/2022 revealed a diagnosis of bipolar disorder that had a line through it without initials or a date of when it was crossed out. Interview on 6/27/2023 at 8:13 AM with the Assistant Director of Nursing (ADON) revealed Resident 12's MDS dated [DATE] identified resident had a diagnosis of bipolar. The ADON revealed Resident 12's admission diagnosis of bipolar had a line through it but it was added to Resident 12's medical record.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].11E Based on observation, record review and interview; the facility kitchen staff failed to ensure that outdated foods were not available for use. This had the potential to affect all residents in the facility. The facility census was 22 residents. The sample size was12 residents. Findings are: An observation on [DATE] at 02:21 PM during the initial tour of the kitchen revealed the following in one refrigerator: [NAME] Lynch, manufacturers date best if used by [DATE] and Thousand Island, manufacturers date best if used by [DATE]. On [DATE] at 02:36 PM an interview with the Dietary Services Manager confirmed that there were 2 containers of salad dressing that were expired per manufacturer dates. Review of the [DATE] 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 services sanitation practices, revealed the following: ,d+[DATE].11(C)Packaged food shall be labeled as specified by law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under ,d+[DATE].17 and ,d+[DATE].18.

Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observations, record reviews and interviews; the facility failed to ensure that transfer slings were removed from the wheelchairs or tucked in while residents were in public areas to promote dignity for two current sampled residents (Residents 2 and 1). The facility census was 22 with 12 current sampled residents. Findings are: A. Observations on 3/7/22 at 5:45 PM and 3/9/22 at 12:00 PM revealed Resident 2 seated in a wheelchair in the dining room with the transfer sling draped over the back of the wheelchair. Review of the Care Plan, goal date 4/18/22, revealed that the resident required a full mechanical lift for transfers. Further review revealed instructions to leave the sling in place at the resident's request and tuck the sling legs and wings in the chair. Interview with the Director of Nursing on 3/15/22 at 9:00 AM confirmed that the staff were to follow the care plan instructions and tuck in the transfer sling while the resident was in public areas to promote dignity. B) An observation on 03/07/2022 at 05:53 PM and 03/08/2022 at 12:05 PM revealed Resident 1 was sitting in the dining room in a wheelchair with the transfer sling draped over the back of the wheelchair in view of the public. Review of Resident 1's Care Plan revealed the following: goal date 06/08/2022 revealed full body mechanical lift and 2X assist for all transfers. Further review revealed instruction; may leave lift sling under Resident 1 in chair and wheelchair and make sure smooth and tucked away when in wheelchair and in dining room. An Interview with the Director of Nursing on 03/15/2022 at 09:54 AM confirmed that the sling for Resident 1 should be tucked away and not visible while the resident is in public areas and that the staff should follow the residents care plan instructions to promote dignity for Resident 1.

Licensure Reference: 175 NAC 12-006.09D8b Based on observation, record review, and interview, the facility failed to evaluate and implement nutritional interventions to prevent significant weight loss from occurring for Resident 10. The facility census was 39 residents, and 15 residents were included on the stage 2 survey sample. Findings are: A review of Resident 10's record revealed a face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) dated 3/7/2011, that stated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the facility provided weights for all residents during the stage one survey revealed the following weights for Resident 10: -7/12/2011: 96.5 lbs (pounds) -8/08/2011: 92.0 lbs -9/12/2011: 90.5 lbs -10/10/2011: 88.5 lbs -11/7/2011: 87.5 lbs -12/13/2011: 88.0 lbs -1/09/2012: 80.0 lbs From July 12, 2011 to January 9, 2012, Resident 10 lost 16.5 lbs, going from 96.5 lbs to 80 lbs, representing a 17.1% significant weight loss in 6 months. From October 10, 2011 to January 9, 2012, Resident 10 lost 8.5 lbs, going from 88.5 lbs to 80 lbs, representing a 9.6% significant weight loss in 3 months. From December 13, 2011 to January 9, 2012, Resident 10 lost 8 lbs, going from 88 lbs to 80 lbs, representing a 9.1% significant weight loss in a month. A review of Resident 10's quarterly Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/21/11, revealed the resident was assessed as having had weight loss but was not on a physician prescribed weight loss regime. A review of Resident 10's Care Plan in the resident record, dated 10/25/11, revealed a Problem noted for the resident being at risk for nutritional health decline related to poor appetite. The Goal listed was "We will attempt to maintain or increase (Resident's name) nutritional health over the next 90 days as evidenced by his/her weight. On 10/24/11 88.5 pounds. Interventions listed to achieve that goal were: -We will offer a Regular diet with chop meat. We will offer any foods that he/she likes or requests. -(Resident) usually leaves 25% or more of meals uneaten -An alternate menu will be offered at lunch and dinner M-F (Monday through Friday) to offer more choices, as there are many foods he/she doesn't like. A food preference list will be followed on other meals. -We will monitor meal intake daily. -We will monitor weekly weights -Snacks will be offered AM and PM - he/she will be offered desserts high in calories and high in proteins. -Dietary assessment as required. -(handwritten entry) 11/11/11 Fortify meals A review of Resident 10's record found no documentation of a food preference list. In an interview at 11:55AM on 1/12/12, the Director of Nursing (DON) stated he/she had just called Dietary Manager, and he/she said the food preference list should be on the chart; but there isn't any food preference sheet (pointed to another chart - like that) in (Resident 10's) record. A review of Resident 10's record revealed the following dietary interventions: -In the Dietary section of the record, a Dieticians Note to Physician (dated and signed 9/2/2010) that the resident was refusing to drink Boost Plus twice a day. This page stated Resident 10 ' s weight was 103 pounds. -In the Dietary section of the record, a note by the Dietary Director dated 11/21/11 stated the resident was often not wanting meals; the resident would eat a good breakfast and refuse lunch or dinner. A thick milk shake was to be provided, or other special foods offered that the resident might eat. -12/9/11 a note written by the Registered Dietician that stated foods of preference were being provided and that dietary was to make the resident an Oreo Blizzard which the resident would drink when he/she refused to eat the meal or other foods offered. -In the Dietary section of the record, the next Dieticians Note to Physician dated 11/03/11 stated the resident refused supplements, and recommended a fortified diet. The Physician signed/ordered the fortified diet on 11/11/11. (This recommendation was 14 months after the 9/2/2010 recommendation, and the resident had lost 14.5 pounds in that time.) -In the Recertification section of Resident 10's record, Physician order [REDACTED]. No clarification was found regarding the 12/7/11 change of diet order. Observation of Resident 10 on 1/10/12 at 6:15PM revealed the resident seated at the dining room table with water and dessert in front of him/her; and the resident was eating the dessert independently. (According to the menu, the dessert was Heavenly Delight.) At 6:30PM, Resident 10 was observed to have to have a dinner plate that had a large smoked type sausage on the plate (the resident had removed it from the hot dog bun, which was on the table to the left of the plate). Observation of Resident 10 during the noon-time meal on 1/11/12 and 1/12/12 revealed the resident had fruit cocktail and pears for dessert, respectively. A review of the Dietary Menu card used by the dietary staff when serving meals in the service kitchen of the facility revealed the Diet was listed as Regular Chop, with a check in the "SM" box (indicating small portions). Coffee was checked for all three meals, and under the Breakfast section "Likes" area, "oatmeal" and "hard fried eggs sometimes" were written in. There were no notations for likes or dislikes for Lunch or Dinner; or notation of the ordered and care planned 'extra desserts high in calories and high in proteins.' A review of the October, November, and December 2011 meal intakes for Resident 10 revealed no separate tracking was documented for the prescribed 'extra desserts high in calorie and proteins.' No documentation of fortified food intake was found on the intake sheets for the days of November and December the resident was prescribed a fortified diet. Neither of the November or December 2011 meal intake sheets had had the Diet listed at the bottom of the page updated with the 11/11/11 fortified diet order. In an interview on 1/12/12 at 11:35AM, Cook-A stated a chop meat diet was just cut up meat; not cut up to a particular size, but he/she tended to cut it up smaller than some others. A whole polish sausage would not be considered chopped meat. When queried about crisp, whole slices of bacon Cook-A stated (Resident name) requests his/her bacon crisp and whole. A review of Resident 10's afternoon Snack Pass record for December 2011 revealed the resident did not receive or refused snacks 15 of 31 days; and the afternoon Snack Pass record for January 2012 revealed the resident had refused a snack 6 of 11 days. A review of the December 2011 morning snack pass record for Resident 10 revealed the resident did not receive or refused a snack 21 of 31 days; and the morning snack pass record for January revealed the resident did not receive or refused a snack 6 of 12 days. In an interview on 1/12/12 at 11:30A Resident 10 stated the upper denture was a problem eating, but that he/she was getting new ones any day now. Resident 10 stated he/she was able to eat the whole sausage just fine - didn't want the bread though. In response to a query about that morning's snack, Resident 10 stated he/she got Ritz Bits and juice for a snack this morning; (Resident 10 has a whole bin of snacks next to recliner, other packages of Ritz Bits were noted to be inside) - but that he/she just drank the juice. When asked about the observed 1 lb box of chocolate candies on table next to the recliner, the resident granted permission to look inside. When the box was opened, three pieces of candy were observed left. The resident stated it was a Christmas gift, and that "I love that". When asked if he/she had candy every day, would he/she eat it, Resident 10 responded "Probably not." In an interview on 1/12/12 at 2:10PM, Cook-A referred to the dietary menu card and stated the coffee checked for each meal was incorrect as Resident 10 was to receive hot chocolate for lunch and dinner. According to Cook-A, there was no specified foods that were to be fortified; the dietary staff just added an extra squirt of butter to potatoes or vegetables, or perhaps a bit more gravy on meat or potatoes. Cook-A stated that the lighter meal, which usually had fruit for dessert. In response to a query about replacing the fruit with a more calorie and protein dense dessert for a resident with weight loss, Cook-A responded that it should be considered, but is not currently done. Cook-A stated that morning snacks are whatever is available on the snack cart for Resident 10 to choose from, but in the afternoon someone from the dietary department would usually go ask the resident what he/she would like; then the snack would be prepared in the kitchen and labeled with the resident's name. Cook-A stated the dietary department did not keep track of resident intakes of fortified foods or extra items (such as dessert) intake. In an interview on 1/12/12 at 3:15PM, NA-H (Nurse Aide) stated usually when I go in there he/she refuses (snacks). If he/she refuses, we start with items on the (snack) cart - the kitchen was baking cookies, then that got old, then they tried milk shakes. If the resident says he/she wants something, I get it. I always give him/her a few choices. In an interview on 1/12/12 at 3:17PM, NA-D stated during snack pass, that he/she would offer juice or snack daily; Ritz Bits (the resident) really likes. NA-D stated he/she did not offer Resident 10 a snack on 1/11/12 as he/she was running behind, but that "I went back and offered to get him/her something, but he/she didn't want anything." The Dietary Manager was not available for interview on 1/12/12 due to a family emergency. At 3:50PM on 1/12/12, the DON stated he/she was not aware of the dietary policies and was unable to access the Dietary Manager's office.

Licensure Reference: 175 NAC 12-006.09D2b Based on observation, record review and interview, the facility failed to ensure that pressure ulcer Resident 11 was admitted with to the facility healed without developing an infection and that development of additional pressure ulcers was avoided. The facility census was 39 and the stage 2 survey sample included 15 residents. Findings are: A review of Resident11's record revealed a face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) dated 10/20/2011, that stated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 10/28/11 Admission Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) revealed Resident 11 was assessed as having 2 stage 2 pressure ulcers present upon admit. A review of Resident 11's Care Plan, dated 11/1/11 for the problem of pressure ulcers w a goal of Resident 11 ' s skin not developing further breakdown revealed interventions as follows: -adequate fluid and food intake -Assess for pressure ulcer size, depth, and color each wk -Assist/teach resident to reposition self -Body/skin audit at least wkly -Keep linens dry and wrinkle free -Treatment as ordered -Pressure reducing mattress -Pressure reducing cushion in chair -Orthopedic/diabetic shoes -Braden scale assessment every 90 days and as condition warrants. (Handwritten updates on the CP were:) -11/1/11 off load heel while in bed -11/1//11 Supplement per order -11/10/11 Cue to reposition in bed using trapeze -12/22/11 Restorative to massage lower extremities 5 - 10 min BID 5xwk. The next page of the CP had a discontinued Goal of problematic or affected area will be healed, and a handwritten note under that that stated: History of Coccyx breakdown. Will remain intact. Approaches to attain that goal that had not been discontinued were: -Assist/teach resident to reposition self. -Body/skin audit at least weekly. -Keep linens dry and wrinkle free. -Treatments as ordered. (handwritten goal added) -11/10/11 Cue resident to reposition self. A review of the wound assessment sheets located in Resident 11's record revealed: -10/21/11 wound assessment stated: "Left heel ulceration 7 cm (centimeters) long x 3 cm wide. Ulceration to coccyx 1.5cm x 0.5cm deep (stage 2 pressure ulcers)." -10/29/11 wound assessment stated: "left heel ulceration measures 5.5 cm x 2.2 cm. Coccyx pressure ulcer measures 0.5 cm diameter." -11/5/11 wound assessment stated: " Left heel ulceration measures 5 cm x 2 cm. Granulation issue present to wound bed. Pressure ulcer to coccyx has closed. Red skin to buttocks remain. Prescribed treatment done as ordered." -11/19/11 wound assessment stated: "Ulceration to left heel measures 5cm x 3.2cm. Shape is (small kidney shaped drawing inserted). Dressing applied as ordered. Area to coccyx is filling in, measures 0.6cm diameter. Dressings applied as ordered. Coloring on 3rd and 4th digit on right foot appears to be from rubbing. Appears improved. No new impairments noted." -11/26/11 wound assessment stated: "Left heel ulceration measures 5 x 4 and 5 x 1cm. Red area to left posterior ankle measures 2x2. Coccyx has a closed sheared area measures 4x4cm." -12/3/11 wound assessment stated: "Left heel ulceration 4.5cm x 4cm and 5 x 1cm. Ulcer showing improvement with new tx. Small area above heel (ulcer) measures 1.7x1.8cm. Skin on buttocks red - tx applied as ordered. No new impairments noted." -12/10/11 wound assessment stated: "Left heel ulceration measures 4x4cm. Area to left posterior ankle measures 2x2cm open with 2cm x2cm dark closed area. Area to coccyx closed." -12/17/11 wound assessment stated: "Upper ulceration left heel measures 2cm x 3cm. Lower ulceration measures 4cm x 5cm. Area to the right measures 3cm x 1cm - area is red but no open area observed. Coccyx closed. Dressing changes done as ordered." -12/24/11 wound assessment stated: ">0.3cm deep wound to upper left heel measure 3 cm diameter. Serosanguinous drainage observed. No odor present. Wound to lower area of heel measures 4cm x 5cm. This wound also has serosanguinous drainage. No Odor. Dressing changes don as ordered. Skin to coccyx intact." -12/31/11 wound assessment stated: "Wound to at upper left heel measures 3cm x 3cm and to the left heel 4cm x 5cm. No odor noted. No other impairments noted." -1/7/12 wound assessment stated: "Wound to upper left heel measures 3 x 3.5cm, 1cm in depth and left heel measures 5 x 3.5cm and 3 x 2cm area to the side of heel wound. No other impairments noted." The page was marked as Stage 2 pressure ulcers. -1/9/12 wound assessment stated: "When changing dressing to left heel appears wound has increased in depth. Appears to now be a Stage 3. Measures 3 x 3.5cm, 2cm deep. Lower wound remains unchanged from prior assessment." A review of the Physician Orders; signed and dated 12/22/11 and located in the Recertification section of Resident 11's record; revealed the resident had been [MEDICATION NAME]([MEDICATION NAME], an antibiotic medication) for an infected lower leg wound; and to clean the wound on posterior lower leg and left heel with soap and water; apply [MEDICATION NAME] over [MEDICAL CONDITION]; and to change only if malodorous drainage was noted. (Signed by the provider.) A review of the Physician order [REDACTED]. [MEDICATION NAME] ordered. Corresponding progress notes written stated: 12/22/11 Wound debridement gangrenous. Culture pending. (Signed by the provider) Observation of Resident 11's wounds on 1/11/12 at 10:30AM revealed a stage three pressure ulcer on the upper heel, a kidney shaped left heel ulcer and a stage two pressure ulcer to the side of the heel ulcer. A review of the facility provided policy titled Pressure Ulcers Treatment revealed the following: -Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. -General Guidelines: 1. The pressure ulcer treatment program should focus on the following strategies: -a. Assessing the resident and the pressure ulcer(s). -b. Managing tissue loads. -c. Pressure ulcer care. -d. Managing bacterial colonization and infection. -e. Operative repair of the pressure ulcer(s). -f. Education and quality improvement. -Interventions/Care Strategies - Stage I Protocol 1. Pressure: -a. Determine cause of pressure and relieve; -b. Redistribute pressure; -c. Implement pressure-relieving device(s) in accordance with resident ' s assessed needs; -d. Evaluate until redness is no longer persistent; -e. Persistent redness is determined only after pressure has been relieved for at least three/quarters of the time it was applied and the redness remains; -f. Notify physician, family, and appropriate facility personnel; and -g. Initiate a skin grid and care plan. -Stage II Protocol (Interventions/Care Strategies) Clean, shallow, minimal drainage: -1. Protect; -2. Manage drainage; -3. Promote moist wound healing; -4. Treatment per order; -5. Manage pain. Medium drainage: -1. Follow above procedure, consider the need for alginate or foam (dressings). Follow-up -If wound does not improve in 2 - 3 weeks, notify physician. Consider a skin consult with a wound specialist. A review of Resident 11's record revealed the resident was seen by a certified wound nurse on 11/29/2011 as documented by notes in the Physician order [REDACTED]. In an interview on 1/11/12 at 1:55PM, the Director of Nurses (DON) stated the resident had ortho (orthopedic) boots - we got him diabetic boots. The DON thought the old ortho boots caused the pressure sore, the boots were for physical therapy and that considering Resident 11's medical condition and circulation, the DON considers the new wounds to be venous ulcers and unavoidable. In an interview on 1/11/12 at 3:00PM, the Physical Therapy Assistant (PTA) stated the boots were not orthotic boots, they were regular boots - an old pair. The resident started getting the upper sore and the back was then cut out of the back of the boots.