Every finding on record at Gordon Countryside Care

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure accuracy of the 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) related to an active diagnosis for Resident 14 and weight loss for Resident 1. The sample size was 12 and the facility census was 33.Findings Are: A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2024 revealed in Chapter 3 coding instructions for Active Diagnoses that diseases should be coded that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Chapter 3 also revealed that the definition of a physician-prescribed weight-loss regimen included planned diuresis. A.A record review of Resident 14's Quarterly MDS dated [DATE] revealed the resident was admitted to the facility on [DATE]. In section I, the MDS indicated the resident had an active diagnosis of Pneumonia (an infection that causes inflammation in the lungs, leading to fluid or pus filling the air sacs). A record review of Resident 14's active diagnoses, conducted on 9/22/2025, revealed no evidence of a pneumonia diagnosis. A record review of Resident 14's Progress Notes from 4/21/2025 through 7/22/2025 revealed no evidence of the resident being diagnosed with or treated for pneumonia. A record review of Resident 14's Medication Administration Records for the months of April, May, June, and July 2025 revealed no evidence of the resident being treated for pneumonia. An interview on 9/23/2025 at 8:19 AM with the MDS Coordinator (MDSC) revealed Resident 14 had been admitted to the facility with a diagnosis of pneumonia that never got resolved. MDSC confirmed that the diagnosis of pneumonia should not have been included on the MDS that was completed on 7/8/2025. B.A record review of Resident 1's quarterly MDS dated [DATE] revealed the resident was admitted to the facility on [DATE]. Section K of the MDS indicated that the resident had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a prescribed weight-loss regimen. A record review of Resident 1's weights revealed the following:-On 1/7/2025 the resident weighed 119 pounds,-On 6/10/2025 the resident weighed 118.5 pounds,-On 7/1/2025 the resident weighed 119 pounds,-On 7/15/2025 the resident weighed 127 pounds,-On 7/22/2025 the resident weighed 121.5 pounds, and-On 7/25/2025 the resident weighed 118 pounds. A record review of Resident 1's Progress Note dated 7/16/2025 revealed the resident was seen by their provider that date. The provider noted the resident did not return to the facility from their hospitalization with an order for Bumex (a diuretic medication), which they had been on prior to the hospitalization. The resident was having edema (swelling) to the lower extremities from not being on the diuretic. The resident received a new order for Bumex 1 milligram daily. A record review of Resident 1's Progress Notes revealed a quarterly nutrition assessment documented on 7/28/2025. This note revealed the resident had been hospitalized earlier in the month for pneumonia and upon returning to the facility, did not have an order for a diuretic. The resident's weight was up to 127 pounds on 7/15/2025 when re-admitted to the facility but had trended back down with re-initiation of the diuretic. An interview on 9/23/2025 at 8:20 AM with MDSC confirmed Resident 1's MDS dated [DATE] indicated the resident had an unplanned weight loss and should not have since the resident had a planned diuresis upon return from their hospitalization.

Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review and interview, the facility failed to follow their bowel protocol to prevent constipation for 1 (Resident 4) of 5 sampled residents. The facility census was 33.Findings Are: A record review of facility policy Bowel Management Policy dated 8/1/2024 revealed all residents will have a bowel management plan tailored to their individual needs, preferences, and medical conditions. In the Documentation section the policy states staff are to document absence of bowel movements for 3 days or more and initiate appropriate action. In the Intervention Protocol for Constipation section the policy states that on Day 1 staff are to monitor and encourage natural bowel movement and offer fluids and dietary fiber. On Day 2, staff are to administer prescribed stool softener or laxative. On Day 3, staff are to reassess and consider use of a suppository if no bowel movement, and on Day 4+ staff are to notify the physician and consider enema or other medical interventions. A record review of Resident 4's quarterly 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) dated 9/2/2025 revealed the resident was always continent of bowels and required substantial assistance from staff for their toileting hygiene. A record review of Resident 4's undated Care Plan revealed the resident had a history of constipation and staff were to monitor and document the resident's bowel movements. The staff were also to administer medications as ordered by the physician. A record review of Resident 4's physician's orders revealed the following:-An order for Milk of Magnesia (a laxative medication), give 30 milliliters every 12 hours as needed for constipation. This order had a start date of 5/11/2025.-An order for Miralax (a laxative medication), give 17 grams every 24 hours as needed for constipation. This order had a start date of 10/23/2024. A record review of Resident 4's Task: B&B- Bowel Elimination for 8/1/2025 through 9/22/2025 revealed:-No bowel movements from 8/10/2025 through 8/13/2025, which was 4 days.-No bowel movements from 9/5/2025 through 9/9/2025, which was 5 days. A record review of Resident 4's Progress Notes from 8/1/25 through 9/22/25 revealed no evidence of assessments or interventions related to their bowels during the timeframes when they had no bowel movements. A record review of Resident 4's Medication Administration Records for August and September of 2025 revealed no usage of their as needed Milk of Magnesia or Miralax. An interview on 9/23/2025 at 10:07 AM with the Director of Nursing confirmed there were no interventions implemented for Resident 4's constipation that occurred in August and September 2025.

Licensure Reference 175 NAC 12-006.09(I) Based on record review, observation, and interview, the facility failed to ensure developed interventions were implemented to prevent falls for 1 (Resident 19) of 3 sampled residents. The facility identified a census of 33.Findings are: A record review of the facility's policy, Falls - Clinical Protocol (dated March 2018) revealed the facility would monitor and document a resident's response to interventions intended to reduce falls or their consequences. A record review of Resident 19's undated Care Plan Report revealed Resident 19 was at risk for falls due to deconditioning, knee pain, and occasional incontinence. Additionally, it revealed on 8/29/2025, the resident had fallen when attempting to get up from their bed unassisted and on 9/16/2025 had fall from their bed and received a bruise to the center of their forehead. On 9/16/2025, an intervention was added to place a fall mat beside the bed when the resident was in bed. An observation on 9/18/2025 at 11:00 AM revealed Resident 19 had been resting in bed. Resident 19's floor mat had been tucked underneath the bed. An observation on 9/18/2025 at 11:25 AM revealed Resident 19 continued to be resting in their bed and was beginning to become restless, yelling out for help. Resident 19's floor mat had been tucked underneath the bed. An observation on 9/18/2025 at 11:30 AM revealed Resident 19 continued to be resting in their bed and continued to be restless. Resident 19's floor mat had been tucked underneath the bed. An interview on 9/18/2025 at 11:35 AM with Nurse Aide (NA) - I confirmed Resident 19's floor mat was tucked underneath the bed and that, as part of the resident's fall interventions, it should be placed beside the bed when the resident is in the bed.

Licensure Reference Number 175 NAC 12-006.11(D) Based on record reviews, observations, and interviews, the facility failed to ensure staff followed proper glove use of hand hygiene practices prior to food preparation or between tasks in accordance with the food code and Center for Disease Control (CDC) guidelines during meal service to prevent the potential for cross-contamination. This had the potential to affect 1 resident who resided within the facility. The facility identified with a census of 33. Findings are: A review of the Nebraska food code (last revised 2017, 3.301.11, Section ( A3 ) and (F)) revealed staff are required to perform hand hygiene during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Before donning (put on) gloves to initiate a task that involves working with food. A CDC guideline titled Clinical Safety: Hand Hygiene for Healthcare Workers (dated 2/27/2024) revealed gloves are to be changed between tasks and after contact with potentially contaminated surfaces or residents. - An observation on 9/23/2025 at 11:53 AM revealed the Certified Dietary Manager (CDM) entered the kitchen AM and advised [NAME] -A that CDM would take care of the grilled cheese sandwich ordered. The CDM walked to the walk-in refrigerator grabbed a loaf of bread and a pack of cheese and butter. Placed the items on the preparation table. CDM grabbed a frying pan placed on stove and turned on gas. CDM opened the bread and butter and without wearing gloves or performing handwashing and proceeded to butter two pieces of bread, grabbed one slice of cheese, placing the cheese between the two slices of bread and placing the sandwich into the frying pan with bare hands. - CDM began washing down the counter where sandwich had been made. - CDM took a spatula from a drawer and turned the sandwich. - At 11:58 PM Grilled cheese sandwich plated and covered with a clear plastic wrap, placed on counter and notified [NAME] A sandwich was ready. CDM washed hands and left the kitchen. An interview on 9/23/2024 9:30 AM CDM in the kitchen, revealed CDM was aware of [gender] error in touching the food with bare hands stated it was too late to start over had already started the process of making the grilled cheese sandwich, but admitted that gloves should have been worn and bare hands should not have touched the food.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews; the facility failed to notify the family or responsible party of a change in condition for 2 (Resident 1 and Resident 2) of 3 sampled residents. The facility identified a census of 30. The findings are: A record review of an undated policy titled Notification of Changes stated the facility will notify resident representative or responsible party regardless of competency level since the resident may not be able to notify them themselves. A. A record review of an Admission Record indicated the facility admitted Resident 1 on 3/21/24. Under the Contacts section, the Emergency Contact section listed 2 people with their phone numbers. A record review of Resident 1's Progress Notes with a date of 10/16/24, written by Registered Nurse (RN-A) indicated that Resident 1 had no improvement to to their right lower extremity with a marked increase in redness and swelling. The physician was notified and provided an order to transfer Resident 1 to the hospital as a direct admit for intravenous (administered directly into vein) antibiotics. There was no evidence that Resident 1's emergency contact had been notified of Resident 1's change of condition A telephone interview on 1/8/2025 at 1:15 PM with RN-A confirmed RN-A did not notify Resident 1's emergency contact of their change of condition and should have. 49766 B. A record review of an Admission Record indicated the facility admitted Resident 2 on 9/8/2023. Under the Contacts section, an emergency contact of Resident 2's friend was listed with their emergency contact. A record review of Resident 2's Progress Notes with a date of 11/25/2024, written by Registered Nurse (RN-A) indicated that Resident 2 had fallen and was found to have audible wheezing and low oxygen levels, requiring the implementation of oxygen. The physician was notified and provided an order to transfer Resident 2 to the Emergency Department for possible respiratory failure. There was no evidence that Resident 2's emergency contact had been notified of Resident 2's change of condition. A telephone interview on 1/8/2025 at 1:15 PM with RN-A confirmed RN-A did not notify Resident 2's emergency contact of their change of condition and should have.

Licensure Reference 175 NAC 12- 006.11(E) Based on observations, interviews, and record reviews; the facility failed to ensure foods were disposed or consumed prior to best-by and use by dates, store foods at least six inches off the floor as required, and to implement hand hygiene practices as required to prevent the potential for cross contamination and foodborne illness. This had the potential to affect all 26 residents who resided within the facility. Findings are: A. A record review of a facility policy Food Storage with a last reviewed date of January 2021, indicated date marking should be visible on foods to indicate the date by which ready to eat foods should be consumed or discarded and that all foods will be consumed by their safe use by dates or discarded. An initial kitchen tour observation on 7/29/2024 at 9:50 AM revealed the following: -In the dry food storage area: -An opened bag of French-Fried Onions that had been opened, but no open date or use by date. -Five cans of Whole Oysters with best if used by dates of 5/31/2024. -One loaf of [NAME] Texas Toast with a best by date of 7/24/2024. -In the walk-in refrigerator: -A container of Deviled Egg Potato Salad with a use by date of 7/16/2024. -A container of Macaroni Salad with a use by date of 7/26/2024. -A jug of Fat Free Milk that was 3/4 empty with a best by date of 7/23/2024. -A container of Original Strawberry Yoplait Yogurt with a best by date of 7/19/2024. -In the reach-in refrigerator: -A bottle of Strawberry Syrup with a best by date of 5/2024. An interview on 7/29/2024 at 10:05 AM with the Certified Dietary Manager (CDM) confirmed the items observed during the initial kitchen tour should have been dated with an open and use by date and consumed or disposed of by the use by or best by dates. B. A record review of a facility policy Food Storage with a last reviewed date of January 2021, indicated that food should be stored a minimum of six inches above the floor. An initial kitchen tour observation on 7/29/2024 at 9:50 AM revealed four cardboard boxes of food being stored on the floor of the freezer. An interview on 7/29/2024 at 10:05 AM with the CDM confirmed that all food should be stored at least six inches off the floor. C. A record review of a facility policy Standards, Review and Frequency LTC (Long Term Care) Nutrition Regulations Being Met with a last reviewed date of January 2021, revealed the following: - Employees must wash their hands - before coming in contact with any food surfaces, when switching between working with raw food and working with ready-to-eat food, after handling soiled equipment or utensils, during food preparation as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, after engaging in other activities that contaminate hands. - Contact between food and bare (ungloved hands is prohibited). - Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. - Further review of the policy revealed the policy did not include information regarding the length of time required to wash hands with soap and water or the procedure for handwashing to avoid contamination of items in the kitchen. A record review of the 2017 Nebraska Food Code, under section 2-301.12 indicated food employees shall clean their hands for at least 20 seconds. It also included procedures that stated to avoid re-contaminating hands, food employees shall use a disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a handwashing sink. A continuous observation on 7/30/2024 from 9:09 AM to 11:15 AM during meal preparation completed by the CDM revealed the following: -The CDM had thrown lettuce in the trashcan, touching the rim of the trash can with their hand, then touched the refrigerator door twice, then obtained clean supplies including a bowl, cutting board, and knife without first performing hand hygiene to prevent cross contamination. -The CDM turned on the water faucet with their soiled hands, washed their hands with soap and water for 20 seconds as required, then turned off the soiled faucet with their bare hand, and then applied gloves. -The CDM had applied gloves but then touched potentially soiled boxes of lettuce, contaminating their gloves, then touched the lettuce with their gloved hands and peeled the lettuce. -The CDM had removed their gloves then obtained a clean cutting board and scale without first performing hand hygiene as required. -The CDM turned on the water faucet with their soiled hands, washed their hands with soap and water for 20 seconds as required, then turned off the soiled faucet with their bare hand. The CDM then checked on a cake they were baking in the oven, inserted a toothpick into the cake using their bare hand and touched the cake with their bare contaminated hands. -The CDM applied clean gloves after they touched the cake without first performing hand hygiene. -The CDM then touched the food scale's power button with their gloved hand, then picked up a tomato to prepare for the salad. -The CDM then removed their gloves, turned on the potentially soiled water faucet, completed hand hygiene for 15 seconds, and then turned off the faucet with their clean hands, contaminating their hands. The CDM then applied clean gloves and began chopping a tomato to prepare for the salad. -The CDM removed their gloves, then began to wash their hands with soap and water for 15 seconds, the CDM then returned to chopping the tomatoes without. -After chopping the tomatoes, the CDM applied new gloves, sanitized the preparation table with a rag then removed their gloves. The CDM then opened a drawer and obtained a knife, vegetable peeler, and new cutting board without first performing hand hygiene. -The CDM then turned on the potentially soiled water faucet, washed their hands with soap and water for 15 seconds, shut off the faucet with their clean hands, contaminating their clean hands. The CDM then began to chop and peel a cucumber. -The CDM again turned on the potentially soiled water faucet, washed their hands for 15 seconds, shut off the faucet with their clean hands, contaminating their clean hands. The CDM then applied clean gloves and prepared pizza dough, pressing the dough into the pans. -The CDM then rolled the trashcan near the can opener, using a paper towel to touch the trashcan. However, the CDM's hand still did touch the trashcan. The CDM did not complete hand hygiene after touching the trashcan with their bare hand. The CDM then began to spread pizza sauce on top of the pizza dough with a spatula and had touched their two knuckles of their right hand into the pizza sauce as they spread the sauce onto the dough. -The CDM then turned on the potentially soiled water faucet, washed their hands with soap and water for 17 seconds, shut off the faucet with their clean hands, contaminating their clean hands. The CDM then obtained ground beef and put into a pan to fry. -The CDM then turned on the potentially soiled water faucet washed their hands with soap and water for 15 seconds, shut off the faucet with their clean hands, contaminating their clean hands. The CDM then began to chop an onion with their bare hands. An interview on 7/30/2024 at 10:25 AM with the CDM revealed that the CDM believed they only needed to glove their hands when food items were not going to be cooked, such as the salad. An interview on 7/30/2024 at 11:30 AM with the CDM confirmed hand hygiene should be completed in between tasks, when hands are dirty, immediately before and after gloves, and after contamination of their hands. The CDM confirmed hands are contaminated when touching meats, doors, drawers, and other dirty items. The interview also revealed the CDM believed hands should be washed for 15 seconds.

Licensure Reference 175 NAC 12- 006.18(B) Based on observations, interview, and record review; the facility failed to disinfect multi-use equipment during medication administration for 3 (Residents 1, 16, and 23) of 3 sampled residents and implement infection control practices during wound to prevent the potential for cross-contamination for 1 (Resident 23) of 1 sampled resident. Findings are: A. A record review of a facility policy Cleaning of Patient Care Equipment with a last reviewed date of 7/20/2021 indicated patient care equipment should be cleaned after each use. A continuous observation on 7/30/2024 from 7:37 AM to 8:04 AM revealed Medication Aide (MA)-B had taken a pair of tweezers from the side of the medication cart from a graduated cylinder to pull a piece of plastic from Resident 23's medication cup, touching Resident 23's medication in the cup with the tweezers. MA-B did not disinfect the tweezer prior to use or after use. At 7:39 AM, MA-B had taken the pair of tweezers back out of the side of the medication cart to pull a piece of plastic from Resident 16's medication cup, touching Resident 16's medications in the cup with the tweezers. MA-B did not disinfect the tweezers prior to use or after use. At 8:04 AM MA-B had taken the pair of tweezers from the side of the medication cart to pull out Resident 1's pantoprazole from the medication cup, touching the other medications with the tweezers. MA-B did not disinfect the tweezer prior to use or after use. An interview on 7/30/2024 at 11:35 AM with MA-B confirmed the tweezers should be cleaned or sanitized after each use. B. A record review of the facility's undated policy Wound Care revealed instructions to place a barrier before starting, wash and dry hands thoroughly, and that a gown was only necessary if there was potential to soil the employee's skin. The policy did not include information on how long to wash hands for or that a gown was necessary for Enhanced Barrier Precautions during wound care. A record review of the Center for Disease Control (CDC)'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 skin opening that requires a dressing. A record review of the CDC's Clean Hands with a date of February 16, 2024, indicated hands should be scrubbed with soap and water for at least 20 seconds. An observation on 7/31/2024 at 10:10 AM of Registered Nurse (RN)-A performing wound care for Resident 23 revealed the following: -Upon entrance, RN-A washed their hands for 15 seconds. -RN-A applied gloves, then removed keys from around their neck. -RN-A donned their gown, touching their hair with their own gloved hands. -RN-A touched the trashcan with their own gloved hands. -RN-A opened and reclosed Resident 23's drawer when obtaining additional supplies with their gloved hands. -RN-A removed their gloves, then washed their hands with soap and water for 13 seconds. An interview on 7/31/2024 at 11:00 AM with RN-A revealed RN-A was unaware of the amount of time required when washing hands with soap and water. The interview also confirmed RN-A contaminated their gloves during the wound care procedure.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observations, record review, and interviews; the facility failed to ensure 1 (Resident 18) of 2 sampled residents' oxygen concentrator was turned off when not in use and unattended. The facility census was 26. The Findings Are: A record review of facility policy Oxygen Administration with revision date of October 2010 revealed that the facility would instruct the resident, their family, visitors, and roommate (if any) of the oxygen safety precautions. The policy also stated that the facility would provide the resident with a written copy of the Oxygen Safety Handout. A record review of undated facility provided document Using Oxygen Safely, revealed instruction to Turn off your oxygen when you're not using it. A record review of Resident 18's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 7/2/2024, revealed that the resident had diagnoses of non-Alzheimer's dementia, pulmonary hypertension due to lung diseases and hypoxia (An absence of enough oxygen in the tissues to sustain bodily functions), and dependence on supplemental oxygen. A record review of Resident 18's physician's orders revealed an order for continuous oxygen therapy at 3 Liters Per Minute (LPM) via nasal cannula. An observation on 7/29/24 at 10:31 AM revealed Resident 18 was not in their room. Resident 18's oxygen concentrator was turned on and running at 3 LPM. An interview on 7/29/24 at 10:33 AM with Registered Nurse (RN)-E confirmed that Resident 18 was not in their room, they had been attending a facility activity since 10:00 AM, and that Resident 18's oxygen concentrator had been left turned on and unattended in the resident's room. An observation on 7/30/24 at 3:20 PM revealed Resident 18 was not in their room. Resident 18's oxygen concentrator was turned on and running at 3 LPM. An interview on 7/30/24 at 3:24 PM with the Director of Nursing (DON) confirmed that Resident 18 had been out of their room at a facility activity since 2:00 PM, and that Resident 18's oxygen concentrator had been left turned on and that the oxygen concentrator should have been turned off while the resident was out of their room.

Based on record review and interview, the facility failed to ensure 1 (Resident 8) of 2 sampled residents was free from unnecessary medications related to a) the long-term use of an antibiotic medication which did not specify a duration and b) the use of an antibiotic which had no supporting documentation for clinical use based on laboratory results. The facility census was 26. The Findings Are: A record review of facility policy Antibiotic Stewardship Program with revision date of 3/4/24 revealed that all prescriptions for antibiotics would specify the dose, duration, and indication for use. The policy also stated that the facility would monitor resident response to antibiotics, and laboratory results when available, to determine if the antibiotic was still indicated or adjustments should be made. A. A record review of Resident 8's facility admission orders dated 10/25/23, revealed Resident 8 was admitted to the facility with an order for nitrofurantoin (an antibiotic used to treat urinary tract infections (UTI)) 100 milligrams (MG) at bedtime for UTI prevention. A record review conducted on 7/30/24 of Resident 8's current physician's orders revealed an order for Nitrofurantoin 100 MG to be given on time a day for UTI prophylaxis. The order had a start date of 10/25/23 and did not have a stop date or an intended duration. A record review of Resident 8's scanned physician visit documents, revealed Resident 8 was seen by their physician on the following dates with no references made to the continued use, or duration for, Resident 8's Nitrofurantoin order: -12/20/2023 -1/17/2024 -3/29/2024 -5/21/2024 -7/17/2024 B. A record review of Resident 8's progress note dated 5/17/2024 revealed that Resident 8 was having increased confusion and a decreased appetite. The progress note also stated that a urinalysis (UA) had been obtained and sent to the lab, the resident's urine was amber cloudy, that the doctor was aware, and that the resident had denied pain with urination. A record review of a urinalysis collected for Resident 8 on 5/17/24 revealed a final culture result was received on 5/19/24 which showed there was 50,000-100,000 cfu/ml of Mixed Flora- More than 3 organisms isolated. The report also stated, please review specimen collection procedure and consider resubmitting if clinically indicated. Further record review of Resident 8's urinalysis collected on 5/17/24 revealed a handwritten note on the document stating to start the resident on cephalexin (an antibiotic medication used to treat infections) 500 MG three times a day (TID) for 7 days. The document did not have an antibiotic susceptibility report, which is normally included in a final culture report and details which antibiotics will work to eliminate the infection. A record review of Resident 8's physician's orders revealed an order for cephalexin 500 MG TID for 7 days for UTI with a start date of 5/17/24 and an end date of 5/24/24. The resident also continued to take their nitrofurantoin antibiotic during this time period. A record review of the website asap.nebraskamed.com revealed the Revised McGeer Criteria for Infection Surveillance Checklist which stated that for a voided urine sample, there was to be at least 100,000 cfu/ml of no more than two species of organisms when determining if a person had a urinary tract infection. The McGeer Criteria did not list confusion, decreased appetite, or cloudy urine as signs or symptoms of UTI. A record review of the website pubmed.ncbi.nlm.gov revealed in an article titled The significance of urine culture with mixed flora that urine cultures that contained more than one organism were usually considered contaminated. An interview on 7/31/24 at 8:35 AM with Registered Nurse (RN)-F revealed that RN-F had not specifically discussed Resident 8's antibiotic use with their primary provider in an effort to reduce the unnecessary use of antibiotics. RN-F confirmed that the facility utilized McGeer's Criteria when determining whether a resident had an infection.

Licensure Reference 175 NAC 12-002.10 Based on observations, interviews, and record reviews; the facility failed to ensure medications were administered at the right time for 2 (Residents 1 and 15) of 6 sampled residents and to ensure the medication error rate was less than 5%. The medication error rate was 5.4% (37 medications administered with 2 medication errors.) The facility census was 26. Findings are: A record review of a facility policy Administering Medications with a revision date of April 2019 indicated medications are to be administered within one hour of their prescribed time unless otherwise specified and the individual administering the medication is to check the label to verify the right time before administering the medication. A record review of Resident 15's Medication Administration Record with a date of July 2024 indicated an order for Basaglar insulin (a medication used to treat hyperglycemia) to be administered at 9:00 AM with no special instructions related to the administration time. An observation on 7/30/2024 at 7:29 AM revealed Registered Nurse (RN)-A administered the Basaglar insulin to Resident 15. An interview on 7/30/2024 at 7:32 AM with RN-A confirmed RN-A was aware of the administration time of 9:00 AM, but due to Resident 15 being up early, was going to override that. A record review of Resident 1's Medication Administration Record indicated an order for levothyroxine (a medication used to treat thyroid disorder). A record review of Resident 1's levothyroxine label revealed instructions that included to take on an empty stomach. An observation on 7/30/2024 at 8:07 AM revealed Resident 1 had been sitting in the dining room with a plate of food in front of them. Resident 1 had already consumed approximately 25% of the food that was on the plate. Medication Aide (MA) - B attempted to administer the levothyroxine to Resident 1 but was unsuccessful due to Resident 1's refusal. MA-B then asked the Director of Nursing (DON) to attempt to administer the medication to Resident 1. The DON was successful at getting Resident 1 to take the levothyroxine. An interview on 7/30/2024 at 11:35 AM with MA-B revealed MA-B did not notice the instructions that stated to give on an empty stomach for Resident 1's levothyroxine.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, interviews, and record reviews, the facility staff failed to ensure cleaning agents were not next to food, failed to ensure high risk food preparation splashing did not contaminate clean dishes and equipment to prevent the potential food contamination. This had the potential to affect all 25 residents who resided at the facility. The facility identified a census of 25 residents at the time of the survey. Findings are: An initial tour of the kitchen on 7/19/2023 at 1:25 PM revealed the handwashing sink was on the middle island countertop where the dietary staff prep the food and there were three trays filled with clean cups that were on the counter, directly behind the faucet of the handwashing sink. There were clean dishes pitchers, cups and pan sitting on the counter directly to the left of the handwashing sink as well. There was no guard in-between the clean dishes and the handwashing sink. An observation of lunch meal preparation on 7/25/2023 at 9:26 AM revealed Cook-B preparing BBQ chicken, au gratin potatoes, and baked beans. The following observations were made: -There were two small buckets filled with liquid sitting on the island counter, next to the vegetable sink, and right next to where food was being prepped. -There were clean dishes that were placed on the island counter to dry right after coming out of the dishwasher that was sitting right next to where food was being prepped and next to the handwashing sink. There was no barrier between the handwashing sink and the clean dishes, or the food being prepared and the clean dishes. -There was a toaster and package of bread on the island counter next to the clean dishes and where the food was being prepped. -The island counter was cluttered which made little room for food preparation. -At 9:42 AM, Cook-B had begun to cut bones out of pieces of chicken and had removed the skin. The bags of chicken were sitting on a baking sheet that was filled with blood and was sitting next to clean dishes, a toaster, and a loaf of bread that was sitting on the island. Cook-B had placed pieces of chicken on two other baking sheets that were sitting on the island counter and were resting against the two buckets that were filled with soapy water and sanitizing water, in addition, a box of gloves sitting next to the buckets and pans of chicken. -At 10:20 AM, the two filled buckets of sanitizing and soapy water had not been moved and the pans remained sitting up against them while Cook-B covered the pieces of chicken with BBQ sauce. -At 10:31 am Dietary Aide (DA)-D used the handwashing sink to fill a pitcher with water and used it to fill the resident's cups that were being prepared for lunch. -At 11:31 AM Cook-B was trying to open a large plastic pan liner and it was touching the front of their clothing. When Cook-B had placed the plastic liner in the pan, their clothing was touching the inside of the liner. -Both cleaning buckets were on the food prepping counter/island next to the vegetable sink throughout the lunch meal preparation. In an interview, on 7-25-2023 11:31 AM with Cook-B revealed the buckets sitting on the food prepping counter, next to the vegetable sink were filled with soapy water and sanitizing water. Cook-B confirmed the two cleaning buckets normally sit on the island counter where they prepare food. Cook-B also confirmed the pans of chicken were sitting against the buckets filled with soapy and sanitizing water as well as, near the clean dishes that sat on the counter to dry. A tour of the kitchen on 7/25/23 at 10:45 AM with the Dietary Supervisor (DS) confirmed the same findings as the initial tour that was conducted on 7/19/23 at 1:25 PM except for the three trays of clean drink cups had been moved away from the handwashing sink. DS revealed the dietary staff were not supposed to use the handwashing sink to fill pitchers with water and then pour it into residents' cups.

Licensure Reference Number 175 NAC 12.006.14 Based on record review, observations, and interviews, the facility staff failed to ensure 1(Resident 2) of 3 sampled residents received routine dental services. The facility staff identified a census of 25 residents at the time of the survey. Findings are: An interview with Resident 2 on 7/19/2023 at 2:42 PM revealed Resident 2 was concerned about their teeth. Resident 2 explained the facility staff had transported them to a dentist who Just broke my teeth instead of pulling them. Resident 2's teeth were sore, and they were concerned about an infection. Resident 2 said they can barely eat as they cannot chew. Resident 2 had reported their concerns to Social Services Coordinator (SSC)-A who arranges appointments, however, Resident 2 did not have a scheduled dental appointment. Resident 2 indicated Resident 2 was told there was nothing they (the facility) could do. An observation of Resident 2's mouth on 7/19/2023 at 2:42 PM revealed the bottom front to the bottom right side of their jaw had teeth that were flat to the gum line and appeared to have been shaven/filed down as they were perfectly flat on the top. All the flattened teeth were brown, black, and cream-colored. Record review of Resident 2's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 5/29/2023 revealed they had a Brief Interview for Mental Status (BIMS-a tool used to assess cognitive function) score of 14. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. An interview with the Director of Nursing (DON) on 7/25/2023 at 4:17 PM revealed the facility had taken Resident 2 to a dentist a while back. The DON was aware Resident 2's teeth were shaved down and flush with their gum line and said the dentist had thought it would not be reasonable to pull all of Resident 2's teeth that needed to be pulled due to their age. However, the dentist did extract two of the Resident's teeth at that time. The dentist had said Resident 2's teeth had a lot of decay. The DON revealed they had not checked with another dentist to get an appointment scheduled for Resident 2. Record review of the facility's, Clinic Referral (for visits to doctor or hospital outpatient) with a date of 8/31/2022 revealed Resident 2 had been seen by the dentist for a follow-up visit. The dentist had removed three necrotic teeth (numbers 8, 9, and 10) during the appointment. Resident 2 had seen the dentist for a follow-up appointment on 10/6/2022 and they had completed the removal of two grossly decayed and chronically infected teeth (numbers 5 and 6). A record review of Resident 2's Progress Notes (PN) with a date of 7/20/2023 and a time of 4:38 PM, revealed that SSC-A had visited the resident who had asked SSC-A if it were true that there was only one dentist they could go to. SSC-A had told Resident 2 there was only one dentist in their area who accepted NE Medicaid. Resident 2 explained they did not like that dentist because Resident 2 thought they had broken their teeth off. SSC-A explained Resident 2's teeth had broken off due to their age, hygiene, and diet. Resident 2 had requested to see a different dentist during their conversation. An interview with the Administrator on 7/25/2023 at 11:00 AM confirmed Resident 2 and their POA had concerns about dental services and potential related to Resident 2's teeth. The Administrator revealed Resident 2 had not been to a dentist since August 2022. An Observation of Resident 2's teeth on 7/25/2023 at 11:00 A.M. with the Administrator and MDS revealed the same findings as the observation on 7/19/2023 at 2:42 PM. Resident 2 had verbalized they were concerned about an infection in their teeth and wanted them taken care of. A record review of the facility's Dental Services policy with a date of 1/7/2023 revealed the facility assists residents in obtaining routine (to the extent covered under the state plan) and emergency dental care. Under Policy Explanation and Compliance Guidelines, number 1 b. Oral care shall be provided in accordance with identified needs and as specified in the plan of care. 3. The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost. 4. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, interviews, and record review; the facility kitchen failed to ensure food items stored in two of the refrigerators had open dates and labels. The facility had a census of 26 residents and the sample size was 12. Findings are: An observation on 06/06/22 at 04:00 PM during the initial tour of the facility kitchen revealed that several food and liquid items were open in the walk-in refrigerator without being labeled with an open date. An observation on 06/07/22 at 09:45 AM with the Dietary Service Manager (DSM) revealed that several food and liquid items were opened in the walk-in refrigerator without a label of an open date. An interview on 06/07/22 at 09:50 AM with DSM confirmed that several food and drink items were not dated upon opening. On 06/08/2022 a review of the facility Policy dated 07/07/09 for Perishable Food Storage revealed that; All foods are to be dated and properly labeled. Review of the 07/21/2016 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: Packaged food shall be labeled as specified by law.

Based on observation, record review, and interview; the facility failed to ensure 1) a prescription label matched a current physicians order for one of four sampled residents (Resident 24) to reduce the risk of a potential medication error and 2) ensure a medication cart was not left unlocked while unattended. The facility identified a census of 26 at the time of survey. Findings are: License Reference Number 175 NAC 12-006.12E7 A. Observation of medication administration on 6/7/2022 at 09:15 AM, revealed the label on Resident 24's [MEDICATION(S)] Flex Touch Insulin pen (used to treat high blood sugar) did not match the current physician's order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN-A (Registered Nurse) on 6/7/2022 at 09:23 AM, revealed the facility protocol is to call the pharmacy if there is a discrepancy between the label on a medication and the active order, so a new label can be received and placed on the medication. RN-A confirmed the medication label on Resident 24's [MEDICATION(S)] insulin pen did not match the order on the MAR. RN-A stated, I know the order is right. RN-A did not call the pharmacy at that time with the discrepancy and proceeded with administering 25 units of [MEDICATION(S)] to Resident 24. Record review of Resident 24's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy, Administering Medications dated 4/2019, stated that the individual administering medication is to check the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. Further review of the facility policy, Labeling of medication containers stated that any medication packaging or containers that are inadequately or improperly labeled are to be returned to the issuing pharmacy. License Reference Number 175 NAC 12-006.12E1 B. Observation of RN-A administering medications on 6/7/2022 at 09:15 AM revealed RN-A passing medications to a resident and had left the medication cart unlocked and unattended. The medication cart was left parked across from the nurse's station as RN-A walked down the hallway to Resident 24's room (room [ROOM NUMBER]). RN-A entered Resident 24's room and the medication cart was not within the nurse's line of vison. Interview with RN-A on 6/7/2022 at 09:26 AM, confirmed the medication cart was left unlocked, unattended, and not within the RN-A's line of sight. Review of the facility policy, Administering Medications dated 4/2019, stated that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The medication cart must be clearly visible to personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Further review of the policy under the section titled, Security of Medication Cart revealed the nurse must secure the medication cart during the medication pass to prevent unauthorized entry.

Licensure Reference Number: 175-NAC 12-006.11E Based on observation and interviews, the facility failed to date and label an open bag of chicken breasts and hot dogs. These failures had the potential to affect all residents. Facility census was 22. Findings are: Kitchen observation upon entry on 02/03/21 at 10:38 AM revealed an open bag of chicken breasts and an open bag of hot dogs in the walk in freezer, located by the pantry that had not been labeled or dated. Staff interview on 02/03/21 at 10:45 AM with the Dietary Manager verified there was an open bag of chicken breasts and an open bag of hot dogs in the walk in freezer located by the pantry. The Dietary Manger confirmed these items should have been dated and labeled. Staff interview on 02/09/21 at 11:50 AM with the Administrator verified there was an open bag of chicken breasts and an open bag of hot dogs located in the walk in freezer located by the pantry. Review of the 07/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 3-201.11(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 Labeling and Containers, and as specified under 3-202.17 and 3-202.18.

Based on observations, interviews, and record review; the facility failed to 1) ensure that the insulin pen (a device used for injecting insulin under the skin) was primed (the practice of ejecting a small amount of insulin before administering a dose to ensure air bubbles are removed and the needle is open and working) before administration of insulin to ensure the correct dose was given to one sampled resident (Resident 19), and 2) ensure that the Daily Narcotic Count Sheet was signed by both the on-coming and off-going nurse at each change of shift to ensure narcotics were accounted for for 12 sampled residents ( Residents 1, 3, 7, 9, 10, 11, 12, 17, 19, 20, 21, 23) and 5 non-sampled residents (Residents 8, 13, 14, 15, and 16). Facility census was 22. Sample size was 13. Findings are: A. Licensure Reference Number 175 NAC 12-006.12A On 2/4/21 at 9:53 AM, observation of RN (Registered Nurse)-A revealed that when preparing to administer [MEDICATION NAME] Insuin using an insulin pen for Resident 19 the RN did not prime the pen. An interview with RN-A revealed their practice was to dial the correct dose on the pen and ensure the full amount was injected by watching the dial on the side of the pen. At 10:05 AM, the DON (Director of Nursing) was called to join the interview, RN-A verified they did not prime the insulin pen before administering insulin to Resident 19. At 10:45 AM, the DON verified that the facility policy showed it was necessary to prime the pen to ensure the full dose of insulin was administered. Review of the facility's Insulin Pen policy revealed, Insulin pens will be primed as the manufacturer recommends. The policy included instructions to dial 2 units by turning the dose selector clockwise, and with the needle pointing up push the plunger watching to see that at least one drop of insulin appeared on the tip of the needle. If no insulin appeared, the instruction stated to repeat this process until at least one drop appeared. The Medication Administration Record [REDACTED]. B. Licensure Reference Number 175 NAC 12-006.12E1b On 2/8/21 at 3:54 PM, observation of the facility's medication cart with LPN (Licensed Practical Nurse)-B revealed that the Daily Narcotic Count Sheet had not been signed to verify that the count of narcotics was correct at change of shift that morning when LPN-B began work. An interview with LPN-B verified that a count of the narcotics had been made and was correct at that time, but LPN-B acknowledged that neither nurse had signed the sheet to verify that this was done. In addition, it was noted that on 2/1/21 and 2/2/21 the count at 6:00 AM was only signed by the on-coming nurse. On 2/8/21 at 4:00 PM, this concern was reviewed with the facility's DON and RN-C who was the facility's MDS nurse and was familiar with the facility's policies. Both nurses verified that facility policy required both nurses to sign immediately when counting the narcotics at change of shift. Both acknowledged that there were no signatures for the 6:00 AM shift change on 2/8/21 and that there was only one signature at that time on 2/1/21/ and 2/2/21. Review of the facility's Controlled Substances policy showed, Nursing staff must count controlled medications at the end of each shift. Review of the Individual Resident's Narcotic Record sheets kept in the book with the Daily Narcotic Count Sheet showed that medications for 12 sampled residents ( Residents 1, 3, 7, 9, 10, 11, 12, 17, 19, 20, 21, 23) and 5 non-sampled residents (Residents 8, 13, 14, 15, and 16) were in the cart on 2/8/21 and should have been counted and signed to verify that those medications were accounted for at 6:00 AM.

Licensure Reference Number 175 NAC 12-007.04B Based on observation and interview, the facility failed to maintain hot water to accommodate resident comfort for 1 sampled resident (Resident #17.) Facility Census was 22 residents. Sample size was 13 current residents. An observation on 02/03/2021 at 03:40 PM in Resident #17's bathroom located in room [ROOM NUMBER] revealed the hot water temperature was 96.3 degrees Farenheit. An observation on 02/08/2021 at 04:46 PM in Resident #17's bathroom located in room [ROOM NUMBER], revealed the hot water temperature was 82 degrees Farenheit. An interview on 02/08/2021 at 04:46 PM with the Administrator verified the hot water temperature was cold at 82 degrees Farenheit which was colder than the original temperature taken on 02/03/2021.

Licensure Reference Number: 175 NAC ,d+[DATE].09D7 Based on record reviews and interviews, the facility failed to ensure that anti tipping devices were installed correctly on the wheelchair to prevent the wheelchair from tipping backward for one sampled resident (Resident 1) who fell backwards in the wheelchair and sustained a head injury. The facility census was 23 with two current sampled residents and one closed record reviewed. Findings are: Review of the facility Accidents report, dated [DATE], revealed that on [DATE] Resident 1 fell backward in the wheelchair and sustained a head injury. The resident was transferred to the hospital for evaluation and treatment. Further review revealed that Equipment/Causal factor potentially involved was that the anti-tippers on the wheelchair were placed too far up and did not prevent the wheelchair from falling backwards. Review of Resident 1's Care Plan, goal date [DATE], revealed that the resident was a high risk for falls related to an amputation of the right leg, poor vision, weakness to the left leg and decreased ability to perform activities of daily living functions. Further review revealed that the resident was able to propel self in the wheelchair and needed the assistance of staff for longer distances. Review of the Rehabilitative Nursing Program Evaluation, dated [DATE], revealed that the resident was mobile per regular wheelchair and was able to propel self with occasional staff assistance. Further review revealed no documentation of the anti tipping devices on the wheelchair, including the need for the devices or that they were evaluated to ensure that they were installed correctly to prevent the resident from falling backwards. Interview with the Maintenance Director on [DATE] at 11:15 AM revealed that anti tipping devices needed to be installed correctly on wheelchairs to ensure that they function properly to prevent the wheelchair from tipping backwards. Interview with the Administrator on [DATE] at 12:15 PM confirmed that wheelchair safety assessments needed to be completed. The Administrator confirmed that the assessment needed to include the resident's need for added devices and ensure that the devices were installed properly to promote safety for the resident including the risk for falls and injuries. Further interview revealed that the resident returned to the facility on [DATE] and expired on [DATE].

Licensure Reference Number: 175 NAC 12-006.04D2a Based on record review and interview, the facility failed to ensure the Dietary Manager met the required qualifications. The failure could affect all residents receiving meals from the facility kitchen. Facility census was 25. Findings are Staff interview on 10/15/19 11:07 p.m. Administrator verified the Dietary manager did not have the required credentials for the Dietary Manager portion of the job. Administrator reported the Dietary Manager being enrolled in a food service management course but was unclear of the completion date. Record review of the Dietary Managers employee records verified the Dietary Manager did not have the regulator required training to meet the required credentials.

Licensure Reference Number: 175 NAC 12-006.12E1b Based on record review, and interviews, the facility failed to ensure narcotic inventory sheets were signed to verify accuracy of the count at the time of shift change. The failure could potentially result in misappropriation of narcotics for 10 sampled residents (Residents 3, 17, 5, 16, 13, 19, 1, 15, 7, and 18) and 6 non-sampled residents (Residents 10, 25, 4, 9, 8, and 14). Sample size was 14 current residents. Facility census was 25. Findings are: On 10/16/19 at 12:08 PM during an observation of medication administration by RN (Registered Nurse)-C, review of the Individual Resident's Narcotic Record which RN-C signed revealed this form had not been signed by two nurses at 5:30 AM that day when change of shift occurred and the responsibility for the narcotics passed from the night shift charge nurse to the day shift nurse. An interview with RN-C and review of the Narcotic Book with that nurse verified that the night shift nurse had signed each Individual Resident's Narcotic Record at least once before leaving the facility but RN-C had not signed to verify that the narcotic count for each medication was correct although the count had been made at 5:30AM. Review of the facility's Controlled Substances Policy Statement showed that Nursing staff must count controlled medications at the end of each shift, and The nurse coming on duty and the nurse going off duty must make the count together. On 10/16/19 at 12:28 PM, the Narcotic Book was reviewed with the facility's DON (Director of Nursing) who verified that the day shift nurse had not signed any Individual Resident's Narcotic Record sheets for the day to document that the count was made at the change of shift and that the count was correct. The DON verified that this should be done at the time the count was made. The DON provided copies of all the Individual Resident's Narcotic Record sheets to document this concern.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and staff interview, the facility failed to identify increased risk factors for falls and change interventions to reduce the risk for falls for one sampled resident (Resident 1). The facility census was 27. Findings are: Review of the admission sheet revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical, dated 4/21/13, revealed that the resident presented with left hip pain and fracture after a fall in the nursing home. Further review revealed that the resident had left hip surgery in February and right hip surgery in March to repair fractures. Review of the "Care Plan", goal date 6/6/13, revealed that on 4/2/13 the resident started taking "Ambien" (Hypnotic) every night for insomnia and on 4/17/13 the resident started taking "Ativan" for increased anxiety. Further review revealed no changes in the care plan to address the resident's increased risk for falls related to the use of these medications. Review of the "Interdisciplinary Notes", dated 4/20/13 at 11:50 PM, revealed that the resident was found on the floor in room on left side. Further review revealed that the resident's left leg was internally rotated and the resident complained of left leg pain. The resident was transferred to the emergency room for evaluation and was diagnosed with [REDACTED]. Interview on 6/5/13 at 2:30 PM with the Administrator and the Interim Director of Nursing confirmed that the resident was a high risk for falls due to history of multiple hip fractures, increased confusion, increased anxiety, and the addition of the psychotropic medications. Further interview confirmed that the staff did not identify the resident's increased risk for falls or change care plan interventions to reduce the risk for falls.