Every finding on record at Hilltop Estates

Licensure Reference Number 175 NAC 12-006.11(E) Based on record review, observation, and interview, the facility failed to perform handwashing when working with foods, failed to perform temperature checks of the facility's kitchen refrigerator and freezer units, and failed to maintain potentially hazardous foods at the appropriate temperature. This affected all residents in the facility. The facility census was 39. A. Record review of the facility policy Hand Hygiene dated June 2022 revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel residents and visitors. This applies to all staff working in all locations with in the facility. Hand Hygiene is defined as a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol based hand rub. 1.) Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. 6.) Additional considerations include; a.) the use of gloves does not replace hand hygiene. If you task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Observation of the facility cook (Cook-D) on 6/16/26 during the period of 10:15 AM to 10:42 AM revealed Cook-D used gloves during the preparation of the meat and broccoli. Cook-D put on gloves and removed a pan of meat from the oven. When Cook-D finished removing the meat from the pan and transferring to another one, Cook-D removed gloves from both hands and continued to work without performing hand hygiene.Observation of Cook-D on 6/16/26 12:05 PM to 12:55 PM in the kitchen while the noon meal was served revealed: -Cook-D washed both hands with soap and water prior to starting the meal service and filled several dishes of food. Cook-D used separate tongs for the meat/vegetable dish, the noodles, and the bread. -At 12:14 PM Cook-D went to the refrigerator to obtain prepared sandwiches. Cook-D put a glove on the left hand only, obtained and prepared a plate with a ham and cheese sandwich and chips, and handed this to the dietary aide through the dining room service window. Cook-D removed the glove from the left hand, put the used glove on the counter approximately two feet away, and prepared more plates for meal service without hand hygiene. -At 12:18 PM, Cook-D donned a glove on the left hand, fixed a hamburger, removed the glove and put it next to the other glove on the counter approximately two feet to the left with the glove discarded earlier. Without the benefit of hand hygiene, Cook-D added a small amount of the main meal to the resident's plate. Cook-D continued to prepare more plates for the residents in the dining room. -At 12:27 PM, Cook-D donned a glove on the right hand only, prepared a plate of hamburger and chips and gave the plate to DA-C. Cook-D did not perform hand hygiene and continued to prepare more plates for service. -At 12:39 PM, Cook-D was told one resident wanted a peanut butter and jelly sandwich. Cook-D removed the plastic from the container with the already prepared sandwiches, removed a sandwich with their bare hands, and prepared the plate and handed it to DA-C. -At 12:43 PM, Cook-D was told one resident wanted a ham and cheese sandwich, removed a ham and cheese sandwich from the container of sandwiches with bare hands, prepared the plate with chips. -At 12:46 PM, Cook-D was informed another resident wanted 2 ham sandwiches, Cook-D removed 2 ham sandwiches from the container of sandwiches with bare hands, and prepared the resident's plate.Interview with Cook-D on 6/16/26 at 11:05 AM confirmed they had not washed hands after donning and doffing gloves when working with the meat and should have.In a confirmation interview with the DM on 6/16/26 at 1:05 PM, confirmed that hand hygiene must be followed during meal service and while preparing foods in the kitchen.B. Record review of the policy titled HACCP and Food Safety with a copyright date of 2013 it was revealed that facility staff will be well trained on food safety policies and procedures. Supervisors will monitor staff and correct any problems or concerns at the time they occur. The food service manager will implement a food safety system to prevent food borne illness. (A food borne illness is an illness that is transmitted to humans through food.) The US Department of Health and Human Services Food Code uses 41 degrees Fahrenheit (F) for cold foods and 135 degrees F for hot foods. Record review of the dietary staff meeting notes dated 6/8/26 received from the Dietary Manager (DM) revealed;Cooks were told they had to start temping out food, charting it, temp it again before serving, especially the room trays.Survey (mandated yearly state survey of the facility by the department of health and human services) can be any day now so keep yourself prepared by doing things the right way at all times, then there will be no bad habits to break when they get here.Attached to the written notes was information that had been used for training that revealed the temperatures which foods need to be maintained (41 degrees F or below for cold foods and 135 degrees F for hot foods. There was also information pertaining to Food Code implementation and foodborne illness risk factor reduction.Record review of the walk-in freezer temperature logs for the month of June 2026 (which was labeled March 2025 at the top of the page) revealed that freezer temperatures were not logged on 6/6/26, 6/7/26 or the morning of 6/9/26.Record review of the walk-in refrigerator temperature logs for the month of June 2026 (which was labeled March 2025 at the top of the page) revealed that refrigerator temperatures were not logged on 6/6/26, 6/7/26 or the morning of 6/9/26.In an interview with the Dietary Manager on 6/10/26 at 9:10 AM it was revealed that the facility uses and follows the US Department of Agriculture Food Code while working with foods and in the kitchen. The DM also confirmed there were missing temperature recordings for the daily refrigerator and walk-in freezer temperature checks from the past weekend 6/6-7/26 and on 6/9/26.C. Observation of Cook-D on 6/16/26 12:05 PM to 12:55 PM in the kitchen while the noon meal was served revealed: -At 12:31 PM, Cook-D checked the temperature of the beef and broccoli and it measured 105 degrees Fahrenheit (F). Cook-D did not check the temperature of the noodles. The foods were handed to DA-C who delivered the food to the table. -At 12:50 PM [NAME] -D finished serving the meal and did a temperature check of the foods that remained. Foods remained above 135 degrees on the steam table. In an interview with COOK-D at 12:31 it was confirmed that the temperature of the meat/broccoli dish was 105 degrees F and that the noodles were not checked for temperature. Cook-D further confirmed the meal was served to the resident at that time without rewarming.In a confirmation interview with the DM on 6/16/26 at 1:05 PM it was confirmed that the facility does follow the USDA Food Code. The DM further confirmed hot foods are to always be above 135 degrees F during the service of the meals.

Licensure Reference Number 175 NAC 12-006.11Based on record review, observation, and interview the facility failed to follow the menus and recipes to ensure that residents were receiving the required nutritional intake during meals. This affected all residents eating meals from the kitchen. The facility census was 39. Record review of the facility policy The Dining Experience; Staff Responsibilities copyright dated 2013 revealed the goals of the dining experience are to enhance the individual's quality of life through person centered dining: providing nourishing, palatable, and attractive meals that meet the individual's daily nutritional needs. The food service manager will perform meal rounds routinely to determine if the meals are timely, attractive, nutritious, and meet the needs of the individual. The food service manager will observe meals for preferences portion sizes, temperature, flavor, variety, and accuracy. The food service manager will report any concerns to the administrator, nursing director, registered dietician or designee, or other staff as appropriate. Food will be the proper texture/consistency to meet each individuals' needs and desires. Under the subheading portion control the serving utensils were described; a #8 scoop is 1/2 cup or 8 ounces.Record review of the Certified Dietary Manager certificate for the Dietary Manager (DM) revealed that the DM was certified on 7/2/24 and continued to be certified as a Certified Dietary Manager for the facility. Record review of the menu posted for 6.16.2026 revealed the dietary staff was to serve beef and broccoli stir fry with fettuccine noodles, buttered bread roll, soft brownies, and a beverage for the noon meal. A. Record review of recipes received from the Dietary Manager (DM) on 6.16.26 revealed the recipes for beef and broccoli stir fry, soft fried noodles, mini egg rolls, and brownies.In an interview with the DM on 6.16.2026 at 10:12 AM, it was revealed the DM had substituted buttered bread rolls for the egg rolls because nobody liked the egg rolls that I ordered. The DM did not indicate this was an approved substitution from the Registered Dietician.In a confirmation interview on 6.16.26 at 11:20 AM, the DM confirmed that the egg rolls which were to be served were not served and that dinner rolls which had been cooked the day before would be served to the residents.In an interview on 6.16.26 at 1:15 PM, the Administrator (Admin) confirmed that menu substitutions needed consent from the Registered Dietitian, especially the buttered dinner rolls for the egg rolls which were completely different in the nutritional makeup of the foods.B. Record review of the recipe for the brownies received from the DM revealed the only ingredients in the brownie recipe were brownie mix and water. There was no butter called for in the recipe.Observation on 6.16.26 at 10:15 AM revealed brownies that resembled a dump cake with dry ingredients on top.In an interview with the facility cook (Cook-D) on 6.16.26 at 10:15 AM, it was revealed Cook-D had worked at the facility for 18 months and worked only in the kitchen. Cook-D revealed that the dessert for the day was already completed and that Cook-D had used too much butter when the brownies were prepared and so had merely sprinkled more cake mix on the top of the dessert.C. Record review of the recipe of the stir-fried noodles revealed the following recipe requirements for 30 servings:1 pound 13 ounces of dry fettucine pasta1 gallon 3 quarts of water2/3 cup of oil4 3/4 ounce fresh green onion minced1 1/4 teaspoon (tsp) black pepper4 tablespoon (Tbl) soy sauceThe noodles were to be cooked in lightly salted water and cooked until tender. The oil was to be heated in a wok or heated frying pan, and the green onions were to be added and sauteed for 5 minutes. The noodles were to be added slowly while gently stirring the noodles until they were lightly browned and crisp on the outside and seasoned with pepper and soy sauce.Each serving consisted of using a #8 or 1/2 cup serving size per person.Observation on 06/16/2026 10:20 AM of the meal preparation by the facility cook (Cook-D) revealed Cook-D opened 4-16 ounce boxes of Fettuccine noodles, emptied the contents into a large rectangular cooking container, took the container to the sink and ran an unmeasured amount of hot water into the pan with the noodles and placed the pan in the steam oven to cook the noodles at 10:25 AM. The noodles were removed from the steam oven at 10:59 AM, drained, and returned to the rectangular cooking pan. Cook-D poured an unmeasured amount of vegetable oil onto the noodles, stirred the noodles, placed a plastic wrap over the noodles, and placed the covered noodles in a hotbox until time to serve the meal. In a confirmation interview on 6.16.26 at 11:05 AM, Cook-D confirmed that there was nothing added to the water and the pasta during or after it was cooked. D. Record review of the beef and broccoli stir-fry recipe revealed that the recipe called for the following ingredients - among others- to make 48 servings:12 pounds of beef stew meat10 pounds of broccoli florets frozen7 onions1 quart and 2 cups of waterAfter the meat and vegetables were cooked, a mixture of soy sauce, brown sugar, cornstarch, ginger and water was to be added to the meat and broccoli prior to serving and brought up to a final temperature of at least 165 degrees Fahrenheit (F).The resulting serving size was 2-#8 scoops for a total of 1 cup of the meat dish.Observation on 06/16/2026 10:25 AM of the meal preparation by the facility cook (Cook-D) revealed Cook-D removed the beef from the oven and transferred the beef to another large rectangular baking pan and covered with plastic and placed in a hot box until ready for further preparation. Cook-D then poured oil into a large wok/frying pan on the stove and added 6 pounds of broccoli to the pan and 2 small, sliced onions and began to fry the vegetables. Once the vegetables were heated and fried to the point of tender, Cook-D added the beef to the vegetables and cooked everything together, stirring occasionally. Cook-D added a soy sauce, brown sugar, ginger and cornstarch mixture that followed the recipe for the 48 servings to the mixture, brought this all to a temperature over 165 degrees F, covered the food and put this in a hot box to maintain temperature prior to serving. In a confirmation interview on 6.16.26 at 11:05 AM, Cook-D confirmed the beef and broccoli recipe used was for 48 people Cook-D further confirmed only 10 pounds of beef was cooked and the recipe required 12 pounds of beef, only 6 pounds of broccoli were prepared in the dish that required 10 pounds of broccoli, only 2 onions were used in the stir fry which required 7 onions, and that the required 1 quart and 2 cups of water had not been added to the stir fry which resulted in a very sticky meal consistency. E. Observation of Cook-D on 6.16.26 during the time period of 12:05 PM to 12:57 PM during the service of the meal, Cook-D prepared each plate for residents who received the beef and broccoli stir fry using tongs to measure a small amount of noodles and then another small amount of the meat and vegetables onto the noodles. The measurements were inconsistent in size and portion of both the noodles and the meat and vegetable mixture. A total of 32 plates of beef and broccoli stir fry were served to residents. All residents were served the brownie dessert.In an interview on 6.16.26 at 1:15 PM, the Administrator (Admin) confirmed that by not following the recipes that the residents had definitely not received the required amount of protein for each resident. The Admin further confirmed that meat and vegetable portions were not appropriate and that residents needed the appropriate nutritional intake of proteins, vegetables, etc. The Admin reported there was no excuse for facility staff to not follow the recipes.

Licensure Reference Number 175 NAC 12-006.05 (D)(E)Based on record review and interview the facility failed to ensure that all residents and/representatives were given the risks and benefits of psychotropic medications prior to the first dose of a medication or when the psychotropic medication dosage was increased. This affected 3 of 5 sampled residents (Resident 2, 21, and 26). The facility census was 39. Record review of the facility policy dated 6/2026 revealed that it is the intent of the policy to ensure residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A chemical restraint was defined as any drug that is used for discipline or makes it more convenient for staff to care for a resident and not required to treat medical symptoms. Adequate indications for use were defined as the identified and documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. The policy stated that a psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.In a confirmation interview with the Director of Nursing (DON) on 6.15.26 at 10:20 AM, it was revealed that there were no Consents for the Use of Psychotropic Medications found in the files of Residents 21, Resident 26 or Resident 2 while performing resident chart audits prior to the survey. The DON confirmed that (gender) had been the facility DON for one year. Although nursing staff do call the families to let them know of medication changes these forms were not completed prior to 6.3.2026. When it was discovered that the residents did not have these documents in their medical records, the facility staff contacted all the Power's of Attorney (POA) for these residents and received telephone consents. Then a copy of the Consent for the Use of Psychotropic Medications form was mailed to those POA's.A.Record review of the 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 6.5.26 revealed Resident 21 was admitted on 3.1.24, had a Brief Interview for Mental Status (BIMS - a brief screener that aids in detecting cognitive impairment) score of 15 (13-15 indicates a person is cognitively intact), had no rejection of cares, no wandering or behaviors in the 7 day look back time period, had a complex medical history that included non-Alzheimer's dementia, depression, major depressive disorder, and others, and took an antipsychotic medication and an antidepressant medication. The last Gradual Dose Reduction (GDR - stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) was completed on 5.27.25 and the physician had included a rationale stating that it was contraindicated to reduce the medication dosage of the psychotropic medications.Record review of the medication orders for Resident 21 revealed this resident had orders for the following medications: Abilify also known as aripiprazole (an antipsychotic medication used to treat various medical conditions including major depressive disorder) 5 milligram (mg) 1/2 tablet at bedtime used to treat depression started on 10.28.24; and Bupropion hydrochloride (an atypical antidepressant medication used to treat major depressive disorder) 150 mg at bedtime started on 9.19.25.Record review of the Consent for the Use of Psychotropic Medications form revealed a completion date of 6.3.26 in which telephone consent for the use of the medications for Resident 21 was received from this resident's POA. Potential side effects, available alternatives, benefits of the medications, the right to refuse treatment, the need for continued use of the above listed medication would be reviewed quarterly and as needed, consent could be withdrawn at any time, and questions had been asked and answered were all marked as discussed with the resident representative at the time of consent for the medications. The Consent for the Use of Psychotropic Medications form requested consents for the following medications:9.19.25 Bupropion hydrochloride extended release 150 mg every night for major depressive disorder recurrent moderate - an antidepressant depressant medication; and10.28.24 Abilify 5 mg 1/2 tablet every night for depression - an antipsychotic medication.B.Record review of the quarterly MDS dated 3.30.26 for Resident 26 revealed that this resident was admitted to the facility on 4.22.25, had severe cognitive impairment, was rarely understood, had rejection of cares and treatments 1 to 3 times a week in a 7 day look back period, antidepressant and antianxiety medications, had progressive neurological disorder, non-Alzheimer's dementia, severe malnutrition, restlessness, and agitation. Record review of the Progress Notes for Resident 26 revealed that the last GDR was completed on 5.27.26.Record review of the medications orders for Resident 26 revealed there were orders for the following medications:Risperidone (an atypical antipsychotic that can be used at times by healthcare providers to treat behavioral disturbances such as severe agitation and/or aggression associated with dementia) 0.5 mg twice a day for dementia with agitation started on 4.2.26;Lorazepam (a medication used for short-term relief of severe anxiety, anxiety associated with depression, or general anxiety disorders) 0.5 mg twice a day for restlessness and agitation and used as an antianxiety medication started on 5.21.26;Lorazepam 0.5 mg daily as needed for restlessness and agitation used as an antianxiety medication started on 5.21.26; andLorazepam 0.5 mg three times a day as needed for restlessness and agitation that was started 4.27.26 and ended on 5.21.26.Record review of the Consent for the Use of Psychotropic Medications form revealed a completion date of 6.3.26 in which telephone consent for the use of the medications for Resident 26 was received from this resident's POA. Potential side effects, available alternatives, benefits of the medications, the right to refuse treatment, the need for continued use of the above listed medication would be reviewed quarterly and as needed, consent could be withdrawn at any time, and questions had been asked and answered were all marked as discussed with the resident representative at the time of consent for the medications. The Consent for the Use of Psychotropic Medications form requested consents for the following medications:Risperidone 0.5 mg twice a day for dementia with agitation started on 4.2.26;Lorazepam 0.5 mg twice a day for restlessness and agitation and used as an antianxiety medication started on 5.21.26;Lorazepam 0.5 mg daily as needed for restlessness and agitation used as an antianxiety medications started on 5.21.26; andLorazepam 0.5 mg three times a day as needed for restlessness and agitation that was started 4.27.26 and ended on 5.21.26 was not included on the consent form as it had been discontinued prior to date of consent for treatment.C.Record review of the quarterly MDS dated 5.1.26 revealed that Resident 2 had a BIMS score of 15, no signs of hallucinations or delusions, no behaviors, no psychosis, no refusal of cares and no wandering in the 7 day look back period and received antidepressant and antipsychotic medications with indications for the medications, and took an antipsychotic medication regularly, had non-Alzheimer's dementia, depression, post-traumatic stress disorder (a psychiatric condition that can develop after experiencing or witnessing a life-threatening or terrifying event. People with PTSD experience persistent, frightening thoughts, severe anxiety, and flashbacks long after the traumatic event has ended, severely disrupting their daily lives), major depressive disorder, and other diagnoses. The last date for the GDR was completed on 4.6.26 with an indication for use.Record review of the physician orders for Resident 2 revealed that this resident received the following medications:Citalopram (an antidepressant medication) 40 mg daily for major depressive disorder started on 4.4.24; andAbilify 10 mg at bedtime for post-traumatic stress disorder and started 9.12.25.Record review of the Consent for the Use of Psychotropic Medications form revealed a completion date of 6.3.26 in which telephone consent for the use of the medications for Resident 2 was received from this resident's POA. Potential side effects, available alternatives, benefits of the medications, the right to refuse treatment, the need for continued use of the above listed medication would be reviewed quarterly and as needed, consent could be withdrawn at any time, and questions had been asked and answered were all marked as discussed with the resident representative at the time of consent for the medications. The Consent for the Use of Psychotropic Medications form requested consents for the following medications;Citalopram (an antidepressant medication) 40 mg daily for major depressive disorder started on 4.4.24; andAbilify 10 mg at bedtime for post-traumatic stress disorder and started 9.12.25.

Licensure Reference Number 175 NAC 12-006.09Based on record review, observation, and interview the facility failed to complete glucometer control testing per manufacturer recommendations for 2 residents (Resident 4 and Resident 6), Failed to provide cares of a PICC (peripherally inserted central catheter) line (a long, thin, flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart) per professional standards of practice for 1 resident (Resident 6), failed to follow provider orders for performing flushing of a PICC line for 1 resident (Resident 6), failed to ensure orders for the administration of an intravenous medication contained components directing reconstitution and duration of administration of administering an intravenous medication for 1 resident (Resident 6). The facility census was 39.Findings are: A.Record review of a document titled Assure Platinum Blood Glucose Monitoring System and dated 10/2024 revealed a control solution test should be performed when opening a new bottle of test strip to confirm the meter and test strips are working properly.In an observation completed on 06/15/2026 at 10:40 AM it was observed that stored in the medication cart were the supplies for obtaining blood glucose levels for residents including glucometers and bottles of test strips for residents in small plastic bins. The bin containing Resident 6's glucometer and test strips revealed that the bottle of test strips was labeled with the date of 06/10/2026.Record review of an undated facility document titled Glucometer Calibration and Quality Control Log on 06/15/2026 revealed Resident 6's name and dates listed of 11/02/2025, 03/09/2026, and 03/17/2026. Each date was followed by the resident's name, test strip lot number, expiration date, low control results, high control results, test solution information and the nurses initials. There was no date of 06/10/2026 with the subsequent information listed on the document.In an interview completed on 06/15/2026 at 10:40 AM with Registered Nurse A (RN-A), RN-A stated that a control solution test was completed using the resident's dedicated glucometer with the opening of each new test strip bottle. The RN stated the test strip bottle is labeled with the date that the bottle is opened and the information obtained when completing the control solution test is recorded on the Glucometer Calibration and Quality Control Log that is stored on the medication cart. The RN confirmed that Resident 6's test strip bottle was labeled with the open date of 06/10/2026 indicating that was the day the bottle was opened and the control solution test should have been performed and recorded on the log and was not.In an observation completed on 06/15/2026 at 11:20 AM it was observed that stored in a second medication cart were the supplies for obtaining blood glucose levels for residents including glucometers and bottles of test strips for residents in small plastic bins. The bin containing Resident 4's glucometer and test strips revealed that the bottle of test strips was labeled with the date of 06/13/2026.Record review of an undated facility document titled Glucometer Calibration and Quality Control Log on 06/15/2026 revealed Resident 4's name and date listed of 02/21/2026. The test strip lot number, expiration date, low control results, high control results, test solution information and the nurses' initials were also present. There was no date of 06/13/2026 with the subsequent information listed on the document for Resident 4.In an interview completed on 06/15/2026 at 11:20 AM with Medication Aide F (MA-F), MA-F stated that the control solution test is to be completed and recorded on the Glucometer Calibration and Quality Control Log when each bottle of test strips is opened. The MA confirmed that the bottle of test strips is labeled with the opened date. The MA confirmed that Resident 4's test strips were labeled with the date of 06/13/2026 indicating the bottle was opened on that date and there was no information recorded on the Log indicating that the control solution test was completed for Resident 4's test strips that were opened on 06/13/2026.In an interview completed on 06/15/2026 at 2:28 PM with the facility Director of Nursing (DON), the DON confirmed that the Glucometer Calibration and Quality Control Log is to be completed when a new test strip bottle is opened and was not for Resident 6 and Resident 4.B.Record review of a facility policy titled PICC line Dressing Change and dated 05/2026 revealed:-Set up a clean field on the overbed table with the needed supplies.-Open the sterile dressing change kit and lay out the sterile drape. Place supplies on the sterile field, being careful not to contaminate them.-Wash hands and put on clean gloves.-Remove the old dressing beginning at the device hub and gently pull the dressing perpendicular to the skin toward the insertion site.-Remove and discard gloves.-Perform hand hygiene and put on sterile gloves.-Use sterile measuring tape to measure the external length of the catheter the measure the circumference of the arm around the insertion site.-Clean the insertion site with the antiseptic using a side-to-side motion for at least 30 seconds.In an observation completed on 06/16/2026 at 10:45 am through 11:20 AM of RN-A completing a PICC line dressing change to Resident 6 the following was observed:-The RN placed the needed supplies on the resident's cleaned overbed table.-The RN opened the sterile dressing change kit and removed the sterile drape from the kit. The nurse used a fanning motion to open the sterile drape and placed it on the overbed table. (The RN did not place the drape down in a manner to prevent the risk of contamination)-The RN placed the resident's arm on the sterile drape with the other sterile items sitting on it potentially contaminating the items.-The RN removed the old dressing by beginning at the device hub, gently pulling the dressing from the outer positions to the innermost. (The RN did not remove their gloves, perform hand hygiene and place new gloves after opening the package, placing the drape and items, and positioning the resident's arm on the drape)-The RN then removed their gloves and discarded them, completed hand hygiene using an alcohol-based gel and applied sterile gloves.-The RN used a tipped application to cleanse the insertion site of the PICC line in the resident left upper arm. The RN used a wiping motion moving from the outer aspect of the resident's arm moving to the inner aspect of the arm. (The RN did not use a side-to-side motion working from the insertion site to the outer portion of the insertion site preventing the risk of cross contamination when cleansing the site. The RN did not measure the site with the sterile measuring tape prior to cleansing the site)-The RN picked up the sterile measuring tape from the draped table and unraveled the tape. The RN used the sterile measuring tape to measure around the resident's arm above the insertion site the sterile measuring tape meeting the residents' skin and then used the tape to measure the catheter length the measuring tape meeting the catheter. (The RN did not measure the site prior to cleansing the site. The RN allowed the sterile measuring tape to meet the residents' uncleansed skin contaminating the measuring tape and then placed the measuring tape directly on the cleansed catheter possibly contaminating the catheter)In an interview completed on 06/16/2026 at 11:20 AM with RN-A, RN-A confirmed that they used a fanning motion to open the sterile drape and should have handled it by only touching the outermost portion and laying it out on the overbed table. The RN confirmed that they did not complete hand hygiene and changed their gloves after opening the dressing change kit and placing the resident's arm on the table and should have. The RN confirmed that they should not have placed the resident's arm on the sterile drape on the table near the sterile items possibly contaminating them. The RN confirmed that they should have measured the residents' arm and catheter prior to cleansing the site and did not. The RN confirmed that they measured the uncleansed area of the resident's arm with the tape measure and then used the tape measure to measure the catheter possibly contaminating the catheter and should not have. The RN confirmed that they did not cleanse the site using the proper technique working from the cleanest portion of the site working to the dirtiest, decreasing the chance of contamination of the site. The RN confirmed that they did not complete the PICC line dressing change following the facility policy and in a manner that prevented cross contamination and should have.C.Record review of a facility policy titled Peripherally Inserted Catheter Flushing and dated 05/2026 revealed the facility will use a solution and flush Peripheral Inserted Catheters per facility protocol and providers orders. The policy stated peripherally inserted catheters will be flushed and aspirated for blood return prior to each infusion and after each infusion.In an observation completed on 06/11/2026 at 1:05 PM RN-A cleansed the blue capped end of Residents 6's PICC line with an alcohol swab. The RN screwed on a 10-milliliter syringe labeled 0.9% sodium chloride to the end of the catheter and pulled back on the syringe observing for Flash (blood presence in the catheter) and then injected/flushed the catheter with the sodium chloride. The RN then attached the intravenous medication line to the blue end of the catheter initiating the infusion of the intravenous medication into the blue line of the catheter.Record review of Resident 6's Orders for the month of June 2026 revealed the resident had an order listed as sodium chloride 0.9% 10 milliliter syringe with directions to flush both of Resident'6's lumens four times a day dated 05/27/2026.In an observation completed on 06/11/2026 at 3:03 PM RN-A entered Resident 6's room and observed that the intravenous medication bag was empty indicating all the medication had been infused. The RN unscrewed the intravenous medication tubing from the blue line of the catheter and screwed on a 10-milliliter syringe labeled 0.9% sodium chloride to the end of the catheter and injected the solution into the catheter. The nurse thanked the resident and exited the room.In an interview completed on 06/11/2026 at 3:05 PM with RN-A, RN-A confirmed that Resident 6 had orders for both lumens of their catheter to be flushed four times a day. The RN confirmed that Resident 6's catheter is flushed every 6 hours with the infusion of their intravenous medication. The RN confirmed that both lumens should be flushed and the RN did not flush both lumens as ordered by the provider.D.Record review of a document titled Nursing Rights of Medication Administration dated 09/04/2023 from www.ncbi.nlm.nih.gov revealed intravenous medication orders are highly specific instructions detailing how a drug is introduced directly into a patient's bloodstream. They are comprised of critical clinical components such as the exact drug, dosage, route, and rate and require strict adherence to safety.Record review of a facility policy titled Peripherally Inserted Catheter Flushing and dated 05/2026 revealed the nurse will obtain an order for the type of intravenous solution or medication including the dose, rate and length of treatment. Record review of a facility policy titled Medication Orders and dated 05/2026 revealed elements of the medication orders should include the type or formulation of the medication.Record review of Resident 6's Medication Administration Record (MAR) Orders for the month of June 2026 revealed the resident had orders for Unasyn (an antibiotic medication) 3-gram reconstitution solution to be infused every 6 hours until 06/21/2026. The order did not contain the amount of solution to be infused, the length of time the medication was to be infused over, and the rate at which the medication was to be infused.In an observation completed on 06/11/2026 at 1:05 PM RN-A cleansed the end of Residents 6's PICC line with an alcohol swab. The RN then flushed the line with 0.9% sodium chloride 10 milliliter syringe and then attached the intravenous medication line to the end of the catheter initiating the infusion of the intravenous medication into the line of the catheter.In an observation completed on 06/11/2026 at 1:05 PM of Resident 6's intravenous medication bag it was observed to be labeled with the pharmacy label stating Ampicillin/Sulbactam (Unasyn) 3 grams in normal saline 100 milliliters and to infuse the contents of the bag over 30 minutes at 200 milliliters per hour every 6 hours using gravity tubing.In an interview completed on 06/11/2026 at 3:05 PM with RN-A, RN-A confirmed that the MAR Orders for Resident 6's intravenous medication Unasyn did not contain the amount of solution to be infused, the length of time the medication was to be infused over, and the rate at which the medication was to be infused. The RN confirmed that the orders on the residents MAR and the order on pharmacy label on the resident's intravenous medication did not match. The RN confirmed that the order in the MAR should contain the amount of solution to be infused, the length of time the medication should be infused over and the rate at which the medication should be infused and did not.

Licensure Reference Number 175 NAC 12-006.09(c)(ii)Based on record review and interview the facility failed to complete a Significant Change 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) Assessment with in 14 days of a identified significant status change for 2 (Resident 6 and Resident 43) of 12 sampled residents. The facility census was 39.Findings are: Record review of a facility policy titled MDS 3.0 Completion and dated 05/2026 revealed it was the policy of the facility that residents are assessed using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan. A Significant Change Assessment (SCSA) should be completed within 14 days of the identification of a status change. A significant change is defined according to 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) as a decline or improvement in a resident's status that:-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and is not self-limiting.-Impacts more than one area of the resident's health status-Requires interdisciplinary review and or revision of the care plan.Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated 10/2025 revealed a (SCSA) is appropriate when:-A condition is not self-limiting (will resolve without clinical intervention within 2 weeks)-If there are either two or more areas of decline or two or more areas of improvement such as a change in Activities of Daily Living (ADL), residents decision-making ability, presence of a resident mood item not previously reported, resident incontinence pattern changes, unplanned weight loss, emergence of a new pressure related skin alteration (Stage 2 or higher), resident begins to use a restraint, emergence of a condition or disease in which a resident is judged to be unstable.A.Record review of a Face Sheet revealed that the facility re-admitted Resident 6 on 05/07/2026 with a diagnosis of osteomyelitis (an infection in the bone) of the right thigh, abscess (an enclosed pocket of infection that forms in the tissue) of the right lower limb and pressure-induced deep tissue damage of the sacral region.Record review of the Quarterly MDS assessment with the Assessment Reference Date (ARD) of 02/24/2026 for Resident 6 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10 and no alterations in mood. The resident used a walker and wheelchair for mobility throughout the facility. Staff provided set up or clean up assistance with eating, and partial moderate assistance with bed mobility, toilet use, and transfers. The resident was coded to be continent of both bowel and bladder and no unhealed pressure related skin alterations.Record review of the Annual MDS assessment with the ARD of 05/11/2026 for Resident 6 revealed the resident had a BIMS score of 6 (a decline from the previous assessment) and alterations in mood of little pleasure and interest in doing things several days (the prior assessment revealed no alterations in mood). The resident used a wheelchair for mobility throughout the facility (used a wheelchair and walker in the prior assessment). Staff provided partial to moderate assistance with eating, substantial or maximal assistance with bed mobility, and the resident was dependent on staff assistance for toilet use and transfers (the resident required more assistance from staff than the prior assessment). The resident was coded to be frequently incontinent of bladder and bowel (a decline from the prior assessment) and had an unhealed pressure-related skin alteration coded as a stage 2 (no pressure related skin alterations in the prior assessment). The resident was also coded to have a surgical wound and was receiving routine intravenous antibiotic medication.In an interview completed on 06/17/2026 at 2:30 PM with the Minimum Data Set Coordinator (MDSC), the MDSC confirmed that Resident 6 was readmitted to the facility on [DATE]. The MDSC confirmed that the resident had a change or decline in condition. The MDSC confirmed that Resident 6 changes met the definition of a significant change in status per the RAI Manual and a SCSA assessment should have been completed instead of the Annual assessment that was completed on 05/11/2026. B.Record review of Resident 43's Census record on 06/11/2026 revealed that the facility re-admitted resident 43 to the facility from a hospital leave.Record review of Resident 43's Progress Notes revealed documentation that the resident re-admitted to the facility following a surgical repair of a hip fracture.Record review of the admission MDS assessment with the ARD of 10/29/2025 revealed the resident had no coding indicating the resident had any behavior, and staff provided moderate assistance with bed mobility, toilet use and transfers. The resident was coded to be continent of bowel and bladder and no limitations to functional range of motion to either upper or lower extremities.Record review of the Quarterly MDS assessment with the ARD of 02/04/2026 revealed the resident was coded to have exhibited the behavior of rejection (a change from previous assessment), and staff providing substantial or maximal assistance with bed mobility (a decline from the previous assessment). The resident was coded to be dependent on staff assistance with toilet use and transfers (a decline from the previous assessment) and to have limitation in functional range of motion to one side on the lower extremity (a change from the previous assessment). The resident was also coded to be occasionally incontinent of bowel and bladder (a decline from the previous assessment).In an interview completed on 06/17/2026 at 2:30 PM with the Minimum Data Set Coordinator (MDSC), the MDSC confirmed that Resident 43 was readmitted to the facility on [DATE]. The MDSC confirmed that the resident had a change or decline in condition. The MDSC confirmed that Resident 43's changes met the definition of a significant change in status per the RAI Manual and a SCSA assessment should have been completed instead of the Quarterly assessment that was completed on 02/04/2026.

Licensure Reference Number 175 NAC 12-00.09 (D)Based on record review and interviews, the facility failed to accurately code 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) for 2 residents (Resident 6 and Resident 43) of 12 sampled residents. The facility census was 39.Findings are:Record review of a facility policy titled MDS 3.0 Completion dated 05/2026 revealed the facility according to federal regulations conducts accurate standardized assessment of each residents functional capacity using 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). It the policy of the facility to follow the guidelines of the RAI Manual for the coding of each assessment.A.Record review of Resident 6's Medication Administration Record for the month of February 2026 revealed that Resident 6 received Aspirin (a medication classified as an antiplatelet) 81 milligram tablet once daily every day. It was documented that the resident was administered the medication every day 02/17/2026 through 02/24/2026.Record review of the Quarterly MDS assessment with the Assessment Reference Date (ARD) of 02/24/2026 for Resident 6 revealed in section N0415 item I was not coded that the resident received an antiplatelet medication during the 7 day look back period (02/17/2026 through 02/24/2026) Record review of Resident 6's Medication Administration Record for the month of May 2026 revealed that Resident 6 received Aspirin (a medication classified as an antiplatelet) 81 milligram tablet once daily every day. It was documented that the resident was administered the medication every day 05/04/2026 through 05/11/2026.Record review of the Annual MDS with the ARD of 05/11/2026 for Resident 6 revealed in section N0415 item I was not coded that the resident received an antiplatelet medication during the 7 day look back period (05/04/2026 through 05/11/2026) In an interview completed on 06/17/2026 at 2:30 PM with the Minimum Data Set Coordinator (MDSC) the MDSC confirmed that Resident 6 received Aspirin an antiplatelet medication 05/04/2026 through 05/11/2026. The MDSC confirmed that the Quarterly MDS with the ARD of 02/24/2026 and the Annual MDS with the ARD of 05/11/2026 were not coded correctly in section N0415. The MDSC confirmed that the resident receiving an antiplatelet medication should have been coded on both MDS's.B.Record review of Resident 43's Treatment Administration Record (TAR) for the time period of 03/31/2026 through 04/06/2026 revealed documentation that the resident utilized a BiPAP (a noninvasive ventilator used to assist breathing) at night. Documentation was present that staff verified the use every bedtime.Record review of the comprehensive MDS dated [DATE] revealed in section O0110 item G2 BiPAP was not coded that the resident utilized this during the look back period (03/31/2026 through 04/06/2026)In an interview completed on 06/17/2026 at 2:30 PM with the MDSC, the MDSC confirmed that the comprehensive MDS with the ARD of 04/06/2026 was not coded correctly. The MDSC confirmed that residents' use of the BiPAP should have been coded on the MDS and was not.

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review, and interviews, the facility failed to dispose of items of regulated waste (items potentially or contaminated with blood or other potentially infectious material) in a manner consistent with manufacturer and facility policy for 2 residents (Resident 21 and Resident 6) of 2 sampled residents. The facility census was 39.Findings are:A.In an observation completed on 06/11/2026 at 7:50 AM of obtaining a blood glucose level by finger stick by Licensed Practical Nurse E (LPN-E) to Resident 21, LPN-E used a retractable lancet to poke Resident 21's finger. The LPN squeezed the resident's finger until a visible drop of blood was present. The LPN used a cotton ball to wipe away the visible drop of blood and squeezed the resident's finger until another visible drop of blood was present. The LPN touched the end of an Assure Platinum blood glucose test strip to the visible drop of blood. After a reading of the resident's blood sugar was obtained the LPN removed the test strip with the blood on it from the testing monitor. The LPN threw the test strip with blood on it and the cotton ball with the blood on it into the resident's trash can located beside the resident's bed.Record review of a facility policy titled Regulated (Biohazard) Medical Waste dated 02/26/2026 revealed the definition of regulated waste includes pathological and microbiological wastes containing blood or other potentially infectious materials. The facility will utilize single, leak resistant biohazard bags to contain regulated medical waste.Record review of a document titled Assure Platinum Blood Glucose Monitoring System and dated 10/2024 revealed all components that come into contact with blood samples should be considered to be biohazards capable of transmitting viral diseases between patients and healthcare professionals.In an interview completed on 06/11/2026 at 8:05 PM with LPN-E, LPN-E confirmed that the cotton ball and the test strips were potentially contaminated items due to having blood on them and should be disposed of following the facility policy.B.In an observation completed on 06/15/2026 at 1:05 PM Registered Nurse A (RN-A) prepared to administer an intravenous medication to Resident 6. The RN used an alcohol wipe to wipe off the catheter end of the residents double lumen PICC (a long, thin, flexible tube inserted into a vein in the upper arm extending to just above the heart) line. The RN connected a syringe containing 10 milliliters of sodium chloride to the cleansed catheter tip and attached the syringe by using a twisting motion. The RN depressed the plunger at the end of the syringe injecting the sodium chloride into Resident 6's PICC line. Once all of the solution was instilled the RN left the empty syringe attached to the PICC line and walked over to the IV pole. The RN prepared the IV solution to be administered to the resident. The RN returned to the resident with the syringe still attached to the PICC line and unscrewed the syringe from the end of the PICC line. There was visible red liquid substance in the syringe approximately 1/4 of the syringe. The RN threw the syringe containing the red liquid substance into the resident's trash can sitting on the floor beside the resident. The RN proceeded to complete the procedure for administration of the intravenous medication and left the resident's room.In an interview completed on 06/15/2026 at 1:20 PM with RN-A, RN-A confirmed that there was blood (red fluid) in the syringe and they should not have thrown it away in the resident's trash can. In an interview completed on 06/15/2026 at 3:30 PM with the facility Director of Nursing (DON), the DON confirmed that contaminated waste should not be disposed of in residents trash cans.

Licensure Reference Number 175 NAC 12-006.12(D)(vii)Based on observation, record review, and interview the facility failed to dispose and or destroy a medication in a manner in compliance with applicable state and federal requirements for 1 resident (Resident 21) of 3 residents. The facility census was 39.Findings are: In an observation completed on 06/11/2026 at 7:50 AM of medication administration by Licensed Practical Nurse E (LPN-E) to Resident 21, LPN-E emptied a packet labeled Questran Powder 4gm into a clear plastic cup containing approximately 4 ounces of water. The LPN stirred the powder into the water. The LPN took the cup with the powder dissolved into the water and a clear plastic cup containing the resident's pills into the resident's room. Resident 21 told the LPN that they did not wish to take the powder dissolved into the water medication until after breakfast or about 9:00 AM. The resident stated that they did not like to take that medication until after their meal and other medications. The LPN told the resident that was ok and took the cup with the dissolved powder medication and water into the residents bathroom and poured the substance into the resident's toilet and flushed the resident's toilet.Record review of a facility policy titled Destruction of Unused Drugs and dated 04/2026 revealed it was the facility's policy that drugs would be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. The policy stated that prescription drugs may not be flushed down the toilet in accordance with Environmental Protection Agency (EPA) regulations. Drug destruction was to be witnessed by 2 approved staff members, recorded on the medication destruction record, and placed into a drug disposal bottle.Record review of a document titled Information for Hospitals, Pharmacies and other Businesses that have Medicines to Dispose dated 01/22/2026 from https://www.epa.gov/ revealed the EPA prohibits sewering (flushing down the sink or toilet) of pharmaceuticals. In an interview completed on 06/11/2026 at 8:05 AM with LPN-E, LPN-E stated that the facility utilizes medication destruction bottles for disposal of medications. To dispose of medications the medication is to be recorded on the log and 2 staff sign off on the log as witnessing the medication being placed into the medication destruction bottle. The LPN confirmed that they did not dispose of the Questran Powder correctly and should have.In an interview completed on 06/11/2026 at 1:40 PM with the facility Director of Nursing (DON), the DON confirmed that LPN-E did not correctly destroy the prepared medication for Resident 21. The DON confirmed that the medication should not have been flushed down the toilet.

Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.04(A)(ii) Based on observation, record review, and interview the facility failed to ensure an insulin pen tip was cleansed prior to use for 1 (Resident 20) of 1 sampled resident, ensure the glucometer was disinfected after use for 1 (Resident 20) of 1 sampled resident, and failed to ensure an employee health screening was completed and reviewed for 2 of 5 sampled staff. The facility census was 44. Findings are: A. A record review of a facility policy titled Insulin Pen dated 01/2020 revealed to remove the cap from the insulin pen and wipe the rubber seal with an alcohol pad, then screw on the needle cap to the insulin pen. In an observation completed on 03/17/2025 at 11:50 AM, Medication Aide (MA)-D was preparing an insulin pen to administer insulin to Resident 20. MA-D removed the cap from the insulin pen with gloved hands. MA-D then screwed on the needle cap to the insulin pen. The MA did not cleanse the tip of the insulin pen with an alcohol wipe prior to screwing on the needle cap. The MA then administered the dose of insulin to the resident. In an interview completed on 03/17/2025 at 12:10 PM with MA-D, MA-D confirmed that they did not cleanse the tip of the insulin pen with an alcohol wipe prior to applying the needle cap. The MA confirmed that they should have cleansed the tip of the insulin pen with an alcohol wipe prior to applying the needle cap. In an interview completed on 03/17/2025 at 1:00 PM with the facility Director of Nursing (DON), the DON confirmed that MA-D should have cleansed the tip of the insulin pen with an alcohol wipe prior to applying the needle cap. B. A record review of a facility policy titled Glucometer Disinfection dated 08/16/2023 revealed that glucometers will be cleaned and disinfected after each use by using disinfectant wipes. In an observation completed on 03/17/2025 at 11:50 AM, MA-D used a glucometer to obtain Resident 20's blood sugar. MA-D then placed the glucometer back into a plastic drawer and placed the plastic drawer into the medication cart parked in the hall outside of Resident 20's room. The MA did not disinfect the glucometer by using disinfectant wipes prior to putting it away after using it to obtain Resident 20's blood sugar. In an interview completed on 03/17/2025 at 12:10 PM with MA-D, MA-D confirmed that they should have used a disinfectant wipe to cleanse the glucometer prior to placing it back in the drawer and returning it to the medication cart. In an interview completed on 03/17/2025 at 1:00 PM with the DON, the DON confirmed that the glucometer should have been cleansed with a disinfectant wipe prior to being placed back into the drawer and being returned to the medication cart. C. A record review of a facility supplied document titled Employee Health Checklist dated 11/22/2024 revealed the form being completed with MA-I's signature present on the document. No other signature was present on the form. Record review of Dietary Aide (DA)- J's employee file revealed no document present titled Employee Health Checklist. No other documents were present indicating an employee health screen was completed. On 03/17/2024 at 2:10 PM in an interview with Human Resources (HR), HR revealed that each employee is to complete the document titled Employee Health Checklist and this form is the employees' health screen. HR stated that they then review and sign the document verifying the employee has completed the health screen. HR confirmed that the Employee Health Checklist for MA-I was not signed indicating it had been reviewed by facility staff member and DA-J did not have the document present in their file indicating they had completed the employee health screen.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations and interviews, the facility failed to ensure the walk-through refrigerator maintained safe temperatures and failed to ensure the dishwashing machine reached the required temperatures during cycles to prevent the potential for foodborne illness. This had the potential to affect all facility residents eating out of the kitchen. The facility census was 44. Findings Are: A. A record review of the Nebraska Food Code, dated 2017, revealed ready to eat foods should be held at a temperature of 41 degrees Fahrenheit (F) or below. On 03/12/2025 at 8:44 AM an initial observation of the kitchen revealed a walk-through refrigerator with a temperature log labeled March with annotations of greater than 41 degrees F on the following dates: -On March 5th: 42, -On March 9th: 42, -On March 11th: 45. An observation on 03/12/2025 at 8:45 AM the reading outside of the walk-through temperature gauge revealed 44 degrees Fahrenheit. An interview on 03/12/2025 at 8:45 AM with the Dietary Manager-I (DM-I) revealed that the temperature reading on the refrigerator revealed a reading outside of the parameters for safe food handling and suggested that continuous in and out of the walk-through refrigerator was the reason for the increase in temperature. DM-I agreed to keep a watch on the temperature readings and stated they would recheck the gauges again shortly. On 03/12/2025 at 9:45 AM the facility Administrator (ADMIN) was interviewed on the walk-through refrigerator temperatures. The surveyor, DM-I and the ADMIN observed the refrigerator gauge outside of the walk-through refrigerator reading 46 degrees F. Upon entering the walk-through refrigerator, a zip-tie attached manual temperature (temp) gauge was observed reading 46 degrees F. An opened gallon of milk was taken out of the walk-through refrigerator and was poured into a cup and temped and observed to reach a maximum temperature reading of 56 degrees F. The ADMIN then threw away the milk and stated they would temp an unopened gallon of milk which was taken out of the walk-through refrigerator, poured into a cup and read a maximum temperature reading of 46 degrees F. The ADMIN then asked DM-I what a safe temperature reading would be for milk and other refrigerated products, upon which DM-I revealed 41 degrees F or below. The ADMIN agreed that the refrigerator was not maintaining safe temperatures for food at that time. B. An observation on 03/12/2025 at 9:30 AM revealed Dietary Aide (DA)-F and DA-G in the dishwashing soiled area moving dishware from the dining area into the soiled dishware area. DA-F stacked soiled dishware onto a rack and pushed out dishes from inside the high temperature dishwasher. Racks of other dishes were then moved forward onto the clean side of the dishwasher while dirty dishes were being stacked and moved into the high temperature dishwasher simultaneously. A record review of a facility document Dishwasher Temperature Log, which was labeled March, had annotations for AM and PM temperatures which were to be written for initial rinse temperature, wash temperature and final rinse temperature readings. The log revealed many missing temperature annotations for several days. A record review of a sticker on the temperature gauge of the facility's dishwashing machine revealed a statement of, Minimum Rinse Temperature 180 degrees Fahrenheit (F) on the sticker. On 3/12/2025 at 9:32 AM an observation of the high temperature dishwasher cycle readings revealed the temperature was maxing out at 140 degrees F for the high temperature dishwasher's initial rinse temperature, wash temperature, and final rinse temperature cycle. On 3/12/2025 at 9:35 AM DA-F was asked if the high temperature dishwasher was reaching temperatures appropriate for meeting standards. DA-F stated that the cycle typically needs to be ran several times to reach temperature, upon which DA-F ran the cycle again. The cycles continued to reach a maximum temperature of 140 degrees F. DA-F was then asked if this is acceptable, DA-F then inquired with DA-G on the temperature readings. DA-G revealed a second gauge below the dishwasher and stated this is the gauge that is to be read when reaching temperature ranges acceptable for the high temperature dishwasher. DA-F ran the cycle a third time revealing the second gauge which is a digitalized reading, revealing a maximum temperature reading up to 141 degrees F. DA-F and DA-G stated they were not 100% certain what to do, upon which they notified their supervisor and stopped processing dishes in the dishwasher. On 03/12/2025 at 9:40 AM the Administrator (ADMIN) was observed watching a cycle run on the high temperature dishwasher revealing a maximum temperature reading of 140 degrees F. The ADMIN agreed that the dishwasher was not maintaining safe temperature readings to prevent foodborne illness and instructed the kitchen staff to stop using the high temperature dishwasher until the machine was fixed.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review the facility failed to maintain a medication error rate of 5% or less with an actual medication error rate of 12%. This affected 2 residents (Resident 9 and Resident 37) of 4 sampled residents. The facility census was 44. Findings are: A record review of a facility policy titled Preventing Medication Errors dated 01/2018 revealed the facility must ensure that it is free of medication error rates of 5% or greater. A. A record review of Resident 9's Electronic Medical Record revealed Resident 9 had physician's orders to receive Sennosides-Docusate Sodium (a medication used to promote bowel movements) one tablet twice daily every day and Viactive Chewable (a vitamin and mineral supplement) once daily every day. An observation of medication administration by Licensed Practical Nurse A (LPN-A) completed on 03/13/2025 at 7:35 AM revealed the following: -LPN-A removed 2 round orange tablets from a white bottle labeled Senna Plus (sennosides-docusate sodium) and placed them in a clear plastic cup containing other medications. LPN-A then removed a white oblong tablet from a white plastic bottle labeled Calcium with Vitamin D (a vitamin and mineral supplement) and placed it in the clear plastic cup with the other medications. LPN-A proceeded to administer all the medications in the cup to Resident 9. Resident 9 ingested all the medications. In an interview completed on 03/13/2025 at 2:06 PM with LPN-A, LPN-A confirmed that Resident 9 had an order to receive 1 Senna Plus tablet and not 2 Senna Plus tablets. The LPN also confirmed that Resident 9 did not have an order to receive the Calcium with Vitamin D tablet that they administered. LPN-A confirmed that these were medication errors. In an interview completed on 03/13/2025 at 3:30 PM with the Director of Nursing (DON), the DON confirmed the resident receiving 2 tablets and not the prescribed 1 tablet was a medication error. B. A record review of Resident 37's Electronic Medical Record revealed Resident 37 had a physician's order to receive Acetaminophen (a pain-relieving medication) 500 milligrams (MG), one tablet three times a day, every day. An observation of medication administration by LPN-A completed on 03/13/2025 at 7:40 AM revealed the following: -LPN-A removed 2 oblong white tablets from a white bottle labeled Acetaminophen 500 MG tablets. The LPN placed the tablets in a clear plastic cup with other medications. LPN-A proceeded to administer all the medications in the cup to Resident 37. Resident 37 ingested all the medications. In an interview completed on 03/13/2025 at 2:08 PM with LPN-A, LPN-A confirmed that Resident 18 had an order to receive 1 Acetaminophen 500 MG tablet and not 2 Acetaminophen 500 MG tablets. The LPN confirmed that this was a medication error. In an interview completed on 03/13/2025 at 3:30 PM with the Director of Nursing (DON), the DON confirmed the resident receiving 2 tablets and not the prescribed 1 tablet was a medication error.

Licensure Reference Number 175 NAC 12-006.09(H) Based on observation interview and record review the facility failed to observe 1 (Resident 41) of 1 sampled resident for changes in their psychosocial or mood state and failed to monitor the resident for adverse effects from their psychotropic medication in accordance with the resident's plan of care. The facility census was 44. Findings are: Review of a facility policy titled Behavioral Health Services and dated 10/24/2022 revealed it is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. The facility will ensure that necessary behavioral health care services are person centered and reflect the resident's goals for care while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, psychosocial adjustment difficulty and trauma. A record review of a Resident Face Sheet revealed Resident 41 was admitted to the facility on [DATE] with diagnoses of Polyosteoarthritis (a condition where multiple joints are affected by a degenerative joint disease), Macular Degeneration (a disease of the eye resulting in lack of vision), and Depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities). A record review of Resident 41's Admission 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) with an Assessment Reference Date (ARD) of 01/17/2025 revealed Resident 41 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11/15 indicating the resident was moderately cognitively impaired. The resident had a Patient Health Questionnaire (PHQ-2 to 9, A validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder) score of 6/27 indicating mild depression. The resident indicated during the interview for daily preferences that listening to music, keeping up with the news, going outside when the weather is good, and participating in religious services or practices were very important to them. The resident was dependent on staff assistance using a wheelchair for mobility over long distances. A record review of Resident 41's Care Plan revealed a problem of psychosocial well being stating the resident was experiencing a decline in their psychosocial wellbeing and or mood state dated 01/29/2025 with a goal stating the resident would not show a decline in their psychosocial well being through the next review date. Approaches were listed including being involved with telehealth for medication management and mental health therapy, to observe the resident for changes in their psychosocial or mood state and report changes to their physician and facility social worker, and target behaviors of social isolation poor appetite and difficulty coping with adjustment to placement and loss of husband all dated 01/29/2025. Resident 41 also had a problem of psychotropic drug use due to depression dated 01/24/2025 with a goal that the resident would not exhibit signs of drug related sedation or anticholinergic symptoms (dry mouth, blurred vision, confusion, hallucinations, delirium and heat intolerance). An approach was listed to assess and record effectiveness of drug treatment and monitor and report signs of sedation, hypotension, or anticholinergic symptoms dated 01/24/2025. A record review of Resident 41's Electronic Medical Health Record revealed an order for Duloxetine (a medication used to treat depression) 20 milligrams once daily. In an interview conducted on 03/12/2025 at 4:30 PM with Resident 41, Resident 41 stated they had recently lost their spouse and moved into the facility due to not being able to care for themself. The resident reported feeling sad and lonely most of the time and feeling like they were sleeping more than normal. The resident stated they enjoyed the exercise activity and sitting with a family member at mealtime and visiting with them. The resident reported enjoying the bible on tape but could not operate the recorder in the room due to a decline in vision function. In an interview conducted on 03/17/2025 at 2:10 PM with the facility Activity Director (ACTD), the ACTD stated that Resident 41 was participating in activities daily after admission. The ACTD confirmed that the resident, over the past couple of weeks, had started declining to go to activities that the resident had attended previously. The ACTD confirmed they did not report this change to nursing or social service staff. In an interview conducted on 03/17/2025 at 3:50 PM with the facility Social Service Director (SSD), the SSD denied being made aware of Resident 41's recent change of not coming out to meals and attending activities that had previously. In an interview conducted on 03/18/2025 with Medication Aide (MA)-H, MA-H revealed that Resident 41 had previously been going to the dining room for meals but started refusing to come to the dining room for a while. The MA confirmed that they had not reported this to the nurse or social services. In an interview conducted on 03/18/2025 at 1:15 PM with Registered Nurse (RN)-C, RN-C stated that Resident 41 was not being monitored for any mood or behavior problems or changes. In an interview conducted on 03/18/2025 at 3:00 PM with the Director of Nursing (DON), the DON confirmed that Resident 41 was not being monitored for the changes of not regularly attending activities and meals as they had previously and should have been.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review the facility failed to follow transmission-based precautions to prevent the spread of communicable disease. This had the potential to affect 43 residents. Facility stated census was 43. Findings are: In an interview on 03/18/2024 at 9:30 AM with the Facility Administrator (FA), FA stated the facility was in COVID-19 outbreak and had residents on isolation due to testing positive for COVID-19. In an observation on 03/18/2024 at 10:00 AM the following was observed: room [ROOM NUMBER], 302, 306, and 310 with signs on the door stating Red Zone Isolation area, and Centers for Disease Control (CDC) Sequence for putting on personal protective equipment (PPE), which is the equipment worn to minimize exposure to hazards that can cause serious injury or illness. Beside the door in the hall a clear plastic rectangle container with 3 drawers. In the first drawer were blue individually wrapped gowns. In the second drawer were more blue gowns. In the third drawer was a roll of clear plastic trash bags and black plastic trash bags. There were no surgical masks, N95 masks, Alcohol based hand gel, goggles or face shied or sanitizing wipes on any of the clear plastic 3 drawer containers in the hall outside of the doors. In an interview on 03/18/2024 at 11:00 AM with Housekeeper F (HSK-F), revealed staff wore their N95 mask all shift. HSK-F further revealed staff did not change their masks after exiting an isolation room. HSK-F revealed staff did not clean their goggles or face shield after exiting an isolation room. In an interview on 03/18/2024 at 11:05 AM with Medication Aide G (MA-G), revealed staff wore their goggles for the entire shift and would put them up on top of their heads or in their pockets when not in an isolation room. MA-G revealed they were not instructed to clean their goggles after exiting an isolation room. MA-G confirmed that staff were wearing N95 masks and wore their mask for their entire shift. In an interview on 03/18/2024 at 11:10 AM with the Director of Nursing (DON), DON stated the facility had enough of Personal Protective Equipment (PPE) to meet the needs of the residents and facility staff. In an interview on 03/18/2024 at 11:20 AM with the Infection Preventionist (IP), the IP confirmed that staff were not changing masks or cleaning goggles when exiting isolation rooms. IP confirmed that if staff needed to change their mask during their shift, they would have to obtain a new mask from the staff entrance area by the time clock. IP stated the facility communicated and received direction on infection control from the local health department and Infection Control Assessment and Promotion Program (ICAP). In an interview on 03/18/2024 at 11:40 AM with the DON, the DON stated facility staff were using N95 masks and goggles on an extended use basis that did not require staff to change masks, goggles, or face shield from isolation room to non-isolation area. The DON stated the facility communicated and received directions from ICAP regarding isolation precautions and standards. The DON stated would contact ICAP for current standards for isolation precautions and extended use of masks and goggles or face shields. In an observation on 03/18/2024 at 3:45 PM it was observed that on top of the clear plastic containers in the hall outside rooms 204, 302, 306, and 310 was a white and purple container with a label reflecting sanitization wipes, N95 masks, and alcohol-based hand gel. In the second drawer of each container were clear plastic face shields. A record review of facility supplied document unlabeled dated 03/18/2024 revealed communication from ICAP to the DON stating extended use of N95 masks could only be used in a contingency capacity strategy if unable to sustain quantity for conventional mask changes. Also stated the same N95 could be worn when grouping cares between isolation rooms then the N95 should be discarded, and a new mask put on prior to care for in a non-infectious area. With extended use or use of reusable goggles or face shields they should be cleaned each time they are removed. A record review of facility supplied policy COVID-19 Prevention, Responses, and Reporting dated 05/23/2023 revealed under source control measures if being used during the care of a resident for which a N95 or face mask is indicated for PPE, they should be removed and discarded after the resident care encounter and a new on put on. A record review of Centers for Disease Control Strategies for conserving the supply of eye protection dated 05/09/2023 revealed reusable eye protection should be cleaned and disinfected whenever it is removed. A record review of Centers for Disease Control Strategies for conserving the supply of N95 respirators dated 01/24/2024 revealed during conventional use in patient care, a disposable respirator should be removed and discarded between patients. Practices allowing extended use of N95 respirators should only be considered as a contingency capacity strategy which means strategies consistent with CDC guidance that may be used during temporary periods of actual or expected PPE shortages.

Licensure Reference Number 175NAC 12-006.11E Based on observations, record reviews and interviews, the facility failed to ensure that the high temperature dishwashing machine maintained the required high temperature for sanitization of facility dishware. This affected all 43 facility residents that receive meals out of the facility kitchen. The facility census was 43. Findings are: A. Record review revealed an undated policy titled Dishwasher Temperature: Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 3. For high temperature dishwashers (heat sanitization): a. The wash temperature shall be 150-160 degrees F. b. The final rinse temperature shall be 180 degrees F or above but not to exceed 194 degrees F (165 degrees F for stationary rack, single temperature machine). Corrective actions shall be taken for final temperature below the required final rinse temperatures. 6. Water temperatures shall be measured and recorded prior to each meal and /or after the dishwasher has been emptied or re-filled for cleaning purposes. A review of the Dishwasher Temperature Chart on the wall that contains an area for annotating the temperatures of the dishwasher during its process revealed it contained columns listed for the time of record, the temperature for the wash cycle, the temperature for the rinse cycle and the temperature for the final cycle every morning, noon, and evening. The last part of this chart is an area for corrective action when the temperature does not reach 180 degrees F on the final rinse or when the temperature exceeds 194 degrees F. Record review revealed that the Dishwasher Temperature Chart for the month of March 2024 listed the temperatures all in the required range. The area of the chart for corrective action if the final rinse temperature was below 180 degrees F or above 194 degrees F was blank. On 03/20/2024 at 10:35 AM observation of Dietary Cook-C (DC-C) during the dishwashing process revealed that the final rinse cycle was reaching a temperature of 142 degrees Fahrenheit (F) on the gauge of the dishwashing machine. The facility Dietary Manager (DM) placed a manual temperature gauge in the dishwasher to test the temperature of the final rinse cycle which revealed a temperature of 147.5 degrees F. The DC-C revealed they were unfamiliar with the process and monitoring the temperature. The facility DM was interviewed on 03/21/2024 at 07:41 AM about the dishwasher machine and stated the facility dishwasher is a high temperature sanitization dishwasher, provided the temperature log for the month of March and the policy for dishwasher temperatures During an interview on 03/21/2024 at 10:53 AM the facility DM stated that all facility residents eat out of the kitchen.

Based on record review, observation, and interview the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage (a required notice of the cost of continuing to receive skilled services) and the Notice of Medicare Non-Coverage (a required notice allowing the resident to appeal the facility decision to end Medicare Part A coverage) was given to a beneficiaries at least two days prior to the end of covered services which affected 1 (Resident 29) of 3 sampled residents. The facility census was 43. Findings are: Record Review of Resident 29's Advanced Beneficiary Notice of Non-Coverage dated 3/18/2024 revealed the last covered day of Medicare Part A services was on 3/15/24. Resident/resident representative were not notified at least two days in advance of the end of the Medicare part A services. Record Review of Resident 29's Notice of Medicare Non-Coverage dated 3/18/24, revealed the effective date of coverage ended on 03/15/2024. The Notice of Medicare Non-Coverage was not provided prior to the end of Medicare Part A coverage as required. Observation on 03/20/24 at 10:03 AM in Resident 29's room revealed the resident was in their room sitting in their chair. Interview with the Business Office Manager (BOM) on 03/20/24 at 9:40 AM revealed a notice was not given to Resident 29 or their representative prior to ending services on 3/15/24.

Licensure Reference Number: 175 NAC 12-006.04D2a Based on interviews, and record review; the facility failed to ensure the dietary manager had the required credentialing for the position. This failure could affect all residents receiving meals from the facility kitchen. The facility census was 41. Findings are: Staff interview on 08/09/21 at 2:00 PM with Dietary Manager confirmed not having the required regulatory credentialing for the position of Dietary Manager. Record Review of the Dietary Managers employee record verified the Dietary Manager did not have the regulatory required credentialing for the position of Dietary Manager. Staff interview on 08/10/21 at 3:00 PM Administrator verified that the Dietary Manager did not have the required credentials for the Dietary Manager portion of the job.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility staff failed to perform hand hygiene during distribution of resident clothing on Unit A. This affected all 9 residents who resided on the unit, Residents 21, 39, 15, 28, 10, 14, 32, 31, and 40. The facility identified a census of 41 at the time of survey. Findings are: Observation of EVS-D (Environmental Services) on 8/10/21 from 2:14 PM to 2:22 PM revealed they exited an unidentified resident's room on Unit B with an undergarment bag and hung it on the clothing cart. EVS-D then pushed the cart down the hall, took clothes that were on hangers and an undergarment bag into room Resident 21's room, opened the closet door and hung the clothes in the closet, removed empty hangers from the closet, closed the closet door, opened a drawer and took clothes from the undergarment bag, placed them in the drawer, closed the drawer, then walked out into the hall to the cart, hung the empty hangers and the undergarment bag on the rack, removed clothing that was on hangers and an undergarment bag from the cart and took them into Resident 39's room. EVS-S repeated the same process with Residents 15, 28, 10, 14, 32, 31, and 40 by touching the closet doors, drawer handles, bringing out the empty hangers from the residents' closets, hanging them on the cart, then taking the clean clothing into a different resident's room. EVS-D did not do any hand hygiene after handling the closet doors, drawer handles, and the hangers that EVS-D had removed from the residents' closets before taking the clean clothing into the residents. EVS-D did not do any hand hygiene between each room after they handled the cart, the closet doors, the drawer handles, and the hangers from the residents' closets. Interview with the IP (Infection Preventionist) on 8/12/21 at 9:28 AM revealed it was the expectation the facility staff performed hand hygiene between resident rooms when passing laundry/clothing. Interview with EVS-D on 8/12/21 at 11:09 AM confirmed the clothing on the cart was clean. EVS-D confirmed the hangers they had taken out of the residents' closets were potentially contaminated as they could have been handled by the residents and the nursing staff. EVS-D agreed hand hygiene would have been expected after handling the hangers before taking clean clothing into the residents' rooms. Review of the facility policy Hand Hygiene dated January 2020 revealed the following: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Review of the facility policy Handling Clean Linen dated January 2020 revealed the following: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Carry clean linen with clean hands away from your body.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.16A Based on observation, interview, and record review; the facility failed to ensure dietary supplement intake was documented for Residents 14, 31, and 10. This affected 3 of 6 residents sampled. The facility identified a census of 41 at the time of survey. Findings are: Interview with the FSS (Food Service Supervisor) on 08/11/21 at 9:30 AM revealed the dietary supplement orders for all of the residents were not listed with the physician's orders. The FSS revealed they had a list of all of the supplements that were being offered to the residents. A. Review of the untitled supplements list dated August 1, 2021 revealed Resident 14 received IB with breakfast and lunch and Magic Cup (Magic Cup® frozen dessert is like ice cream when frozen but is a pudding after thawing. It's an .option for adding calories and protein for those experiencing involuntary weight loss). Review of the Vitals Report Supplements report for Resident 14 for January 1, 2021 through August 11, 2021 revealed the supplements were not documented as ordered and scheduled. Supplement intake was documented once on these days: 8/10, 8/4, 8/3, 8/1, 7/20, 7/18, 7/12, 7/10, 7/9, 7/6, 7/3, 6/30, 6/26, 6/23, 6/21, 6/18, 6/7, 6/6, 6/5, 6/1, 5/30, 5/27, 5/25, 5/24, 5/18, 5/17, 5/16, 5/15, 5/12, 5/11, 5/9, 5/6, 4/30, 4/27, 4/26, 4/25, 4/21, 4/18, 4/12, 4/9, 4/8, 4/7, 4/2, 3/30, 3/29, 3/28, 3/23, 3/17, 3/15, 3/8, 3/3, 3/2, 2/28, 2/20, 2/17, 2/16, 2/9, 2/7, 2/5, 1/28, 1/27, 1/24, 1/23, 1/22, 1/19, 1/18, 1/5, 1/4, 1/2, and 1/1/21. There was no documentation of supplement intake on 8/9, 8/8, 7/2, 6/25, 6/20, 6/16, 6/9, 6/3, 5/29, 5/23, 5/22, 5/21, 4/15, 4/10, 4/3, 4/1, 3/27, 3/24, 3/19, 3/18, 3/16, 3/14, 3/13, 3/11, 3/10, 3/9, 3/1, 2/24, 2/23, 2/21, 2/19, 2/15, 2/14, 2/13, 2/8, 2/4, 1/26, 1/9, and 1/8/21. Review of Resident 14's Dietary Notes revealed the following: 05/27/2021 10:43 AM Resident continues to be on a diet as tolerated (currently on puree texture with thin liquids), nutritional supplements are offered as ordered/recommended. Needs assistance with food and liquids for all meals. 05/24/2021 04:30 PM Annual nutritional assessment completed. Annual nutritional assessment for this .resident .Resident has a very small appetite, 25-50% generally, needing assistance of staff for meal consumption. Resident consumes a Regular diet with as tolerated texture, presently on a pureed texture with regular thin liquids. Resident has lost 18 pounds this past year with weight more stable the past 5 months, presently 166. L (left) heel wound is under nursing interventions with area cultured today. Will continue with present dietary interventions for maximum nutritional support. 05/21/2021 06:19 PM Continues on a consistency as tolerated which currently is a puree texture with thin liquids. Resident is offered nutritional supplements as ordered with meals. Needs assistance from staff while dining. Will continue to monitor. 05/12/2021 02:25 PM Resident continues to dine in the Activity Room. Is on a Consistency as Tolerated Diet which at this time is on puree texture with thin liquids. Receives IB with meals for added nutritional support. Needs assistance in dining and meal set up. Will continue to monitor. 05/10/2021 03:12 PM Nutritional note due to skin impairment that is under nursing interventions. Resident's meal intake is 25-75% of a regular diet with texture as tolerated, and regular thin liquids. Most meals are pureed texture. Weight is 167 and typical. Will continue with present dietary interventions. B. Review of the untitled supplements list dated August 1, 2021 revealed Resident 31 received Magic Cup at lunch and supper. Review of the Vitals Report Supplements reports for Resident 31 for January 1, 2021 through August 11, 2021 revealed the supplements were not documented as ordered and scheduled. There was no documentation of supplement intake on the following dates: 8/9, 8/8, 8/1, 7/29, 7/28, 7/20, 7/18, 7/16, 7/14, 7/12, 7/11, 7/9, 7/2, 6/30, 6/29, 6/26, 6/6/16, 6/7, 6/5, 6/4, 5/29, 5/25, 5/21, 5/19, 5/18, 5/17, 5/15, 5/11, 5/10, 5/9, 5/8, 5/6, 5/5, 5/4, 5/3, 5/2, 5/1, 4/30, 4/27, 4/26, 425, 4/20, 4/16, 4/15, 4/12, 4/11, 4/10, 4/8, 4/7, 4/4, 4/3, 4/2, 4/1, 3/29, 3/27, 3/21, 3/16, 3/15, 3/14, 3/13, 3/8, 3/7, 3/4, 3/2, 3/1, 2/27, 2/26, 2/23, 2/22, 2/20, 2/15, 2/14, 2/9, 2/8, 2/6, 2/5, 2/4, 2/2, 1/29, 1/25, 1/24, 1/18, 1/4, and 1/2/21. Review of Resident 31's Dietary Notes revealed the following: 05/12/2021 09:47 AM Offered Magic Cup BID with meals for added nutritional support. Uses a divided plate and weighted cups to promote independence while dining due to disease progression. Propels to and from meals via wheelchair and at times needs assistance from staff. Pleasantly confused at times while dining. Dislikes are accommodated, preferences and requests are honored within reason. Needs assistance while dining and meal set up. Will continue to monitor. 04/20/2021 05:54 AM Is on a diabetic diet, regular texture with thin liquids. Uses a divided plate with two handled weighted cups for ease while dining. Needs cueing and at times needs assistance with meals. Is a complete meal set up for all meals. For added nutritional support is offered a Magic Cup BID with meals. Ambulates to and from meals using a wheelchair. Preferences and requests are honored during meals within reason. At times in pleasantly confused but easily redirected. Will continue to monitor. C. Review of the untitled supplements list dated August 1, 2021 revealed Resident 10 received IB and Prostat (a protein supplement) at each meal. Review of the Vitals Report Supplements reports for Resident 10 for January 1, 2021 through August 11, 2021 revealed the supplements were not documented as ordered and scheduled. There was no documentation of supplement intake on the following dates: 7/2, 5/29, 3/14, and 3/13/21. There was no documentation of the intake of both the IB and the Prostat at each meal on any of the other days. Review of Resident 10's Dietary Notes revealed the following: 05/21/2021 06:02 PM For added nutritional support is offered IB and ProStat with meals. 05/12/2021 02:06 PM Is on IB and ProStat for additional nutritional support. 04/20/2021 08:34 AM IB is offered at all meals for added Nutritional Support. 02/15/2021 03:38 PM Annual nutritional assessment completed .resident who has gradually lost 13 pounds over the past year. Resident has a very small appetite, often times consuming only 25% of a Regular diet with pureed texture and regular thin liquids. Resident takes 8 oz house supplement TID (three times a day) for added nutrition along with a multivitamin. Resident will be assisted with meals as much as possible to help maintain (their) weight. Interview with the FSS (Food Service Supervisor) on 8/11/21 at 9:36 AM revealed IB was Carnation Instant Breakfast. The FSS confirmed the supplements were to be documented in the EHR (Electronic Health Record) under supplements and they would have been documented separately; if the resident received IB for 2 meals and Magic Cup for 2 meals, there should have been 4 supplement entries. Review of the Vitals Report Supplements reports with the FSS on 08/11/21 at 9:43 AM confirmed the supplements were not always documented. Interview with the FSS on 8/11/21 at 10:15 AM revealed the dietary staff were expected to document supplement intake at each meal. The FSS revealed the dietary staff either charted the supplements under fluid intake by mistake or forgot to chart it. The FSS said there was no way to differentiate in the fluid documentation if it was a supplement. The FSS revealed the supplements were being given for nutrition and pressure ulcer interventions so if they weren't being documented it was a concern. The FSS revealed the supplements were being offered because that was one of the things the FSS checked when they were here, but they were not getting charted. The FSS revealed the dietary supplement intake was expected to be documented in the residents' medical records. Review of the facility policy Documentation in Medical Record dated 2020 revealed the following: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].04C3a(6) Based on observation, interview, and record review; the facility failed to ensure Resident 10's guardian was informed of Resident 10's weight loss and the advance directive regarding nutritional interventions was reviewed with the guardian. This affected 1 of 3 sampled residents. The facility identified a census of 41 at the time of survey. Findings are: Review of Resident 10's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated [DATE] revealed an admitted [DATE]. Resident 10 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 10 required assistance of 1 staff person for eating. Resident 10's height was 64 inches and weight was 116 pounds. Review of Resident 10's quarterly MDS dated [DATE] revealed a BIMS score of 0 which indicated severe cognitive impairment. Resident 10 required set up assistance of 1 staff person for eating. Resident 10 weighed 111 pounds. Review of Resident 10's Letters of Guardianship dated [DATE] revealed Resident 10's guardian was appointed a full guardianship. The guardian was granted all powers conferred upon guardians by law. Guardian: Person(s) appointed by the court to make the personal decisions for the protected person. The guardian may be given authority to make decisions on behalf of the protected person about such things as where to live, medical decisions, training and education, etc. Review of Resident 10's weights revealed the following: [DATE] 08:25 AM Weight: 104.0 lbs (2.8 % weight loss 30 days) [DATE] 02:06 AM Weight: 107.0 lbs [DATE] 03:04 PM Weight: 108.0 lbs (3.7 % weight loss in 90 days) [DATE] 11:30 AM Weight: 115.5 lbs (10 % weight loss in 180 days) [DATE] 01:56 PM Weight: 123 lbs (15 % weight loss in 12 months) Observation of Resident 10 on [DATE] at 1:38 PM revealed they ate a few bites of the meal at lunch. Resident 10 did not take their fluids or supplements. Review of Resident 10's Care Plan dated [DATE] revealed the following: Provide me and/or my responsible party nutritional updates and education PRN (as needed). Review of Resident 10's Release of Responsibility for Life Prolonging Intervention dated [DATE] revealed the following: Please put a yes next to the interventions you want to be performed and a no next to those interventions you do not want to be performed. Yes was marked next to CPR, Feeding Tubes (Feeding Tubes: tubes inserted through the nose, mouth, or abdominal wall into the stomach to provide nutrition if you are unable to eat normally), Intravenous Lines, [MEDICATION(S)], Advanced Life Support, and Hospital Transfer. Interview with Resident 10's guardian on [DATE] at 10:12 AM revealed they were not aware of the severity of Resident 10's weight loss and the facility had not discussed Resident 10's advance directive in which Resident 10 had indicated they wanted a feeding tube. The guardian reported the facility had told them about some supplements Resident 10 was receiving but they had not approached them about the feeding tube. The guardian asked what Resident 10's weight was and responded (Resident 10) is really skinny when the guardian was notified Resident 10's most recent weight was 104 pounds. Review of Resident 10's Progress Notes for [DATE] to [DATE] revealed no documentation Resident 10's weight loss and their advance directive with their wishes for nutritional approaches was discussed with Resident 10's guardian. Interview with the DON (Director of Nursing) on [DATE] at 10:29 AM confirmed the facility staff had not discussed the feeding tube with Resident 10's guardian. The DON revealed the FSS (Food Service Supervisor) went to the care plan meetings and discussed Resident 10's weight loss. On the days the guardian was not available for a phone conference, the facility sent the guardian a summary of the care plan. Review of Resident 10's Care Conference Report dated [DATE] revealed there was no documentation the guardian was notified about Resident 10's weight loss at the care conferences on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with the DON on [DATE] at 12:15 PM confirmed there was no documentation Resident 10's weights and nutritional approaches were discussed with Resident 10's guardian. Review of the facility policy Notification of Changes dated 2020 revealed the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.

Based on observation, record review, and interview; the facility failed to ensure that the resident record accurately documented the resident's choice regarding Cardiopulmonary Resuscitation (CPR) (an emergency medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person whose heart has stopped and is not breathing) for 1 resident (Resident 11) of 6 residents reviewed. This had the potential for the facility to not follow the resident's choice related to CPR. The facility census was 41. Findings are: Record review of the undated facility policy titled Residents' Rights Regarding Treatment and Advance Directives revealed that it is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The policy contained the definition for Advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated (unable to make decisions on their own behalf). Step 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Observation of the electronic health record for Resident 11 on [DATE] at 9:52 AM revealed that the information box for Resident 11 documented the resident CPR choice as Full Code (if the resident's heart stopped beating and the resident stopped breathing CPR procedures would be provided to attempt to keep the resident alive). The words Full Code were highlighted in green. Record review of the face sheet (a document that gives a patient's information at a quick glance) for Resident 11 revealed that the resident was a Full Code at the top of the form. The face sheet section titled Advanced Directives (a legal documentation of a resident's choices regarding health care) documented that Resident 11 was a full code. Record review of the Continuity of Care Document (a document sharing patient summary information between health care providers) for Resident 11 revealed that the resident's advanced directive regarding CPR was to be a Full Code. Interview on [DATE] at 4:53 PM in the medication storage room with Registered Nurse-A (RN-A) revealed that if a staff member reported that a resident was unresponsive RN-A would immediately go and assess the resident. RN-A revealed that if the assessment revealed the resident to be in [CONDITION(S)] that RN-A would perform CPR if the resident CPR choice is a full code. RN-A revealed that the resident CPR choice is located on the resident computer electronic health record, report sheets, the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A confirmed that they should all match. Interview on [DATE] at 2:10 PM at the nurse's station with RN-A revealed that if Resident 11 was pulseless (no heart beat) and not breathing that RN-A would start CPR on Resident 11. RN-A confirmed that RN-A would begin CPR as Resident 11 is a full code according to the resident's health record. Record review of the Full Code/Do Not Resuscitate form for Resident 11 dated [DATE] revealed that the resident choice regarding CPR was Do Not Resuscitate (indicating that the resident did not want CPR performed and would be allowed to die naturally if their heart stopped beating and they stopped breathing). The form was signed by the physician on [DATE]. Record review of the Full Code/Do Not Resuscitate form for Resident 11 dated [DATE] revealed that the resident choice regarding CPR was Do Not Resuscitate (indicating that the resident did not want CPR performed and would be allowed to die naturally if their heart stopped beating and they stopped breathing). The form was signed by the physician on [DATE]. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 11 revealed that the resident has the following Advance Directive on record: Do Not Resuscitate. Interview on [DATE] at 11:33 AM with Resident 11 in the resident's room revealed that the resident was a full code when the resident first came to the facility. Resident 11 confirmed that the resident later changed the CPR choice to Do Not Resuscitate as the resident did not want to live in a vegetative state. Interview on [DATE] at 2:18 PM with the facility Social Services Director (SSD) revealed that Resident 11's choice for CPR was a full code on admission to the facility. The SSD confirmed that Resident 11 later changed the CPR choice to Do Not Resuscitate. Interview with the SSD on [DATE] at 9:47 AM confirmed that the most recent CPR choice for Resident 11 that the facility has is Do Not Resuscitate. The SSD confirmed that the resident record currently shows Resident 11 to be a full code for CPR in error. The SSD confirmed that the resident CPR code status (choice) of full code in the resident electronic health record is incorrect. The SSD revealed that Resident 11 was recently hospitalized . The SSD revealed that the resident changed the CPR choice to a full code at the hospital. The SSD confirmed that the facility does not have documentation changing the resident CPR choice from Do Not Resuscitate to be a full code. The SSD confirmed that the most recent physician signed CPR choice for Resident 11 designates the resident CPR choice is Do Not Resuscitate. Interview with the facility Social Services Director (SSD) on [DATE] at 1:59 PM in the facility conference room confirmed that the facility was unable to locate a signed CPR choice order for full code for Resident 11. The SSD confirmed that the resident currently should be identified as Do Not Resuscitate.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on interview and record review, the consultant RPh (registered pharmacist) failed to identify the irregularity of [MEDICATION(S)] (a medication used to treat psychotic disorders) being administered for non-psychotic disorders (anxiety disorder and Alzheimer's disease) to Residents 15 and 26 and failed to ensure Resident 11's medical record was updated to reflect current allergies. This affected 3 of 5 residents sampled. The facility identified a census of 42 at the time of survey. Findings are: A. Review of Resident 15's diagnoses revealed active diagnoses of Alzheimer's Disease and Anxiety disorder. Review of Resident 15's Prescription Order dated 12/7/2017 revealed an order for [MEDICATION(S)] 1 mg (milligram) by mouth twice a day for other specified anxiety disorders. Review of Resident 15's MAR (Medication Administration Record) for November 2018 revealed documentation the [MEDICATION(S)] was administered to Resident 15. Review of Resident 15's Pharmacy Monthly [CONDITION(S)] Evaluation forms for December 2017 and January through September 2018 revealed no documentation the consultant RPh had identified the [MEDICATION(S)] was being administered for a disorder the medication was not approved for. B. Review of Resident 26's diagnoses revealed active diagnoses of Alzheimer's disease and unspecified dementia without behavioral disturbance. Review of Resident 26's Prescription Order dated 8/15/2018 revealed an order for [MEDICATION(S)] 0.5 mg by mouth twice a day for Alzheimer's Disease. Review of Resident 26's MAR (Medication Administration Record) for November 2018 revealed documentation the [MEDICATION(S)] was administered to Resident 26. Review of Resident 26's Pharmacy Monthly [CONDITION(S)] Evaluations dated 9/19/2018 revealed no documentation the consultant RPh had identified the [MEDICATION(S)] was being administered for a disorder the medication was not approved for. Review of the Nursing 2018 Drug Handbook revealed the following: Indications and dosage for [MEDICATION(S)] ([MEDICATION(S)]): [CONDITION(S)], [MEDICATION(S)] maintenance therapy for [CONDITION(S)] or [CONDITION(S)] 1 disorder, monotherapy or combination therapy with [MEDICATION(S)] or valproate for 3-week treatment of acute manic or mixed episodes from [CONDITION(S)] 1 disorder, irritability, including aggression, self-injury, and temper tantrums, associated with autistic disorder. Medication is not indicated to treat Alzheimer's Disease. Black box warning: Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotics are at increased risk for death. Drug isn't approved to treat elderly patients with dementia-related [CONDITION(S)]. Interview with the DON (Director of Nursing) on 11/7/2018 at 11:52 AM revealed there was no documentation the consultant RPh had identified the irregularity of the [MEDICATION(S)] being administered for Alzheimer's disease or anxiety. C. Review of Resident 11's Face Sheet dated 11-6-18 revealed date of admission on 12-1-17 and listed Allergies as [MEDICATION(S)] and Penicillin (both antibiotics). Review of Resident 11's allergies under the Allergies tab in the medical record also listed the resident's allergies as [MEDICATION(S)] and Penicillin. Review of the admission PN (Progress Notes) dated 12/01/2017 at 02:31 PM revealed Resident 11 was in the hospital for the past 6 weeks. While in the hospital, the resident went through antibiotic therapy and had an allergic reaction to an antibiotic. The resident still had the skin rash. Review of the PN dated 12-2-17 revealed the resident was in the hospital for the last 6 weeks and went through antibiotic therapy and had an allergic reaction to an antibiotic. The skin was very red and flaky. Interview on 11-5-18 at 3:10 PM with the ADON (Assistant Director of Nursing) revealed the facility was aware the resident had a reaction to the IV [MEDICATION(S)] when the resident admitted in [DATE] as they had documentation from an incident of the resident being given the [MEDICATION(S)] in Nov. 2017 before admission. The ADON revealed the reaction was called Red Man Syndrome. However, the ADON revealed the facility was informed it was not a true allergy so they decided not to put it on the allergy list. Review of Resident 11's undated census sheet revealed the resident started hospital leave on 01/01/2018 at 08:19 PM. Review of GSH (Good Samaritan Hospital) H/P (History and Physical) dated 1-1-18 for Resident 11 revealed the resident was sent to the ER (emergency room ) for an elevated fever then transferred to GSH and admitted on [DATE] for a [CONDITION(S)] and infection in the hip joint. Listed for allergies was Penicillin and apparently also an allergy to [MEDICATION(S)] and [MEDICATION(S)] (all 3 are antibiotics). The H/P went on to state I called the nursing home and they told me that while the patient was getting [MEDICATION(S)] and [MEDICATION(S)], the patient broke out in a very bad skin rash, which is generalized including sloughing of the skin. This was according to the nurse while at Nursing Home. Review of Resident 11's undated census sheet revealed the resident returned from the hospital on 01/09/2018, was admitted again on 1-24-18 and then admitted to the GSH again on 1-25-18. Review of the Good Samaritan Home Medications List form with print date 1-25-18 when the resident was discharged back to the facility, the Allergies/ADR and the reaction from that medication were listed: Penicillin was listed with a rash as the reaction, [MEDICATION(S)] was listed with [MEDICATION(S)] - tolerated [MEDICATION(S)] 1/2018 as the reaction, and [MEDICATION(S)] with SEVERE RED MAN'S SYNDROME (typed in all capital letters) listed as the reaction. Review of Resident 11's undated census sheet revealed on 05/15/2018 at 02:49 PM the resident was placed on Hospital Leave. Review of UNMC (Nebraska Medical Center) H/P dated 5-18-18 revealed the resident was transferred from the Nursing Home because of a persistently draining hip wound. In the past history documentation, allergies listed were Penicillin G. Review of UNMC Discharge Summary dated 6-15-18 revealed during the Hospital Course the resident had surgery on the hip then received for the infection in the hip [MEDICATION(S)] for antibiotic therapy. Unfortunately, (the resident) had a reaction to the [MEDICATION(S)] that was thought to be red man syndrome therefore (gender) was required to change to [MEDICATION(S)] (antibiotic). Review of the admission H/P dated 7-17-18 revealed Resident 11 had allergies of [MEDICATION(S)], Penicillin, and [MEDICATION(S)]. The H/P revealed the resident had a hypersensitivity reaction of itching and a rash developed a few days after the start of the [MEDICATION(S)]. Review of the [NAME] (Journal of the American Medical Association) article '[MEDICATION(S)] and the 'Red-Neck Syndrome' July 1986 revealed When a patient is allergic to Penicillin, [MEDICATION(S)] [MEDICATION(S)] is often chosen to avoid allergic cross-reactions. [MEDICATION(S)] can cause histamine-induced facial and neck flushing. This 'red-neck syndrome' can be associated with profound [CONDITION(S)] and even [CONDITION(S)]. [CONDITION(S)] has been reported during intravenous [MEDICATION(S)] [MEDICATION(S)] administration, but it can usually be avoided by infusing the drug in a dilute (0.25% to 0.5%) solution over one hour. Despite prolonged infusion, the red-neck syndrome has been reported, although without [CONDITION(S)]. The syndrome usually subsides when administration of the drug is stopped. An antihistamine and/or fluid resuscitation can be added in severe cases. Review of the [NAME] article October 1990 Desensitization in the Management of [MEDICATION(S)] Hypersensitivity revealed one of the most well-known hypersensitivity reactions to [MEDICATION(S)] is the red-man syndrome which is believed to involve drug-induced histamine release in certain individuals. Although rate and/or dose reductions may be effective in some cases, some hypersensitivity reactions necessitate the discontinuation of [MEDICATION(S)]. Interview on 11/06/18 at 11:46 AM with the DON (Director of Nursing) revealed the resident had a reaction to the [MEDICATION(S)] at GSH in January 2018. The DON confirmed when the resident returned to the facility the negative reaction to the IV [MEDICATION(S)] should have been listed on the allergy list to communicate to future medical providers. The DON reviewed the forms from the facility that would have been sent with the resident when Resident 11 was transferred to UNMC in May 2018 and the DON confirmed none of the papers sent to the hospital communicated to the Medical Providers that the resident had a history of a reaction of the Red Man Syndrome to IV [MEDICATION(S)].