Every finding on record at Holdrege Memorial Homes, Inc

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(3)Based on record review and interviews, the facility failed to implement the facility policy and procedure when an allegation of abuse or neglect was made. This had the potential to affect all of the residents residing in the facility. The facility census was 74.Findings are:Record review of a undated facility policy titled Abuse and Neglect Prevention Protocol revealed:-It is the policy of the facility to protect and prevent abuse and neglect from occurring.-Definition of physical abuse described as including but not limited to withholding of personal care and medical care or food.-Investigating stated that the Social Service Director (SSD) would take the lead role and responsibility for the investigation. If the complaint involved a staff member the department supervisor and employee would be made aware as soon as possible and the employee being investigated would be placed on suspension pending the outcome of the investigation.-Reporting stated the facility would report immediately to the Department of Health and Human Services Adult Protective Services (APS) alleged abuse and neglect and would submit a written report of the investigation with in 5 working days to Health and Human Services Regulation Licensure and Facility investigation. Record review of a facility supplied document titled Grievance Investigation and dated 06/15/2026 revealed a resident's family voiced a grievance or complaint that a staff member, Nurse Aide g (NA-G), told the resident that they had to wait for mealtime to receive a drink of water when the resident requested a drink of water. The resident was later sent to the local emergency room and evaluated then subsequently admitted to the hospital for inpatient treatment with diagnosis of dehydration. The document revealed that an interview was conducted at 9:00 AM with the resident's family member that was completing the grievance/complaint. The document also revealed that NA-G was interviewed by the facility on 06/15/2026 at 2:30 PM. Record review of a facility supplied document titled CNA and dated June 2026 revealed that the staff member involved was scheduled to work on 06/15/2026 from 2:00 PM to 10:30 PM.Record review of a facility supplied document titled Timecard Report and NA-G's name dated 06/14/2026 through 06/27/2026 revealed that on 06/15/2026 NA-G clocked in at 1:51 PM for their scheduled shift.In an interview completed on 07/06/2026 at 2:00 PM with the facility SSD, the SSD stated that they did not feel that the Grievance/Complaint met the definition of abuse or neglect therefore did not follow the facility policy and procedure when conducting the investigation into the Grievance/Complaint. The SSD did confirm that the facility policy defined physical abuse including the withholding of foods or fluids from residents. The SSD confirmed that the Grievance/Complaint stated that NA-G withheld fluid from the resident when the resident requested it. The SSD confirmed that NA-G's immediate supervisor was not notified of the Grievance/Complaint as soon as possible, APS was not immediately notified, and that a report of the investigation was not submitted to Licensure and Facility investigation within 5 working days.In an interview completed on 07/06/2026 at 2:10 PM with the Facility Administrator (FA), the FA confirmed that the Grievance/Complaint made on 06/15/2026 did meet the facilities definition of physical abuse and the facilities policy and procedure should have been followed. The FA confirmed that reporting as outlined in the facility policy should have been followed and was not.In an interview completed on 07/07/2026 at 11:15 AM with the facility Director of Nursing, the DON stated that they were NA-G's direct supervisor. The DON stated that when they were informed of the Grievance/Complaint by the SSD in the afternoon of 06/15/2026 NA-G had already started working their regularly scheduled shift providing direct care to residents in the facility. The DON confirmed that NA-G should have been placed on suspension while the Grievance/Complaint was being investigated and should not have been allowed to provide direct care to residents until the investigation was completed. The DON confirmed that the facility policy and procedure was not followed for the Grievance/Complaint that was filed on 06/15/2026 that alleged physical abuse of a resident.

Based on observation, record review, and interview the facility failed to ensure that the Direct Care Daily Staffing posting (a required daily posting of facility nurse staffing information) included the required actual hours worked for each staff category. The facility census was 73. Findings are:Record review of the undated facility policy titled Posting Direct Care Daily Staffing Numbers revealed that the facility will post the number of nursing personnel responsible for providing direct care to residents on a daily basis for each shift. The information recorded on the form shall include the actual time worked during that shift for each category and type of nursing staff. Observation on 7/31/25 at 8:23 AM on the wall between the facility Activity Room and Greenhouse Cafe revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted. The report was dated 7/31/25 and revealed a census of 74 residents. The report revealed day shift staff consisting of 1 Registered Nurse (RN), 3 Licensed Professional Nurses (LPN), and 10 nurse aides (NA). The report revealed evening shift staff consisting of 3 RNs, 1 LPN, and 9 NAs. The report revealed night shift staff consisting of 1 LPN and 5.5 NAs. The report did not contain the number of work hours for the RNs, LPNs, or NAs. Observation on 8/4/25 at 10:42 AM on the wall between the facility Activity Room and Greenhouse Cafe revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted. The report was dated 8/4/25 and revealed a census of 72 residents. The report revealed day shift staff consisting of 3 Registered Nurses (RN), 1 Licensed Professional Nurse (LPN), and 10 nurse aides (NA). The report revealed evening shift staff consisting of 2 RNs, 1 LPN, and 10 NAs. The report revealed night shift staff consisting of 1 RN and 5 NAs. The report did not contain the number of work hours for the RNs, LPNs, or NAs. Observation on 8/5/25 at 11:55 AM on the wall between the facility Activity Room and Greenhouse Cafe revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted. The report was dated 8/5/2025 and revealed a census of 74 residents. The report revealed day shift staff consisting of 1 Registered Nurse (RN), 3 Licensed Professional Nurses (LPN), and 9.5 nurse aides (NA). The report revealed evening shift staff consisting of 3.5 RNs, 0.5 LPN, and 9.5 NAs. The report revealed night shift staff consisting of 1 LPN and 5 NAs. The report did not contain the number of work hours for the RNs, LPNs, or NAs. Interview on 8/5/25 at 11:58 AM with the facility Director of Nursing (DON) confirmed that the facility Report of Nursing Staff Directly Responsible for Resident Care posted did not contain the actual hours worked by each staff category as required.

Licensure Reference Number 175NAC 12-006.04(A)(iii)(2)(c)Licensure Reference Number 175NAC 12-006.04(A)(iii)(3)Based on record review and interview the facility failed to ensure that required registry checks (Child/adult abuse and neglect central registry checks, maintained by the Nebraska Department of Health and Human Services (DHHS), identify individuals with substantiated cases of abuse or neglect) were completed for new staff prior to working in the facility for 5 of 6 sampled staff. This had the potential for residents to be at risk of abuse and neglect. The facility census was 73. Findings are: A.Record review of the facility policy titled Abuse and Neglect Prevention Protocol dated 1/10/19 revealed that it is the facility policy to prohibit and prevent abuse, neglect, and exploitation from occurring. The section titled Screening revealed that the facility will not knowingly employ or otherwise engage individuals who have been found guilty of abuse, neglect exploitation, misappropriation of property, or mistreatment by a court of law; have a finding entered into the State Nurse Aide Registry concerning abuse; or that have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse. In order to screen potential employees for a history of abuse, neglect or mistreating residents as defined by law, the facility will follow the following procedure. Human Resource personnel will inform applicant of requirement for background checks upon application. Contact both the Adult Abuse and Child Abuse Registry for all new potential employees. Conduct an online search for the applicant on the Nebraska License Information System. Search for the applicant on the National Sex Offender Public Registry. All applicants who are initially offered employment following the application and interview process are hired contingent on the satisfactory return of the above checks and reference information. In cases where agency response indicates that an individual's name was found on a registry or there is an assault conviction or disqualifying criminal history present, the applicant will not be hired or any contingent offer of employment will be withdrawn. Record review of the undated facility policy titled Employee Orientation and Training revealed that employee orientation will be provided in two stages for new hires. General Orientation will be provided to complete facility and regulatory employment information and forms. Department Orientation will be used to provide employees with information related to their specific department, position, and job tasks. All newly hired personnel must attend general orientation prior to working in their respective department and position. General orientation will be made available to department employees on a twice per week basis where there is a need. All facility employment is initially considered conditional employment (a job offer that is contingent upon the candidate meeting certain requirements or conditions before officially starting the job). Not-conditional employment (signifies that the employer is ready to hire the candidate, pending only standard paperwork like onboarding forms, and that the candidate has already met all necessary requirements including criminal and abuse screening) will be based on the satisfactory completion of the criminal background check, verification of the nurse aide registry, verification with adult and child protective service agencies (the Adult Abuse and Child Abuse Registry check), and completion of the health screening and testing. Once all areas have been satisfactorily completed, the employee will receive a non-conditional offer of employment from the facility. The General Orientation program content includes completion of the facility health screening information, vital signs testing, and tuberculosis testing. Copies of all verifications, checklist or test results will be maintained in each employee's individual personnel file. In addition to the general orientation program each department supervisor or designee will ensure that each new employee receives and satisfactorily completes orientation specific to their department and job tasks. Department orientation is initiated following general orientation. An orientation checklist will be used by the facility for the documentation of general orientation participation. The in-service coordinator will complete all sections related to general orientation and forward to the business office. A separate checklist will be used by the department supervisor or their designee for the completion of department orientation. Interview on 8/4/25 at 2:42 PM with the facility Business Office Manager (BOM) revealed that the BOM checks the Nurse Aide Registry (a state required record of a successful completion of training and competency to be a nurse aide and any findings of abuse, neglect, or misappropriation of property) of an applicant prior to offer of contingent employment. The BOM revealed that the Business Office Payroll (BOP) ensures that other background and registry checks are completed. The BOM revealed that on the one day general orientation the new hire does complete online basic training. The BOM revealed that the department orientation is sometimes completed the same week as the general orientation. The BOM confirmed that the criminal background checks and APS/CNA (Adult Protective Services/Child Abuse and Neglect) Central Registry checks are to be completed prior to the new hire doing the department orientation. Record review of the undated and untitled list of all facility employees revealed that Housekeeper-E (HSK-E) had a current hire date of 5/5/25.Record review of the personnel file for HSK-E revealed that it contained a Nebraska Central Registry Check of the APS and CNA registries (the Adult Abuse and Child Abuse Registry check) dated 5/20/25 (15 days after the hire date of 5/5/25). The personnel file contained a General Orientation Checklist dated for completion of general orientation on 5/13/25.Record review of the Time Card Report dated 8/4/25 for HSK-E for May 2025 revealed that HSK-E had work hours documented on 5/5/25, 5/6/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/17/25, 5/18/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/27/25, 5/28/25, 5/29/25, and 5/30/25. Interview on 8/4/25 at 3:08 PM with the Business Office Payroll (BOP) confirmed that the APS/CAN Central Registry check should be completed prior to the new hire starting. The BOP confirmed that the APS/CAN Central Registry check for HSK-E was not obtained until 5/20/25 and should have been obtained prior to hire. The BOP revealed that since the previous BOM left that lots of stuff was missed.B.Record review of the undated and untitled list of all facility employees revealed that Nurse Aide-C (NA-C) had a current hire date of 5/16/25.Record review of the personnel file for NA-C revealed that it contained a Nebraska Central Registry Check of the APS and CNA registries (the Adult Abuse and Child Abuse Registry check) dated 5/22/25 (6 days after the hire date of 5/16/25). The personnel file contained a General Orientation Checklist dated for completion of general orientation on 5/16/25.Record review of the department orientation checklist titled Orientation Check List for New Nursing CNA (Certified Nursing Assistant-nurse aide) Review and Initial Each Item dated 5/19/25 revealed that NA-C completed department orientation on 5/19/25.Record review of the Time Card Report dated 8/4/25 for NA-C for May 2025 revealed that NA-C had work hours documented on 5/16/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/25/25, 5/27/25, 5/29/25, and 5/30/25.Interview on 8/4/25 at 3:08 PM with the Business Office Payroll (BOP) confirmed that the APS/CAN Central Registry check should be completed prior to the new hire starting. The BOP confirmed that the APS/CAN Central Registry check for NA-C was not obtained until 5/22/25 and should have been obtained prior to hire. C.Record review of the undated and untitled list of all facility employees revealed that Nurse Aide-B (NA-B) had a current hire date of 6/20/25.Record review of the personnel file for NA-B revealed that it contained a Nebraska Central Registry Check of the APS and CNA registries (the Adult Abuse and Child Abuse Registry check) dated 7/7/25 (17 days after the hire date of 6/20/25). The personnel file contained a General Orientation Checklist dated for completion of general orientation on 6/23/25.Record review of the department orientation checklist titled Orientation Check List for New Nursing CNA (Certified Nursing Assistant-nurse aide) Review and Initial Each Item dated 6/24/25 revealed that NA-B completed department orientation with last items checked and dated on 6/30/25.Record review of the Time Card Report dated 8/4/25 for NA-B for June and July 2025 revealed that NA-B had work hours documented on 6/20/25, 6/23/25, 6/24/25, 6/25/25, 6/26/25, 6/30/25, 7/1/25, 7/2/25, 7/7/25, 7/8/25, 7/9/25, 7/14/25, 7/15/25, 7/19/25, and 7/27/25.Interview on 8/4/25 at 3:08 PM with the Business Office Payroll (BOP) confirmed that the APS/CNA Central Registry check should be completed prior to the new hire starting. The BOP confirmed that the APS/CAN Central Registry check for NA-B was not obtained until 7/7/25 and should have been obtained prior to hire. D.Record review of the undated and untitled list of all facility employees revealed that Transportation Aide-D (TA-D) had a current hire date of 7/7/25.Record review of the personnel file for TA-D revealed that it contained a Nebraska Central Registry Check of the APS and CNA registries (the Adult Abuse and Child Abuse Registry check) dated 7/24/25 (17 days after the hire date of 7/7/25). The personnel file contained a General Orientation Checklist dated for completion of general orientation on 7/14/25.Record review of the Time Card Report dated 8/4/25 for TA-D for July 2025 revealed that TA-D had work hours documented on 7/7/25, 7/8/25, 7/9/25, 7/10/25, 7/15/25, 7/17/25, 7/24/25, 7/28/25, and 7/29/25.Interview on 8/4/25 at 3:08 PM with the Business Office Payroll (BOP) confirmed that the APS/CNA Central Registry check should be completed prior to the new hire starting. The BOP confirmed that the APS/CAN Central Registry check for TA-D was not obtained until 7/24/25 and should have been obtained prior to hire. E.Record review of the undated and untitled list of all facility employees revealed that Nurse Aide-A (NA-A) had a current hire date of 7/14/25.Record review of the personnel file for NA-A revealed that it contained a Nebraska Central Registry Check of the APS and CNA registries (the Adult Abuse and Child Abuse Registry check) dated 7/23/25 (9 days after the hire date of 7/14/25). The personnel file contained a General Orientation Checklist dated for completion of general orientation on 7/14/25.Record review of the department orientation checklist titled Orientation Check List for New Nursing CNA (Certified Nursing Assistant-nurse aide) Review and Initial Each Item dated 7/18/25 revealed that NA-A completed department orientation with last items checked and dated on 7/19/25.Record review of the Time Card Report dated 8/4/25 for NA-A revealed that NA-A had work hours documented on 7/14/25, 7/18/25, 7/19/25, 7/20/25, 7/25/25, 7/26/25, 7/27/25, 8/2/25, and 8/3/25.Interview on 8/4/25 at 3:08 PM with the Business Office Payroll (BOP) confirmed that the APS/CNA Central Registry check should be completed prior to the new hire starting. The BOP confirmed that the APS/CNA Central Registry check for NA-A was not obtained until 7/23/25 and should have been obtained prior to hire. The BOP revealed that the BOP was out so the Central Registry check was not completed for NA-A until the BOP returned.

Licensure Reference Number 175NAC 1-005.06(D) Licensure Reference Number 175NAC 12-006.18(B)Licensure Reference Number 175NAC 12-006.18(C) Based on observation, record review, and interview the facility failed to ensure that pre-employment health screens were completed for 1 of 6 sampled staff to prevent the potential for communicable diseases, failed to maintain fingernails while working with exposed foods that affected all facility residents, failed to ensure oxygen delivery devices were stored in a sanitary manner for 2 of 3 sampled residents (Resident 37 and 46), and failed to ensure the required PPE (Personal Protective Equipment) was available and used during care for 2 of 2 sampled residents (Resident 2 and 85). The facility census was 73. Findings are:A. Record review of the undated facility policy titled Employee Orientation and Training revealed that employee orientation will be provided in two stages for new hires. General Orientation will be provided to complete facility and regulatory employment information and forms. Department Orientation will be used to provide employees with information related to their specific department, position, and job tasks. All newly hired personnel must attend general orientation prior to working in their respective department and position. General orientation program content includes completion of the facility health screening information, vital signs testing, and tuberculosis testing. Copies of all verifications, checklist or test results will be maintained in each employee's individual personnel file. Medical information will be maintained in each employee's individual medical file. Interview on 8/4/25 at 2:42 PM with the facility Business Office Manager (BOM) revealed that the Business Office Payroll (BOP) ensures that during the one day general orientation the new hire completes the health screening and a tuberculosis test (a test for a chronic bacterial infection caused by Mycobacterium tuberculosis bacteria that can be transmitted through the air when an infected person coughs, sneezes, or talks) is completed. Record review of the undated and untitled list of all facility staff revealed that Nurse Aide-A (NA-A) had a current hire date of 7/14/25. Record review of the individual employee personnel file for NA-A revealed no health screening for NA-A. Record review of the individual employee medical file for NA-A revealed an Employee Medical History Form dated 12/2/24. The file did not contain a health screening for NA-A’s current hire on 7/14/25. Interview on 8/4/25 at 3:08 PM with the Business Office Payroll (BOP) confirmed that NA-A originally worked in the facility from 12/2/24 to 5/31/25. BOP revealed that NA-A was only gone for a couple of months before being re-hired so the Infection Preventionist chose not to redo the health screen. Record review of the undated COBRA Coverage Details (Consolidated Omnibus Budget Reconciliation Act, is a federal law that allows eligible individuals to temporarily continue their employer-sponsored health insurance coverage after certain qualifying events, such as job loss that would otherwise cause them to lose coverage) for NA-A revealed a qualifying event of Voluntary Termination with a date of 5/31/25. Record review of the Application for Employment dated 7/14/25 for NA-A revealed that it was an application for full-time employment. Record review of the General Orientation Checklist dated 7/14/25 for NA-A revealed that NA-A had a date of hire of 7/14/25. Record review of the Time Card Report dated 8/4/25 for NA-A revealed that NA-A worked hours in the facility from 12/2/24 to 5/31/25. The Time Card Report revealed no hours worked by NA-A after termination of employment on 5/31/25 until the re-hire date of 7/14/25. Interview on 8/5/25 at 11:59 AM with the facility Infection Preventionist (IP) confirmed that the facility did not complete a health screen for Nurse Aide-A (NA-A) on hire 7/14/25. B. Record review of the undated facility policy titled Enhanced Barrier Precautions (an infection control intervention involving the use of gown and gloves during high-contact resident care activities for residents with Multi-Drug Resistant Organisms (MDROs) as well as residents at increased risk of MDRO acquisition such as residents with wounds) revealed it is the facility policy to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). The policy defined “wound” as including residents with chronic wound, and not those with only shorter lasting wounds such as skin tears covered with a Band-aid or similar dressing. Enhanced Barrier Precautions are recommended for residents with wounds. EBP is indicated for residents with wounds. Record review of the Face Sheet for Resident 85 revealed that Resident 85 admitted into the facility on 7/21/25. Resident 85 had a chronic ulcer (an open wound on the surface of your skin that takes a long time to heal) of the right foot with the fat layer exposed. Record review of the care plan dated 7/31/25 for Resident 85 revealed that Resident 85 had a skin issue of a diabetic ulcer (an open sore or wound on the foot of a person with diabetes, often caused by a combination of nerve damage and poor circulation-a chronic ulcer) to the right lower leg. The care plan did not include the intervention for Enhanced Barrier Precautions (EBP). Record review of the progress note dated 7/30/25 at 5:03 PM for Resident 85 revealed that Resident 85 had an appointment with the Doctor of Podiatry (medical professional specializing in the diagnosis, treatment, and prevention of disorders of the foot, ankle, and related structures of the lower leg) for wound care of the right lower leg. Keep the area dry and covered. Change if it soaks through. Record review of the Orders list (a listing of all physician orders for a resident) for Resident 85 dated 7/31/25 revealed that Resident 85 is to have an Unna Boot (a compression gauze dressing filled with Zinc paste) in place to the right lower extremity- if soaks through use iodosorb (an antimicrobial gel) followed by absorbent pads and ace wrap as needed. Observation on 7/31/25 at 9:04 AM at the facility East Dining Room revealed that Nurse Aide-M (NA-M) assisted Resident 85 from the dining room into the resident’s room per wheelchair. NA-M assisted Resident 85 from the wheelchair into the recliner. NA-M did not wear gloves or an isolation gown. Interview on 7/31/25 at 9:44 AM with NA-M revealed that Resident 85 is not on Enhanced Barrier Precautions. Record review of the undated list titled Current Residents in EBP received from the facility on 7/31/25 revealed that Resident 85 was not included on the list. Observation on 7/31/25 at 11:46 AM at the room of Resident 85 revealed that the room door contained no identifier for Enhanced Barrier Precautions (EBP) and no signage for EBP in the resident room. Observation of both closets in the room revealed no isolation gowns in the room. Two boxes of disposable gloves were in a rack on the wall inside the resident room door across from the bathroom door. Interview on 07/31/2025 at 2:28 PM with the facility Infection Preventionist (IP) revealed that residents on EBP were identified by a “Blue” dot adhered to the outside of the door to their room. The IP revealed that personal protective equipment (PPE) gowns are stored in the resident’s room in their individual closet along with a trash can for disposing of used PPE. Interview on 7/31/2025 at 3:28 PM with the facility Director of Nursing (DON) revealed that the facility identified that the previously provided list of Current Residents in EBP was missing 4 residents including Resident 85. The DON provided a handwritten list of the 4 residents that had been omitted. The handwritten list included Resident 85 as being on EBP. Observation on 8/4/2025 at 7:59 AM outside the room of Resident 85 revealed that the room door was closed. A blue dot indicating the need for use of EBP was now in place on the upper left door frame for Resident 85. Observation on 8/5/25 at 9:10 AM in the facility therapy room revealed Resident 85 exercising on exercise equipment with the therapist monitoring the resident. The right foot of Resident 85 had an ace wrap over the ankle and mid foot with white dressing material visible protruding from the front of the ace wrap. The resident toes were medium red in color and swollen. C. Record review of facility's undated policy titled “Handwashing” revealed: Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedures: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rubs, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 5. Employees must wash their hands for at least twenty (20) seconds using antimicrobial soap and water or alcohol-based hand rub under the following conditions: g. Before and after eating or handling food (hand washing with soap and water); h. Before and after assisting a resident with meals 8. The wearing of artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities and is prohibited among those caring for severely ill or immunocompromised residents. The Infection Control Coordinator maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an unusual infection control risk. Record review of a policy titled, “Food Safety Requirements-Use and Storage of Food and Beverage Brought in for Resident, Food Procurement” undated reveals: Policy: It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state or local authorities. The food service workers, cooks, dietary aides, dishwashers, food prep aides or any person(s) who are in the kitchen working with any type of food, are responsible to adhere to the food and safety requirements. Types of Food Contamination Food contamination falls into 3 categories as follow: 1. Biological Contamination-biological contaminants are pathogenic bacteria, viruses, toxins, and spores that contaminate food. The two most common types of disease producing organism are bacteria and viruses. Parasites may also contaminate food but are less common. 2. Chemical Contamination-The most common chemicals that can be found in a food system are cleaning agents, (such as glass cleaners, soaps, and oven cleaners) and insecticides. 3. Physical Contamination-Physical contaminants are foreign objects that may advertently enter the food. Examples include but are not limited to staples, fingernails, jewelry, hair, glass, metal shavings from can openers, and pieces of bones. An observation on 08/04/2025 at 12:00 PM just prior to meal service residents were observed sitting at dining tables while Dietary Aide (DA)-N pushed a hand cart with salad items, bowls and drinks. DA-N picked up a serving spoon from the container of salad and placed the salad in a bowl and served the item to several residents. DA-N was observed pouring and serving drinks to the residents. While pushing a hand cart, DA-N poured several drinks into cups and placed them on the table for several residents, hand hygiene was not observed to occur between resident meal/drink delivery. Two additional dietary aides arrived to set up and serve hot cooked/prepared foods. One dietary aide scooped items from the steam table onto the plates and bowls, then placing the plates and bowls onto the hand cart along with a placard that detailed the specific residents’ choices and dietary restrictions. DA-N picked up the placard, plate/bowl of food and delivered the items to the resident, DA-N then returned placing the placard in a pile and waited for the next plate/bowl to be assembled. During service, DA-N was observed to have long artificial nails, not wearing gloves. After meals were delivered, DA-N pulled out of the freezer a container of homemade ice cream, placed the item on the hand cart, in addition to bowls, and other items to add to the ice cream. DA-N pushed the cart from table to table, scooped the ice cream into a bowl, and served the dessert to all residents requesting the item. Other pre-prepared bowls of fruit cocktail were served to residents not requesting ice cream. Hand hygiene was observed to not occur between drinks, salads, resident meal delivery and dessert delivery for the entirety of the meal service. An interview on 08/04/2025 at 1:42 PM, the Dietary Manager (DM) revealed they were aware that DA-N has long artificial nails. A review of the Nebraska Food Code and policy, the DM revealed, since DA-N only delivers food and does not cook, they did not agree that the artificial nails were a concern. When DM was interviewed about speaking with the Infection Preventionist (IP) about the policy that details it is at the discretion of the IP regarding artificial nail use, the DM revealed No. An interview on 08/05/2025 at 10:05 AM, the IP confirmed that artificial nails should not be worn in the dietary department and had communicated this previously as a concern. Record review of a dietary skill competency and annual performance review for DA-N dated 03/08/2024 revealed staff member demonstrates acceptable personal hygiene habits for the following areas: -Keeps fingernails short, unpolished and clean. -Washes hands as necessary -Uses and changes gloves as necessary D. A record review of an undated facility policy titled “Cleaning and Storage of Respiratory Devices” revealed oxygen tubing is changed monthly and this order will be on the treatment administration record as a nursing order. Resident oxygen tubing will be stored in a bag attached to oxygen concentrator. A review of a “Resident Face Sheet” revealed the facility admitted Resident 37 on 02/19/2019 with diagnoses that included Chronic Obstructive Pulmonary Disease (a condition that causes air flow blockage and breathing problems that is progressive). A review of Resident 37 “Administration Record” from 07/05/2025 through 08/04/2025 revealed the resident received supplemental oxygen via a nasal cannula on a routine basis. The resident had direction entered to have oxygen tubing changed once a month and this was documented as completed on 07/15/2025. In an observation completed on 07/30/2025 at 11:05 AM, Resident 37 was observed to be sitting in their recliner with eyes closed. The resident had their oxygen placed in their nasal passage. There was no labeling on the oxygen tubing indicating when it had been changed or replaced. There was no storage for the oxygen tubing attached to the oxygen concentrator. The excess oxygen tubing was on the floor of the residents room from where the concentrator was sitting at the foot of the bed to where the resident was sitting in their recliner approximately 10 feet. In an observation completed on 07/31/2025 at 9:04 AM, Resident 37 was observed to be sitting in their recliner with eyes closed. The resident had their oxygen placed in their nasal passage. There was no labeling on the oxygen tubing indicating when it (tubing) had been changed or replaced. There was no storage for the oxygen tubing attached to the oxygen concentrator. The excess oxygen tubing was on the floor of the resident’s room from where the concentrator was sitting at the foot of the bed to where the resident was sitting in their recliner approximately 10 feet. In an observation completed on 08/04/2025 at 10:15 AM, Resident 37 was observed to be sitting in their wheel chair in front of their recliner. The resident had their oxygen placed in their nasal passage. There was no labeling on the oxygen tubing indicating when it (tubing) had been changed or replaced. There was no storage for the oxygen tubing attached to the oxygen concentrator. The excess oxygen tubing was on the floor of the residents room from where the concentrator was sitting at the foot of the bed to where the resident was sitting in their wheel chair approximately 10 feet. In an interview completed on 08/05/2025 with Licensed Practical Nurse K (LPN-K), LPN-K stated that oxygen tubing and supplies are changed once a month on the night shift. The LPN stated they were not aware if the tubing or storage bags for the oxygen tubing were labeled or dated indicating when they were placed or changed. The LPN confirmed that staff just assumed that this was completed on the once monthly basis. The LPN confirmed that Resident 37’s oxygen tubing should not be sitting on the floor and each resident was to have a bag hanging on the back of their concentrator for oxygen tubing storage. The LPN confirmed that Resident 37 did not have this present for storage of their oxygen tubing. In an interview completed on 08/05/2025 with the Director of Nursing (DON) the DON confirmed that there should be a storage bag hanging on the concentrator for oxygen tubing storage. E. A record review of a facility's undated policy titled “Cleaning and Storage of Respiratory Devices” revealed nebulizer masks are rinsed with clean water and allowed to dry prior to the next use and soaked daily in a diluted vinegar solution. After rinsing masks- is to be stored in a basin and allowed to air dry. Tubing, masks and storage basin are to be changed monthly and this direction will be placed on the administration record. A review of a “Resident Face Sheet” revealed the facility admitted Resident 46 on 04/26/2024 with diagnoses of unspecified circulatory and respiratory symptoms. A review of Resident 46's “Administration Record” from 07/05/2025 through 08/04/2025 revealed the resident received Ipratropium-albuterol solution inhalation via nebulizer three times a day every day and supplemental oxygen via nasal cannula at bed time every night. The resident had direction entered to soak nebulizer mask and cup in vinegar one time daily in the evening. There was no direction to change the resident’s oxygen tubing once a month or nebulizer equipment (mask cup and tubing). In an observation completed on 07/30/2025 at 11:31 AM Resident 46’s nebulizer equipment was observed to be sitting on the table behind the resident’s chair on top of magazine and a Kleenex box. The resident had an oxygen concentrator at the foot of their bed. A bag was attached to the back of the concentrator and was dated 02/11 and had unlabeled or dated oxygen tubing coiled and being stored in the bag. In an observation completed on 07/31/2025 at 1:25 PM Resident 46’s nebulizer equipment was observed to be sitting on the table behind the resident’s chair in a gray kidney shaped plastic basin lined with a paper towel. The basin was not labeled or dated. The resident had an oxygen concentrator at the foot of their bed. A bag was attached to the back of the concentrator and was dated 02/11 and had unlabeled or dated oxygen tubing coiled and being stored in the bag. In an interview completed on 08/05/2025 with Licensed Practical Nurse K (LPN-K), LPN-K stated that oxygen tubing, and supplies are changed once a month on the night shift. The LPN stated they were not aware if the tubing or storage bags for the oxygen tubing were labeled or dated indicating when they were placed or changed. The LPN confirmed that staff just assumed that this was completed monthly. The LPN confirmed that Resident 46 did not have directions placed in their administration record for the oxygen tubing to be changed monthly or for the nebulizer equipment to be changed monthly and should be. The LPN confirmed the gray kidney shaped plastic basin should not be labeled with the date of 08/15/2025 and was and that the storage bag on the oxygen concentrator had the date of 02/11 on it. In an interview completed on 08/05/2025 with the Director of Nursing (DON) the DON confirmed that directions for changing of the nebulizer equipment and storage basin should be in the resident’s administration record and was not. The DON confirmed that the resident also did not have direction for their oxygen tubing to be changed monthly and should. The DON confirmed that the basin present in the resident’s room should not be labeled 08/15/2025 and the tubing storage bag should not be dated 02/11. F. A review of a facility policy titled “Enhanced Barrier Precautions” Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices), revealed gowns and gloves will be available near or outside of the resident’s room. A record review of an “Resident Face Sheet” revealed the facility admitted Resident 2 on 11/05/2024 with a diagnosis of stage 3 chronic kidney disease (a condition of moderate kidney damage and reduced kidney function where the kidneys filter blood less effectively leading to a buildup of waste products in the body), left toe amputation, and diabetes (a condition characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). A record review of Resident 2’s “Care Plan” revealed a problem of Enhanced Barrier Precautions with a start date of 02/06/2025. The goal was stated that the resident will remain free from infection and a target date of 09/01/2025. The approach of enhanced barrier precautions being in place and dated 02/06/2025 was the only listed approach for this problem. In an observation completed on 07/30/2025 at 2:45 PM it was observed that Resident 2 did not have any Personal Protective Equipment (PPE, includes clothing, gloves, face shields, goggles, facemasks, respirators, and other equipment to protect front-line workers from injury, infection, or illness) stored outside or near the outside of the resident’s room. There was no trash can near the exit of the resident’s room. In an observation completed on 07/31/2025 at 8:59 AM it was observed that Resident 2 did not have any PPE stored outside or near the outside of the resident’s room. In an interview on 07/31/2025 at 1:42 PM with Licensed Practical Nurse K (LPN-K), the nurse denied knowledge of what EBP was. When explaining the question further to the nurse the nurse was able to state 4 names of residents residing on the hall that staff were to use gowns when providing assistance to them. In an interview on 07/31/2025 at 2:28 PM with the facility Infection Preventionist (IP), the IP stated that residents on EBP were identified by a “Blue” dot adhered to the outside of the door to their room. The IP stated that personal protective equipment is stored in the resident’s room in their individual closet. In an observation completed on 07/31/2025 at 3:00 PM of Resident 2’s room. No gowns were in either of the residents’ closets or in the drawers of their room. In an interview completed on 07/31/2025 at 3:28 PM with the facility Director of Nursing (DON) the DON confirmed that the facility policy stated that personal protective equipment was to be available near or outside of the resident’s room and storing the items in the resident’s closet of their room did not comply with the facilities policy. The DON confirmed that there should have been always gowns in Resident 2’s closet for use.

The facility failed to ensure that all Minimum Data Set transmissions for each resident were submitted within 14 days after completion. This affected 7 of 7 residents (Residents 20, 53, 8, 55, 62, 68 and 70) sampled. The facility census was 73. Based on record review and interviews, the facility failed to ensure that all Minimum Data Set assessments (MDS - information which provides a comprehensive overview of a resident's functional status, diagnoses, and treatments used for resident care planning and quality monitoring in the long term care setting) was submitted within 14 days of completing the resident assessments. This affected 7 residents (Residents 20, 53, 8, 55, 62, 68 and 70) of 7 residents sampled. The facility census was 73. Findings are: Record review of the undated facility policy MDS Policy (in regulation with CMS guidelines) revealed the purpose of the policy was to ensure accurate and timely completion of the MDS in compliance with federal and state regulations for all residents of the facility. The procedures were as follows; 1. Resident will be assessed per the MDS Schedule as outlines in CMS (Centers for Medicare and Medicaid Services) regulations 2. The MDS Coordinator and Interdisciplinary team will review all assessments for completeness and accuracy before submission 3. The facility will maintain documentation to support all MDS items in the resident's medical record 4. The Administrator and the Director of Nursing will ensure that MDS processes remain in compliance with all applicable regulations. Interview on 07/31/2025 at 9:45 AM with the MDS COORDINATOR (MDSC) who stated due to personal issues, the MDSC had been out of the office more than in the facility as of late. As the only person who is currently working with the MDS data, MDSC had gotten behind and realized these had not been sent for finalization after being completed at the facility. Nobody else had checked the MDS work load in the absence of the MDSC. In reference to the data, the MDSC explained that MDS data that has been Finalized means that the MDS DATA had been gathered but it had not been submitted. Production Batch means it was submitted but had not been reviewed and accepted. Interview on 07/31/2025 at 10:00 AM with the MDSC confirmed that the MDS's were not submitted on time for Residents 20, 53, 8, 55, 62, 68, and 70. A. Record review of the MDS data dated 06/24/2025 for Resident 20 revealed the data was finalized; gathered but not sent within the 14 day required time period. B.Record review of the MDS data dated 06/24/2025 for Resident 53 revealed the data was finalized; gathered by not sent within the 14 day required time period. C.Record review of the MDS data dated 06/24/2025for Resident 8 revealed the data was finalized; gathered by not sent within the 14 day required time period. D.Record review of the MDS data dated 06/24/2025 for Resident 55 revealed the data was finalized; gathered by not sent within the 14 day required time period. E.Record review of the MDS data dated 07/01/2025 for Resident 62 revealed the data was finalized; gathered by not sent within the 14 day required time period. F.Record review of the MDS data dated 06/24/2025 for Resident 68 revealed the data was finalized; gathered by not sent within the 14 day required time period. G.Record review of the MDS data dated 06/24/2025 for Resident 70 the data was in the Production Batch; submitted but not reviewed and accepted within the required time period of 14 days.

Licensure Reference Number 175NAC 12-006.09(E)(ii) Licensure Reference Number 175NAC 12-006.09(E)(iii) Licensure Reference Number 175NAC 12-006.09(E)(iv) Based on Record reviews, observations, and interviews, the facility failed to ensure the comprehensive care plans had person-centered goals, measurable objectives, and interventions related to respiratory infections, nutrition, diabetes, resident choices, urinary tract infections and other infections, resident fluid restrictions, and self-directed care wishes for 4 of 18 sampled residents (Residents 68, 55, 9, and 2). The facility census was 73.Findings are:A. Review of the progress notes revealed that on 12/27/2024 Resident 68 was transferred to the emergency room via ambulance and admitted on [DATE] with a diagnosis of pneumonia. Resident 68 was readmitted to the facility on [DATE]. An entry on 01/10/2025 revealed that the primary care physician had changed the current antibiotic, Bactrim, to cefdinir to treat Resident 68’s pneumonia. An entry on 01/17/2025 revealed the antibiotic was changed once again to Augmentin (antibiotic) for another 10 days for the pneumonia. On 01/30/2025 the progress notes revealed that the nebulizer treatments were to be given routinely. On 03/12/2025 a new order for another antibiotic was ordered for the diagnosis of pneumonia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident 68 was admitted on [DATE] and had been readmitted on [DATE] after a short stay hospitalization. Resident 68 wore bilateral hearing aides and could communicate without difficulty, had a Brief Interview for Mental Status (BIMS, a brief screening aide to assist in detecting cognitive impairment) score: 15/15 with a score determining: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment; and had a complex medical history which included coronary artery disease, congestive heart failure, high blood pressure, pneumonia, and hypoxemia (low levels of oxygen in the blood stream). Furthermore, Resident 68 became short of breath when lying flat and took diuretics (medications that help remove fluids) and opioid pain medications. Record review of the March 2025 Medication Administration Record (MAR) for Resident 68 revealed a new order for Albuterol treatments on 03/13/2025 and was used everyday from 03/13/2025 to 03/31/2025 except on 03/18, 03/21, and 03/28/2025. Levaquin (an antibiotic for respiratory infections) was ordered and started on 03/13/2025 and continued daily through 03/22/2025. Record review of the April 2025 MAR for Resident 68 revealed a new order for dextromethorphan/guaifenesin (a cough medicine) was ordered for pneumonia on 04/11/2025. Resident 68 used this cough medicine on the following dates in April 2025; April 12, 13, 15, 18, 21, 22, 23, 25, 26, 27, 29 and 30. Resident 68 continued to use the albuterol breathing treatments at least once a day through the month of April 2025 except on; April 1, 5, 6, 16, 17, 19, 20, and 28. The MAR also revealed a new order for Augmentin (an antibiotic) was started 04/30/2025 for and upper respiratory infection and pneumonia. Record review of the Doctor’s Appointment Sheet dated 04/16/2025 revealed the resident had been on Levaquin (an antibiotic for respiratory infections) during the month of March and had been on oxygen to keep oxygen saturations above 90% since that time and continued to have wheezing (a high-pitched, whistling sound that occurs when air flows through narrowed airways in the lungs) and a cough. Robitussin (cough medication) had been ordered on 04/11/2025. The physician ordered a respiratory lab panel to include checking for Mycoplasma (a laboratory test that detects multiple pathogens that can cause respiratory infections). Record review of the May 2025 MAR revealed Resident 68 continued receiving Augmentin twice a day to the stop date of 05/14/2025. A new order for Prednisone (a steroid medication) was started on 05/01/2025 (prednisone and antibiotics can be used together to treat certain bacterial and viral infections) and continued through 05/09/2025. Resident 68 also continued to take albuterol treatments throughout the month of May 2025 with the exception of the following dates in May of 2025: 8, 12, 14, 15, 17-23, 26, and 31. Record review of the “Summary of Care” record dated 05/14/2025 revealed the resident continued to have a chronic cough. The cough did not bother (Resident 68) but the nurses noticed it relatively frequently. Also noted was the fact that (Resident 68) had a history of basal cell lymphoproliferative disorder, hypothyroidism, chronic kidney disease stage 4 (severe), benign hypertrophy of the prostate and hypertension. Further past medical history included status post nephrectomy (removal of a kidney), colostomy (surgical revision of the bowel in which the resident now has an opening on the abdomen), congestive heart failure (a condition in which the heart doesn't pump enough blood to meet the body's need and can cause fluid buildup in the lungs causing shortness of breath and fatigue), and others. Due to the chronic cough, the orders were to discontinue Resident 68’s valsartan, have nursing staff check blood pressures daily, and other changes related to medications, and ordered lab work. Record review of the Doctor’s Appointment Sheet dated 05/14/2025 revealed the physician questioned whether the cough was related to medication valsartan and the valsartan was discontinued. The physician ordered several different labs which included the BNP - (Brain Natriuretic Peptide - primarily used to help diagnose and assess the severity of heart failure) which may have been causing the cough. Record review of the June 2025 MAR for Resident 68 revealed use of the prescribed cough medication on 06/02, 3, 5, 6, and 7. Resident 68 had used the albuterol treatments 11 days in the month of June; 2, 3, 6, 7, 8, 13, 17,23, 24, 28, and 29. Record review of the July 2025 MAR for Resident 68 revealed the use of the albuterol treatments on 07/06/2025 and 07/24-31, 2025. Resident was restarted on an Antibiotic 07/28 for the following 14 days. Review of the working care plan reviewed on 07/31/2025 for Resident 68 revealed a problem of Levaquin (antibiotic for upper respiratory infections) 500 mg daily. The goal, with a goal target date of 09/23/2025, to resolve after the antibiotic series was completed. Interventions were: monitor the vitals signs and condition of the resident, and monitor the signs and symptoms of adverse effects of the antibiotic. Also related to the respiratory system was the problem of oxygen, with a goal target date of 09/23/2025, to keep oxygen saturations of the blood above 90%. The interventions listed were: change the oxygen tubing monthly, clean the concentrator filter weekly, oxygen saturation every shift, and observe top of ears for signs of irritation, pad tubing as needed. There were no other care plan interventions related to Resident 68’s respiratory status. Observation of Resident 68 in this resident's room [ROOM NUMBER]/20/2025 at 2:10 PM revealed this resident had a coarse, wet cough. Observation of Resident 68 on 07/31/2025 at 12:15 PM in the dining room while seated for the noon meal. Coughed occasionally while partaking of the meal. Observation of Resident 68 on 08/04/2025 at 08:25 AM in the dining room while seated for breakfast. Coughs occasionally while eating. Interview with Resident 68 on 08/04/2025 at 08:25 AM in the dining room. Ya, I still have that cough, but I am still here. B. Record review of the MDS for Resident 55 revealed the resident was admitted on [DATE] from the hospital. Resident 55 wore glasses, had adequate hearing, had a BIMS of 15/15, had no behaviors either verbally or physically towards others and did not wander. Resident had functional impairment of both lower extremities related to amputations, needed maximum or total assistance with cares and dressing, needed set up assistance with meals, and was diagnosed with amputation of both lower extremities, coronary artery disease, congestive heart failure, hypertension (high blood pressure), peripheral vascular disease ( a circulatory problem affecting blood vessels outside the brain and heart, often causing pain and other symptoms in the legs), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively, leading to a buildup of waste and fluid in the body), diabetes, and obstructive sleep apnea. Resident 55 had orders for an anticoagulant ( a medication that interrupts blood clotting), diuretic ( a medication that helps remove fluids), antiplatelet ( a medication that interrupts blood clotting, hypoglycemic (a medication to reduce blood sugars), and an anticonvulsant. Record review of the Care Plan last reviewed and revised on 06/24/2025 for Resident 55 revealed a problem of Diabetes, with a goal to have no signs and symptoms of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) with the short term goal of 09/24/2025. The interventions listed were: Dexcom or one touch as ordered, Insulin and metformin as ordered, observe for signs and symptoms of hypo/hyperglycemia, blurred vision, hunger, shaky, headache, confused thinking, cold sweats, weak tired feeling, change in behavior, irritability, faint feeling, nausea and vomiting, excessive thirst, drowsiness, dry flaky skin, abdominal pain and cramping, fruity breath, rapid breathing, excessive urination. A second Care Plan problem of nutritional status; Resident 55 is alert and oriented, able to demonstrate safety in drinking hot beverages without a lid. Has a bilateral above the knee amputation, uses adaptive equipment, and receives Bumex (a medication primary used to eliminate excess fluid and salt from the body by increasing urine production). The goal for 09/24/2025 was to consume more than 75% of meals and fluids. The interventions listed were: monitor weights, prefers to wear clothing protector to keep clothing clean, and provide a regular diet with small portions, built up silverware, divided plate, cooks cut meats, egg, and meat daily. Observation of Resident 55’s room on 07/30/2025 at 2:33 PM revealed 8 cans of Vienna sausages, 2 jars of nuts, and other snacks on his bedside table within arm’s reach. Interview 07/20/2025 at 2:33 PM with Resident 55 who stated my (spouse) brings me many snacks every week when here to visit. I lost both of my legs due to diabetes. But I am not on any particular diet, I just eat what I want to eat. I am on insulin and take metformin (an oral medication for diabetes) and I think my blood sugars are in the 150 to 200 range most of the time. Observation 07/31/2025 at 8:24 AM of Resident #55 was seated at the dining room table for breakfast who had no issues eating and ate 100% of the meal. Observation on 07/31/2025 at 8:40 AM of Resident #55 who ate 100% of breakfast. Observation on 07/31/2025 at 12:13 PM of Resident 55 who used silverware with larger handles, visited with table mates, and had edema wear on the left arm. Observation on 08/04/2025 at 8:11 AM in the room of Resident 55 who has a can of potato chips, a large box of whoppers candy, and 6 cans of Vienna sausages sitting on the bedside table in the resident room. Record review of Resident 55’s weights from admission revealed that on 03/21/2025 the resident weighed 214 pounds. On 07/20/2025 Resident 55 weighed 247.7 pounds. On 07/29/2025 Resident 55 weighed 254 pounds. This was a weight gain of 18.69% since admission and 2.54% weight gain in one week. Interview on 08/04/2025 at 9:48 AM with Resident #55 who stated “I keep snacks at bedside but don't eat too many. My (spouse) brings many things to eat on Saturdays as needed. I just keep the food on the bedside table so I can reach it. I have been educated and am knowledgeable about the effects of sugar and high blood sugar on the system. I feel my blood sugars are “pretty well maintained” in the normal range most of the time. Wounds not healing. They started me on an antibiotic for my left leg now. Record review of the care plans last revised on 06/24/2025 did not reveal any goals for Resident 55 related to nutritional choices, diabetic education, and interventions about healthy food choices. Although there was mention of monitoring Resident 55’s weights, there were no identified measurable goals for the weights. C. Record review of the quarterly MDS dated [DATE] revealed Resident 9 was admitted to the facility on [DATE], wore glasses, had adequate hearing, a BIMS of 15/15 with a score determining: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, had no issues with moods or behaviors, was wheelchair dependent and used an electric wheelchair, was totally dependent upon cares, was occasionally incontinent of bladder and always continent of bowel, had diagnoses for a progressive neurological condition of muscular sclerosis, anemia, hypertension, urinary tract infections, and depression, received pain medications occasionally, had no swallowing or dental issues, and received antibiotics, opioid, and anticonvulsants medications. Interview on 07/30/2025 at 11:38 AM Resident 9 revealed having had 2 urinary tract infections in the past 8 weeks and a yeast infection. Resident 9 stated the conditions seemed to be under control now. Record review of the care plan for Resident 9 revealed a problem of UTI (urinary tract infection with a start date of 06/27/2025. The goal, with a target date of 07/15/2025, stated the condition will resolve after antibiotic series is complete. Interventions included; condition monitored by checking vital signs and condition of resident. Update the primary care physician as needed. The second intervention listed was to monitor for signs and symptoms of adverse effects of antibiotic. There was no mention of this resident having had any other urinary tract infections or other infections in the past. Resident 9’s care plan also had a problem of “falls”. The care plan stated Resident 9 is at risk for falls related to a history of falls, immobility, weakness, and a diagnosis of muscular sclerosis. Resident 9 is dependent on staff for transfers, repositioning, and has been evaluated by Occupational Therapy with balance precautions in place, due to poor sitting balance, Resident 9 is at risk for falls. The goal written was that “Resident 9 will not sustain serious injuries if a fall occurs”. Interventions included but were not limited to “keeping frequently used items within reach. (Resident 9) has a special device attached to this resident’s bed in which the resident’s phone is on to ensure this is close to (Resident 9’s) reach when in bed. Also likes to have push call light on chest so Resident 9 is able to use chin to turn the call light on.” A third identified problem on the care plan was Resident 9’s Nutritional Status which revealed Resident 9 had a diagnosis of muscular sclerosis (MS) and edema. Resident 9 used adaptive equipment which included a lid for coffee. Resident 9 didn’t eat sugar - very aware of MS and monitors the diet closely. Resident 9 didn’t drink milk or juice. had a good intake, and was fed at meals. Didn’t want any interventions in place to gain weight. BMI (a screening tool used to estimate body weight status based on height and weight)= 17. There was no mention of the use of extended straws used by the resident to promote dignity while consuming meals. Interview on 07/30/2025 at 3:45 PM with Resident 9 who revealed an inability to move much of (Resident9’s) body except my head due to diagnosis of Muscular Sclerosis. The staff always answer my needs as soon as I ring the call light. The staff leave the soft call light right next to my head so if I need to call them staff, I just have to move my head to the side and they will answer the call light right away. “I just can’t use my arms anymore.” Observation on 07/31/2025 at 08:12 PM of Resident 9 seated at the dining table for breakfast. Resident 9 was seated at the table with table mates and an assistant who helped Resident 9 consume breakfast. The drinking glasses had a very long straw in the cup that allowed Resident 9 to bend at the neck and drink per self without the assistant always having to help. Observation on 07/31/2025 on 12:17 PM Resident 9 was seated at the dining table for the noon meal. An assistant was seated next to Resident 9 who helped Resident 9 while Resident 9 ate dinner. Medications were given to Resident 9 while seated at the table. Two large drinks were on the table each with a very long straw. Resident 9 was able to consume drinks per self. Record review of the April 2025 Medication Administration Record (MAR) revealed that there was an order for Levofloxacin 250 mg for 7 days ordered for Resident 9 due to a urinary tract infection. The medication was given the 19th through the 24th. Resident 9 only had 6 documented doses of the 7 ordered. Record review of the May 2025 MAR revealed Resident 9 was diagnosed with a yeast infection and miconazole was ordered for the infection. The resident received this medication on May 4, 5, 6, 7, 9, 10, 11, 13, and 19. Nystatin powder was also ordered to be used twice daily and was started on May 8th. Resident 9 received this medication twice a day starting on the 8th. Record review of the June 2025 MAR for resident 9 revealed the nystatin powder continued to be used until the discontinuation date of June 30th. There was a new order for Levofloxacin 250 milligrams daily for 7 days which had been ordered for a urinary tract infection. This medication was given on the 27, 28, 29, and 30th. Record review of the July 2025 MAR for Resident 9 revealed that the order for Levofloxacin continued into the month of July and was given on the 1,2, and 3 of July. D. A record review of an “Resident Face Sheet” revealed the facility admitted Resident 2 on 11/05/2024 with a diagnosis of stage 3 chronic kidney disease (a condition of moderate kidney damage and reduced kidney function where the kidneys filter blood less effectively leading to a buildup of waste products in the body), left toe amputation, and diabetes (a condition characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). Review of Resident 2’s “Care Plan” revealed a problem of nutritional status stating the resident was alert and orientated and can demonstrate safety in drinking hot beverages with out a lid. The resident received a therapeutic diet and had significant weight loss due to a decrease in edema with a start date of 11/06/2024. A goal was listed that the resident would consume more than 50% of meals and fluids dated 02/19/2025. Approaches were listed to monitor weights, the resident preferred to wear clothing protector to keep their clothing clean, and staff provide a regular diet with small portions, 8 ounces of a supplement twice daily yogurt at breakfast, to have an egg daily and fruit for dessert all dated 11/06/2025. A record review of Resident 2 physician orders revealed an diet order for a regular diet with 1400 milliliters a day fluid restriction dated 05/27/2025. In an interview completed on 07/30/2025 at 3:10 PM with Resident 2 spouse they revealed that the resident was on a fluid restriction and was aware of how much fluid they could consume a day but often would consume more per their choice. The spouse stated facility staff and the resident’s provider were both aware of the resident’s noncompliance with the ordered fluid restriction. In an interview completed on 08/04/2025 at 2:32 PM with Nurse Aide L (NA-L), NA-L confirmed knowledge of Resident 2’s fluid restriction. In an interview completed on 08/04/2025 at 2:34 PM with Registered Nurse J (RN-J), RN-J stated the dietary department tracked fluid intake consumed by the resident at mealtime and nursing staff provided and 8-ounce cup of fluid in the resident’s room three times a day to encourage the resident to comply with their fluid restriction as prescribed. The RN confirmed that the resident often chose not to comply with the fluid restriction as ordered by their provider. In an interview completed on 08/04/2025 at 4:02 PM with the facility Director of Nursing (DON), the DON confirmed that the resident was on a fluid restriction and was often noncompliance with following the prescribed fluid restriction. The DON confirmed that this should be reflected on the resident’s care plan and was not. In an interview completed on 08/05/2025 with the facility 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) Coordinator (MDSC), the MDSC confirmed that the resident’s fluid restriction and noncompliance should be reflected in the resident plan of care and was not. Based on record reviews, observations, and interviews, the facility failed to ensure the individualized and personalized comprehensive care plans had person-centered goals, measurable objectives, and interventions related to respiratory infections, nutrition, diabetes, resident choices, urinary tract infections and other infections, resident fluid restrictions, and self-directed care wishes for 4 of 18 sampled residents (Residents 55, 9, 68, and 2). Findings were: Review of the undated facility “Care Plan Policy” revealed the purpose was to ensure that all residents of (Facility name) have an individualized, comprehensive care plan (plans used to prepare for and manage the potential need for ongoing care due to chronic illness, disability, or aging),that reflects their current needs, goals, and preferences, and is maintained in compliance with federal and state regulations. The policy further stated; 1. Each resident will have a care plan developed and maintained by the interdisciplinary team (IDT) to address medical, nursing, psychosocial, and functional needs. 2. Care plans will be A.) Developed within required federal and state timeframes following admission and significant change in condition, B.) Reviewed and updated as residents’ conditions, physician orders or needs change, and C.) Revised whenever new assessments, physician orders , or changes in condition require adjustments in care. 3. The care plan will guide staff in providing individualized care and will be accessible to all appropriate team members. 4. Residents and/or their representatives will be invited and encouraged to participate in care planning and updates. 5. All care plans and updates will comply with 42 CFR 483.21 (Federal regulation) and CMS (Centers for Medicare and Medicaid Services) and state guidelines. The procedure was as follows: 1. The IDT will develop the initial care plan per regulatory timelines. 2. Updates to the care plan will occur A.) following any change in condition, B.) with any new or changed physician orders, and C.) after completion of significant MDS (minimum data set assessments - a key component of the Resident Assessment Instrument (RAI) and helps identify residents' functional capabilities and health problems, forming the basis for their individualized care plans). 3. Nursing staff will ensure care plans accurately reflect current orders, treatments, and resident needs 4. Documentation supporting care plan changes will be maintained in the resident medical record. Interview with Minimum Data Set Coordinator (MDSC) on 7/31/2025 at 10:00 AM in the MDS office revealed that the care plans are updated when the resident assessments are completed. They are updated again at any time there are falls, changes in medications, and any other needs to care for the residents. The MDSC records all of the changes in medications and another individual records and updates all of the falls. Interview with the MDSC on 7/31/2025 at 11:12 AM in the MDS office. The care plans are revised as soon as the acute problem is resolved. The falls stay on the care plan, but the medications usually come off the care plans. Anything that is acute (short term) issue or problem, is usually removed once it is resolved because it goes away. The MDSC was also in agreement that the care plans are not very descriptive for the individual being cared for. Agreed that the comprehensive care plans are not very personalized to each individual. The MDSC was going to review the federal and state regulations to see what must be included on the care plans and make changes as needed. Confirmation interview with the Director of Nursing on 08/04/2025 at 11:10 AM revealed the care plans are updated as needed with the medication changes and falls. The fall information stays on the care plans. But information that is related to respiratory infections or urinary tract infections are deleted from the care plan once they are resolved. No, they do not leave a history of that illness on the care plan because maybe it only occurred one time. Agreed that an example listing a problem of “Resident is a diabetic with a goal to show no signs of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar)” did not personalize the comprehensive care plan or show the whole picture of a resident’s care in comparison to “The resident is a diabetic, with XYZ problems and issues related to diabetes and other co-morbidities, whose choice is to keep high carbohydrate (sugar filled) foods at the bedside which are not recommended for those with diabetes” The DON confirmed that the comprehensive care plans needed to be more detailed in order to create a more personalized, individual comprehensive care plan so that those individuals caring for that resident had a better understanding of each resident being cared for.

Licensure Reference Number NAC 175 12-006.09(H)(iii)Based on interview and record review the facility failed to ensure wounds were comprehensively assessed on a routine basis and failed to ensure a wound had treatment orders for 1 resident (Resident 10) of 2 sampled residents. The facility census was 73.Findings are:A record review of a document titled Best Practices for Wound Assessment and Documentation dated 04/17/2025 by the Wound Care Education Institute revealed the foundational elements of wound assessment should include precise anatomical location, classification and etiology, accurate wound measurements, wound bed characteristics, wound edge and margin assessment, exudate (drainage) characteristics, peri wound (skin surrounding the wound) status, and pain and symptom reporting.A record review of facility's undated policy titled Skin Assessment and Treatment Policy revealed it is the policy of the facility to routinely monitor, assess, and manage residents' skin integrity. All assessments and treatments are conducted in accordance with physician orders, accepted clinical standards and facility procedures. A comprehensive skin assessment is completed weekly, and wounds are treated per physician orders and standards of practice.A record review of a Resident Face Sheet revealed the facility admitted Resident 10 on 05/29/25 with diagnoses of Multiple Sclerosis (a chronic often disabling disease that attacks the central nervous system which includes the brain and spinal cord).A record review of Resident 10's Care Plan revealed the resident was listed to have a problem of having the potential for skin breakdown with a denuded area to the left buttock dated 05/29/2025. An intervention was listed for the resident to have a weekly skin assessment dated [DATE]. No treatment interventions were listed for the denuded area to the left buttock.A.A record review of a Skin Condition Record labeled with Resident 10's name revealed:-Documentation dated 06/18/2025 a 1.0 centimeter (cm) X 0.2 cm open area to the residents left lower buttock. No other assessment information was documented.-Documentation dated 06/30/2025 the area did not have any drainage, and the area was cleaned, and the resident had no complaints of discomfort. No other assessment information was documented.-Documentation dated 07/07/2025 the area did not have any drainage, and the area was cleansed, and Vaseline gauze was applied to the area. No other assessment information was documented.-Documentation dated 07/14/2025 the area did not have any drainage, and the area was cleansed without the resident having complaints of discomfort. No other assessment information was documented.-Documentation on 07/28/2025 that the area is without drainage and it was cleansed. No other assessment information was documented.A review of Resident 10 Progress Notes revealed:-On 05/29/2025 documentation reflecting the resident's admission to the facility with left buttock discomfort complaints and an abraded area on the left buttock measuring 0.4cm in diameter. Calzinc was applied to the area.-On 06/13/2025 documentation reflecting the resident was noted to have scant amount of red drainage and had an deep open area. No documentation of where the open area was located or further assessment of the drainage or open area. Aquaphor and Vaseline gauze were applied.-On 06/18/2025 documentation reflecting the resident had and open area to the left lower buttock measuring 1.0cm x 0.2cm. Documentation stated the area was cleansed and Vaseline gauze was applied.-On 06/20/2025 documentation that the resident continued to have an open area and the dietician was requesting to start a protein supplement.A review of Resident 10 Physician orders from 05/29/2025 through 08/04/2025 revealed no physician orders for wound care.In an interview completed on 07/31/2025 with Licensed Practical Nurse K (LPN-K), LPN-K stated that all residents receive a weekly head to toe skin assessment that is signed off as completed in the resident treatment administration record. The nurse stated if there is an alteration in skin integrity it is documented in the residents Progress Notes or Skin Condition sheet. The area is measured and assessed weekly and documented on. If a resident has a wound or sore the provider is notified and treatment orders are obtained for the area and entered as a physician order. Documentation of the treatment being completed is signed off on the residents Treatment Administration Record.In an interview completed on 08/04/2025 at 3:48 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 10 had a wound to their left buttock that was not completely assessed and documented on on a routine or weekly basis. The DON confirmed that there was no treatment orders in the residents medical record for this area.

Licensure Reference Number 175NAC 12-006.05(E) Based on record review, and interview the facility failed to ensure that the risk versus benefit information for 2 of 5 sampled residents, (Resident 50 and 72), were discussed to the resident and resident representative for any psychotropic medications and prior to starting any psychotropic medications which describe in plain language the risks, benefits, options, and alternatives of the medication being prescribed. The facility census was 73. Findings are:Based on record review and interview, the facility failed to ensure that the risk versus benefit information for 2 of 5 sampled residents, (Resident 50 and 72), was given to the resident and resident representative for any psychotropic medications and prior to starting any psychotropic medications (medications are drugs that affect the mind, emotions, and behavior) which describe in plain language the risks, benefits, options, and alternatives of the medication being prescribed. Findings are: A. Record review of the Doctor Appointment Sheet dated 02/12/2025 revealed Resident 50 received a new order for Buspar (a medication for anxiety). Review of the 04/22/2025 quarterly MDS Assessment data revealed Resident 50 had a Brief Interview for Mental Status (BIMS - is a cognitive screening tool used in long-term care (LTC) facilities to assess the cognitive function of residents) score of 15 (13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment ) displayed no behaviors, rejection of cares, or wandering behaviors. Resident 50 used a walker and a wheelchair and needed supervision while eating and moderate to maximum assistance with dressing, toileting, bathing, sitting, standing, and walking, was occasionally incontinent of urine and frequently incontinent of bowel, had complex diagnoses of breast cancer, diabetes, hypertension (high blood pressure) and coronary artery disease and received daily insulin injections, and prescribed antianxiety and antidepressant medications as well as opioid medications for pain. Review of the working care plan (a comprehensive plan to address the support and services needed by individuals who can no longer perform daily activities independently due to chronic illness, disability, or aging) last reviewed and revised on 07/30/2025 revealed that Resident 50 had been admitted to the facility on [DATE] with orders for Zoloft and Trazodone (medications for depression and insomnia), received a new order for the medication Buspirone 5 milligrams for anxiety on 02/12/2025 which was increased to 10 milligrams with an order on 06/11/2025, received a new order for Ativan (a medication for anxiety) on 04/30/2025, and an order for Hydroxyzine on 06/11/2025 for anxiety. Record review of the Doctor Appointment Sheet dated 04/30/2025 revealed Resident 50 received a new order to Ativan 0.5 milligrams (mg) orally as needed for anxiety. Record Review of the progress notes dated 4/30/2025 for Resident 50 revealed information is noted about the medication changes. The final sentence stated, Called and updated son, (son’s name). Record review of the May 2025 medication administration record (MAR) of Resident 50 revealed that the resident started taking Ativan (lorazepam - a psychotropic medication for anxiety) the first week of May 2025 (first dose of the medication was given on May 6, 2025) on an as needed only basis. Record review of the Doctor Appointment Sheet dated 06/11/2025 revealed Resident 50 received new orders to discontinue the use of the Ativan (medication for anxiety), start Hydroxyzine (medication used for anxiety), and to increase the Buspar (medication for anxiety) to 10 mg twice a day. Record review of the progress notes dated 6/11/2025 for Resident 50 revealed: “(Resident 50) was seen again by physician on Nursing home rounds. Medications were changed. Son updated on visit today. Record review of the June 2025 MAR of Resident 50 revealed that Resident 50 stopped taking the Ativan the first week of June 2025 (last dose received was 06/07/2025). Record review of the medical record documents revealed there were no risk and benefit documents related to psychotropic medications which explained the risks, benefits, options and alternatives of the medications that were prescribed for Resident 50, who was admitted on [DATE]. Interview on 07/31/2025 at 11:12 AM with the Minimum Data Set (MDS - a key component of the Resident Assessment Instrument (RAI) and helps identify residents' functional capabilities and health problems, forming the basis for their individualized care plans) Coordinator revealed that when doing resident assessments and adding risks and benefits of medications to care plans (plans used to prepare for and manage the potential need for ongoing care due to chronic illness, disability, or aging), there are no “Risk and Benefits” of medications or other treatments used in the facility. We do not have the residents or the resident representatives sign anything. Confirmation interview on 08/05/2025 at 10:15 AM with the Director of Nursing (DON) who confirmed the facility has never had anything that they reviewed with residents or resident representatives to discuss the risks and benefits of psychotropic medications. We do not go over the risks and B. Record review of a “Resident Face Sheet” dated 08/04/2025 for Resident 72 revealed: An admission date of 04/15/2025; Diagnoses of: 1. Alzheimer's disease with late onset (a progressive decline in memory and cognitive function, including challenges with language, problem-solving, and spatial reasoning) 2. Insomnia (sleep disorder that makes it difficult to fall asleep, stay asleep, or both) 3. Nightmare Disorder (frequent, vivid, and disturbing dreams that can significantly disrupt sleep and daytime) 4. Nontraumatic intracerebral hemorrhage (bleeding within the brain tissue, occurring without a prior injury or surgery) 5. Depression (mood disorder that can affect how you think, feel, and handle daily activities) 6. Unspecified dementia, unspecified severity, with agitation (a type of dementia (a decline in mental ability severe enough to interfere with daily life) with cognitive impairment who exhibits behaviors such as restlessness, pacing, shouting, aggression, or other forms of agitation) 7. Unspecified convulsions (condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking) Record review of Resident 72’s 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 07/22/2025 revealed: A Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 03/15 with a score determining: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Additional reviews of Resident 72’s MDS revealed no potential indicators of psychosis, physical behavioral symptoms directed towards others were not exhibited, verbal behavioral symptoms directed towards others were not exhibited, and rejection of cares were not exhibited. Wandering behavior (a tendency to leave a safe, supervised area without awareness of potential dangers or consequences) was however exhibited between 1 to 3 days out of 7 days a week. The MDS further revealed Resident 72 is taking the following high-risk drug class medications: -Antipsychotic (a class of medications primarily used to treat psychosis) -Antidepressant (a class of medications used to treat depression and other mental health conditions) -Diuretic (a class of a medication that helps the body eliminate excess salt and water through urine) -Anticonvulsant (a class of medication used to prevent or treat seizures by controlling abnormal electrical activity in the brain) Record review of Resident 72’s Medication Administration Record (MAR) for April 2025 revealed the following medications were administered as scheduled: -Celexa 20 milligrams (mg) once a day (a medication used to treat depression) with an indication of depression -Keppra 500mg twice a day (a medication to aide in controlling certain types of seizures) with an indication of convulsions -Seroquel 50mg once a day (a medication used to treat the symptoms of schizophrenia, bipolar disorder and major depressive disorder) with an indication of Unspecified dementia, unspecified severity, with agitation -Trazadone 50mg once a day (a medication used to treat depression, anxiety, and insomnia) with an indication of depression Record review of Resident 72’s MAR for July 2025 revealed the following medications were administered as scheduled: -Buspirone 10mg twice a day (a medication used to treat generalized anxiety and relieve the symptoms of anxiety) with an indication of Alzheimer’s disease for anxiety/agitation -Celexa 20mg once a day -Keppra 500mg twice a day -Trazadone 50mg once a day Record review of Resident 72’s Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) with a last revision date of 07/31/2025 revealed the following non-pharmacological interventions for the high-risk medication use and target behaviors: Utilizes Celexa for depression - 1-1 time to voice concerns Utilizes Buspar PRN daily for anxiety/agitation - data collection for agitation Utilizes Trazodone to assist with sleep - Observe for side effects of trazodone: drowsiness, dizziness, fatigue, headaches, nausea/vomiting, and stuffy nose Record review of a risk versus benefit information form provided to the resident/resident representative revealed the information is not available. An interview with the Director of Nursing (DON) on 08/05/2025 10:15 AM; confirmed there are no psychotropic risk and benefit forms that are reviewed with the resident or the resident representatives stating We (the facility) have never done anything like that before. benefits of medications. Do we need to have a form that they sign? All we do is chart that we have contacted the family in our progress notes. We do not chart what is discussed, just that there were updates to the medications, etcetera. So, like with Resident 50, when there were medication changes, we just charted in the progress notes that we called and notified the resident representative. The residents do not sign anything either.

Based on interview and record review the facility failed to ensure coordination of care of dialysis for 1 resident (Resident 2) of 1 sampled residents. The facility census was 73.Findings are:A record review of facility's undated policy titled Policy and Procedures revealed it was the policy of the facility to ensure that residents who require dialysis are monitored and have care needs related to dialysis. Under section 3, monitoring and observation is to occur upon return for dialysis and the resident was assessed for general condition and tolerance of dialysis. Under section 5, Nurses will document date and time of transport to and from dialysis, resident condition before and after dialysis and all communication with dialysis providers and physicians will be documented in the resident's chart.A record review of an Resident Face Sheet revealed the facility admitted Resident 2 on 11/05/2024 with a diagnosis of stage 3 chronic kidney disease (a condition of moderate kidney damage and reduced kidney function where the kidneys filter blood less effectively leading to a buildup of waste products in the body), left toe amputation, and diabetes (a condition characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).A record review of Resident 2's Care Plan revealed a problem of Dialysis with a start date of 04/23/2025. A goal was stated that the resident will remain stable while receiving dialysis with a target date of 08/26/2025. Approaches were listed as daily weights, labs as ordered, and dialysis site will remain free from infection and to monitor the site daily all dated 04/23/2025.In an interview completed on 07/30/2025 at 3:10 PM with Resident 2's spouse they stated that Resident 2 received dialysis 3 times a week on Monday, Wednesday, and Friday and the facility assisted with the transportation to and from the dialysis center in [NAME].A record review completed on 07/30/2025 at 5:00 PM of Resident 2's physician orders revealed no orders for the resident to receive dialysis three times a week at the dialysis center in [NAME].In an interview completed on 07/31/2025 at 10:30 AM with Licensed Practical Nurse K (LPN-K), LPN-K confirmed that the resident received dialysis outside of the facility on Mondays, Wednesdays, and Fridays.A record review conducted on 07/31/2025 of Resident 2's Progress Notes for 06/01/2025 through 07/29/2025 revealed:-Documentation on 06/06/2025 stating resident was transported via facility transportation for dialysis appointment. No documentation present of assessment of resident prior to or post dialysis no documentation reflecting the resident returned from dialysis.-Documentation on 06/09/2025 that resident went out of facility for dialysis and returned at 5:00 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 06/11/2025 that resident went out of facility for dialysis and returned at 5:36 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 06/18/2025 that resident went out of facility for dialysis. No documentation present resident returned to facility from dialysis. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 06/23/2025 that resident went out of facility for dialysis. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 06/25/2025 that resident went out of facility for dialysis and returned at 5:42 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 06/28/2025 that resident stated they went to dialysis and returned on 06/28/2025. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 06/30/2025 that resident went out of facility for dialysis and returned at 6:40 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 07/02/2025 that resident went out of facility for dialysis and returned at 5:30 PM. No documentation present of resident condition prior to leaving the facility for dialysis. Documentation stated no change of condition upon return from dialysis.- Documentation on 07/07/2025 that resident went out of facility for dialysis. No documentation of resident returning from dialysis. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 07/11/2025 that resident went out of facility for dialysis. No documentation of resident returning from dialysis. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 07/16/2025 that resident went out of facility for dialysis. Documentation stated resident returned to the facility with family at 7:15 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 07/25/2025 that resident went out of facility for dialysis. Documentation stated resident returned to the facility with family at 8:50 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 07/28/2025 that resident went out of facility for dialysis. No documentation present that resident returned to the facility. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.- Documentation on 07/30/2025 that resident went out of facility for dialysis. Documentation stated resident returned to facility with family at 5:15 PM. No documentation present of resident condition prior to leaving facility for dialysis or upon return to facility from receiving dialysis.In an interview conducted on 08/04/2025 at 2:30 PM with Registered Nurse J (RN-J), RN-J stated documentation should be completed of resident leaving and returning to facility. The RN denied sending any paperwork with resident to the dialysis facility or receiving any paperwork back from the dialysis center communicating the residents condition prior to dialysis, during dialysis, or post dialysis. The RN denies doing assessments on the resident prior to dialysis treatments or after the resident returns to the facility from dialysis.In an interview completed on 08/04/2025 at 4:00 PM with the facility Director of Nursing (DON), the DON confirmed that the resident should have orders stating what kind of and how often the resident received dialysis, and this was not present in the resident's medical record. The DON confirmed that documentation should be present in the residents progress notes reflecting assessment prior to leaving facility for dialysis, when and how the resident left the facility for dialysis, when and how the resident returned to the facility from dialysis, any changes that may have occurred during dialysis, resident assessment after returning to the facility from dialysis and these were not present. The DON confirmed that the facility does not send anything paperwork with the resident communicating with the dialysis center on the residents condition prior to going for dialysis. The DON confirmed the facility received no communication from the dialysis center as to what occurred during the dialysis therapy and condition of the resident when transported back to the facility or post dialysis and should be.

Based on record review and interview the facility failed to notify the ombudsman (a state appointed advocate for residents of nursing homes) of resident discharge for 1 of 2 residents reviewed (Resident 82) as required. The facility census was 73. Findings are:Record review of the undated facility policy titled Transfer and Discharge from the Facility Policy revealed that each resident has the right to remain in the facility and not transfer or discharge a resident. The facility forwards a copy of all discharge notices to the Office of the State Long Term Care Ombudsman and required state agencies. The facility staff will document in the resident's record the date that a copy of the discharge notice was sent to the representative of the Office of the State Long Term Care Ombudsman and identified state agencies per requirements. Record review of the discharge Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 82 dated 6/5/25 revealed that Resident 82 admitted into the facility on 5/7/25. The MDS revealed that Resident 82 had a discharge date from the facility of 6/5/25.Record review of the Discharge summary dated [DATE] for Resident 82 revealed a discharge date of 6/5/25. Record review of the medical record for Resident 82 revealed no documentation of discharge notice provided to the ombudsman.Interview on 8/4/25 at 12:01 PM with the facility Social Services Director (SSD) revealed that the SSD provides notification of resident hospital transfers and discharges to the ombudsman monthly by email. The SSD revealed that the Emergency Transfers From Facility form is attached to the monthly email notification to the ombudsman.Record review of the facility Emergency Transfers from Facility form for June 2025 revealed that the discharge of Resident 82 on 6/5/25 was not included in the ombudsman notification. Interview on 8/5/25 at 12:02 PM with the facility Social Services Director (SSD) confirmed that the SSD was not aware of the requirement to notify the state ombudsman of resident discharges. The SSD revealed that the SSD only notified the ombudsman of resident hospital transfers. The SSD confirmed that the facility did not notify the state ombudsman of the 6/5/25 discharge of Resident 82.

Licensure Reference Number 175 NAC 12-006.02(H) as directed in the Adult Protective Services Act, Neb. Rev. Stat. S 28-372. Based on record reviews and interviews, the facility failed to report incidents resulting in serious bodily injury within 2 hours for 2 residents, Resident 2 and Resident 6, of 4 residents sampled for reporting and for 1 resident, Resident 2, of 4 residents sampled for reporting. The facility census was 71. Findings are: A. A record review of the facility's Abuse and Neglect Prevention Protocol revised May 2024 revealed that the facility was required to report a reasonable suspicion of abuse or neglect to the state agency within 2 hours of forming the suspicion if there was a serious bodily injury, and within 24 hours of forming the suspicion if there was not a serious bodily injury. B. A record review of Resident 2's Continuity of Care Document created 12/12/2024 revealed Resident 2 was admitted on [DATE] and had diagnoses of a fractured right fibula (the bone on the outer side of the lower leg), dizziness, type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities). A record review of Resident 2's Progress Notes revealed a note from 10/19/2024 at 9:00 AM that stated the resident had fallen and denied injury. A note from 10/19/2024 at 5:38 PM revealed the resident had a bruise to the right inner ankle, and had pain to the right ankle. A note from 10/20/2024 at 7:30 AM revealed the resident had continued bruising and pain to the right ankle, the nurse educated the resident that the bruising could indicate a fracture or a sprain, and the resident declined going to the emergency room . A note from 10/21/2024 at 9:35 AM revealed the resident had continued bruising and pain to the right ankle, and had a physician appointment scheduled for later in the day. A note from 10/21/2024 at 4:57 PM revealed the resident had returned to the facility with a diagnosis of a fracture of the distal (farthest away from the center of the body) right fibula. A record review of the Adult Protective Services (APS) Intake Worksheet revealed the report of Resident 2's fall with serious bodily injury was received on 10/22/2024 at 3:01 PM. A record review of the facility's Investigation Report revealed that Resident 2's fall with serious bodily injury was called to APS on 10/22/2024 at 3: 30 PM, and was submitted to the state agency on 10/28/2024. An interview on 12/16/2024 at 2:27 PM with the Director of Nursing (DON) confirmed that the incident for Resident 2 resulted in serious bodily injury, was called in to APS more than two hours after forming the suspicion of abuse or neglect, and the DON further confirmed that the investigative report for Resident 2 was submitted to the state agency after more than five calendar days. C. A record review of Resident 6's Continuity of Care Document created 12/12/2024 revealed Resident 6 was admitted [DATE] and had diagnoses of a fractured right femur (thigh bone), an irregular heartbeat, heart failure, dementia, high blood pressure, and a history of a heart attack. A record review of Resident 6's Progress Notes revealed a note from 08/16/2024 at 8:59 PM that stated the resident had been found lying on the floor at 8:20 PM, had pain to the right side of the body near the right hip, and was unable to move their right leg, and was transported by an ambulance to the emergency room at 8:40 PM. A note from 08/17/2024 at 12:10 AM revealed the resident had a fracture of the right femur. A record review of the APS Intake Worksheet revealed the report of Resident 6's fall with serious bodily injury was received on 08/19/2024 at 9:20 AM. A record review of the facility's Investigation Report revealed that Resident 6's fall with serious bodily injury was called to APS on 08/19/2024 at 9:17 AM, and was submitted to the state agency on 08/22/2024. An interview on 12/16/2024 at 2:27 PM with the DON confirmed that the incident for Resident 6 resulted in serious bodily injury and was called in to APS more than two hours after forming the suspicion of abuse or neglect.

Licensure Reference Number 175 NAC 12.006.18(B) Based on observations, interviews, and record reviews: the facility failed to store oxygen tubing and CPAP (Continuous Positive Airway Pressure) (a machine that is used to keep airways open while sleeping) mask/tubing in a manner to prevent the potential for cross contamination for 5 (Residents 7, 23, 59, 53, 42) of 6 sampled residents. The facility census was 71. Findings are: A record review of the undated facility policy titled Storage of Medications and Treatment Supplies revealed: -When not in use oxygen tubing should be placed in the bag that is attached to the resident's oxygen concentrator. -No mention of CPAP supply storage was located on the policy. A. An observation on 7/9/24 at 8:53 AM revealed that Resident 7's oxygen tubing was not in use and was underneath the handle of the oxygen concentrator at the end of the bed. A bag was attached to the concentrator and was empty. A record review of Resident 7's Order summary dated 7/08/24 revealed the following order: -Oxygen per nasal cannula at 0-5 liters as needed to keep oxygen saturations above 90% as needed. B. An observation on 7/9/24 at 9:15 AM revealed that Residents 23's CPAP mask and tubing was not in use and was draped over the CPAP machine located on the bedside table. There was not a bag located for storage of the CPAP mask and tubing. The observation also revealed oxygen tubing that was not in use and was under the handle of a oxygen concentrator. There was not a bag located for the storage of the oxygen tubing. A record review of Resident 7's Order summary dated 7/9/24 revealed the following orders: -Administer oxygen at 1-4 liters per nasal cannula as needed for shortness of breath and anxiety. Keep oxygen saturations greater than 90% as needed. - Administer the CPAP with 2 liters of oxygen attached to machine, use while napping and at night C. An observation 7/9/24 at 8:33 AM revealed that Resident 59's oxygen tubing was connected to a concentrator and not in use. The tubing was under the handle of a concentrator at the end of the resident's bed. An observation on 7/10/24 at 9:25 AM revealed Resident 59's oxygen tubing was under the handle of a concentrator at the end of the resident's bed. A review of Resident 59's Order Summary dated 7/9/24 revealed the following: -Administer oxygen at 3 liters per nasal cannula at bedtime. An interview on 7/10/24 at 11:27 AM with the Director of Nursing (DON) confirmed the facility expectation was to store oxygen and CPAP supplies in a bag to prevent cross contamination when not in use. The DON revealed the facility staff have been educated about this facility practice. The DON did confirm Resident 7's and Resident 59's oxygen tubing was not stored per policy to prevent cross contamination. The DON confirmed Resident 23's CPAP mask and tubing was not stored per policy. 42861 E. A record review of the document titled Resident Face Sheet revealed Resident 53 had been readmitted into the facility on [DATE] with a primary diagnosis of Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) infection with hypoxia (low levels of oxygen in your body tissues). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 5/28/24 revealed Resident 53 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function, while scores of 00 or 99 indicate total confusion) score of 14. An observation on 7/8/24 at 2:24 PM revealed Resident 53 had oxygen tubing on (gender) face however the nasal prongs were not in Resident 53's nostrils but resting on (gender) chin. The observation revealed that the oxygen tubing was not dated. An observation on 7/10/24 at 09:04 AM revealed Resident 53's oxygen tubing to be coiled up and tucked under the handle of the oxygen concentrator and not stored in a bag or in a manner to prevent cross contamination. An interview on 7/10/24 at 9:07 AM with Registered Nurse (RN) I, after an observation of Resident 53's oxygen tubing, confirmed that the oxygen tubing should be stored in a bag when not in use. F. A record review of the document titled Resident Face Sheet revealed Resident 42 had been accepted into the facility on [DATE] with a primary diagnosis of Heart Failure and a secondary diagnosis of hypoxemia. A record review of the MDS dated [DATE] revealed a BIMS score of 15. An observation on 07/09/24 at 10:03 AM, during an interview, revealed Resident 42 to be on oxygen (O2) continuously and the O2 tubing currently in use which was connected to the concentrator had not been dated. The observation also revealed Resident 42 had a portable oxygen tank attached to the wheelchair with O2 tubing attached and hanging from tank with the nasal cannula touching the wheelchair tire. During the observation/interview, Resident 42 voiced not requiring oxygen prior to hospital stay and admission into the facility and voiced hopes of weaning from oxygen. An observation on 7/9/24 at 2:49 PM revealed Resident 42's oxygen tubing was connected to the portable tank and was remained wrapped around the dial of the flow meter and was not being stored in a bag or in any manner to prevent the potential for cross contamination. An observation on 7/10/24 at 08:55 AM, while accompanied by RN-I, revealed that Resident 42's oxygen tubing was connected to the portable oxygen tank and wrapped around the flow meter with the nasal cannula touching the back of the wheelchair and the tank. An interview on 7/10/24 at 09:07 AM with RN-I, confirmed that oxygen tubing should be stored in a bag when not in use and voiced (gender) would change the tubing right away. The record review revealed that the facility policy titled Storage of Medications and Treatment Supplies did not address use or storage of oxygen tubing with portable oxygen tanks. An interview on 7/10/24 at 4:21 PM with the DON confirmed that the facility expectation was that oxygen tubing connected to portable oxygen tanks should be stored in a bag when not in use.

Licensure Reference Number 175 NAC 12.006.4(B)(ii)(1) Based on interview and record review the facility failed to ensure 12 hours of continuing education had been completed for 3 Nursing Assistants (NA-A, NA-C and NA-D) of 5 reviewed employees that had been employed more than one year. This had the potential to affect all residents in house. The facility identified a census of 71. Findings Are: A record review of continuing education hours for NA (Nurse Aide)-A, hired on 3/21/2011, revealed a total of zero hours had been completed for the last one year, covering 3/21/23 through 3/21/24. A record review of continuing education hours for NA-C, hired on 7/6/2022, revealed a total of 11.75 hours had been completed for the last one year, covering 7/6/23 through 7/6/24. A record review of continuing education hours for NA-D, hired on 4/3/2023, revealed a total of 9.25 hours had been completed for the last one year, covering 4/3/23 through 4/3/24. A record review of the undated facility policy titled Training Requirements revealed it contained the following guidelines related to training and education hours; 4. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. It is the responsibility of each employee, volunteer or contract staff to complete required training. a. The facility offers a variety of training methods and times to accommodate individuals. b. An individual's failure to complete required training, within the time requirements, will forfeit their annual evaluation increases until all training has been completed. 8. The Staff Development Coordinator maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. An interview on 7/10/24 at 8:47 AM with NA-F revealed (gender) did not know how many hours of continuing education was required for NA's annually but voiced I think it is 72 hours. An interview on 7/10/24 at 8:47 AM with NA-G revealed (gender) did not know how many hours of continuing education was required for NA's annually. NA-G voiced (gender) thought it was 40 hours. NA-G voiced that opportunities for education were through Relias as well as facility in-person meetings which occur at least monthly. An interview on 7/9/24 at 11:34 AM with the facility DON (Director of Nursing), after review of the continuing education hours for NA-A, NA-C, NA-D and NA-E, confirmed that the requirement for the annual 12 hours of continuing education for NA's was annually from their hire date and that hours had not been monitored or met. The DON confirmed that staff were continuing to work and provide cares that staff were not removed from the working schedule if hours had not been completed but that annual pay increases were not given until education hours were completed. On 7/10/24 at 08:15 AM the BOM (Business Office Manager) confirmed that the facility did not have a Staff Development Coordinator and that the Payroll Coordinator runs an audit report from Relias (a provider of education, training, and workforce enablement solutions for human services and healthcare organizations) quarterly and reviews the education hours for NA's and then will notify the supervisors of the staff needing to complete their education hours. The BOM also revealed that the Payroll Coordinator monitors this around the time of the staff's evaluation due date and if education hours are not completed, staff pay increases do not go into effect until the education hours are completed.

Licensure Reference Number 175 NAC 12-006.09D6 (7) Based on observation, record review, and interview, the facility failed to ensure that a Metered Dose Inhaler (Nebulizer), (a machine that turns a liquid medication into a vapor for inhalation) was cleaned after each use to prevent the potential for cross contamination for 1 (Resident 58) of 1 sampled resident. The facility census was 71. Findings are. A record review of the facility's undated policy titled Administering Medications through a Metered Dose Inhaler (Nebulizer) revealed the following: - the purpose of the policy was to provide guidelines for the safe administration of inhaled medications, - the resident has the right to have their medications in the right dose, - when the dosing is complete, rinse the nebulizer equipment in warm water. A record review of Resident 58's Face Sheet dated 7/10/24 revealed the resident was admitted into the facility on [DATE] with a diagnosis of Asthma (a disease that causes the breathing passages to swell and /or close off). A record review of Resident 58's Order Summary dated 7/10/24 revealed the resident had an order for: -Ipratropium-Albuterol (medications that open airways and assist to expel mucous) solution for nebulization; 0.5 mg (milligrams) -3 mg (2.5 mg base)/3mL (milliliter) give 1 vial 3 times a day at 7:00 AM, 1:00 PM, 7:00PM An observation on 7/9/24 at 10:48 AM of Resident 58's end table revealed that there was a clear liquid in the nebulizer chamber. An interview on 7/9/24 at 10:49 AM with Resident 58 revealed the facility staff do not rinse out the nebulizer when the treatment is completed. An observation on 07/10/24 8:02 AM revealed Resident 58's nebulizer on the table in Resident 58's room with a clear liquid forming drops around the chamber. An interview on 7/10/24 at 8:53 AM with Licensed Practical Nurse (LPN)-N confirmed the nebulizers are not rinsed after each use. An interview on 7/10/24 at 4:14 PM with the facility Director of Nursing confirmed the facility expectation is for the staff to rinse the nebulizer after the medication has been administered per the policy.

Licensure reference 175 NAC 12-006.12E7 Based on observation and interviews, the facility failed to ensure that potentially expired medications were not available for resident use on two of three medication carts, and failed to secure one of three medication carts. Sample size was 13 residents. The facility census was 67. Findings are: A. Observation of the 300 unit Medication Cart on 5/24/22 at 4:00 PM with RN (Registered Nurse)-I revealed: -1 open and undated Akwa Tears eyedrops for Resident #65. -1 open and undated Akwa Tears eyedrops for Resident #19. -1 open and undated [MEDICATION(S)] eyedrops for Resident #64. -1 open and undated Akwa Tears eyedrops for Resident # 53. -1 open and undated Refresh eyedrops for Resident # 62. -1 open and undated Refresh eyedrops for Resident # 62. Interview with RN-I on 5/24/22 at 4:00 PM revealed confirmation of undated medications in the medication cart. B. Observation of the 100 South unit Medication Cart on 5/25/22 at 9:00 AM with LPN (Licensed Practical Nurse)-C revealed: -1 open and undated [MEDICATION(S)] eyedrops for Resident # 68. -1 open and undated [MEDICATION(S)] eyedrops for Resident # 68. -1 open and undated Akwa Tears eyedrops for Resident # 6. -1 open and undated [MEDICATION(S)] [MEDICATION(S)] eyedrops for Resident # 38. -1 open and undated [MEDICATION(S)] eyedrops for Resident # 38. -1 open and undated [MEDICATION(S)] eyedrops for Resident # 30. -1 open and undated [MEDICATION(S)] eyedrops for Resident # 30. -1 open and undated [MEDICATION(S)] [MEDICATION(S)] eyedrops for Resident # 30. -1 open and undated Refresh eyedrops for Resident # 55. -1 open and undated Artificial Tears eyedrops for Resident # 29. -1 open and undated Akwa Tears eyedrops for Resident # 59. -1 open and undated [MEDICATION(S)] eyedrops for Resident # 41. Interview with LPN-C on 5/25/22 at 9:15 AM revealed confirmation of undated medications in the medication cart. Interview with the DON (Director of Nursing) on 5/25/22 at 3:25 PM revealed confirmation of undated medications in the medication carts. C. Observation of 100 South medication administration on 5/25/22 at 8:11 AM, revealed LPN-C left the medication cart unlocked and unattended when administering medications to a resident in the dining room. The medication cart was parked by the Nurse's station. There was no line of sight from where LPN-C was standing in the dining room to where the medication cart was parked as the cart was 50 feet away. There was also a wall and a pillar/support beam blocking the line of vision to the cart. Interview with LPN-C on 5/25/22 at 08:12 AM, revealed LPN-C confirmed the 100 South medication cart had been left unlocked and unsecured during the medication pass. Observation of 100 South's medication administration on 5/25/22 at 08:20 AM, revealed LPN-C walked away from the medication cart and had left the cart unlocked as LPN-C went into the dining room to administer a resident's medications. LPN-C's back was to the medication cart as LPN-C administered medication to the resident. Interview with LPN-C on 5/25/22 at 08:36 AM, confirmed the medication cart was left unlocked two out of three times during medication administration. LPN-C also acknowledged the medication cart was not within the line of vision when administering residents their medications in the dining room as LPN-C's back was to the medication cart which was parked next to 100 South's Nurse's station.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation and interview, the facility staff failed to serve food in a manner to prevent potential cross contamination by holding trays of food against their clothing. This affected 11 of 26 residents served food in the dining room, Residents 22, 68, 42, 6, 38, 36, 4, 59, 60, 29, and 12. The facility identified a census of 67 at the time of survey. Findings are: Observation of the facility dining room on 5/23/22 at 12:22 PM revealed DA-H was holding a tray of desserts against their T-shirt. DS-G (Dietary Supervisor) picked up a tray of desserts and held the tray against their shirt. DS-G and DA-H served desserts from the trays to Resident 22, Resident 68, Resident 42, Resident 6, Resident 38, Resident 36, Resident 4, Resident 59, Resident 60, Resident 29, and Resident 12. At 12:28 PM all of the residents were observed eating the dessert that DA-H and DS-G had served them from the trays that were held against their clothing. Interview with the DM (Dietary Manager) on 5/25/22 at 10:20 AM revealed the expectation was the staff would not hold the trays of food up against their clothing.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility failed to ensure resident beds were monitored and maintained to prevent a potential entrapment hazard for 4 of 4 sampled residents, Resident 17, 2, 1, and 68. The facility identified a census of 67 at the time of survey. Findings are: A. Observation of Resident 2's room on 5/23/22 at 11:49 AM and 5/25/22 at 8:10 AM revealed the bed was against the wall and the mattress was not secured to the bed and could be slid away from the wall which created a gap between the wall and the mattress and a potential entrapment hazard. B. Observation of Resident 17's room on 5/23/22 at 11:57 AM and 05/24/22 at 9:10 AM revealed the bed was against the wall. The mattress was not secured to the bed and the mattress could be slid away from the wall which created a gap between the wall and the mattress and a potential entrapment hazard. Observation Resident 2's room and Resident 17's room on 5/25/22 at 9:40 AM with the DON (Director of Nursing) revealed the mattresses were not secured to the beds and could be slid away from the wall which created a gap between the wall and the mattress. Interview with the DON on 5/25/22 at 9:50 AM revealed the facility did not have the brackets to secure the mattresses to the beds. The DON revealed the facility was in the process of replacing beds, however; the beds for Resident 2 and Resident 17 had not been replaced. Review of the facility Bed and Rail Checklist dated 10/25/2021 revealed no documentation the facility staff had identified the mattresses were not secured to the beds and created a potential entrapment hazard. C. Interview with Resident 1 on 05/23/22 at 2:55 PM revealed that the resident utilized the overhead trapeze to reposition in bed. Observation in Resident 1's room on 5/23/22 at 2:55 PM revealed the resident's bed side rail was loose as it wiggled back and forth and side to side. Resident 1's mattress was not secured to the bed frame and slid toward the wall when pushed on. There was a gap between the mattress/bedframe and the side rail. Observation in Resident 1's room on 5/24/22 at 09:05 AM revealed that the resident's mattress was unsecured and slid on the bedframe. The bedside rail was loose and wiggled back and forth. Interview with Resident 1 on 05/24/22 at 09:05 AM revealed the resident repositioned self on the bed utilizing the resident's trapeze bar and the bedside rail. Interview with Nursing Assistant- L (NA-L) on 5/25/22 at 1:12 PM revealed Resident 1 needed a one person, staff assist with transfers. NA-L reported Resident 1 elevates the foot of the resident's bed and uses the bedside rail for support to turn toward the edge of the bed to stand and pivot while transferring out of bed. Review of the facility's Bed and Rail checklist provided by the Maintenance Director (MD) on 05/25/22 at 4:05 PM, revealed that 10/28/21 was the last documented date of inspection for Resident 1's bed and rail. Record review of Resident 1's quarterly Minimum Data Set (MDS), section C (cognition) dated 5/17/22, revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognition). Review of Resident 1's Care Plan dated 5/17/22 revealed the resident was able to reposition resident's self in bed. Further review of Resident 1's care plan revealed the resident preferred to have the side rails up at all times to assist the resident with bed mobility and transfers in and out of bed. Interview in Resident 1's room with the Director of Nursing (DON) on 5/25/22 at 2:38 PM, confirmed the resident's bedside rail attached to the bed was loose and unsafe. The DON also confirmed Resident 1 does use the bedside rail for transfers. The DON stated Resident 1's bed is old and needs to be replaced. D. Record review of the face sheet dated 5/24/22 for Resident 68 revealed that Resident 68 admitted into the facility on [DATE]. Observation on 5/23/22 at 11:53 AM in the room of Resident 68 revealed that the resident's bed was against the wall. The mattress was not secured to the bed and could be slid away which created a gap between the wall and the mattress. Observation on 5/24/22 at 9:02 AM in the room of Resident 68 revealed that the mattress was not secured to the bed. The mattress slid away from the wall with minimal force. This created a gap between the wall and the mattress. Observation on 5/25/22 at 1:18 PM in the room of Resident 68 revealed that Resident 68 was in bed. Resident 68's eyes were closed. Record review of the facility Bed and Rail Checklist dated 10/25/2021 revealed no documentation that the resident mattress was checked to ensure that it was secured to the bed. Interview on 5/24/22 at 4:03 PM with Registered Nurse-D (RN-D) revealed that Resident 68 is anxious and transfers into the bathroom frequently. Interview on 5/25/22 at 2:01 PM with Nursing Assistant-E (NA-E) revealed that Resident 68 goes to the bathroom frequently. NA-E revealed that Resident 68 will sometimes reposition them self in the bed. Interview on 5/25/22 at 2:05 PM with Nursing Assistant-F (NA-F) revealed that Resident 68 goes to the bathroom frequently.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to perform hand hygiene during meal service when staff hands became contaminated and to perform hand hygiene per facility policy. This had the potential to affect all 25 of the facility residents eating in the south dining room (Residents 20, 14, 45, 17, 55, 13, 60, 12, 221, 29, 59, 4, 33, 36, 38, 26, 6, 39, 42, 68, 2, 7, 41, 22, and 30); and 23 residents in the facility GP Dining Room. The facility failed to store oxygen tubing in a manner to prevent the potential for cross contamination. This affected 2 residents (Resident 55 and 221). The facility identified a census of 67 at the time of survey. Findings are: A. Observation of the south dining room on 5/23/22 at 12:00 PM revealed the unidentified cook started serving the meal from the steam table. DS-G (Dietary Supervisor) served the residents in the dining room after the cook plated the food. DS-G served 2 plates at a time by the bottom. DS-G did not do hand hygiene between residents after placing the plates in front of the unmasked residents and after touching the plates and the surface of the tables. DA-H (Dietary Aide) was observed pushing a cart with salads and coffee and hot cocoa around the dining room and serving the items to the residents from the cart. 25 residents were in the dining room. At 12:05 PM DA-H washed their hands at the handwashing sink, turned the faucet off with their bare hands then dried their hands with paper towels. DA-H then used their bare hands to open the plastic wrap on the salads and check the temperatures of the salads with a thermometer. DS-G was observed leaning over with both hands on their jeans talking to Resident 55. DS-G then went to the steam table and without doing hand hygiene, took plates of food to Resident 33 and Resident 221. DA-H then went to the steam table and got a plate of food then took it to Resident 12. DA-H did not do any hand hygiene after they had turned the faucet off with their bare hands before serving food to Resident 12. Without doing hand hygiene, DA-H then got some drinks out of the refrigerator, put them on a cart, then pushed the cart to Resident 59 and served Resident 59 the drinks and gave Resident 59 a cherry salad out of the container DA-H had checked the temperatures on. DA-H then got a packet of hot chocolate out of the cupboard. DA-H then took the hot chocolate to Resident 59 then came back to the cart and put the condiment basket on the counter. DS-G was observed serving plates of food to the residents in the dining room without doing hand hygiene after they had placed their hands on their jeans. DS-G repeatedly put their hands on their jeans then did no hand hygiene before serving food to the residents. At 12:14 PM DA-H took plates of food to Resident 33 then to Resident 6 without doing any hand hygiene. DS-G served Residents 20, 14, 45, 17, 55, 13, 60, 221, 29, 59, 4, 36, 38, 26, 39, 42, 68, 2, 7, 41, 22, and 30. Resident 12, Resident 33, and Resident 6 were served by DA-H. At 12:28 PM all of the residents were observed eating and drinking from the plates and items that had been served to them by DS-G and DA-H. Interview with the DM (Dietary Manager) on 05/25/22 at 10:20 AM revealed the expectation was for staff to wash their hands when they touched their clothing or when their hands were contaminated. The DM revealed the staff should have used a paper towel to turn the faucet off and then dry their hands; not use their bare hands to turn the faucet off. Review of the undated facility policy Handwashing revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Employees must wash their hands for at least twenty (20) seconds using antimicrobial soap and water or alcohol based hand rub under the following conditions: When hands are visibly soiled (hand washing with soap and water); before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); before and after eating or handling food (hand washing with soap and water); before and after assisting a resident with meals; after handling soiled or used linens, dressing, bed pans, catheters and urinals; after handling soiled equipment or utensils; after clearing tables or busing dirty dishes; after removing gloves or aprons; and after completing duty. Hand hygiene is always the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene. Procedure: Washing Hands: The following equipment and supplies will be necessary when performing this procedure: Running water; soap; paper towels; trash can; lotion; and alcohol-based hand rub containing 60-95% [MEDICATION(S)] or isopropanol. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into the trash. B. Record review of the undated facility policy titled Handwashing revealed that the facility considers hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) the primary means to prevent the spread of infections. The policy revealed that all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Employees must wash their hands for at least twenty seconds using antimicrobial soap and water or alcohol based hand rub under the following conditions; when coming on duty; before and after direct resident contact; before and after eating or handling food; upon and after coming into contact with a resident's intact skin; after handling soiled or used linens, dressings, bedpans, catheters and urinals; after handling soiled equipment or utensils; after taking out garbage or trash; after clearing tables or busing dirty dishes; after removing gloves or aprons; and after completing duty. Observation on 5/23/22 at 11:35 AM in the facility GP Dining Room revealed that Dietary Assistant-A (DA-A) pushed a 3 shelf cart to Resident 67. DA-A picked up a small bowl and dished up lettuce salad. DA-A poured dressing onto the salad and sat it on the table in front of unmasked Resident 67. The bare hands of DA-A touched the table. DA-A did not perform hand hygiene. DA-A pushed the cart to Resident 24. DA-A picked up the coffee cup off of the table from in front of unmasked Resident 24 and poured coffee into the cup. DA-A sat the cup back on the table in front of Resident 24. DA-A offered Resident 24 a choice of salad. DA-A dished cherry salad into a bowl and sat it on the table in front of Resident 24. The bare hands of DA-A touched the table surface in front of the resident. DA-A did not perform hand hygiene. DA-A pushed the cart to Resident 54 and offered the resident a choice of salad. DA-A picked up the coffee cup from the table in front of unmasked Resident 54. DA-A poured coffee into the cup and sat it on the table in front of Resident 54. DA-A did not perform hand hygiene. DA-A pushed the cart to Resident 66 and offered the resident a choice of salad. Resident 66 refused a salad. DA-A offered crackers to Resident 66 and the resident accepted. DA-A opened the package of crackers with the bare hands and sat the crackers on the table in front of unmasked Resident 66. The bare hands of DA-A touched the table in front of the resident. DA-A poured coffee into the cup for Resident 66. DA-A did not perform hand hygiene. DA-A went to the refrigerator in the dining room. DA-A removed a drink glass from the refrigerator and carried it to Resident 58. DA-A sat the drink glass on the table in front of unmasked Resident 58. DA-A did not perform hand hygiene. DA-A returned to the refrigerator and removed a drink glass from the refrigerator. DA-A carried the drink glass to Resident 24 and sat the drink on the table in front of the unmasked Resident 24. DA-A did not perform hand hygiene. At 11:44 AM, DA-A used a thermometer and checked the temperature of the pasta salad. DA-A pushed the cart to Resident 23. DA-A placed a serving of the pasta salad into a bowl and sat it on the table in front of unmasked Resident 23. The bare hands of DA-A touched the table. DA-A picked up Resident 23's cup by the handle and filled it with coffee. DA-A sat the cup on the table in front of Resident 23. DA-A opened a package of crackers and sat the crackers on the table in front of Resident 23. DA-A opened a packet of creamer and poured the creamer into the cup of coffee for Resident 23. DA-A did not perform hand hygiene. Resident 66 asked DA-A for more coffee. Resident 66 handed the coffee cup to DA-A. DA-A took the cup with the bare hands and poured coffee into the cup. DA-A sat the cup back on the table in front of Resident 66. DA-A did not perform hand hygiene. DA-A picked up a cup and poured hot water into the cup and sat it on the table in front of unmasked Resident 21. DA-A opened a tea bag and placed the tea bag into the cup. DA-A picked up the clothing protector from the table and placed it on Resident 21. DA-A secured the clothing protector behind the resident's neck. DA-A's bare hands touched the neck of Resident 21. DA-A did not perform hand hygiene. DA-A went to the refrigerator. DA-A removed a plate of celery. DA-A sat the plate of celery on the table in front of unmasked Resident 67. The bare hands of DA-A touched the table. DA-A did not perform hand hygiene. DA-A went to unmasked Resident 15 and poured coffee into the cup for the resident. DA-A opened a packet of creamer and poured it into the cup for Resident 15. Resident 15 picked up the spoon from the table with the bare hands and handed it to DA-A. DA-A used the spoon with the bare hands and stirred the resident's coffee. DA-A handed the spoon back to Resident 15. DA-A did not perform hand hygiene. DA-A pushed the cart to Resident 61. DA-A picked up the cup from the table and poured coffee into the cup. DA-A sat the cup on the table in front of unmasked Resident 61. DA-A did not perform hand hygiene. DA-A pushed the cart to Resident 50. DA-A dished cherry salad into a bowl and sat it on the table in front of unmasked Resident 50. The bare hands of DA-A touched the table. DA-A did not perform hand hygiene. DA-A pushed the cart to Resident 46. DA-A dished cherry salad into a bowl and sat it on the table in front of unmasked Resident 46. DA-A opened the napkin on the table in front of resident 46 and removed the silverware with the bare hands. DA-A sat the silverware on the napkin in front of Resident 46. DA-A picked up the clothing protector from the table and placed it on Resident 46. DA-A secured the clothing protector behind Resident 46's neck. The bare hands of DA-A touched the neck of Resident 46. DA-A did not perform hand hygiene. DA-A went to Resident 34. DA-A dished cherry salad into a bowl and sat it on the table in front of unmasked Resident 34. The bare hands of DA-A touched the table. DA-A picked up a cup from the table and filled it with hot water. DA-A sat the cup on the table in front of Resident 34. DA-A opened a tea bag packet and placed the tea bag into the cup of hot water. At 11:56 AM, Dietary Cook-B (DC-B) arrived at the GP dining room with the steam table cart. Nursing Assistant-J (NA-J went to DA-A and requested a bowl of pasta salad for Resident 49. DA-A picked up a bowl from the 3 shelf cart and dished a serving of pasta salad and handed it to NA-J. The time was now 11:59 AM. DC-B began to plate the first resident meal. DA-A carried the plate of food to Resident 9. DA-A sat the plate on the table in front of unmasked Resident 9. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 25. DA-A sat the plate on the table in front of unmasked Resident 25. The bare hands of DA-A touched the table. DA-A used the bare hands and picked up the salad bowl on the table in front of Resident 43 and moved it from in front of the resident. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 43. DA-A sat the plate on the table in front of unmasked Resident 43. The bare hands of DA-A touched the table. DA-A returned to the stem table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 18. DA-A sat the plate on the table in front of unmasked Resident 18. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 49. DA-A sat the plate on the table in front of unmasked Resident 49. The bare hands of DA-A touched the table. DA-A returned to the stem table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 40. DA-A sat the plate on the table in front of unmasked Resident 40. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform had hygiene. DA-A carried a plate of food to Resident 54. DA-A sat the plate on the table in front of unmasked Resident 54. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 24. DA-A sat the plate on the table in front of unmasked Resident 24. DA-A went to the refrigerator in the dining room. DA-A did not perform hand hygiene. DA-A removed a glass of milk from the refrigerator and carried the glass of milk to Resident 21. DA-A went to the steam table cart. DA-A carried a plate of food to Resident 21. DA-A sat the plate on the table in front of unmasked Resident 21. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 32. DA-A sat the plate on the table in front of unmasked Resident 32. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 34. DA-A sat the plate on the table in front of unmasked Resident 34. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 51. DA-A sat the plate of food on the table in front of unmasked Resident 51. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 46. DA-A sat the plate on the table in front of unmasked Resident 46. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 50. DA-A sat the plate on the table in front of unmasked Resident 50. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 61. DA-A sat the plate of food on the table in front of unmasked Resident 61. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 23. DA-A sat the plate on the table in front of the unmasked Resident 23. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 67. DA-A sat the plate on the table in front of unmasked Resident 67. The bare hands of DA-A touched the table. DA-A went to the 3 shelf cart. DA-A did not perform hand hygiene. DA-A removed a slice of bread using tongs and placed it on a small plate. DA-A carried the plate with the slice of bread to Resident 67 and sat the plate on the table in front of Resident 67. DA-A returned to the steam cart table. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 63. DA-A sat the plate on the table in front of unmasked Resident 63. The bare hands of DA-A touched the table. DA-A went to the 3 shelf cart. DA-A picked up a coffee cup and poured coffee into the cup. DA-A used the bare hands and placed a lid on the top of the cup. DA-A carried the cup to Resident 63 and sat the cup on the table in front of the resident. DA-A went to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 66. DA-A sat the plate on the table in front of unmasked Resident 66. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 21. DA-A sat the plate of food on the table in front of unmasked Resident 21. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 52. DA-A sat the plate on the table in front of unmasked Resident 52. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 15. DA-A sat the plate of food on the table in front of unmasked Resident 15. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 58. DA-A sat the plate on the table in front of unmasked Resident 58. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 69. DA-A sat the plate of food on the table in front of unmasked Resident 69. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. DA-A carried a plate of food to Resident 48. DA-A sat the plate on the table in front of unmasked Resident 48. The bare hands of DA-A touched the table. DA-A returned to the steam table cart. DA-A did not perform hand hygiene. The time was now 12:11 PM. All residents in the dining room had received their meal. C. An observation in the GP Dining room on 05/24/22 between 12:00 PM and 12:35 PM revealed DS-M (Dietary Supervisor) plating the food for residents. The observation revealed Residents #69 and #58 were seated at the same table. NA-N (Nurse aide) was seated between Resident #69 and Resident #58 and was assisting the residents with their noon meals and drinks. NA-N took Resident #58's spoon in hand, stirred some of the food on Resident #58's plate, and offered Resident #58 a bite of food. NA-N turned to Resident #69, stirred some of the resident food and offered Resident #69 a bite. NA-N turned, picked up the drinking cup for Resident #58 by the top rim of the cup. The straw was held between the fingers of NA-N. NA-N gave Resident #58 a drink from the straw secured in the cup by NA-N's fingers. Continued observation revealed that NA-N was sitting on a rolling stool while assisting Residents #69 and #58 with the noon meal. While sitting on the rolling stool, NA-N rolled through the dining room to the medication cart, used ABHR, placed hands on lap, and returned to the dining table of Residents #69 and #58 while sitting on the rolling stool. NA-N stood and walked to the table where Resident #48 was seated. NA-N cut up the food on Resident #48's plate. NA-N returned to the table to assist Resident's #69 and #58. NA-N began to assist Resident #69 with bites of food, turned, cut up food on Resident #58's plate and gave the resident a bite of food. NA-N then stood, walked to another tabled and handed the salt and pepper shaker to Resident #32. NA-N returned to the stool and began assisting Residents #69 and #58 with the noon meal again. On 05/26/2022 an interview with the ADON (Assistant Director of Nursing) and the Director of Nursing confirmed that staff failed to perform hand hygiene during meal service when their hands were contaminated and failed to perform hand hygiene per facility policy D. An observation on 05/23/22 at 10:58 AM revealed oxygen tubing was coiled up and draped over the oxygen concentrator machine open to air for Resident #55 and Resident #221 when the oxygen was not being used in the residents' rooms. An observation on 05/24/22 at 9:03 AM revealed the oxygen tubing was coiled up and tucked under the handle of the oxygen concentrator machine open to air for Resident # 55 and Resident # 221 in the residents' rooms. An observation on 05/25/22 at 8:36 AM revealed the oxygen tubing was coiled up and was partly draped over the oxygen concentrator machine and tucked under the concentrator handle open to air for Resident # 55 and Resident # 221 in the residents' rooms. An Interview on 05/25/22 at 2:47 PM with DON (Director of Nursing) confirmed that the oxygen tubing in Resident #55 and Resident #221 rooms' was not being stored properly. The DON agreed that the oxygen tubing should not be coiled up, partly draped over the oxygen concentrator machine and tucked under the concentrator handle open to air.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observation, interview, and record review; the facility failed to ensure resident equipment was monitored and maintained to prevent a potential accident hazard for 2 of 4 sampled residents, Resident 17 and Resident 2. The facility identified a census of 67 at the time of survey. Findings are: A. Observation of Resident 2's bathroom on 5/23/22 at 11:49 AM and 5/25/22 at 8:10 AM revealed the toilet riser (a device applied to the toilet to provide height to the toilet and facilitate ease in getting off the toilet) was not secured to the toilet. The toilet riser lifted off the toilet and slid off to the side when pressure was applied against the side of the toilet riser or when the handle was lifted up. The toilet riser had a screw type lock on the front of the riser that was not secured which created a potential accident hazard as Resident 2 could fall of the toilet if the riser tipped while Resident 2 was using the toilet. Review of Resident 2's Care Plan dated 5/17/2022 revealed documentation that Resident 2 used their bathroom for toileting. B. Observation of Resident 17's bathroom on 5/23/22 at 11:57 AM and 5/24/22 at 9:10 AM revealed the toilet riser was not secured to the toilet. The toilet riser lifted off the toilet and slid off to the side when pressure was applied against the side of the toilet riser or when the handle was lifted up. The toilet riser had a screw type lock on the front of the riser that was not secured which created a potential accident hazard as Resident 17 could fall of the toilet if the riser tipped while Resident 17 was using the toilet. Interview with LPN-C (Licensed Practical Nurse) on 05/25/22 at 9:15 AM revealed Resident 17 used the toilet in their bathroom. Observation of the toilet risers in Resident 2's bathroom and Resident 17's bathroom on 5/25/22 at 9:40 AM with the DON (Director of Nursing) revealed the toilet risers were not secured to the toilets. Interview with the DON at this time confirmed the staff were expected to ensure the toilet risers were secured to the toilets. Interview with the DON on 5/25/22 at 9:50 AM confirmed the facility did not document a monthly check of the toilet risers. The DON revealed the staff were expected to ensure the toilet risers were secured to the toilets after removing them for cleaning. Review of the facility Resident Room Inspection List date 4/24/2022 revealed no documentation the toilet risers were monitored to ensure they were secured to the toilets.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.17B Based on observation and interview the facility failed to ensure laundry staff performed hand hygiene when delivering linen and personal clothing to resident's rooms to prevent cross contamination. This had the potential to affect all residents in the facility. Facility census was 72 at the time of the survey. Findings Are: On 1/05/21 at 11:51 AM an observation of LS-B (Laundry Staff) taking laundry to rooms on the east hallway which is classified as a Green Zone revealed LS-B entered the hallway with the laundry carts covered. LS-B opened the cover of each cart and placed the carts against the wall. LS-B did not use hand sanitizer before removing hangers of clothing for Room167 for Resident #67. Resident # 67 staff carried hangers of clothing to room [ROOM NUMBER]. LS-B returned to the cart and took hangers of clothing to room [ROOM NUMBER] without doing hand hygiene. LS-B touched the closet door and removed empty hangers that were placed on the linen cart away from the other clothing. LS-B did not use hand sanitizer when entering the hallway. LS-B took socks from the bin and placed them into the Room of Resident # 9. LS-B returned to the cart in the hallway and removed hangers of clothing for room [ROOM NUMBER] for Resident # 20 and did not use hand sanitizer before or after placing the clothing in the closet. LS-B did not cover the linen cart during deliver of linen and personal clothing to these rooms. LS-B then went to the next hallway with the linen cart remaining uncovered. On 1/07/21 at 7:18 PM an interview with DON (Director of Nursing) revealed that laundry staff are to use hand sanitizer between resident rooms and this expected with all employees. Review of the COVID 19 Infection Control policy dated 6/16/20 revealed under Preventing the Spread of COVID-19 Witin our Campus prevention efforts will include: Handle textiles and laundry carefully; and in accordance with the linen handling policy.

Based on observation, interview, and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to prevent and control the spread of COVID-19 amongst the residents and staff of the facility. The facility failed to thoroughly screen and document staff results, from all facility departments, for COVID-19 prior to working and/or caring for residents of the facility, and provided services to all residents of the facility. In total, the facility failed to thoroughly screen staff and document the results of the screenings in over 200 individual instances since May 19, 2020. This failure has the likelihood to expose all residents in the facility to COVID-19. Additionally, the facility failed to ensure that the residents of the facility practiced appropriate social distancing guidelines during mealtimes. A determination was made that the facility's noncompliance with one or more requirements of participation placed all residents in the facility in immediate jeopardy, which began on 5/15/20. On 7/22/20 at 3:20pm, the Administrator of the facility was notified of the immediate jeopardy at F880, Infection Prevention and Control. The immediate jeopardy was removed on 7/30/20 after surveyors verified implementation of a removal plan. The scope and severity was lowered to an F. Findings include: - Review of CMS guidance, dated 3/4/20, documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019- ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19. The guidance then stated: How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). Review of the facility's COVID-19 Action Plan documented the following: The facility will establish and implement a screening process for the daily screening of residents, staff, and visitors or vendors for signs and symptoms of the COVID-19 virus. This plan will include daily screening of residents and daily screening of staff prior to initiation of work and the testing of vendors and/or visitors prior to entry. The facility will follow the most current guidance and recommendations of the CDC when developing and implementing its screening tool. Individual departments will be responsible for documenting screening results for their staff. Review of facility staff screening sheets for the Dietary department revealed that the log had three columns: one for position scheduled, temperatures, and staff initials. Instructions at the bottom of the log documented: Please take and record your temperature before going to work. Read the instructions on forehead thermometer. Place on temple. Further review of Dietary department screening logs from May, 2020 forward revealed the following: On 5/15/2020, three dietary employees failed to complete the screening process. On 5/27/2020, five dietary employees failed to complete the screening process. On 5/28/2020, one dietary employee failed to complete the screening process. On 6/1/2020, one dietary employee failed to complete the screening process. On 6/3/2020, one dietary employee failed to complete the screening process. On 6/11/2020, three dietary employees failed to complete the screening process. On 6/12/2020, eight dietary employees failed to complete the screening process. On 6/19/2020, one dietary employee failed to complete the screening process. On 6/21/2020, two dietary employees failed to complete the screening process. On 6/23/2020, one dietary employee failed to complete the screening process. On 6/30/2020, one dietary employee failed to complete the screening process. On 7/1/2020, six dietary employees failed to complete the screening process. On 7/3/2020, two dietary employees failed to complete the screening process. On 7/9/2020, four dietary employees failed to complete the screening process. On 7/10/2020, one dietary employee failed to complete the screening process. On 7/13/2020, one dietary employee failed to complete the screening process. On 7/15/20 at 12:50pm, Dietary Aide (D1) indicated that dietary staff entered through a separate door of the facility, went to a room located next to the kitchen, and took their temperatures. They would write their temperature next to their names, and draw a circle with a line through it to show that the staff had no symptoms that could be related to COVID-19. On 7/15/20 at 12:55pm, the Dietary Coordinator (DC) indicated that dietary staff must be screened and have their temperature taken before beginning their shift. Staff were to take their temperature, write it on the daily staffing sheet, then draw a circle with a line through it to indicate that the screening process was completed. The DC indicated that she reviewed the screening logs daily to make sure they were all complete, then gave the sheets to the Dietary Manager (DM). The DC indicated that if there was a missing circle, the staff just forgot to write it down. The DC indicated that she was unaware of any issues with the screening process for dietary staff. On 7/15/20 at 1:14pm, the DM indicated that when dietary staff arrived for work, they must wash their hands, then go to the room off of the kitchen to complete the screening process. Staff must take their temperature then write it down on the staffing sheet next to their name, then must draw a circle with a line through it next to their names to indicate they were free of symptoms that could be related to COVID-19. On the weekend, when the DC was not in the building, the cook would review the sheets. The sheets were then placed in the DM's box for review, then filed. The DM indicated that if staff didn't document the circle with a line through it, it was because they forgot. Review of facility staff screening sheets for the Housekeeping and Laundry department revealed that the log had four columns: staff name, if any symptoms were present, temperatures, and staff initials. There were no instructions present on the log. Further review of two randomly sampled days of Housekeeping and Laundry screening sheets revealed that on 5/22/20, six of the seven employees failed to complete the screening process. On 5/26/20, six of the eight employees failed to complete the screening process. On both days, the staff documented their temperatures, but failed to document the absence of symptoms that could be related to COVID-19. On 7/15/20 at 11:05am, Laundry Aide (L1) indicated that staff must be screened when coming into work. Each staff person must take their temperature, review the screening questions, and then write their temperature down on the daily staffing sheet. The staff would then draw a circle with a line through it to indicate that they completed the screening process. On 7/15/20 at 11:10am, Housekeeping Aide (H1) indicated that the employee completed the screening process each time she came into work. Staff must take their temperature, write it down on the staffing sheet, and then draw a circle with a line through it next to her name to indicate that she completed the screening process. Review of the daily staffing sheets for the Nursing department documented that each staff person scheduled for that day had their name written down for that specific shift. Employees would then document their temperature and draw a circle with a line through it next to their temperature, if they were free of symptoms that could be related to COVID-19. Further review of the daily staffing sheets for the nursing department revealed: On 5/19/2020, day shift had 12 employees, evening shift had 11 employees, and the night shift had two employees, all providing direct care to residents. The 25 staff failed to indicate if the screening process was completed. On 5/22/2020, day shift had four employees, evening shift had four employees, and night shift had two employees, all providing direct care to residents. The ten staff failed to indicate if the screening process was completed. On 5/23/2020, day shift had six employees, evening shift had eight employees, and night shift had two employees, all providing direct care to residents. The 15 employees failed to indicate if the screening process was completed. On 5/24/2020, day shift had nine employees, evening shift had 13 employees, and night shift had three employees, all providing direct care to residents. The 25 employees failed to indicate if the screening process was completed. On 6/2/2020, day shift had four employees, evening shift had nine employees, and night shift had three employees, all providing direct care to residents. The 16 staff failed to indicate if the screening process was completed. On 6/5/2020, day shift had 11 employees, evening shift had 13 employees, and night shift had four employees, all providing direct care to residents. The 28 staff failed to indicate if the screening process was completed. On 6/6/2020, day shift had 15 employees, evening shift had 13 employees, and night shift had six employees, all providing direct care to residents. The 33 staff failed to indicate if the screening process was completed. On 6/7/2020, day shift had 13 employees, evening shift had 12 employees, and night shift had six employees, all providing direct care to residents. The 31 staff failed to indicate if the screening process was completed. On 6/20/2020, day shift had four employees, evening shift had three employees, and night shift had one employee, all providing direct care to residents. The eight employees failed to indicate if the screening process was completed. On 7/5/2020, day shift had five employees, evening shift had five employees, and night shift had two employees, all providing direct care to residents. The 12 employees failed to indicate if the screening process was completed. On 7/7/2020, day shift had four employees and evening shift had seven employees, all providing direct care to residents. The 11 employees failed to indicate if the screening process was completed. On 7/15/20 at 11:00am, Nurse Aide (NA1) indicated that when staff come to work, they must complete the employee screening. All staff must take their temperature, then review the screening questions. If the answers to all of the screening questions were negative, then the employee must draw a circle with a line through it next to their temperature. The temperatures and circles were placed next to each staff person's name on the daily staffing sheet. On 7/15/20 at 11:25am, the Nurse Manager (NM) indicated that all staff must have their temperatures taken before being allowed to work. The staff would take their own temperature, review the screening questions, and then document the temperature on the daily staffing sheet. The staff would also draw a circle with a line through it to indicate that they had completed the screening process. On 7/15/20 at 2:20pm, the Director of Nursing (DON) indicated that all staff must be screened prior to starting their shift. All staff would review the screening questions and have their temperatures taken. The staff would write their temperature down and draw a circle with a line through it next to their name to indicate that they were free of symptoms that could be related to COVID-19. Each of the three shifts would complete this process, then the night shift nurse would compile all of the data onto one form that was reviewed by the Nurse Managers and the DON in the morning, to ensure completeness. The DON indicated that if there was a missing lined circle, that meant that the night shift nurse just forgot to transpose it. The DON indicated that each nursing station had the list of questions that staff must review. The DON indicated that each department manager, such as Dietary, must review their own sheets for completeness and correctness. The DON indicated that she did not review any screening forms for other departments, only the Nursing department. On 7/22/20 at 2:23pm, the Administrator indicated that all staff and visitors were screened prior to entering the facility. The facility staff entered through a variety of doors, usually closest to where they were scheduled to work. Facility staff must review screening questions regarding any signs or symptoms of COVID-19, including if they had a sore throat, fever, or recent travel. The staff would then don their facemasks and begin their shifts. The Administrator indicated that each department head was responsible for ensuring that the screenings were completed appropriately, but could not indicate if that was being done. The Administrator indicated that he was not involved in the screening process, and had failed to review any of the staff screening sheets from any of the departments. - On 7/15/20 at 8:15am, multiple residents sat in the first floor dining area within six feet of each other. Residents sat two to a table, failing to maintain appropriate social distancing. On 7/15/20 at 11:56am, in the third floor dining area, multiple residents sat at dining tables within six feet of each other, failing to maintain social distancing. At three tables, there were three residents seated at the table. Five additional tables had two residents at the same table. On 7/15/20 at 12:59pm, the Dietary Manager (DM) indicated that the larger dining room tables were five feet across, and that the smaller dining room tables were four feet across. On 7/15/20 at 1:22pm, the DON indicated that the facility attempted to practice social distancing among the residents, but could not always do so. The DON indicated that the residents of the facility all ate in the dining room during meals to increase socialization. Review of CDC recommendations, located in Preparing for COVID-19 in Nursing Homes, under the section Additional Strategies Depending on the Facility's Reopening Status, documented the following: Implement Social Distancing Measures Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Cancel communal dining and group activities, such as internal and external activities. Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene.