Every finding on record at Litzenberg Memorial County Hospital

Licensure Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record review; the facility failed to ensure staff performed hand hygiene and change gloves during wound cares for 1 (Resident 2) out 4 sampled residents. The facility also failed to ensure staff wore a gown, did not use contaminated gloves when accessing the clean wipes container, perform hand hygiene and change gloves during catheter cares for 2 (Residents 2 & 4) out of 3 sampled residents to prevent the potential for cross contamination. The facility had a census of 33. Findings are: A. Record review of Resident 2's admission Record dated 9/10/25 revealed admission to the facility was on 8/19/25. Interview on 9/9/2025 at 1:23 PM with Director of Nursing (DON) revealed Resident 2 was admitted to the facility with pressure wounds to both ankles. Record review of Resident 2's Diagnoses dated 9/9/25 revealed diagnoses of unspecified open wound right foot and unspecified open wound left foot. Record review of Resident 2's Braden Scale (The Braden Scale is a risk assessment tool that predicts a patient's likelihood of developing pressure ulcers –generally a score of 18 or less indicates at-risk status) revealed a score of 15, indicating mild risk on 8/19/25. Record review of Resident 2's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 8/25/25 revealed: -Section C: 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) was 8/15, indicating moderate impairment. -Section G: Resident 2 needed supervision with eating, moderate assistance with oral hygiene, was dependent with toileting, required maximum assist with shower and upper body dressing, lower body dressing and footwear is dependent, personal hygiene needed moderate assistance, rolling right and left needed maximum assistance, and transfers needed maximum assistance. -Section M: at risk for pressure ulcers, had 2 Stage 3 ulcers present on admission, used pressure reducing devices in bed and wheelchair. Record review of Resident 2's Physician orders dated 9/9/25 revealed: -Alginate AG to open areas on right inner ankle and left outer ankle. Cover with self-adhesive dressing. Change every day and as needed for pressure ulcer. -Protein Modular 3 times a day for nutritional supplement 8 ounce can. Observation on 9/10/25 at 7:10 AM with Licensed Practical Nurse (LPN-A) during wound cares for Resident 2. LPN-A performed hand hygiene and applied a gown and gloves. LPN-A removed the old dressing from left outer ankle then cleansed with normal saline and gauze without hand hygiene or changing gloves. LPN-A cut a piece of Alginate AG dressing and applied to the wound bed and covered with an adhesive dressing. LPN-A then repositioned Resident 2 onto back and removed the right inner ankle dressing and then did not perform hand hygiene. LPN-A cleansed with normal saline and gauze and cut a piece of Alginate AG dressing and applied to the wound bed and covered with an adhesive dressing. LPN-A kept the same gloves on the entire time of wound cares. LPN-A then removed gown and gloves and performed hand hygiene. LPN-A did not date or initial the dressing. Interview on 9/10/25 at 7:25 AM with LPN-A confirmed [gender] should have performed hand hygiene and changed gloves throughout the dressing change. Interview on 9/10/25 at 11:00 AM with the DON confirmed the nurse should have performed hand hygiene and change gloves throughout the dressing change. Record review of Sandford's Wound Dressing Change policy dated 11/1/24 revealed: Purpose: To promote wound healing. To help wound remain free of infection. Procedure: - Follow Enhance Barrier Precautions (wash hands before entering and exiting the room, wear gloves and gown). -Position resident for comfort and to accommodate dressing change. -Put on gloves. -Remove soiled dressing and discard in plastic bag, avoiding contact and thus contamination of other surfaces. -Remove gloves and discard in same plastic bag. Perform hand hygiene. -Create field with equipment/dressing wrappers. Use sterile technique if required. -Put on gloves. -Cleanse the skin and wound thoroughly with normal saline using gauze wipes, wound cleanser or ordered antiseptic Solution. Remove gloves and perform hand hygiene. -Put on gloves. -Remove dressing from inner wrapper, avoiding finger contact with the dressing. Position the dressing over the wound and press down gently on the skin. Secure dressing as directed. - Identify date and initials on dressing/tape. Record review of [NAME]'s Standard Enhanced Barrier and Transmission-Based Precautions policy dated 7/7/25 revealed: Purpose: To prevent the spread of infection and communicable diseases to residents, patients, employees, and visitors through infection prevention and control practices. Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms (MDRO's) to staff hands and clothing. Enhanced barrier precautions are also used for residents with chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers) and residents with indwelling medical devices (i.e., central lines, hemodialysis catheters, indwelling urinary catheters, feeding tubes and tracheostomies, even if the resident is not known to be infected or colonized with an MDRO. High-contact resident care activities include transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with resident in therapy gym (specifically when anticipating close physical contact while assisting with transfers and mobility), changing linens, indwelling medical device care or use (central line, urinary catheter, feeding tube, tracheostomy) and wound care. B. Observation on 9/8/25 at 11:00 AM revealed Resident 2 was sitting in a recliner in [gender] room, catheter tubing had slightly cloudy urine. Record review of Resident 2's MDS dated [DATE] revealed: -Section C: 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) was 8 indicating moderate impairment. -Section G: Resident 2 needs supervision with eating, moderate assistance with oral hygiene, dependent with toileting, maximum assist with shower and upper body dressing, lower body dressing and footwear is dependent, personal hygiene needs moderate assistance, rolling right and left needs maximum assistance, and transfers needs maximum assistance. -Section H: Indwelling catheter -Section M: at risk for Pressure ulcers, has 2 Stage 3 ulcers present on admission, uses pressure reducing devices used in bed and wheelchair. Record review of Resident 2's physician orders dated 9/9/25 revealed: -Catheter 16 French with 30 CC (cubic centimeter) balloon to dependent drainage. Record review of Resident 2's Diagnoses dated 9/9/25 revealed a diagnosis of neuromuscular dystrophy dysfunction of bladder. Observation on 9/10/25 at 7:52 AM for Resident 2's catheter cares by Nurse Aide (NA)-C. NA-C performed hand hygiene with sanitizing gel and applied gloves and gown. NA-C emptied the catheter drainage bag without concerns. NA-C removed their gown and gloves. NA-C performed hand hygiene with sanitizing gel and applied gloves but no gown. NA-C assisted resident to lay on their back then took the brief off. NA-C took a cleansing wipe out of wipes container with contaminated glove and cleansed the right groin, then got another wipe with the same glove, cleansed the left groin. NA-C took out another wipe with the same gloves and cleansed the urethral meatus. NA-C took another wipe from the wipe's container with the same gloves and cleansed the peri-area. NA-C removed another wipe from the container with the same contaminated gloves and cleansed the catheter tubing going down the tubing approximately 4 inches. NA-C repositioned resident to [gender] side and cleansed buttock, getting into wipes from the container 2 times with contaminated gloves. NA-C assisted Resident 2 to the supine position and applied new brief with the same gloves. NA-C proceeded to dress resident and assist up for breakfast. An interview on 9/10/25 at 8:10 AM with NA-C confirmed [gender] should have worn a gown during catheter cares, perform hand hygiene and change gloves more often, and not get into the wipes with contaminated gloves. Interview on 9/10/25 at 11:00 AM with the Director of Nursing confirmed staff should have worn a gown during catheter cares, perform hand hygiene and change gloves more often, and not get into the wipes with contaminated gloves. Record review of the facility's Hand Hygiene Clinical Skill checklist dated 10/2023 revealed: Hand hygiene (i.e., alcohol-based hand sanitizer, soap and water) is performed at the Moments of Hand Hygiene which includes, but not limited to: -Before entering a room; -Before performing a clean task; -After bodily fluid/glove removal; and -After exiting a room. C. A record review of an admission Record printed on 09/10/2025 revealed that Resident 4 was admitted to the facility on [DATE] with a diagnosis of benign prostatic hyperplasia (BPH a non-cancerous enlargement of the male prostate gland that surrounds the tube that carries the urine from the bladder out of the body). This condition can cause issues with urination, requiring a thin tube (indwelling catheter) to be placed and left inside the bladder to drain the urine. A record review of Resident 4'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 07/02/2025 revealed in Section H: titled Bladder and Bowel under Appliances that Resident 4 had an indwelling catheter. The MDS also revealed Resident 4's Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 13, indicating that the resident was cognitively intact. A record review of Resident 4'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) revealed that The resident has alteration in urinary elimination R/T (related to) BPH and had a foley catheter (indwelling foley catheter). The CCP also revealed the requirement for all staff to use 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 like catheters). A record review of Resident 4's Order Summary dated 09/09/2025 revealed an order for an indwelling catheter: 16 fr foley cath to dependent drainage. Change catheter PRN if dislodged or plugged and unable to clear with irrigation. as needed AND one time a day every 14 day(s) related to benign prostatic hyperplasia with lower urinary tract symptoms. An observation on 09/10/2025 at 9:25 AM revealed a nursing assistant (NA-D, a healthcare professional who provides basic care and support to the residents) performing catheter care on Resident 4. NA-D donned (applied) a gown, and gloves and then proceeded to gather supplies (disposable wipes). NA-D then assisted Resident 4 to the standing position, this was the preferred position as reported by Resident 4. NA-D then removed Resident 4's pants and brief (an absorbent, disposable undergarment designed for adults to have difficulty controlling their bladder and bowels). NA-D then performed perineal care (the cleaning of the area between the genitals and the anus) using one disposable wipe and the original gloves. NA-D then began to clean the meatus (the catheter insertion site) and the catheter tubing using the same wipe and gloves. NA-D did not remove contaminated gloves, perform hand hygiene and don clean gloves prior to cleaning the meatus and catheter tubing. NA-D did not retract the foreskin to clean/inspect the meatus. NA-D then emptied the catheter bag of urine and disposed of the urine in the toilet. A record review of the facility's undated clinical skills checklist titled Catheter Care-Indwelling Catheter Clinical Skills Checklist and the facility's policy titled [NAME] Policy on Catheter: Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen-AL, R/S and LTC. dated 04/06/2025 revealed the steps needed to preform catheter care for an indwelling catheter. 1. Perform the beginning five (assemble equipment, knock on door, identify resident, explain procedure, and provide privacy, perform hand hygiene). Steps 2-3 (perform hand hygiene, raise bed, position resident .) 4. Remove gloves, perform hand hygiene, and don gloves. 5. Expose the ureteral meatus with non-dominate hand. a. (Female instructions). b. Male: Retract the foreskin if not circumcised. Hold the penis at the shaft just below the glans. c. Observe meatus and surrounding tissue for inflammation, encrustation (a buildup of crystals and mineral deposits on or inside the catheter), swelling or discharge, ask the resident if burring or discomfort is present. 6. Stabilize the catheter using non-dominate hand. Do not pull on the catheter. 7. Provide perineal care. An interview with the Director of Nursing on 09/10/2025 at 9:50 AM confirmed that it is the facility's expectation for the staff is to remove contaminated gloves perform hand hygiene and apply clean gloves prior to cleaning the meatus and catheter tubbing. A record review of the results from a urinalysis test, a test used to detect urinary tract infections (UTIs) dated 09/07/2025 revealed that Resident 4 tested positive for a UTI. A record review of Resident 4's Order Summary revealed an order for the antibiotic Ertapenem Sodium Injection to be administered for 5 days with the active start date of 9/8/2025 for the treatment of a UTI.

Licensure Reference Number 175 NAC 12-006.04(A)(ii) Licensure Reference Number 175 NAC 12-006.18 Licensure Reference Number 175 NAC 12-006.19 Based on record review, observations, and interviews; the facility failed to ensure that pre-employment health history screens were reviewed to prevent the potential for transmission of contagious disease for 2 of 3 staff, which had the potential to affect all residents. The facility failed to ensure that the tub and shower room was maintained in a clean and sanitary manner, which had the potential to affect all residents. The facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented as needed upon admission of new residents requiring EBP, which affected 1 resident, (Resident 132) of 3 sampled residents. The facility failed to apply Personal Protective Equipment (PPE) in the correct sequence during care of a resident on transmission-based precautions, failed to perform hand hygiene and change gloves correctly during cares, failed to complete catheter cares per the professional standards, and the facility failed to change oxygen tubing as required. This affected 1 resident, (Resident 3) of 2 sampled residents. The facility failed to prevent Foley catheter tubing and catheter bag from coming into contact with contaminated surfaces. This affected 2 residents, (Resident 132 and Resident 15) of 2 sampled residents. Findings are: A. Record review of the undated and untitled list of facility employees revealed that Housekeeper had a hire date of 09/05/2023. Record review of Housekeeper timeclock revealed first employment day clock in was on 10/02/2023 for a full 7.5 hour day of work. Record review of the Medical History Questionnaire for Housekeeper revealed that it was signed by Housekeeper yet remained undated. The box on the form stating this medical history has been reviewed with this conditional employee was not checked yes, or no. The line for the Human Resource representative or designee signature for review was undated and blank. Record review of the undated and untitled list of facility employees revealed that Laundry Aide had a hire date of 09/06/2023. Record review of Laundry Aide timeclock revealed first employment day clock in was on 09/27/2023 for a full 7.5 hour day of work. Record review of the Medical History Questionnaire for Laundry Aide revealed that it was signed and dated on 02/19/2024 by Laundry Aide. The box on the form stating this medical history has been reviewed with this conditional employee was not checked yes, or no. The line for the HR Representative or Designee signature for review was undated and blank. Interview on 08/13/24 at 9:45 AM with the Social Services Director (SSD) revealed that the Medical History Questionnaire form is part of the orientation packet. The SSD confirmed that the information on the Medical History Questionnaire form should be reviewed, dated, and accepted with a signature prior to the first day of employment. A review of a facility policy titled, Hiring and Screening dated 03/24/2022 revealed under section Health Assessment and Drug Screen: a pre-employment drug screen and health assessment will be conducted on all external job applicants who have accepted offers of employment. The health assessment is required prior to the first day of employment and employment is contingent upon successful competition of the drug screen and/or health assessment. 50253 B. Observation on 8/12/2024 at 09:15 AM of the tub and shower room. The room floor is comprised of 1x1 tiles which then go up the wall part of the way. Many tiles to the left (south side of the door in the tub room) as one enters have grey and dark grey grime on them. The grout lines are discolored, and a grey, dark grey, and brownish color compared to most the other of the grout lines of the other tiles that are white to verylight grey in color. There is a 2'x 6 drain in that area that has grey and brown build up. On the left side of the tub flooring, the tiles have a buildup and accumulation of what appeaed to be soap scum and hard water like deposits that are grey to dark grey in color with hair. To the right side of the tub nearer the wall the floor is unkempt with many hairs of various color and length, dirt particles, and brown and grey in color. Inside the tub, the side walls are covered what appears to be hard water deposits especially under and around the control knobs and the waterspout. There is a hair left on the drain stopper. Above the tub, there is a water reservoir. Under the lip of the water reservoir there is a black, grey, and brown residue. Observation on 8/12/2024 at 9:15 AM as the tub and shower chair are being disinfected and cleaned. The shower chair is submersed completely but the safety harness is only partially submersed as the straps that go around a resident's abdomen remain above the water. Interview on 8/12/2024 at 9:25 AM with Medication Aide-E (MA-E) stated [gender] makes sure the disinfectant is in the water by observing how murky the water is when the tub is filling for the disinfecting process. If the water isn't very murky, MA-E will check the siphoning tube seated inside the disinfectant solution to be certain the container is not empty. MA-E is not certain how hot the water must be to wash the tub or to perform the disinfectant step. C. Record review of the Progress Notes for Resident 132 revealed they had been admitted to the facility on [DATE] from a hospital following surgery to repair a fractured femur (upper long bone) of the right leg. Record review of Res 132's Baseline Care Plan revealed Resident 132 was not placed on Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes to reduce the spread of multidrug-resistant organisms ) at the time of admission following a surgical repair of the right leg. Observation on 8/7/24 at 9:20 AM in the room of Resident 132 revealed staff did not use EBP after Resident 132 had finished breakfast and staff assisted the resident to a new position in the bed. Record review of the Resident 132's Care Plan revealed a revision to the Care Plan was initiated on 8/7/24 to include the required EBP related to surgical wound care. Interview on 8/13/2024 at 04:10 PM with the Director of Nurses (DNS) the resident had not been placed on EBP from the time of admission until 8/7/24 was because I forgot new surgical patients had to be on EBP. 49382 D. Record review of a Centers for Disease Control document labeled Sequence for putting on Personal Protective Equipment (PPE), not dated revealed Step 1 place on the gown fully covering the torso from neck to knees and wrap around and fasten in the back. Step 2. place gloves on and extend them to cover the wrist of the gown. Review of an Admission Record revealed the facility admitted Resident 3 on 5/22/2024 with diagnoses of Multiple Sclerosis (a chronic disease of the central nervous system), and Neuromuscular dysfunction of the Bladder (a condition where the nerves and the muscles of the bladder don't work well together). The Comprehensive Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) with an Assessment Reference Date (ARD) of 5/29/2024 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 15 indicating the resident was cognitively intact. The resident was documented as having an indwelling Foley catheter (a flexible plastic hollow tube inserted into the bladder to continuously drain urine into a plastic collection bag). Review of Resident 3's Care Plan dated 08/07/2024 revealed a Focus that the resident required Enhanced Barrier Precautions due to having an indwelling Foley Catheter with an intervention of don (put on) gown and gloves when performing high contact care activities and doff (take off) gown and gloves inside the resident's room and perform hand hygiene. In an observation on 8/13/2024 at 10:10 AM while care was being provided to Resident 3 the following was observed: Nursing Assistant-D (NA-D) performed alcohol-based hand hygiene and entered Resident 3's room. NA-D obtained disposable gloves from a box hanging on a wire rack on the resident's closet door and applied the gloves to both of their hands. The NA then obtained a blue disposable gown from the same rack and applied the gown covering their torso and tied the gown in the back. The NA did not apply the gown and then the gloves in order as recommended. In an interview completed on08/13/2024 at 10:50 AM with NA-D confirmed [gender] should have put the gown on first and not the gloves when applying PPE. In an interview completed on 08/13/2024 at 10:30 AM with the Director of Nursing Services (DNS) the DNS confirmed that staff are to don their gown and then their gloves when it comes to applying personal protective equipment. E. Review of a facility document titled Hand Hygiene Clinical Skill Checklist dated 10/2023 revealed Hand hygiene is performed at the Moments of Hand Hygiene which includes but is not limited to after glove removal. Under Procedure it is listed to scrub hands for at least 20 seconds, dry hands thoroughly and discard wet paper towels. Turn off the faucet with a dry paper towel and discard. when performing Hand Washing. In an observation completed on 8/13/2024 at 10:18 AM while care was being provided to Resident 3 the following was observed: Nursing Assistant-C (NA-C) with gloved hands emptied Resident 3 Foley catheter drainage bag into a clear plastic container. The NA then took the container into the bathroom and emptied the contents into the toilet. The NA rinsed the plastic container with water and emptied the water into the toilet then placed the container on the back of the toilet on clean dry paper towels. NA-C then removed their gloves from their hands and placed new gloves on both hands. The NA did not complete hand hygiene with an alcohol-based gel or by Hand Washing between glove changes. After completion of cares for Resident 3 NA-C entered the bathroom in the resident's room and removed their gloves. The NA then turned on the sink, wetted hands, applied soap to hands, and rubbed hands with the soap on them for 10 seconds. The NA then rinsed both hands running the water up onto their forearms of both arms and down hands. NA-C obtained paper towels from the dispenser hanging on the wall and dried their hands. The NA then used the same paper towels to turn off the water faucet and disposed of the paper towels in the trash can. In an interview completed on 8/13/2024 at 10:50 AM with NA-C, confirmed [gender] should have completed hand hygiene between glove changes, completed hand washing for 20 seconds, and turned the faucet off with a clean dry paper towel. In an interview completed on 8/13/2024 at 10:30 AM with the DNS confirmed that hand washing is to be completed for a 20 second minimum, hand hygiene is to be completed between glove changes, and that a clean paper towel should be used to turn off the faucet then hand washing is completed. F. Review of a facility policy titled Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, and Specimen dated 07/30/2024 revealed under Procedure: Catheter Care-Indwelling Catheter to perform hand hygiene and apply gloves, Position the resident exposing the perineal area, remove gloves and perform hand hygiene and don gloves, expose the urethral meatus with the non-dominant hand for a female gently retract the labia to fully expose the catheter insertions site, stabilize the catheter using the non-dominant hand and use a clean disposable wipe to clean the perineal area and the portion of the catheter in contact with the perineum or meatus. Use a clean section of the wipe for each stroke. In an observation completed on 8/13/2024 at 10:20 AM while catheter cares were being provided to Resident 3 the following was observed: With gloved hands NA-C obtained 4 disposable wipes from a package and placed the disposable wipe package on the resident's bed with the exposed wipes placed on top of the package. The NA did not prepare a clean surface to place the disposable cloths on. NA-C then placed [gender] left hand to Resident 3's outer labia and grasped onto the catheter tubing with two fingers stabilizing the tube. The NA then used a disposable wipe to wipe from where they were pinching the tube down the catheter tubing about 3 inches. The NA did not separate the labia exposing the insertion site of the catheter and begin cleansing from that point down the catheter tubing. The NA then placed the disposable cloth in their right hand and let go of the tubing with their left hand. With their left hand the NA picked up another disposable wipe and wiped down the catheter tubbing starting at the resident's labia and down the tubing 3-4 inches and placed the disposable cloth in their gloved right hand. NA-C then threw away the disposable wipes. NA-D requested Resident 3 to roll onto the side so they could perform cares to the residents back side. With gloved hands NA-C obtained and used a disposable wipe to cleans the resident's buttock. The NA took the wipe and wiped in a back-and-forth horizontal pattern. The NA did not use a different section of cloth for each wipe. NA-C with the same gloved hands as from performing catheter cares obtained a tube of cream from the resident's bedside stand drawer. The NA squeezed the tube getting some of the cream on their gloved right hand and spread the cream to the resident's buttock in a circular motion. The NA did not remove gloves, perform hand hygiene, and apply new gloves prior to applying the cream. The NA then had the resident roll onto their back. NA-C then removed their gloves and then applied new gloves. The NA did not complete hand hygiene between glove changes. In an interview completed on 8/13/2024 at 10:50 AM with NA-C confirmed [gender] should have completed hand hygiene between glove changes, should have changed gloves when going from soiled to clean task, and should have cleansed the catheter from the insertion site down the catheter tubing, provided a clean surface and ensured the trash can was with in reach prior to providing care. In an interview completed on 8/13/2024 at 10:30 AM the DNS confirmed that the NA should have changed gloves and completed hand hygiene when going from soiled to clean care and cleansed the catheter tubing from the insertion site down not the labia. G. Review of a facility policy titled Oxygen Administration, Safety, Mask Types dated 07/08/2024 revealed Disposable equipment should be changed weekly and marked with a the date and individuals initials. Review of Resident 3's electronic medical record revealed the resident had an order/direction that oxygen tubing and bag is to be changed weekly on Thursdays. In an observation completed on 8/08/2024 at 2:40 PM in Resident 3's room revealed 3 Ziploc disposable baggies were attached to Resident 3's oxygen tubing that went from the concentrator to the resident. One bag was labeled 7/04/2024, another 7/11/2024, and the third 7/12/2024. Located on the actual oxygen tubing was a piece of white tape with 7/18 written on it. In an observation completed on 8/13/2024 at 9:40 AM in Resident 3's room revealed 3 Ziploc disposable baggies were attached to Resident 3 oxygen tubing that went from the concentrator to the resident. One bag was labeled 7/04/2024, another 7/11/2024, and the third 7/12/2024. Located on the actual oxygen tubing was a piece of white tape with 07/18 written on it. In an interview completed on 8/13/2024 at 9:40 AM with Licensed Practical Nurse A (LPN-A), LPN-A stated that the residents oxygen tubing and Ziploc bags are changed on Thursdays. LPN-A confirmed the 3 Ziploc bags with different dates attached to the oxygen tubing dated 7/18 and that the resident should have tubing and a baggies labeled/dated 08/08/2024. In and interview completed on 8/13/2024 at 10:30 AM with the Director of Nursing Services (DNS) the DNS confirmed that Resident 3 oxygen tubing and baggies should have been changed on 8/08/2024 and was not.

Licensure Reference Number 175NAC 12-00.10(D) Based on observation, record review, and interviews; the facility failed to have a medication error rate less then 5% with an observed medication error rate of 10.53%. This affected 3 residents,(Resident 3, 20, and 22), of 9 sampled Residents. The facility stated census was 30 Findings are: Review of a facility policy titled Medication Administration and dated 5/21/2024 revealed to perform three checks including reading the label on the medication container and comparing with the medication administration record and to administer medications with in at least 60 minutes on each side of ordered time. A. Review of an Admission Record revealed the facility admitted Resident 3 on 5/22/2024 with diagnoses of Multiple Sclerosis (a chronic disease of the central nervous system), Chronic Respiratory Failure(a condition where there is not enough oxygen in the blood), and Hypertension(high blood pressure). In an observation of medication administration by Licensed Practical Nurse-B (LPN-B) on 8/08/2024 at 11:13 AM, LPN-B prepared and administered the following medications to Resident 3: -Modafinil (a stimulant medication), Oral Tablet 200 milligrams. Directions on the label of the medication packaging read to give half of a tablet by mouth one time a day around 2 PM. Directions in Resident 3 electronic medication administration record read to give one half of a tablet by mouth one time a day with a indicated administration time of 12:00 AM/PM. -Potassium Chloride (a mineral supplement) Extended-Release Tablet 20 milliequivalents. Directions on the label of the medication packaging read to give 2 tablets three times a day and do not crush or chew the tablets. LPN-B used a pill splitter to cut the medication in half per the resident's request. The tablet crushed into multiple small pieces. The LPN put the pieces in a plastic cup and administered them to the resident. The resident then took the second tablet in [gender] mouth and broke it into pieces with [gender] teeth. In an interview with LPN-B on 8/08/2024 at 11:50 AM, LPN-B confirmed that the label of the Modafinil medication administration time and the order in the electronic medication administration record did not match. LPN-B confirmed the medication error related to right time of medication administration. LPN-B confirmed the directions that the Potassium Chloride Extended-Release Tablet was not to be crushed or chewed and that when attempting to split the tablet it crumbled into multiple pieces and the [gender] should not have administered all the pieces to the resident. LPN-B revealed [gender] was unaware of the resident having difficulties swallowing the tablets due to size and would reach out to the provider alerting to resident needing a different form of the medication so it could be take correctly. B. Review of an Admission Record revealed the facility admitted Resident 20 on 6/10/2022 with diagnoses of Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Parkinson's Disease (a disease that is progressive and affects the nervous system). In an observation of medication administration by Licensed Practical Nurse-B (LPN-B) on 8/08/2024 at 11:13 AM, LPN-B prepared and administered the following medications to Resident 20: -Quetiapine (an antipsychotic medication) 50 milligrams. Directions on the label of the medication packaging read to give one tablet four times a day and once daily as needed. Directions in Resident 20 electronic medication administration record read to give one tablet four times a day. Resident 20 did not have an order to receive this medication once daily as needed. In an interview with LPN-B on 8/08/2024 at 11:50 AM, LPN-B confirmed that the label on the medication did not match the orders for the medication in the resident's electronic medical health record. LPN-B confirmed the as needed order for the medication had been discontinued in September of 2023. C. Review of an Admission Record revealed the facility admitted Resident 22 on 10/04/2023 with diagnoses of hypotension (low blood pressure). In an observation of medication administration by Licensed Practical Nurse B (LPN-B) on 08/08/2024 at 11:20 AM, LPN-B prepared and administered the following medications to Resident 22: -Midodrine Hydrochloric Acid (HCL) (a medication used to treat low blood pressure) 5 milligram tablet. Directions on the medication packaging read to give one tablet three times a day before meals. Directions in Resident 22's electronic medication administration record read to give one tablet three times a day. In an interview with LPN-B on 8/08/2024 at 11:50 AM LPN-B confirmed that the medication packaging directions for administration of the medication and the electronic medication administration record did not match.

Licensure Reference Number 175NAC 12-006.09(F)(i) Based on record review and interviews; the facility failed to ensure that the medical record contained documentation that the written summary of the baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was provided to the resident/resident representative as required for 2 of 9 residents (Residents 23, and 26). This had the potential to prevent the resident/resident representative from identifying additional care and goals required for the resident; and the facility failed to ensure that the baseline care plans were completed with the necessary information to care for 1 of 3 newly admitted residents (Residents 132). The facility census was 30. Findings are: A. Record review of the facility policy titled Comprehensive Care Plan and Care Conferences dated 12/4/23 revealed that the purpose is to develop a person-centered care plan for each resident that includes measurable objectives and timetables to meet his or her physical, mental, spiritual, and psychosocial well-being. The procedure section for Baseline Care Plan revealed to review admission information to develop an initial care plan that includes specific interventions including but not limited to: Initial goals, PASRR (Preadmission Screening and Resident Review is a federal required evaluation of all applicants for serious mental illness and/or intellectual disability to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendations, physician orders, transfer interventions, fall prevention, pain, pressure ulcer prevention, infections and resident specific care. Provide the resident and/or resident representative with a written summary of the baseline care plan. The summary includes initial goals of the resident, summary of medications and dietary restrictions and services and treatments to be administered. Use the Care Conference Note to document that the meeting occurred with the resident and representative and any significant discussion that occurred. Record review of the Admission Record for Resident 23 revealed that Resident 23 admitted into the facility on [DATE] with diagnoses of Dementia, Hip Fracture, and Anxiety. Resident 23 had a Power of Attorney for Health. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 23 dated 4/30/24 revealed that Resident 23 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 9 (a score of 8-12 indicates moderate cognitive impairment). Record review of the Baseline Care Plan dated 1/26/24 for Resident 23 revealed that it contained the signature of Resident 23 on the last page of the care plan. No date was documented for the signature. The Baseline Care Plan contained no documentation of any discussion of the care plan with the resident or the resident representative. Record review of the medical record for Resident 23 revealed no Care Conference Note or any other note documenting that a baseline care plan review meeting occurred with the resident or resident representative. The medical record contained no documentation that a written summary of the baseline care plan was provided to the resident or resident representative. Interview on 8/13/24 at 10:43 AM with the facility Director of Nursing Services (DNS) revealed that the DNS reviews the baseline care plan with the resident usually on the day of admission. The DNS revealed that they review the goals, orders, medications for identified conditions, and the care to be provided. The DNS revealed that the DNS has the resident sign the baseline care plan at that time. The DNS revealed that most residents do not want a copy of the baseline care plan. The DNS confirmed that the DNS does not document the discussion of the baseline care plan with the resident and does not document any offering of a copy of the baseline care plan to the resident. Interview on 8/13/24 with the Facility Administrator confirmed that the facility needs to document the baseline care plan discussion in the medical record and the provision of a copy of the baseline care plan to the resident and representative. Policy does not state they have to document that meeting occurred and any thing significant. Does not say to document a offered copy. Would keep becuase the policy does say to document that it happened but it is very weak since the DNS states they do and that is how the signature is obtained. Seems more a documentation tag vs not providing the careplan and having the meeting. Would have liked an interview with the resident/family. B. Record review of the Admission Record for Resident 26 revealed that Resident 26 admitted into the facility on [DATE] with diagnoses of Pneumonia, Diabetes, and Unsteadiness on feet. Resident 26 had a Power of Attorney for Health. Record review of the MDS Assessment for Resident 26 dated 7/29/24 revealed that Resident 26 had a BIMS score of 15 indicating Resident 26 was cognitively intact. Record review of the Baseline Care Plan dated 7/23/24 for Resident 26 revealed that it was signed by the representative of Resident 26 on the last page of the care plan. No date was documented for the signature. The Baseline Care Plan contained no documentation of any discussion of the care plan with the resident or the resident representative. Record review of the medical record for Resident 26 revealed no Care Conference Note or any other note documenting that a baseline care plan review meeting occurred with the resident or resident representative. The medical record contained no documentation that a written summary of the baseline care plan was provided to the resident or resident representative. Interview on 8/13/24 at 10:43 AM with the facility Director of Nursing Services (DNS) revealed that the DNS reviews the baseline care plan with the resident usually on the day of admission. The DNS revealed that they review the goals, orders, medications for identified conditions, and the care to be provided. The DNS revealed that the DNS has the resident sign the baseline care plan at that time. The DNS revealed that most residents do not want a copy of the baseline care plan. The DNS confirmed that the DNS does not document the discussion of the baseline care plan with the resident and does not document any offering of a copy of the baseline care plan to the resident. Interview on 8/13/24 with the Facility Administrator confirmed that the facility needs to document the baseline care plan discussion in the medical record and the provision of a copy of the baseline care plan to the resident and representative. Same as above 50253 C. Record review of the Progress Notes for Resident 132 revealed they had been admitted to the facility on [DATE] from a hospital following surgery to repair a fractured femur (upper long bone) of the right leg. Record review of Res 132's Baseline Care Plan revealed Resident 132 was not placed on Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes to reduce the spread of multidrug-resistant organisms ) at the time of admission following a surgical repair of the right leg. Observation on 8/7/24 at 9:20 AM in the room of Resident 132 revealed staff did not use EBP after Resident 132 had finished breakfast and staff assisted the resident to a new position in the bed. Record review of the Resident 132's Care Plan revealed a revision to the Care Plan was initiated on 8/7/24 to include the required EBP related to surgical wound care. Interview DATE TIME? with the Director of Nurses (DNS) the resident had not been placed on EBP from the time of admission until 8/7/24 was because I forgot new surgical patients had to be on EBP.

License Reference Number 175 NAC 12-006.09(J) The facility failed to ensure the physician ordered and recommended amount of Glucerna was provided to residents who had triggered for malnutrition or those at risk of malnutrition. This affected 1 (Resident 15) of 3 sampled residents. The facility census was 30. Findings are: Record review of Resident 15's Mini Nurtritional Assessment (MNA, a tool is used to assist registered dieticians (RD) in the assessment of the nutritional needs of individuals whom they are required to give dietary recommendations in institutional settings. A score of 14 is the maximum. Scores of 0-7 indicate one is malnourished. Scores of 8-11 points indicate one is at risk of malnutrition. A score of 12-14 indicates normal nutritional status.) completed by the facility RD dated 5/21/2024 at 10:24 AM revealed a score of 5 which indicated Resident 15 was malnourished. Resident 15 had an admission weight of 172.5 on 5/10/24 and current weight of 167.5 on 5/21/24. Record review of the Dietary Notes written by the RD on 5/21/2024 revealed Resident 15 was a new admission with diagnoses of malnutrition, cellulitis, lymphedema, diabetes, urinary tract infection, and confusion, all of which could or would have an effect on the nutritional status of an individual. The resident's weight was 172.5. Record review of Resident 15's MNA completed by RD dated 6/18/2024 at 8:33 AM revealed a score of 7 which indicated Resident 15 continues to be malnourished. Record review of the Dietary Notes written by the RD on 6/18/2024 revealed Resident 15's nutritional status was starting to improve, but Resident 15 had been started on an antibiotic. Resident 15 was at high risk for weight loss and meal intakes were not greater than 75% of nutritional needs. The RD recommended a liberalized regular diet and 8oz Glucerna/Equivalent twice daily to meet the necessary calories and protein needed. Record review of Resident 15's MNA completed by RD dated 7/2/2024 at 8:22 AM revealed a score of 7 which indicated Resident 15 continues to be malnourished. Record review of the order summary dated 7/3/2024 revealed a Physician Order for Resident 15 to receive Glucerna Supplement 8 ounces twice daily. Record review of Resident 15's MNA completed by RD dated 7/30/2024 at 11:09 AM revealed a score of 9 which indicated Resident 15 was now at risk for malnutrition. Recored review of the Medication Administration Record (MAR) for Resident 15 for the month of July 2024 revealed Resident 15 was to receive the nutritional supplement Glucerna 8 ounces (equivalent to 240 mililiters (mL)) twice a day starting on 7/3/2024. Nursing staff were to chart in milliliters both in the morning and in the evening when the supplement was given. Record review of the July 2024 MAR documentation revealed the following amounts of Glucerna was given: -The morning charting indicated 100 ml was given on the following dates: 19, 20, and the 21st. -The morning charting revealed 120 ml was given on the following dates: 17, 18, 22, 23, 24, 25, 26, 27, 28, 29, and the 30th. -The morning charting revealed just a checkmark indicating the resident received the supplement on the following dates: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and the 16th. -The evening charting indicated 100 ml was given on the following dates: 16, 20, 21, and the 30th. -The evening charting revealed 120 ml was given on the following dates:18, 19, 22, 23, 24, 25, 26, 27, 28, and the 29th. -The evening charting revealed the resident refused the supplement 7/31/2024. Record review of the August 1st through August 12 of 2024 MAR documentation revealed the following amounts of Glucerna was given: -The morning charting revealed 100 ml was given on the following dates: 1, 2, 3, 4, 5, 6, 7, 11, and the 12th. -The morning charting revealed 180 ml was given on the following dates: 8, 9, and the 10th. -The evening charting revealed 100 ml was given on the following dates: 1, 2, 3, 4, 5, 6, and the 11th. -The evening charting revealed 180 ml was given on the following dates: 8, 9, and the10th. -The evening charting revealed 8 ounces (240 ml) was given on the following date 8/7/24. Observation on 8/7/2024 at 8:00 AM revealed Resident 15 sitting at the dinning room table Resident 15 finished [gender] entire breakfast and supplement (240 mililiters) prior leaving the dining room. Observation on 8/12/2024 at 1:00 PM revealed Resident 15 had finished [gender] entire noon meal the supplement (240 mililiters). In an interview on 8/12/2024 at 10:25 AM with the facility Registered Dietician (RD). Confirmed the Resident 15 is to have 8 ounces, or 240mL of Glucerna twice daily for caloric and protein needs due to malnutrition. Asked to review what has been charted on the MAR for clarification of the daily intake, the RD indicated confusion as to what was being charted and was going to follow-up with the nursing staff. Perhaps it means 100% of the supplement instead of 100 ml? In an interview on 8/12/2024 at 10:40 with Licensed Practical Nurse-A (LPN-A) revealed [gender] gives the Glucerna to Resident 15 in the original 8-ounce container with a straw at mealtime. LPN-A further reaveled Resident 15 routinely drinks the entire bottle. The Glucerna is then charted in the MAR. LPN-A always notates the consumption of the supplement as a percentage, which has always been 100% when LPN-A gave the supplement. When asked if nursing staff are to chart in ml or percentages or with just a checkmark, LPN-A stated it gets confusing because there are too many ways to chart the supplements. It depends on which nurse adds the order onto the MAR as to how it will appear. In an interview on 8/12/2024 at 10:50 with Licensed Practical Nurse-J (LPN-J) revealed there are several ways to chart the supplements. LPN-J was dispensing supplements at breakfast on 8/12/2024 and revealed, I only gave 100 ml of the Glucerna because I misread the order. I am just being honest. In an interview on 8/12/2024 at 11:05 PM with the facility Director of Nursing (DNS) confirmed it is difficult to understand how much of the supplement was being given to Resident 15 and what was being consumed. DNS futher confirmed that supplements may be given at mealtime or between meals dependent upon when each resident will consume the supplement.

Licensure Reference Number 175NAC 12-006.09(H)(iv)(1) Based on observations, record review, and interviews; the facility failed to prevent urinary catheters from becoming contaminated during personal cares and transportation of a resident in a wheelchair for 2 (Resident 3 and 27) of 3 sampled residents. Facility stated census of 30. Findings are: Review of a facility policy titled, Catheter: Care, Insertion& Removal, Drainage bags, Irrigation, Specimen dated 7/30/2024 revealed: -All closed collection systems that become contaminated by inappropriate technique, leaks or other means are immediately replaced. A. Review of an Admission Record revealed the facility admitted Resident 3 on 5/22/2024 with diagnoses of Multiple Sclerosis (a chronic disease of the central nervous system), and Neuromuscular dysfunction of the Bladder (a condition where the nerves and the muscles of the bladder don't work well together). The Comprehensive Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) with an Assessment Reference Date (ARD) of 5/29/2024 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 15 indicating the resident was cognitively intact. The resident was documented as having an indwelling Foley catheter (a flexible plastic hollow tube inserted into the bladder to continuously drain urine into a plastic collection bag). In an observation on 8/13/2024 at 10:10 AM Nurse Assistant-C (NA-C) was observed to be assisting Resident 3 get dressed. NA-C removed Resident 3's Foley catheter bag from the frame of the bed. The NA-C took the Foley catheter bag and tubing and threaded it through one leg of the residents' shorts. The NA then dropped the Foley bag onto the bare floor on the right side of the bed. NA-C left the Foley bag on the floor during the remainder of the time while assisting the resident with dressing of the lower half of Resident 3's body and performing catheter cares. In an interview on 08/13/2024 at 11:20 PM with the Director of Nursing Services (DNS), the DNS confirmed that the Foley catheter bag should not meet soiled or dirty surfaces like the resident's floor. B. Review of an Admission Record revealed the facility admitted Resident 27 on 5/24/2024 with diagnoses of Kidney Failure (a condition where the kidneys cannot filter waste from the blood), obstructive uropathy (a condition where the flow of urine from the bladder is blocked), and urinary tract infection (an infection in any part of the urinary system). The Comprehensive Minimum Data Set MDS with an ARD of 5/29/2024 revealed Resident 27 had a BIMS score of 8 indicating the resident was moderately cognitively impaired. The resident was documented as having an indwelling Foley catheter. In an observation on 8/07/2024 at 11:05 AM Resident 27 was observed to be sitting in [gender] wheelchair in the commons area. The residents Foley catheter tubing was observed to be coming out of the pants by the ankle on the left side going past the pedal of the wheelchair and on to the floor then up into a cloth bag attached to the underside frame of the wheelchair. In an interview on 8/07/2024 at 11:10 AM with Licensed Practical Nurse-A (LPN-A), LPN-A confirmed that Resident 27 had an indwelling Foley catheter and a history of urinary tract infections. The LPN stated that catheter bags and or tubing should not be on or come in contact with the floor. In an interview on 8/13/2024 at 11:20 PM with the Director of Nursing Services (DNS), the DNS confirmed that the Foley catheter tubing should not meet soiled or dirty surfaces like the floor.

License Reference Number 175NAC 12-006.11E The facility failed to ensure that staff performed hand sanitization (hand washing using soap and water or an alcohol-based hand rub (ABHR) during meal preparation to prevent the potential for foodborne illness. This affected all facility residents; and the facility failed to provide meal service in a manner to prevent the potential for cross contamination and foodborne illness. This affected 21 residents observed (Residents 85, 4, 30, 15, 84, 25, 14, 1, 7, 29, 21, 13, 8, 28, 5, 3, 6, 2, 18, 16, and 12). The facility census was 31. Findings are: A. Record review of the facility policy titled Hand Washing and Glove Use- Food Nutrition Services dated 6/14/23 revealed that the purpose was to provide guidelines regarding hand hygiene (hand sanitization) and glove use to reduce the risk of cross-contamination when serving highly susceptible populations. Employees must wash the hands before handling food and after performing any activity that could contaminate the hands. The procedure for hand washing revealed that staff are to wet the hands and lather the hands. Rub the hands together vigorously for at least 20 seconds. Rinse hands thoroughly under clean running water. Dry hands completely with paper towels. Use a paper towel to turn off the faucet. Observation of meal preparation in the facility's kitchen on 6/28/23 at 9:26 AM revealed Dietary Cook- A (DC-A) went into the walk in refrigerator and opened the door with bare hands and did not perform hand hygiene. DC- A then removed a large plastic bag with onion slices inside and prepared them to go into the casserole. DC-A then went to the sink and scrubbed all hand surfaces with soap and water for 10 seconds and then rinsed and dried hands with a paper towel. DC-A then opened the refrigerator door with bare hands and pulled out individual cartons of milk and carried them to prep table against clothing. Prepared milk and added to mixture in pan. DC-A then returned to the sink and scrubbed hands with soap and water for 14 seconds and dried with a paper towel. DC-A then retrieved turkey cubes from walk in refrigerator with bare hands and prepared them for a casserole. DC-A then took noodles off of the stove, poured them into a colander in the preparation sick, and had water running over them. DC-A took the pan the noodles were in on the stove and put them on the dirty side of the kitchen. DC-A then returned to the preparation station without performing hand hygiene and prepared the casserole. DC-A then performed hand hygiene with soap and water for 13 seconds and dried their hands with a paper towel. Interview on 6/29/23 at 10:07 AM with the facility Dietary Manager (DM) confirmed that the expectation for hand washing is to apply soap to the wet hands, scrub the hands with soap for 20 seconds, rinse and dry the hands, and turn off the water using a paper towel. 41938 B. Record review of the facility policy titled Hand Washing and Glove Use- Food Nutrition Services dated 6/14/23 revealed that the purpose was to provide guidelines regarding hand hygiene (hand sanitization) and glove use to reduce the risk of cross-contamination when serving highly susceptible populations. Employees must wash the hands before handling food and after performing any activity that could contaminate the hands. Employees involved in serving must consistently use good hygienic (clean) practices. Employees do not need to wear gloves when distributing foods to residents at the dining table. The procedure for hand washing revealed that staff are to wet the hands and lather the hands. Rub the hands together vigorously for at least 20 seconds. Rinse hands thoroughly under clean running water. Dry hands completely with paper towels. Use a paper towel to turn off the faucet. The section titled When to wash hands revealed that hands should be washed before, between, and after resident contact; after touching any contaminated surface; before and after using gloves; between dirty and clean dish handling; and anytime contamination is suspected. The section titled Proper use of Gloves revealed that the hands are washed thoroughly before putting gloves on and after taking gloves off. The use of gloves does not eliminate the need for proper hand washing or good hygiene. Gloves are changed when coming in contact with something that may be contaminated including touching a doorknob or faucet. Record review of the facility policy titled Hand Hygiene and Handwashing dated 4/6/21 revealed that the procedure for use of Alcohol Based Hand Rub included: 2. Apply alcohol gel or foam to the palm of one hand. 3. Rub hands together. 4. Cover all surfaces of hands, fingers, and areas around/under fingernails. 5. Continue rubbing hands together until alcohol dries (about 15-20 seconds). Record review of the Nebraska Food Code, Effective date 7/21/16 section 4-904.11 Kitchen and Tableware revealed that cleaned and sanitized tableware shall be handled so that contamination of food and lip contact surfaces is prevented. Observation on 6/26/23 at 7:58 AM in the facility dining room revealed that Dietary Cook-A (DC-A) and Dietary Aide-B (DA-B) pushed the steam table into the dining room service area. DA-B went to the dining room sink. DA-B applied soap and scrubbed the hands for 8 seconds. DA-B turned off the water faucet with the bare left hand. DA-B dried the hands with a paper towel. (DA-B did not scrub the hands for the required 20 seconds and did not use a paper towel to turn off the water faucet). DA-B put on disposable gloves. DA-B carried a cup of coffee to Resident 85. DA-B sat the cup on the table in front of the resident. The gloved hand touched the table in front of the resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a meal plate from the steam table with the gloved hands to Resident 4. DA-B sat the plate on the table in front of the unmasked resident. DA-B went into the activity room and opened the refrigerator door with the gloved right hand. DA-B obtained a glass of milk and carried it to Resident 85. DA-B removed the disposable gloves and performed hand sanitization with alcohol-based hand rub (ABHR) by applying a small amount of sanitizer and rubbing the hands together for 6 seconds. (DA-B did not apply a sufficient amount of ABHR to rub the hands together for the required 15-20 seconds). DA-B put on a pair of disposable gloves. DA-B carried 2 plates of food from the steam table with the gloved hands to the table of Residents 25 and 19 (tablemates). DA-B sat a plate on the table in front of each of the unmasked residents. The gloved hands of DA-B touched the table as DA-B sat the plates down. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B picked up a bowl of cold cereal from the steam table with the gloved hands. DA-B carried the bowl of cereal to Resident 85 and sat the bowl on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 30. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 15. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 84. DA-B used a gloved hand to move the bowl on the table and sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). Resident 25 asked DA-B for some jelly. DA-B carried a container of jelly with the gloved hands to Resident 25. DA-B used the gloved hands to open the jelly container for Resident 25. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 14. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. DA-B removed and discarded the gloves. DA-B applied a small amount of ABHR to the hands and rubbed the hands together for 6 seconds. (DA-B did not apply a sufficient amount of ABHR to rub the hands together for the required 15-20 seconds). DA-B put on a pair of disposable gloves. DA-B carried a plate of food with the gloved hands to Resident 1. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B picked up a bowl of cold cereal with raisins and carried it to Resident 1. DA-B sat the bowl on the table in front of the resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B picked up a divided plate of food and carried it with the gloved hands to Resident 7. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 29. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 21. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. DA-B removed and discarded the gloves. DA-B went to the sink and applied soap to the dry left hand (DA-B did not wet the hands prior to applying soap). DA-B wet and scrubbed the hands with soap for 12 seconds (DA-B did not scrub the hands together for 20 seconds). DA-B shut the water off with the bare left hand (DA-B did not use a paper towel to turn off the water faucet). DA-B dried the hands with paper towels. DA-B went to the steam table and put on disposable gloves. DA-B carried a plate of food with the gloved hands to Resident 13. DA-B sat the plate on the table in front of the unmasked resident. Resident 13 had spilled some of the water from their water cup. Water was on the lap of Resident 13 and on the floor under the table. DA-B picked up the glass of water in front of the resident using the gloved left hand and repositioned it on the table. DA-B picked up the spoon off the lap of Resident 13 with the gloved right hand. DA-B placed the spoon on the table in front of the resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the same gloved hands to Resident 8. DA-B sat the plate on the table in front of the unmasked resident. Resident 8 asked DA-B for some help with the jelly. DA-B used the gloved hands to open the container of jelly. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the gloved hands to Resident 28. DA-B sat the plate on the table in front of the unmasked resident. DA-B used the gloved hands to open the container of jelly for Resident 28. Resident 85 asked DA-B for some coffee creamer. (DA-B did not change the contaminated gloves). DA-B picked up some packets of creamer with the gloved hands and tore them open. DA-B poured the creamer into the cup for Resident 85. DA-B returned to the steam table. DA-B picked up a menu that had fallen to the floor on the front side of the steam table. DA-B sat the card on the counter. DA-B removed the gloves and applied a small amount of ABHR to the hand and rubbed the hands together for 7 seconds. (DA-B did not apply a sufficient amount of ABHR to rub the hands together for the required 15-20 seconds). DA-B exited the dining room and went to the kitchen. DA-B returned to the dining room and went to the dining room sink. DA-B applied soap to the dry left hand and wet the hands (DA-B did not wet the hands before applying soap). DA-B scrubbed the hands with soap for 12 seconds and rinsed the hands (DA-B did not scrub the hands together for the required 20 seconds). DA-B shut the water off using the bare left hand (DA-B did not use a paper towel to turn off the faucet). DA-B put on disposable gloves. DA-B went to the table of Resident 3. DA-B grabbed the handles of Resident 3's wheelchair with the gloved hands and repositioned the wheelchair underneath the over bed table in front of the resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a plate of food with the same gloved hands to Resident 5. The thumb of the left gloved hand was on the top surface of the plate next to the food. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. DA-B removed the glove from the left hand and picked up a small container from the floor in front of the steam table. DA-B did not remove the glove from the right hand. DA-B applied a small amount of ABHR to the left hand. DA-B rubbed the left hand by itself for 3 seconds. (DA-B did not apply a sufficient amount of ABHR and did not rub the hands together). DA-B grabbed a new glove from inside the glove box using the contaminated right gloved hand. DA-B used the gloved right hand to put the new disposable glove on the left hand. DA-B carried a plate of food and a bowl with the gloved hands to Resident 3. DA-B sat the plate and bowl on the table in front of the unmasked resident. DA-B used the gloved right hand to pick up the fork from the table. DA-B poured a container of brown sugar into the bowl of hot cereal. DA-B used the fork to mix the brown sugar into the hot cereal. DA-B picked up the toast from the plate with the gloved right hand. DA-B picked up the knife with the gloved hand and spread peanut butter on the toast for Resident 3. DA-B continued to hold the toast in the gloved hand. DA-B opened a container of jelly and used the knife to put jelly on the toast. DA-B returned to the steam table. DA-B removed and discarded the gloves. DA-B did not perform hand sanitization. DA-B carried a wet floor sign from the dining room entry and placed it by the table of Resident 13. DA-B went to the dining room sink. DA-B applied soap to the dry left hand (DA-B did not wet the hands before applying soap). DA-B wet the hands. DA-B scrubbed the hands together with soap for 10 seconds and then rinsed the hands (DA-B did not scrub the hands together for 20 seconds). DA-B used the bare left hand to turn off the water (DA-B did not use a paper towel to turn off the faucet). DA-B used paper towels to dry the hands. DA-B returned to the steam table and put on a pair of disposable gloves. DA-B carried a plate of food to Resident 6. DA-B sat the plate on the table in front of the unmasked resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). DA-B carried a divided plate of food with the gloved hands to Resident 2. DA-B used the gloved right hand to pick up the glass sugar container from the table. DA-B poured sugar onto some of the food for the resident. DA-B returned to the steam table. (DA-B did not change the contaminated gloves). Resident 30 came to the steam table and asked DA-B for some fresh water and ice for the resident's mug. Resident 30 handed the mug to DA-B. DA-B used the gloved hands and took the mug from Resident 30. DA-B exited the dining room with the mug and went to the kitchen. DA-B returned to the dining room and handed the mug to Resident 30. DA-B removed and discarded the gloves. DA-B went to the dining room sink and applied soap to the dry left hand (DA-B did not wet the hands before applying soap). DA-B wet the hands and scrubbed the hands with soap for 16 seconds (DA-B dd not scrub the hands together for the required 20 seconds). DA-B turned the water off with the bare left hand (DA-B did not use a paper towel to turn off the faucet). DA-B then dried the hands. DA-B put on a new pair of disposable gloves. DC-A told DA-B that Resident 18 was now going to be a room tray. DA-B went to the table where Resident 18 was assigned to sit. DA-B picked up the drinks and silverware from the table with the gloved hands. DA-B obtained an additional tray at the counter and sat the drinks and silverware on the tray. DA-B removed and discarded the gloves. DA-B picked up a menu card from the floor in front of the steam table. DA-B applied a small amount of ABHR to the left hand and rubbed the hands together for 5 seconds. (DA-B did not apply a sufficient amount of ABHR to rub the hands together for the required 15-20 seconds). DA-B put on a pair of disposable gloves. DA-B went to Resident 5. DA-B grabbed the handles of Resident 5's wheelchair with the gloved hands. DA-B pushed the resident in the wheelchair to the lobby just outside the dining room. DA-B removed and discarded the gloves. DA-B applied a small amount of ABHR to the hands and rubbed the hands together for 7 seconds. (DA-B did not apply a sufficient amount of ABHR to rub the hands together for the required 15-20 seconds). DA-B put on a pair of disposable gloves. DA-B went into the activity room. DA-B opened the refrigerator door with the gloved hands and removed a glass with milk and small bowl of apricots. DA-B returned to the counter in the dining room and set the items on the room tray. (DA-B did not change the contaminated gloves). DA-B grabbed a cup with the gloved hands. DA-B carried the cup with the gloved right hand over the top of the cup and the fingers on the drinking edge of the cup. DA-B filled the cup and carried it to a tray. DA-B carried the cup to the tray with the gloved hand over the top of the cup and the fingers on the drinking edge of the cup. DA-B carried the tray of food with the cup to the room of Resident 16. DA-B carried the tray into the room and sat it on the over bed table in front of the resident. DA-B used the gloved hands to place a napkin on the lap of Resident 16. DA-B used the gloved hands to place a clothing protector (an apron-like cloth placed over the front of a resident to assist with keeping clothes dry and clean) on the chest of Resident 16 and placed the straps around the neck for the resident. DA-B grabbed the cup of coffee with the gloved hand over the top of the cup. DA-B moved the cup to the left side of the over bed table. DA-B exited the resident's room and returned to the dining room. DA-B removed and discarded the gloves. DA-B went to the dining room sink and applied soap to the dry left hand (DA-B did not wet the hands before applying soap). DA-B wet the hands and scrubbed the hands with soap for 9 seconds (DA-B did not scrub the hands together for 20 seconds). DA-B rinsed the hands and turned off the water with the bare left hand (DA-B did not use a paper towel to turn off the faucet). DA-B dried the hands. DA-B put on a pair of disposable gloves. DA-B went to the activity room refrigerator and opened the refrigerator door with the gloved hands. DA-B removed a tray of drinks and small bowls of apricots from the refrigerator. DA-B carried the tray to the dining room counter. (DA-B did not change the contaminated gloves). DA-B picked up a cup and filled it with coffee. DA-B picked up the cup with the gloved hand over the top of the cup and the fingers over the drinking edge of the cup. DA-B sat the cup on the room tray for Resident 12. DA-B pushed the 3-shelf cart with room trays out of the dining room. Interview on 6/29/23 at 10:07 AM with the facility Dietary Manager (DM) confirmed that staff are to sanitize or wash the hands between residents during meal service, after contact with residents or their surroundings, and after touching contaminated surfaces such as a refrigerator door handle. The DM confirmed that hand sanitization is expected after touching a resident's wheelchair handles. The DM confirmed that hand sanitization or hand washing is required before putting on gloves and after taking gloves off. The DM confirmed that gloves should be changed after serving a resident and not used to serve multiple residents. The DM confirmed that the expectation for hand washing is to apply soap to the wet hands, scrub the hands with soap for 20 seconds, rinse and dry the hands, and turn off the water using a paper towel. The DM confirmed that not scrubbing the hands with soap for 20 seconds and turning off the water with the bare hand did not constitute clean hands. The DM confirmed that when using ABHR, staff are to apply enough gel and rub the hands together for 15-20 seconds to be effective. The DM confirmed that staff are expected to handle plates and bowls so that the hands do not touch the food surfaces during meal service. The DM confirmed that cups are to be held by the handle and not with the hand over the top drinking surface of the cup. Interview on 6/29/23 at 10:52 AM with the facility Director of Nursing (DON) confirmed that the expectation for performing hand sanitization with alcohol-based hand rub is to apply enough ABHR product so that it takes 15-20 seconds for the hands to dry while rubbing then together.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to serve food in a manner to prevent potential cross contamination by handling prepared food with soiled gloves and bare hands. This affected 4 of 32 residents, Resident 10, Resident 6, Resident 17, and Resident 13. The facility identified a census of 32 at the time of survey. Findings are: Observation of the facility dining room on 5/09/22 at 12:21 PM revealed DA-B (Dietary Aide) was observed using their bare hand to move 2 carts in the dining room by the handles. DC-A (Dietary Cook) donned gloves then took a pair of tongs the DM (Dietary Manger) handed them, then DC-A moved the carts with their gloved hand then used the gloved hands to open hot dogs buns after removing them from a bag with the tongs, placing them in containers and placing hot dogs into the buns. DC-A prepared 4 hot dogs by handling the buns with the soiled gloves for Residents 10, 6, 17, and Resident 13. At 12:30 PM DA-B put the containers with the hot dogs and hot dog buns into a zipped thermal bag, placed the bag on one of the carts, placed trays on the other carts and took both carts down the hall. DA-B took a container with a hot dog and bun to Resident 10, Resident 6, Resident 17, and Resident 13. DA-B took a container into Resident 10's room and picked up the hot dog in the bun with their bare hand and handed it to Resident 10 who then proceeded to eat it. At 12:36 PM Resident 6, 17, 10, and 13 were all observed eating the food that was delivered to them by DA-B including the hot dog with the bun that had been handled by DC-A. Interview with the DM on 5/12/22 at 10:29 AM revealed staff were expected to handle ready to eat food with clean gloves; not with soiled gloves or bare hands. Review of the facility policy Hand Washing and Glove Use-Food Nutrition Services dated 4/11/2022 revealed the following: Employees do not touch any food with bare hands-ready-to-eat or otherwise. Bare-hand contact with ready-to-eat food is prohibited even when FDA (Food and Drug Administration) approved hand sanitizer has been used. Proper use of Gloves: The use of gloves does not eliminate the need for proper hand washing or good hygiene. Use utensils and single service deli papers whenever possible instead of gloves when touching any food; ready-to-eat or otherwise. Gloves are changed as follows: before handling ready-to-eat foods. When coming in contact with something that may be contaminated. Any time contamination is suspected. Remember, gloves are to protect the consumer from cross contamination.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to ensure that dietary staff performed 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) between resident contacts during meal service and upon returning to the dining room which affected 8 of 27 residents in the dining room; (Residents 32, 8, 15, 18, 16, 31, 10, and 25); failed to perform hand hygiene after handling resident personal items to prevent potential cross contamination during meal service in the dining room which affected 8 of 27 residents in the dining room, Residents 32, 8, 15, 18, 16, 31,10, and 25; and failed to store and maintain respiratory equipment to prevent potential cross contamination for 1 of 1 sampled residents, Resident 31. The facility identified a census of 32 at the time of survey. A. Observation of the facility dining room on 5/09/22 at 2:02 PM revealed 27 residents were observed being served food. At 12:13 PM DA-B (Dietary Aide) moved Resident 11's walker by the handle and did not do hand hygiene. Resident 11 had been observed walking into the dining room with the walker and holding on to the handles with bare hands. DA-B then proceeded to serve plates of food to Residents 32, 8, 15, 18, 16, 31, 10, and 25 after DA-B moved the walker and did not do hand hygiene. DA-B handled all of the residents' plates with their bare hands and all of the residents were observed eating from the plates. At 12:18 PM DA-B, without doing hand hygiene, got Resident 25 a refill of hot water. DA-B handled the cup that Resident 25 had been drinking out of, took the cup to the dispenser, put hot water in it, then returned the cup to Resident 25 who proceeded to drink from it by handling the handle DA-B had just handled. Interview with the DM (Dietary Manager) on 5/12/22 at 10:29 AM revealed staff were expected to do hand hygiene during meal service. The DM revealed the staff should have done hand hygiene after they touched Resident 11's walker before they served the remainder of the residents in the dining room. Review of the facility policy Hand Washing and Glove Use-Food Nutrition Services dated 4/11/2022 revealed the following: Employees wash their hands as required and wear gloves only when appropriate to protect any food from contamination that may be present on hands. When to wash hands: after touching any contaminated object. B. Observation on 5/9/22 at 12:13 PM in the facility dining room revealed that Dietary Aide-B (DA-B) picked up a tray with a meal from the top shelf of the steam table. DA-B carried the tray to the table of Resident 3. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 3. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat the tray on the top shelf of the steam table. DA-B did not perform hand hygiene. The Dietary Cook-A (DC-A) plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 32. DA-B picked up the plate off of the tray and sat it on the table of unmasked Resident 32. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat the tray on the top shelf of the steam table. DA-B did not perform hand hygiene. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 8. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 8. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat it on the top shelf of the steam table. DA-B did not perform hand hygiene. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 15. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 15. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat it on the top shelf of the steam table. DA-B did not perform hand hygiene. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 18. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked resident 18. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat it on the top shelf of the steam table. DA-B did not perform hand hygiene. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 16. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 16. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat it on the top shelf of the steam table. DA-B did not perform hand hygiene. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 31. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 31. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat it on the top shelf of the steam table. DA-B did not perform hand hygiene. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 10. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 10. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B carried the tray back to the steam table and sat it on the top shelf of the steam table. DA-B did not perform hand hygiene. The time was now 12:18 PM. DC-A plated a meal and sat it on the tray on the top shelf of the steam table. DA-B carried the tray to the table of Resident 25. DA-B picked up the plate off of the tray and sat it on the table in front of unmasked Resident 25. The bare hands of DA-B touched the table as DA-B sat the plate on the table. DA-B walked to the counter in the dining room. DA-B did not perform hand hygiene. DA-B picked up a coffee cup from the counter in the dining room and filled it with coffee. DA-B carried the cup to Resident 25 and sat the cup on the table in front of the resident. DA-B carried the empty tray to the steam table and sat the tray on the top shelf of the steam table. DA-B exited the dining room. C. Observation on 5/9/22 at 12:20 PM in the facility dining room revealed that DA-B returned to the dining room with two 3 shelf carts. DA-B did not perform hand hygiene. DA-B put a menu on a tray and sat it on one of the 3 shelf carts. DA-B continued to put a menu on each individual tray and sat the trays on the 3 shelf cart. There were a total of 5 individual trays. DA-B picked up a cup from the counter and filled it with coffee. DA-B put a lid on the coffee cup and sat the cup on one of the trays on the top shelf of the 3 shelf cart. DA-B picked up a cup from the counter and filled it with coffee. DA-B put a lid on the cup and sat the cup on a tray on the middle shelf of the 3 shelf cart. DA-B picked up a mug from the counter. DA-B dispensed cappuccino into the mug. DA-B put a lid on the mug and sat it on a tray on the bottom shelf of the 3 shelf cart. DA-B placed covered bowls of food on each of the 5 trays on the 3 shelf cart. D. Record review of Resident 31's Order Summary Report with order dates of 5/4/22, 5/5/22, and 5/12/22, revealed Resident 31 had respiratory illnesses and depends on enabling machines and devices to assist the resident with breathing. The devices Resident 31 utilized were nebulizer equipment, an oxygen concentrator, and a bilevel positive airway pressure ([CONDITION(S)]) machine (assists with breathing in medical conditions such as sleep apnea). Record review of Resident 31's Treatment Administration Record (TAR) for the month of April 2022 and May 2022, revealed on 3/31/22 at 6:00 PM an order had been put into place to clean Resident 31's oxygen concentrator filter with soap and water once weekly on night shift every Thursday. The filter order had been discontinued on 5/4/22 at 08:09 AM and Thursday 5/28/22 was the last documented date of completion as the order had not been re-entered upon Resident 31's return to the facility from the hospital on 5/4/22. An order was entered on 10/29/20 at 1900 to replace Resident 31's nebulizer equipment one time per week at bedtime every Thursday, but the order had been discontinued on 5/4/22. Resident 31's nebulizer equipment was not re-entered upon resident's return to the facility on [DATE] and the last documented date of order completion was on 4/28/22. Further review of Resident 31's TAR revealed there was not an order to change the resident's oxygen tubing and cannula. Observations in Resident 31's room on 5/9/22 at 3:18 PM and 5/10/22 at 08:50 AM, revealed Resident 31's nebulizer machine had several areas of a brownish/black substance on it, the [CONDITION(S)] machine's water canister contained water with a murky appearance, the water canister appeared dingy/light brown in color with white residue on the inside of the container, the [CONDITION(S)] mask was laying uncovered on the floor, oxygen tubing for Resident 31's oxygen concentrator and nebulizer machine were not labeled or dated, oxygen tubing attached to the oxygen concentrator was laying on the floor and under the black stand next to Resident 31's bed, there was an opened and undated gallon jug of distilled water and opened and non-dated bottle of irrigation water sitting on Resident 31's bedside table/cabinet. Observation of Resident 31's medical equipment on 5/12/11 at 09:54 AM, revealed the [CONDITION(S)] machine's water canister contained water that had a murky appearance, the water canister appeared dingy/light brown in color with a white residue on the inside of it, the oxygen concentrator tubing continued to be laying on the floor under the black stand next to Resident 31's bed, both the nebulizer machine and oxygen concentrator tubing were not dated/labeled, and the nebulizer machine had several areas with a brownish/black substance on it. Interview with RN-C (Registered Nurse) on 5/12/22 at 10:00 AM, confirmed the following findings: Resident 31's [CONDITION(S)] machine to be dirty, the [CONDITION(S)] water canister was dirty with a brown and white colored substances/residue in it, the water in the [CONDITION(S)] canister appeared murky, the oxygen concentrator tubing was not dated/labeled and was laying on the floor under the black stand next to Resident 31's bed, there was an unlabeled/undated oxygen tube laying on the floor next to the oxygen concentrator, the nebulizer oxygen tubing was not dated/labeled, and the nebulizer machine was dirty with a brownish/black substance on several areas of the machine. RN-C reported the oxygen tubing was supposed to be placed in a bag when not in use. RN-C verified there was not a date on the open sterile irrigation water nor on the open gallon jug of distilled water. RN-C confirmed they used the sterile water for the [CONDITION(S)] machine. RN-C stated that night shift was responsible for labeling new nebulizer canisters with a date. RN-C revealed the canisters were kept in the medication cart. Inspection of the medication cart with RN-C on 5/12/22 at 10:05 AM, revealed the nebulizer canister/supplies for Resident 31 were not dated. RN-C confirmed the findings. RN-C revealed the staff were expected to clean the [CONDITION(S)] machine weekly. Interview with the Director of Nursing (DON) on 5/12/22 at 10:37 AM, confirmed the expectation was that oxygen tubing was to be changed weekly. Interview with the DON confirmed there was no documentation on Resident 31's TAR to show the oxygen tubing and cannula had been changed.

Licensure Reference Number 175NAC 12-006.18A(1) Based on observation, interview, and record review; the facility failed to ensure that resident rooms were maintained in a clean and sanitary condition. This affected 8 residents (Residents 12, 31, 22, 26, 27, 29, 13, and 17) of 16 residents reviewed. The facility census was 32. Findings are: A. Record review of the facility Resident Handbook dated June 2017 revealed that resident rooms will be cleaned daily and replenished with paper supplies by housekeeping staff. Observation on 5/9/22 at 10:46 AM in the room of Residents 12 and 31 (roommates) revealed dark black/brown soiling around the base of the toilet. Feces was observed on the toilet seat, the front of the toilet bowl, and inside of the toilet bowl. The toilet tank lid was not fully on. Observation on 5/9/22 at 3:18 PM in the room of Residents 12 and 31 revealed that the bathroom floor was dirty with brown colored build-up residue around the base of the toilet. Feces remained on the toilet seat, the front of the toilet bowl, and in the toilet bowl. The toilet tank lid was not fully on. Observation on 5/10/22 at 8:50 AM in the room of Residents 12 and 31 revealed that the bathroom floor remained dirty with brown colored build-up residue around the base of the toilet. Feces remained on the toilet seat, the front of the toilet bowl, and in the toilet bowl. The toilet tank lid was not fully on. Observation on 5/12/22 from 12:25 PM to 12:40 PM with the Facility Administrator (FA) and the Maintenance Supervisor (MS) during the environmental tour of the facility confirmed the housekeeping issues identified. Interview on 5/12/22 at 12:30 PM with the FA confirmed that housekeeping had not been performed on 5/9/22 and 5/10/22. B. Observation on 5/9/22 at 3:40 PM in the room of Resident 22 revealed that the toilet had feces on the front of the toilet bowl and on the toilet seat. A soiled brief sat in the trash can in the bathroom. The bathroom floor was dirty with a brownish colored substance around the base of the toilet. Observation on 5/10/22 at 9:16 AM in the room of Resident 22 revealed that feces remained on the front of the toilet bowl and on the toilet seat as observed on 5/9/22. A soiled brief was in the trash can. The bathroom floor was dirty with a brownish colored substance around the base of the toilet. Observation on 5/12/22 from 12:25 PM to 12:40 PM with the Facility Administrator (FA) and the Maintenance Supervisor (MS) during the environmental tour of the facility confirmed the housekeeping issues identified. Interview on 5/12/22 at 12:30 PM with the FA confirmed that housekeeping had not been performed on 5/9/22 and 5/10/22. C. Observation on 5/9/22 at 3:34 PM in the room of Resident 26 revealed that the toilet seat was stained with brown stains on the top sitting surface. Interview on 5/12/22 at 12:30 PM with the FA confirmed that housekeeping had not been performed on 5/9/22 and 5/10/22. D. Observation on 5/9/22 at 3:35 PM in the room of Resident 27 revealed that the toilet seat was stained with brown feces stains on the top sitting surface. Interview on 5/12/22 at 12:30 PM with the FA confirmed that housekeeping had not been performed on 5/9/22 and 5/10/22. E. Observation on 5/9/22 at 3:35 PM in the room of Resident 29 revealed brown colored debris on the floor around the toilet. The inside of the toilet bowl was soiled with brown debris. Brown debris was observed on the toilet seat sitting surface. Interview on 5/12/22 at 12:30 PM with the FA confirmed that housekeeping had not been performed on 5/9/22 and 5/10/22. F. Observation on 5/9/22 at 3:32 PM in the room of Resident 13 revealed that feces was splattered on the inside of the toilet and a brown film was present inside of the toilet bowl. Food remnants were observed on the floor around the resident's recliner. Interview on 5/12/22 at 12:30 PM with the FA confirmed that housekeeping had not been performed on 5/9/22 and 5/10/22. G. Observation on 5/9/22 at 10:54 AM in the room of Resident 17 revealed that the bathroom call cord string was soiled with a brownish-tan substance. Observation on 5/12/22 from 12:25 PM to 12:40 PM with the Facility Administrator (FA) and the Maintenance Supervisor (MS) during the environmental tour of the facility confirmed that the call cord string was soiled.

Licensure Reference Number 175NAC 12-006.05 (21) Based on observation, record review, and interview; the facility failed to protect the dignity of residents by not ensuring that the resident mechanical lift slings (a fabric device with straps that is placed underneath a resident when a mechanical assistive device is used to transfer a resident with difficulty or inability to stand up on their own from a seated or lying position) were not visible to other residents and visitors for 3 residents (Residents 12, 22, and 7). The facility census was 32. Findings are: A. Record review of the facility policy titled Resident's Rights for Skilled Nursing Facilities dated 11/2016 revealed that the resident has a right to a dignified existence. The facility must protect and promote the rights of each resident. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 5/11/22 for Resident 12 revealed that Resident 12 required a mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) with the assistance of two staff for transfers between surfaces. The care plan revealed that staff may leave the lift sling behind and under the resident after transfer. Observation on 5/9/22 at 12:05 PM in the facility dining room revealed that Resident 12 sat in a wheelchair. The mechanical lift sling was visible outside of the back and the sides of the wheelchair. Observation on 5/11/22 at 12:16 PM in the facility dining room revealed that Medication Aide-E (MA-E) positioned Resident 12 in the wheelchair. MA-E began to feed Resident 12. The mesh mechanical lift sling was visible and covered the back of the neck of Resident 12. The mechanical lift sling hung visibly more than 6 inches per visual measurement along the sides of the resident. Observation on 5/12/22 at 8:02 AM in the facility dining room revealed that Resident 12 sat in a wheelchair. The mechanical lift sling was visible outside of the back of the chair up the back of the resident's neck. The sling hung visibly outside the sides of the wheelchair from the resident's shoulders to the resident's thighs. Observation on 5/12/22 at 12:08 PM in the facility dining room revealed that Resident 12 sat in a wheelchair. The mechanical lift sling was visible for approximately 10 inches up the back of the resident's neck. The mechanical lift sling was visible outside of the wheelchair on both sides of the resident. Interview on 5/12/22 at 12:19 PM in the facility dining room with the facility Director of Nursing (DON) confirmed that the mechanical lift sling should be tucked in underneath the resident so that the sling is not visible to maintain resident dignity. The DON confirmed that the mechanical lift sling for Resident 12 was visible and should have been tucked in. B. Record review of the care plan for Resident 22 dated 5/10/22 revealed that Resident 22 required a mechanical total body lift with a large sling and the assistance of two staff for transfers between surfaces. The care plan revealed that staff may leave the lift sling behind and under the resident after transfer. Observation on 5/9/22 at 12:05 PM in the facility dining room revealed that Resident 22 sat in a wheelchair adjacent to a dining room table. The mechanical lift sling was visible outside of the back and the sides of the wheelchair. Observation on 5/11/22 at 12:16 PM in the facility dining room revealed that Resident 22 sat in a wheelchair next to a dining room table. The mechanical lift sling was visible out of the top of the back of the wheelchair with the lift sling hook loops hanging down the back of the wheelchair approximately 12 inches per visual measurement. The mechanical lift sling hung visibly outside of the wheelchair along the sides of Resident 22. The bottom sling lift hook loops hung visibly for approximately 12 inches per visual measurement from the front of the wheelchair seat on each side of the resident. Observation on 5/12/22 at 8:02 AM in the facility dining room revealed that Resident 22 sat in wheelchair. The mechanical lift sling was visible out of the top of the back of the wheelchair. The top lift sling hook loops hung down the back and sides of the wheelchair approximately 16 inches per visible measurement. Observation on 5/12/22 at 12:08 PM in the facility dining room revealed that Resident 22 sat in a wheelchair. The mechanical lift sling was visible for approximately 6 inches out of the top of the back of the wheelchair. The mechanical lift sling was visible outside of the wheelchair on both sides of the resident. The top lift sling hook loops hung down the back of the wheelchair with approximately 18 inches visible per visual measurement. Interview on 5/12/22 at 12:19 PM in the facility dining room with the facility Director of Nursing (DON) confirmed that the mechanical lift sling should be tucked in underneath the resident so that the sling is not visible to maintain resident dignity. The DON confirmed that the mechanical lift sling for Resident 22 was visible and should have been tucked in. C. Record review of the care plan for Resident 7 dated 5/11/22 revealed that Resident 7 required a mechanical total body lift with the assistance of two staff for all transfers. Observation on 5/9/22 at 12:05 PM in the facility dining room revealed that Resident 7 sat in a wheelchair at a table with 3 other residents. The mechanical lift sling was visible outside of the top of the back of the wheelchair. Observation on 5/11/22 at 12:16 PM in the facility dining room revealed that Resident 7 sat in a wheelchair at a table with 3 other residents. The mechanical lift sling was visible for approximately 6 inches per visual measurement outside of the top of the back of the wheelchair. The mechanical lift sling was visible along the sides of the wheelchair. Observation on 5/12/22 at 8:02 AM in the facility dining room revealed that Resident 7 sat in a wheelchair. The mechanical lift sling hung visibly out of the back of the wheelchair over the resident's neck support pad. The mechanical lift sling was visible outside of both of the resident's shoulders. The top sling hook loops hung down the back of the wheelchair for approximately 10 inches per visual measurement. Observation on 5/12/22 at 12:08 PM in the facility dining room revealed that Resident 7 sat in a wheelchair at a table with 3 other residents. The mechanical lift sling was visible for approximately 6 inches per visual measurement outside of the top of the back of the wheelchair. The mechanical lift sling was visible along the sides of the wheelchair. Interview on 5/12/22 at 12:19 PM in the facility dining room with the facility Director of Nursing (DON) confirmed that the mechanical lift sling should be tucked in underneath the resident so that the sling is not visible to maintain resident dignity. The DON confirmed that the mechanical lift sling for Resident 7 was visible and should have been tucked in.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record review, and interview; the facility failed to implement interventions to prevent potential falls for 1 of 4 sampled residents (Resident 31) who was identified as having a high risk for falls. The facility census was 32. Findings are: Review of Resident 31's Care Plan dated 5/4/22 revealed Resident 31 had a history of falls prior to admission as well as, since being admitted to the facility. Resident 31 had a fall in the bathroom on 4/8/21 where Resident 31 obtained a skin tear, a fall By wheel chair (w/c) on 9/14/21, and a fall in Resident 31's room on 4/8/22 where Resident 31 obtained a small purple bruise on the right elbow. Further review of Resident 31's Care Plan revealed a fall intervention dated 4/9/22 that was to modify and maximize safety by removing the resident's walker from the resident's room to help prevent the resident from attempting to ambulate without assistance and thats signs should be hanging in the resident's room and bathroom reminding the resident to call for assistance. Record review of Resident 31's Progress Note dated 4/8/22 at 05:15 AM revealed the resident was attempting to ambulate to the restroom without assistance. As a result, Resident 31 slipped and fell . Resident 31 obtained a bruise to the resident's right elbow. Record review of Resident 31's Incident report completed on 4/8/22 at 05:15 AM, revealed the resident was incontinent at the time the resident slipped and fell . Review of Resident 31's Progress Note dated 4/9/22 revealed documentation at 05:40 AM and 2:00 PM revealed Resident 31 had complaints of severe pain in the right arm and shoulder. It was also documented Resident 31 had bruising down the right arm to the hand and an elevated blood pressure (BP). It was documented Resident 31 was taken to the hospital for an x-ray. Record review of Resident 31's radiology report dated 4/9/22 revealed a two view X-ray had been completed at 10:02 AM. The x-ray study results confirmed Resident 31 had a right shoulder injury. Observation of Resident 31's room on 5/10/22 at 08:50 AM, revealed Resident 31 sitting unattended in an unlocked w/c in front of the recliner in Resident 31's room. Resident 31's call light was draped over the head of the recliner and not within the resident's reach. Resident 31's walker was sitting in resident's room next to a built in dresser/cabinet. There was a sign posted on the outside of the bathroom door reminding Resident 31 to use the call light to call for assistance. Observation in the room of Resident 31 on 05/10/22 at 2:22 PM, revealed Resident 31 was sitting unattended in an unlocked w/c in front of the recliner. Resident 31's call light was draped over the head of Resident 31's recliner and not within the resident's reach. Resident 31's walker was sitting in resident's room next to a built in dresser/cabinet. Interview with Resident 31 on 5/9/22 at 3:18 PM, revealed Resident 31 was aware there was a call light and demonstrated how the call light worked. Resident 31 explained awareness of needing to use the call for assistance if needing to use the bathroom or needing to get out of bed. Resident 31 stated, I fell in my room and it damaged my right shoulder and other things in my body. Resident 31 explained resident's right shoulder hurts with movement. Resident 31 confirmed the w/c and walker present in the room were the resident's. Interview with the Director of Nursing (DON) on 5/11/22 at 4:36 PM, confirmed Resident 31 was able to use the call light and needed it to call for assistance due to Resident 31's high fall risk. The DON revealed if a resident was able to use their call light, the expectation was it would be kept within the resident's reach.

Licensure Reference Number 175NAC 12-006.12E7 Based on observation, record review, and interview; the facility failed to ensure that resident medication labels were updated to match the current physician's order for 1 resident (Resident 14) of 5 residents observed. This had the potential to cause the resident to receive additional doses of the medication. The facility census was 32. Findings are: Record review of the facility policy titled Medication: Administration Including Scheduling and Medications Aides dated 5/3/22 revealed that the purpose of the policy was to administer medications correctly. The section of the policy titled Procedure revealed that the staff administering the medication was to perform three checks: Read the label on the medication container and compare it with the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Record for Resident 14 dated 5/12/22 revealed that Resident 14 admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Order Recap Report (a report of active, completed, and discontinued physician orders for a resident) for Resident 14 dated 5/12/22 revealed that Resident 14 had a discontinued order for [MEDICATION(S)] tablet 0.5 milligrams (mg) (a medication used to treat anxiety) ½ tablet one time a day and give 0.5 mg ½ tablet as needed for anxiety once daily. The order start date was 12/15/22. The order end date was 1/4/22. Record review of the Order Recap Report for Resident 14 dated 5/12/22 revealed that Resident 14 had a discontinued order for [MEDICATION(S)] tablet 0.5 mg give ½ tablet as needed for anxiety and ½ tablet one time a day related to anxiety. That order had a start date of 1/4/22 and an end date of 2/15/22. Record review of the Order Recap Report for Resident 14 dated 5/12/22 revealed that Resident 14 had a discontinued order for [MEDICATION(S)] tablet 0.5 mg give ½ tablet one time a day for anxiety. That order had a start date of 2/16/22 and an end date of 2/16/22. Record review of the Order Recap Report for Resident 14 dated 5/12/22 revealed that Resident 14 had a current active order for [MEDICATION(S)] tablet 0.5 mg give ½ tablet one time a day for anxiety. The order had a start date of 2/17/22. The order had no end date and was the current active order. Record review of the Order Summary Report (a report of current physician orders for a resident) for Resident 14 dated 5/12/22 revealed that Resident 14 had a current order for [MEDICATION(S)] tablet 0.5 mg ½ tablet one time a day for anxiety. The order start date was 2/17/22. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tablet one time a day for anxiety was scheduled to be given in the morning. Observation on 5/12/22 at 8:27 AM at the medication cart next to the nurse's station revealed that Registered Nurse-D (RN-D) began medication set up for Resident 14. RN-D reviewed the MAR for Resident 14. RN-D removed the medication card containing [MEDICATION(S)] for Resident 14 from the supply drawer of the medication cart. RN-D removed a tablet of [MEDICATION(S)] from the medication card and placed it into a medication cup. RN-D provided the [MEDICATION(S)] medication card to this surveyor for review. The label on the [MEDICATION(S)] medication card read [MEDICATION(S)] 0.5 mg give 1/2 tablet every AM and an additional 1/2 tablet as needed. Interview on 5/12/22 at 12:21 PM with the facility Director of Nursing (DON) confirmed that the medication card label for the [MEDICATION(S)] for Resident 14 did not match the current physician's order and that the DON would notify pharmacy to correct the label.

Licensure Reference Number 175NAC 12-006.05 (1) Based on record review and interview, the facility failed to provide the resident or resident representative with one of the two required beneficiary notice forms regarding the discontinuation of Medicare Part A benefits to 2 of 3 residents reviewed (Residents 21 and 22). This had the potential to prevent the resident/resident representative from having the opportunity to appeal the facility's decision to discontinue the resident's Medicare Part A benefits and make an informed decision. The facility census was 32. Findings are: A. Record review of the facility policy titled SNF (Skilled Nursing Facility) Medicare Part A Advance Beneficiary Notice of Non-Coverage (SNFABN) dated 10/2019 revealed that the facility is required to issue the SNFABN when Medicare services are terminated when the facility believes that Medicare may not pay for, or will not continue to pay for skilled services. The timing of the notice section revealed that the SNFABN must be issued to provide enough time for the beneficiary (resident/resident representative) to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability. The policy revealed the definition of Termination of Services: In the situation in which a SNF proposes to stop furnishing all extended care services to a beneficiary because it expects that Medicare will not continue to pay for the services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNFABN to the beneficiary before it terminates such extended care services. Record review of the Admission Record for Resident 21 dated 5/10/22 revealed that Resident 21 admitted into the facility on [DATE]. The Admission Record revealed that Resident 21's most recent hospital stay was 12/22/21 through 12/25/21. Record review of the progress note dated 1/4/22 at 4:27 PM revealed that Resident 21 was hospitalized with acute confusion. The progress note revealed that Resident 21 would receive physical therapy and occupational therapy skilled services. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 21 dated 3/29/22 revealed that Resident 21 had a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13-15 means that the resident is cognitively intact to make decisions). Record review of the Skilled Nursing Facility Beneficiary Protection Notification Review form for Resident 21 provided by the facility revealed that the facility initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted. The form revealed that the last covered day of Resident 21's Medicare Part A services was 2/15/22. Record review of the Beneficiary Notice- Residents discharged Within the Last Six Months (a worksheet listing facility residents that were discharged from Medicare Part A benefits with benefit days remaining) completed by the facility revealed that Resident 21 discharged from Medicare Part A benefits on 2/15/22. The worksheet revealed that Resident 21 continued to reside in the facility. Record review revealed that the facility did not provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (A notice required to be provided by the facility to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare Part A and assume financial responsibility) to Resident 21. Interview on 5/10/22 at 11:16 AM with the Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that the MDSC was the facility staff person responsible for providing beneficiary notice forms to residents and their representatives. The MDSC confirmed that the facility had only been providing residents/resident representatives with one notice for discontinuation of Medicare Part A benefits. The MDSC confirmed that the facility had only been providing the Notice of Medicare Non-Coverage (NOMNOC) form to residents and resident representatives. The MDSC confirmed that the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was not provided to the residents or resident representatives by the facility. B. Record review of the Admission Record for Resident 22 revealed that Resident 22 admitted into the facility on [DATE]. The Admission Record revealed that Resident 22's most recent hospital stay was from 11/29/21 through 1/10/22. The Admission Record revealed that Resident 22 had a power of attorney for health care and financial decisions. Record review of the progress note dated 1/10/22 at 12:56 PM revealed that Resident 22 was hospitalized due to a stroke. The progress note revealed that Resident 22 would receive physical therapy, occupational therapy, and speech therapy skilled services. Record review of the MDS assessment for Resident 22 dated 3/29/22 revealed that Resident 22 had a BIMS score of 6 (a score of 0-7 means that the resident has severely impaired cognition). Record review of the Skilled Nursing Facility Beneficiary Protection Notification Review form for Resident 22 provided by the facility revealed that the facility initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted. The form revealed that the last covered day of Resident 22's Medicare Part A services was 2/3/22. Record review of the Beneficiary Notice- Residents discharged Within the Last Six Months (a worksheet listing facility residents that were discharged from Medicare Part A benefits with benefit days remaining) completed by the facility revealed that Resident 22 discharged from Medicare Part A benefits on 2/3/22. The worksheet revealed that Resident 22 continued to reside in the facility. Record review revealed that the facility did not provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (A notice required to be provided by the facility to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare Part A and assume financial responsibility) to Resident 22 or the resident's representative (power of attorney). Interview on 5/10/22 at 11:16 AM with the Minimum Data Set Coordinator (MDSC) confirmed that the MDSC was the facility staff person responsible for providing beneficiary notice forms to residents and their representatives. The MDSC confirmed that the facility had only been providing residents/resident representatives with one notice for discontinuation of Medicare Part A benefits. The MDSC confirmed that the facility had only been providing the Notice of Medicare Non-Coverage (NOMNOC) form to residents and resident representatives. The MDSC confirmed that the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was not provided to the residents or resident representatives by the facility.

Licensure Reference Number 175NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure that dietary staff performed hand washing after touching contaminated surfaces during food service to prevent the potential for foodborne illness. This had the potential to affect all 30 residents receiving food from the facility kitchen. The facility staff failed to prevent potential cross contamination by not performing hand hygiene between residents during room tray meal delivery, handling ready to eat food with their bare hands, and failing to perform hand hygiene after hands were contaminated then handling a resident's personal silverware which the resident then used to eat. This affected 4 of the 30 residents who received food during dining in the facility (Resident 2, Resident 29, Resident 25, and Resident 20). The facility census was 30. Findings are: A. Observation on 1/21/21 at 12:00 PM in the facility kitchen revealed that Dietary Cook-G (DC-G) began to plate (serve) resident meals from the steam table. Observation on 1/21/21 at 12:07 PM in the facility kitchen revealed that the menu card (a plastic note card containing the meal items ordered for a resident) for Resident 5 fell from the shelf on top of the steam table onto the floor. DC-G did not observe the menu card fall to the floor. DC-G stepped on the menu card while plating resident meals. Observation on 1/21/21 at 12:11 PM in the facility kitchen revealed that DC-G picked up the menu card for Resident 5 from the floor and placed it on the front shelf of the steam table. The gray scoop being used to serve food was laying on the front shelf of the steam table. DC-G did not wash the hands after picking up the menu card from the floor. DC-G picked up the gray scoop from the front serving shelf and obtained a scoop of pureed hot dog from the steam table and put the scoop of pureed hot dog into the Styrofoam meal container for Resident 4. The menu card of Resident 5 that had been on the floor remained on the front serving shelf. DC-G moved the menu card for Resident 5 on the front serving shelf. DC-G then placed the menu cards for Resident 7 and Resident 11 on the front serving shelf. DC-G picked up the menu card for Resident 5 from the front shelf of the steam table and handed the menu card for Resident 5 to Dietary Aide-H (DA-H) with the gloved left hand. DA-H placed the menu card on the meal tray for Resident 5. DC-G grabbed a hot dog bun from the package with the gloved hand and placed it into the Styrofoam container for Resident 5. DC-G plated the rest of the meal for Resident 5 and then placed the Styrofoam container on the meal tray for Resident 5. DC-G removed the glove from the left hand and put a new glove on the left hand. DC-G laid additional menu cards on the front serving shelf of the steam table. DC-G plated the meal for Resident 25 and placed the menu card and Styrofoam container onto the meal tray for Resident 25. DC-G picked up the gray scoop and plated pureed hot dog into the Styrofoam container for Resident 24. DC-G plated the rest of the meal for Resident 24. Record review of the facility policy titled Hand Washing and Glove Use- Food Nutrition dated 5/17/2020 revealed the purpose of the policy was to provide guidelines regarding hand hygiene (hand washing using soap and water to remove germs for reducing the risk of transmitting illness), glove use and foodborne illness when serving highly susceptible populations. The policy included that employees wash their hands as required and wear gloves only when appropriate to protect any food from contamination that may be present on hands. The procedure section titled Handwashing contained step 2: when to wash hands. Step 2c c. After touching any contaminated object (face, hair, body or clothing, garbage or dirty utensils, dirty dishes, phone, linen, or money). d. Before eating or touching food. g. Before and after using gloves. h. Between dirty and clean dish handling. n. Anytime contamination is suspected. 5. Gloves are changed as follows: a. Before handling ready-to-eat foods. b. When coming in contact with something that may be contaminated, such as handling pot/pans/tray/utensils, opening a trash can or touching a doorknob or faucet. g. Any time contamination is suspected. LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E B. Observation of the facility on 01/19/21 at 12:07 PM revealed NA-C (Nurse Aide) served containers of food to residents who were in their rooms. NA-C took a tray with food containers on it into Resident 19, placed the food containers on the tray table in front of Resident 19, then took the tray out of the room and placed it on the cart. NA-C did hand hygiene for 3 seconds with ABHR (Alcohol Based Hand Rub) then took a tray of food into Resident 2. NA-C placed the food containers on the table in front of Resident 2 then left the room with the tray and placed it on the cart. NA-C pushed the cart part way down the hall by the handle then did hand hygiene for 3 seconds with ABHR. NA-C then took food into Resident 29, placed the items on the table in front of Resident 29, then took the tray out and placed it on the cart. NA-C pushed the cart partway down the hall by the handle, then did ABHR for 3 seconds with ABHR. NA-C then took a tray of food items in to Resident 20, placed the food items on the residents table, then NA-C came out of Resident 20's room, put the tray on the cart then pushed the cart down the hall to Resident 12's room. NA-C went into Resident 12's room and asked if they wanted the tray of food which Resident 12 refused. NA-C then then pushed the cart back down to the kitchen. NA-C then got gravy and another item in round foam containers and took them to Resident 29. NA-C then used Resident 29's own silverware to cut the food and opened the container of gravy and poured it on the food. Resident 29 then used the silverware to eat. NA-C did not do any hand hygiene after they took the items to Resident 20 and after handling the cart which NA-C had touched without doing hand hygiene. NA-C did not do hand hygiene with the ABHR as required and handled Resident 29's silverware with the bare hands and without doing any hand hygiene. None of the residents who NA-C passed trays to were wearing masks and NA-C was within 6 feet of the residents as NA-C put the containers of food on the tables that were in front of the residents. C. Observation of the facility dining room on 1/21/21 at 12:27 PM revealed MA-D (Medication Aide) picked up a hot dog in a bun with their bare hand and gave it to Resident 25 by placing it in Resident 25's hand then Resident 25 proceeded to take a bite of it. Review of the facility policy Hand Hygiene and Handwashing dated 4/14/2020 revealed the following: Purpose: To ensure appropriate hand hygiene technique for clinical use. Patient care: the goal is to prevent the spread of infection between residents. Handwashing and changing gloves occurs after care is delivered to prevent the spread of organisms to other residents. Sanitizers are used in patient care areas. Food service: The goal is to protect all residents from foodborne illness by never touching their food with bare hands or contaminated gloves. Proper handwashing and appropriate use of gloves protects residents against foodborne illness from improperly handled time/temperature control for safety (TCS) foods. Sanitizers are not used in food service or dining except immediately after proper handwashing. During Service of Meals: Nursing and all other employees: Wash hands before meals service begins, when visibly soiled and whenever hands are contaminated by touching a resident, self or any surface (e.g. table, chair, counter); do not touch any food or eating surfaces with bare hands (i.e. fork tines, eating surface of plates, drinking surface of glasses); use a barrier such as deli paper, knife and fork, or tongs when ready-to-eat food needs setup (e.g., buttering bread). Gloves require handwashing when donned and doffed. Handwashing techniques: Wet hands with water. Avoid hot water. Apply soap from dispenser. Work up a generous lather by rubbing hands together vigorously for at least 20 seconds. Cover all surfaces of hands, fingers and areas around/under fingernails. Rinse hands with water and dry thoroughly. Use paper towel to turn off water faucet, light switches and to open doors to handwashing area before discarding paper towel. Use of Alcohol-Based Hand Rub during Patient Care: Refer to product label for amount of gel or foam to use. Apply alcohol gel or foam to palm of one hand. Rub hands together. Cover all surfaces of hands, fingers, and areas around/under fingernails. Continue rubbing hands together until alcohol dries (about 15-25 seconds). Make sure hands are completely dry before putting on gloves. Interview with the DON (Director of Nursing) on 1/27/21 at 1:50 PM revealed it was their expectation staff should have done hand hygiene whenever they walked out of a resident's room when they were taking the food into the residents' rooms and taking the trays out. The DON revealed the staff should not have touched resident ready to eat food or silverware with their bare hands.

Licensure Reference Number 175NAC 12-006.11D Based on observation, interview, and record review the facility failed to ensure that food service temperatures were monitored and documented to ensure that hot foods were served at temperatures within the recommended guidelines to prevent the potential for foodborne illness and the facility failed to ensure that hot foods were served at an appetizing temperature. This had the potential to discourage residents from eating the foods and to contribute to insufficient nutritional intake for all 30 residents that were served meals by the facility kitchen. The facility census was 30. Findings are: A. Record review of the facility policy titled Food Temperature Monitoring- Food and Nutrition Services dated 4/29/20 policy section titled definition revealed the definition: Time/temperature Control for Safety (TCS) food- A food that requires time/temperature control to limit pathogenic microorganism (a bacteria or virus capable of causing illness in humans) growth or toxin (a poison produced by a bacteria) formation. The definition of Proper holding temperature: Temperature required for food safety (cold food less than 41 degrees Fahrenheit, hot food greater than 135 degrees Fahrenheit. The policy section titled policy revealed that food temperatures are taken and recorded before each meal service. Periodically, temperatures are taken at other timed during or at the end of meal service to ensure temperatures are held within acceptable ranges. The policy section titled procedure revealed that before meal service, the cook/designee takes the cook to and serve temperatures of all Time/temperature Control for Safety (TCS) menu items and records on the Weekly Food Temperature Record. The location monitors TCS foods throughout meal service: By temperature: Retake temperatures periodically throughout meal service to ensure TCS foods are held below 41 degrees Fahrenheit for cold foods or above 135 degrees Fahrenheit for hot foods. If temperatures are not within recommended guidelines, food/fluids are reheated/chilled to acceptable temperatures before service. TCS hot foods should be served at 135 degrees Fahrenheit or higher. TCS cold foods will be held at or lower than 41 degrees Fahrenheit and served promptly after being removed from the refrigerator. Temperatures are periodically taken during or at the end of meal service to ensure that holding temperatures are adequate. Observation on 1/21/21 at 11:50 AM in the facility kitchen revealed that Dietary Cook-G (DC-G) removed the large pan of hot dogs from the oven and placed the pan into the steam table. DC-G then removed the small pan of ground hot dogs from the oven and placed the pan into the steam table. DC-G removed the pan of pureed (a cooked food item that has been ground with a blender into a smooth consistency for residents with difficulty chewing or swallowing) hot dogs from the oven and placed the pan into the steam table. DC-G removed the baking pan of brussel sprouts from the oven and poured them into a large pan and placed the pan into the steam table. DC-G removed the small pan of pureed brussel sprouts from the oven and placed the pan into the steam table. DC-G wiped off a thermometer with an alcohol prep pad and checked the temperature of the pan of hot dogs in the steam table. The temperature of the hot dogs was 204 degrees Fahrenheit. DC-G checked the temperature of the ground hot dogs with a result of 140 degrees Fahrenheit. DC-G checked the temperature of the pureed hot dogs with a result of 188 degrees Fahrenheit. DC-G checked the temperature of the brussel sprouts with a result of 152 degrees Fahrenheit. DC-G checked the temperature of the pureed brussel sprouts with a result of 198 degrees Fahrenheit. Observation on 1/21/21 at 12:00 PM in the facility kitchen revealed that DC-G began to plate (serve) resident meals from the steam table. Observation on 1/21/21 at 12:36 PM in the facility kitchen revealed that DC-G plated the meal for Resident 19 and revealed that it was the last resident meal to be plated and served. DC-G removed the small pan of pureed brussel sprouts from the steam table and placed it into the dish sink. DC-G removed the small pan of pureed hot dogs from the steam table and placed it into the dish sink. DC-G ran water into the pans in the dish sink. DC-G had not obtained the end of service temperatures of the pureed brussel sprouts or the pureed hot dogs. Observation on 1/21/21 at 12:40 PM in the facility kitchen revealed that the documentation of food temperatures before serving were documented on the food temperature log for the noon meal as main dish (hot dogs) 204 degrees Fahrenheit, pureed meat (pureed hot dogs) 186 degrees Fahrenheit , and vegetable (brussel sprouts) as 185 degrees Fahrenheit . Observation on 1/21/21 at 12:41 PM revealed that DC-G went to the food temperature log and recorded the temperature of the ground meat (ground hot dogs) as 158 degrees Fahrenheit and the pureed vegetable (pureed brussel sprouts) as 152 degrees Fahrenheit in the column of the food temperature log for food temperatures before serving. No temperatures were recorded on the food temperature log to document the end of serving food temperatures to ensure that they were within the acceptable ranges for food safety. Observation on 1/27/21 at 9:39 AM in the facility kitchen revealed that no end of service food temperatures were documented for the breakfast items served on 1/27/20. Record review of the facility daily food temperature logs from 1/17/21 through 1/27/21 revealed that no end of service food temperatures were documented on the daily food temperature logs for any meals. Interview on 1/21/21 at 12:50 PM in the facility kitchen with the Dietary Manager (DM) confirmed that the facility had not been recording end of service temperatures of food items. B. Interview on 1/19/21 at 3:26 PM with Resident 12 revealed that the hot foods are sometimes cool when the resident receives the meal. The resident revealed that the resident does not eat much when the hot food is cool. Interview on 1/19/21 at 3:58 PM with Resident 29 revealed that the hot food served to residents is not always hot and that the facility did not offer alternate food items. Observation on 1/27/21 at 12:30 PM revealed that Dietary Aide-H (DA-H) brought the requested meal test tray to the administrator's office. The tray contained a plate covered with a lid. This surveyor removed the lid from the plate. The plate contained ham with scalloped potatoes, a biscuit, and a lettuce salad. The plate of food looked and smelled appetizing. The temperature of the ham with scalloped potatoes was 130 degrees Fahrenheit with the thermometer. The temperature was below the required guideline for hot foods to be served at 135 degrees Fahrenheit or higher. C. Interview with Resident 19 on 1/19/21 at 11:19 AM revealed Resident 19 said the food could be warmer in response to the question how is the food? Review of the 2017 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees C (135 degrees F) or above.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during the administration of medications which affected 1 of 8 residents observed during medication administration (Resident 11) and failed to perform hand hygiene to prevent potential cross contamination during direct care which affected 1 of 3 sampled residents (Resident 21). The facility failed to ensure that staff performed hand washing following the facility hand washing guidelines during resident care to prevent the potential for cross contamination. This affected 3 residents (Residents 10, 23, and 12) of 3 residents observed. The facility identified a census of 30 at the time of survey. Findings are: A. Observation of LPN-B (Licensed Practical Nurse) on 1/20/2021 at 4:15 PM revealed LPN-B prepared medication for Resident 11. LPN-B dispensed the medications from the cards and placed them into 2 plastic medication cups. LPN-B reported they had to crush the medications. LPN-B placed the capsules in one medication cup and put the pills in another medication cup. LPN-B put on gloves and opened each capsule and poured it into a plastic med cup. LPN-B opened the first capsule then lifted the lid on the trash can on the medication cart with the gloved hands and put the capsule in it. LPN-B then opened the next capsule by taking it out of the medication cup with the same gloved hands and poured it into the plastic medication cup then opened the trash bin lid with the same gloved hand and tried to discard it. LPN-B had static on their gloves and 1/2 of the outer capsule went on the floor and the other capsule half LPN-B placed back on top of the cart. LPN-B then opened the other 2 capsules with the same gloved hands and laid them on the cart. LPN-B then put the capsules in the glove then took the gloves off. As LPN-B was discarding the gloves with the capsules into the trash bin, LPN-B picked up the other capsule off the floor their bare hand then discarded it and the gloves in the trash bin by lifting the lid on the bin with their bare hand. Without doing hand hygiene, LPN-B took a pill crusher pouch out of the holder and pushed their bare finger into it to open it then poured the pills into it. LPN-B then put the pouch into the crusher, crushed the pills, poured them into the plastic medication cup with the medications that had been in the capsules, put applesauce in the cup, put a spoon in the cup, mixed the applesauce with the medications, then took the cup into Resident 11's room and gave Resident 11 the medications by putting them into their mouth with the spoon. B. Observation on 1/20/21 at 2:45 PM revealed NA-E (Nurse Aide) assisted Resident 21 with using the bathroom. NA-E had gloves on and walked with Resident 21 to the bathroom. NA-E removed Resident 21's brief then removed the gloves and washed their hands after helping Resident 21 sit down on the toilet. NA-E then applied a seat alarm to Resident 21 wheelchair. NA-E then donned clean gloves. NA-E closed the door because Resident 21 said they needed a few minutes. When Resident 21 said they were done, NA-E went into the bathroom and washed the front of Resident 21's groin area with pre-moistened wipes. NA-E wiped each side of Resident 21's groin then discarded the wipe each time. NA-E then helped Resident 21 stand and wiped Resident 21's perineum (bottom) with the wipes. NA-E used a new wipe each time and cleaned Resident 21 from front to back. NA-E then applied a clean brief then removed the gloves. NA-E then adjusted Resident 21's clothing and touched the gait belt. NA-E then walked with Resident 21 out of the bathroom to the wheelchair which was in Resident 21's room using the gait belt and walker. NA-E helped Resident 21 sit down and removed the gait belt and placed it on Resident 21's walker in the bag. NA-E then went into the bathroom and pulled the trash out of the can in the bathroom by the liner. NA-E tied a knot in the bag and placed the trash on the floor of the bathroom. NA-E then washed their hands. NA-E then placed a new liner in the can and touched the trash can in the process. NA-E then picked the bag of trash up off the bathroom floor with their bare hands and carried it into Resident 21's room and placed it on the floor. NA-E then picked up a cloth face mask off the built in and put the mask on Resident 21's face. NA-E then picked up the bag of trash and carried it as NA-E wheeled Resident 21 out of the room by holding onto the handles of the wheelchair with their hands with the bag of trash dangling from one of the hands. NA-E then stopped by the utility room and dropped off the trash then did hand hygiene with ABHR (Alcohol Based Hand Rub). NA-E then wheeled Resident 21 to the door by touching the handles on the wheelchair. NA-E did not do hand hygiene after NA-E handled the trash before NA-E put Resident 21's mask on. NA-E also cross contaminated Resident 21's wheelchair handles after handling the wheelchair handles with the trash in their hand then didn't clean them and touched them again after NA-E dropped the trash off. NA-E did not change their gloves after doing peri-care and touching the clean brief. NA-E removed the gloves and did not do hand hygiene before handling Resident 21's clothing and gait belt. Review of the facility policy Hand Hygiene and Handwashing dated 4/14/2020 revealed the following: Purpose: To ensure appropriate hand hygiene technique for clinical use. Patient care: the goal is to prevent the spread of infection between residents. Handwashing and changing gloves occurs after care is delivered to prevent the spread of organisms to other residents. During patient care wash hands with plain soap and water or with anti-microbial soap and water: if hands are visibly soiled, if hands are visibly contaminated with blood or body fluids, before eating, after using the restroom, when a build-up of [MEDICATION NAME] (moisturizer such as ointments, lotions, or creams) is felt on hands (usually after five to 10 applications of a gel). If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning hands: before having direct contact with residents, patients, and children; after having direct contact with another person's skin; after having contact with body fluids, wounds or broken skin; after touching equipment or furniture near the resident/patient; after removing gloves. Alternatively, hands may be washed with an anti-microbial soap and water in clinical situations described above. Handwashing techniques: Wet hands with water. Avoid hot water. Apply soap from dispenser. Work up a generous lather by rubbing hands together vigorously for at least 20 seconds. Cover all surfaces of hands, fingers and areas around/under fingernails. Rinse hands with water and dry thoroughly. Use a paper towel to turn off water faucet, light switches and to open doors to handwashing area before discarding paper towel. Use of Alcohol-Based Hand Rub during Patient Care: Refer to product label for amount of gel or foam to use. Apply alcohol gel or foam to palm of one hand. Rub hands together. Cover all surfaces of hands, fingers, and areas around/under fingernails. Continue rubbing hands together until alcohol dries (about 15-25 seconds). Make sure hands are completely dry before putting on gloves. Interview with the DON (Director of Nursing) on 1/27/21 at 1:50 PM revealed the staff were expected to perform hand hygiene between dirty and clean tasks, after soiled gloves were removed, when the hands were contaminated and after the staff touched the trash can and picked up the capsules off the floor before taking Resident 11 their medications. C. Record review of the facility policy titled Hand Hygiene and Handwashing dated 4/14/2020 revealed the purpose of the policy was to ensure appropriate hand hygiene technique for clinical use. The steps for Handwashing: 1. Wet hands with water. 2. Apply soap from dispenser. 3. Work up a generous lather by rubbing hands together vigorously for at least 20 seconds. 4. Cover all surfaces of hands, fingers, and areas around/under fingernails. 5. Rinse hands with water and dry thoroughly. 6. Use a paper towel to turn off water faucet. Observation on 1/21/21 at 9:09 AM revealed Nursing Assistant-I (NA-I) and Medication Aide-J (MA-J) performed 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) with ABHR. NA-I and MA-J entered the room of Resident 10. MA-J performed hand washing with soap and scrubbed the hands for 22 seconds. MA-J put on disposable gloves. NA-I performed hand washing with soap and scrubbed the hands for 3 seconds. NA-I put a disposable glove on one hand and dropped the second disposable glove on the floor. NA-I picked the glove up off of the floor and discarded it into the trash can in the resident bathroom. NA-I obtained another disposable glove and put it on without performing hand hygiene. NA-I removed the gown from the resident. NA-I lifted the resident's left arm while MA-J sprayed deodorant to the resident's arm pit. MA-J placed a t shirt over the resident's head and NA-I assisted in positioning the shirt on Resident 10. MA-J asked the resident to lift the resident's head to assist with placement of the t shirt. NA-I unfastened the resident's brief and discarded it into the trash can at the bedside. MA-J handed NA-I a disposable wipe. NA-I wiped the tip of the resident's penis. NA-I was handed a new disposable wipe by MA-J. NA-I wiped the urinary catheter (a rubber like tube placed into the resident's bladder to drain urine from the bladder) tubing from the tip of the penis toward the catheter bag (a collection bag for urine drained from the bladder) for approximately 4-6 inches. NA-I wiped the resident's left groin with a new disposable wipe. NA-I wiped the resident's right groin area with a new disposable wipe. MA-J placed a new brief on the resident's bed. MA-J and NA-I assisted the resident to roll onto the resident's right side. MA-J handed NA-I a new disposable wipe. NA-I wiped the resident's anal area from front to back. NA-I picked up the container of disposable wipes and moved them to an area on the bed near the resident's thighs. MA-J positioned the soaker pad under the resident and then positioned the brief underneath the resident. NA-I positioned the resident with the gloved hands on the resident's arms. NA-I handed the catheter bag to MA-J. MA-J and NA-I placed the resident's legs into a pair of sweatpants. NA-I asked the resident to lift up the resident's bottom and MA-J and NA-I pulled the sweatpants up to the resident's waist. NA-I threaded the catheter bag and tubing through the left leg of the sweatpants and then hung the catheter bag on the side of the bed. NA-I removed the trash bag from the trash can at bedside containing the resident's used brief and the used disposable wipes and tied it shut. NA-I dropped the trash bag on the floor near the resident bathroom doorway. NA-I placed a new trash bag in the trash can. NA-I removed the disposable gloves and discarded them in the trash can in the resident's bathroom. NA-I performed hand washing and scrubbed the hands with soap for 6 seconds. NA-I wet a wash cloth at the bathroom sink. NA-I took the wash cloth and a hand towel to Resident 10. NA-I assisted Resident 10 to wash the resident's face and then the resident's hands. MA-J removed the disposable gloves and discarded them in the trash can in the resident bathroom and washed the hands with soap and scrubbed for 23 seconds. NA-I removed the trash bag from the trash can in the resident's bathroom and placed the trash on the floor near the bathroom doorway. NA-I performed hand washing with soap and scrubbed the hands for 5 seconds. NA-I picked up the two bags of trash from the floor and exited the resident's room. NA-I carried the trash bags into the utility room and discarded them. NA-I exited the utility room and performed hand hygiene with ABHR. NA-I returned to the room of Resident 10 and picked up the bag of dirty laundry and carried it to the utility room. NA-I performed hand hygiene with ABHR and returned to the resident's room. NA-I set up breakfast for Resident 10 and then exited the resident's room. Interview on 1/27/21 at 2:29 PM with the facility Director of Nursing (DON) confirmed that staff are required to scrub the hands with soap for a minimum of 20 seconds before rinsing during hand washing. D. Observation on 1/21/21 at 10:39 AM revealed that Registered Nurse-A (RN-A) received permission from Resident 23 and entered the resident's room. RN-A went into the resident's bathroom and performed hand washing and scrubbed the hands with soap for 24 seconds. RN dried the hands with a paper towel and put on disposable gloves. RN-A removed the covers from the legs of Resident 23. RN-A opened the heel protector boot (a soft padded cloth device applied around the resident's foot to reduce pressure on the bones of the resident's heel) on the resident's right leg and noted increased [MEDICAL CONDITION] (swelling caused by excess fluid trapped in the body's tissues). Resident 23's second toe of the right foot had a dark purple black color over 1/2 of the toenail. RN-A opened a Sure Prep No Sting wipe (a wipe used to apply skin protectant) and wiped the toes of the resident's right foot. RN-A opened the heel protector from the resident's left foot. No discoloration or wounds were observed. RN-A closed the heel protectors and replaced the blankets over the resident's feet. RN-A went to the resident's bathroom and removed the disposable gloves and discarded them into the trash can. RN-A performed hand washing with soap and scrubbed the hands for 16 seconds. RN-A dried the hands with a paper towel. Interview on 1/27/21 at 2:29 PM with the facility Director of Nursing (DON) confirmed that staff are required to scrub the hands with soap for a minimum of 20 seconds before rinsing during hand washing. E. Observation on 1/21/21 at 12:57 AM revealed that Registered Nurse-A (RN-A) entered the room of Resident 12 and performed hand hygiene with ABHR. RN-A put on disposable gloves and removed the sock from the resident's left foot. RN-A cut the gauze wrap from around the resident's ankle with a pair of scissors and discarded the used gauze wrap into the trash can. RN-A removed the disposable gloves and discarded them into the trash can. RN-A performed hand washing with soap and scrubbed the hands with soap for 14 seconds. RN-A applied additional soap by pressing the soap dispenser and scrubbed the hands for 9 seconds. RN-A rinsed and dried the hands and put on disposable gloves. RN-A placed a dry wash cloth on the floor underneath Resident 12's left foot. RN-A wiped the wound on the resident's left ankle with [MEDICATION NAME] (a skin cleanser used to kill germs and bacteria) and then wiped the wound on the resident's left ankle with saline solution (a medical solution used to clean wounds). The wound on the resident's ankle was approximately 15 centimeters in length and 3 centimeters in width. RN-A removed the disposable gloves and discarded them into the trash. RN-A turned on the water at the sink and applied soap from the dispenser to the dry right hand. RN-A scrubbed the hands with soap for 19 seconds. The water flow had stopped at the sink and RN-A touched the faucet handle with the left hand to initiate a flow of water. RN-A rinsed the hands and dried the hands with a paper towel. RN-A did not rewash the hands after touching the sink handle. RN-A put on a pair of disposable gloves. RN-A wiped the wound with a dry gauze and then applied a [MEDICATION NAME] Extra AG+ dressing (a wound dressing with an antimicrobial substance to assist with wound healing) over the wound. RN-A obtained a roll of gauze dressing and wrapped the resident's ankle with the gauze dressing to hold the [MEDICATION NAME] dressing in place on the resident's left ankle. RN-A picked up the wash cloth from the floor under the resident's foot and placed the roll of gauze dressing back into the gauze wrapper and returned the roll of gauze and the scissors to a tub on the counter near the sink. RN-A put the sock back on the resident's left foot. RN-A removed the disposable gloves and discarded them into the trash. RN-A performed hand washing and scrubbed the hands for 23 seconds. Interview on 1/27/21 at 2:29 PM with the facility Director of Nursing revealed that staff are required to scrub the hands with soap for a minimum of 20 seconds before rinsing during hand washing. The DON confirmed that if staff touch anything during the hand washing procedure they must restart the procedure. The DON confirmed that if a staff scrubbed with soap and then adjusted the water faucet with soapy hands the staff would be expected to begin hand washing over.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review; the facility staff failed to maintain a medication error rate below 5% by failing to administer medications that were indicated to be administered with food. The facility had 3 medication errors with 25 opportunities resulting in a medication error rate of 12%. This affected 3 of 8 residents observed during medication administration (Residents 6, 13, and 20). The facility identified a census of 30 at the time of survey. Findings are: A. Observation of LPN-B (Licensed Practical Nurse) on 1/20/2021 at 4:07 PM revealed they administered Potassium Chloride ER (Extended Release) 20 mEq (milliequivalents) 1 PO (by mouth) to Resident 6. LPN-B did not offer Resident 6 any food or juice/milk. Review of Resident 6's Order Summary Report dated 1/20/2021 revealed an order for [REDACTED]. B. Observation of LPN-B on 1/20/2021 at 4:11 PM revealed they administered Potassium Chloride 20 mEq 1 PO to Resident 13. LPN-B did not offer Resident 13 any food or juice/milk. Review of Resident 13's Medication Administration Record [REDACTED]. Observation on 1/20/2021 at 4:11 PM of the medication label for Resident 20's Potassium Chloride 20 mEq 1 PO BID revealed it read take with food. C. Observation of LPN-B at 1/20/2021 at 4:21 PM revealed they administered Carvedilol 3.125 mg 1 PO BID to Resident 20. LPN-B did not offer Resident 20 any food or juice/milk. Review of Resident 20's Order Summary Report dated 1/20/2021 revealed an order for [REDACTED]. Observation of the medication label for Resident 20's carvedilol on 1/20/2021 at 4:21 PM revealed it read Carvedilol Tablet 3.125 MG Give 1 tablet by mouth two times a day with meals. Observation on 1/20/21 at 4:24 PM revealed Residents 6, 13, and 20 were in their rooms and they did not have any food or milk/juice. Review of the Medication Admin Audit Reports for January 2021 revealed LPN-B signed that they had administered the Potassium Chloride ER to Resident 6 at 16:09 (4:09 PM) on 1/20/2021; the Potassium Chloride ER to Resident 13 at 16:13 (4:13 PM) on 1/20/2021; and the carvedilol to Resident 20 at 16:21 (4:21 PM) on 1/20/2021. Review of the facility meal times revealed they were at 8:00 AM, 12:15 PM, and 6:00 PM per information received from the entrance conference. Interview with the DON (Director of Nursing) on 1/27/21 at 1:50 PM revealed the expectation for administering medications with food was generally those medications should be administered around a meal time. Review of the facility policy Medication-Administration Including Scheduling and Medication Aides revised 1/1/20 revealed the following: Medications will be scheduled to: Maximize the effectiveness (optimal therapeutic effect) of the medication; Avoid potential significant medication interactions such as medication-food or medication-medication interactions. Follow the Six Rights: Right medication, right dose, right resident, right route, right time, and right documentation. Review of the Nursing2018 Drug Handbook revealed the following nursing considerations for potassium chloride: take with or after meals with full glass of water or fruit juice to lessen GI (gastrointestinal-stomach) distress. Review of the Nursing2018 Drug Handbook revealed the following nursing considerations for carvedilol: take drug with food.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6(1) Based on observation, interview, and record review; the facility staff failed to follow the standard of practice for instilling liquid into a GTube (Gastrostomy tube ([DEVICE]) a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) by using force to plunge liquid into the resident's GTube placing the resident at risk for complications including aspiration (aspiration pneumonia occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach). This affected 1 of 1 sampled residents who had a GTube in the facility (Resident 25). The facility identified a census of 30 at the time of survey. Findings are: Review of Resident 25's SCSA MDS (Significant Change in Status Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 9/25/2020 revealed an admission date of [DATE]. Resident 25 had a BIMS (Brief Interview for Mental Status) score of 5 which indicated severe cognitive impairment. Resident 25 was dependent upon 2 staff for bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, toilet use, and bathing. Active [DIAGNOSES REDACTED]. Review of Resident 25's Order Summary Report dated 1/21/2021 revealed the following orders: FLUSH tube with 50 cc of additional water two times a day with and active date of 10/19/2020. Observation of RN-A (Registered Nurse) on 1/21/21 at 10:18 AM revealed RN-A pulled up Resident 25's shirt to expose the abdomen. A GTube was in place on the left side of Resident 25's abdomen. RN-A drew up 50 cc of water into a syringe, connected the syringe and plunger into the GTube, then used the plunger to push the water into the GTube within a 3 second time frame. Review of the facility policy Tube-Gastrostomy or Jejunostomy-Enteral Feeding, Care, Replacement or Removal-Rehab/Skilled dated 11/23/2020 revealed the following: A resident who is fed by a nasogastric tube or gastrostomy tube will receive appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers. Instill formula as ordered by physician. Give slowly and never use force. Interview with the DON (Director of Nursing) on 01/27/21 at 1:50 PM revealed the expectations for [DEVICE] procedure for flushing revealed the nurse should not use force to flush the GTube. The DON agreed gravity would be the best method for flushing the GTube. Review of the article Enteral Tube Flushing: A Review of Current Practice in The American Journal of Nursing March 2005 revealed the following: Don't force or apply excessive pressure when flushing the tube. Review of the current clinical practice guidelines from the Indiana Department of Health revealed the following: Do not force any medication or fluid into the tube. Allow gravity to work as possible. Review of the Ohio State University [MEDICAL CONDITION] Center Flushing Your Feeding Tube dated February 21, 2018 revealed the following: pour the water into the syringe. Raise the syringe above your stomach. Let the water flow into your feeding tube by gravity.

Licensure Reference Number 175NAC 12-006.09C Based on record review and interview the facility failed to care plan (develop a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) the resident use of an antianxiety medication (a medication used to treat anxiety- a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and the resident use of a diuretic medication (a medication used to treat [MEDICAL CONDITION]- swelling caused by excess fluid trapped in the body's tissues) for 1 resident (Resident 12) of 6 residents reviewed. This had the potential for the resident to experience adverse outcomes related to the use of the medications. The facility census was 30. Findings are: Record review of the Admission Record (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) revealed that Resident 12 had a [DIAGNOSES REDACTED]. Record review of the physician orders [REDACTED]. Record review of the physician orders [REDACTED]. Record review of the annual Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 12 dated 11/11/2020 section N0410 (Medications Received) revealed that Resident 12 received an antianxiety medication and a diuretic medication. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 12 revealed that no care plan section for the resident antianxiety medication use was present in the care plan. Record review of the care plan for Resident 12 revealed that no care plan section for the resident diuretic medication use was present in the care plan. Interview on 1/27/21 at 2:22 PM with the facility Director of Nursing (DON) confirmed that Resident 12 used an antianxiety medication and a diuretic medication. The DON confirmed that the care plan for Resident 12 did not contain a section with information for resident use of the antianxiety medication. The DON confirmed that the care plan did not contain a section with information for resident use of the diuretic medication. The DON confirmed that the expectation was that the care plan contained a section for the antianxiety medication and the diuretic medication. The DON revealed that these would be added to the care plan for Resident 12.

LICENSURE REFERENCE NUMBER 175 12-006.09D2a Based on observation, record review, and interview; the facility failed to prevent one stage 3 pressure ulcer (Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.) on the left buttock and one stage 2 (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). Presents as a shiny or dry shallow ulcer without slough or bruising ulcer.) on the right buttock of Resident 12. The census was 27. Findings are: Review of Resident 12's undated [DIAGNOSES REDACTED]. Review of Resident 12's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 12-6-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 12 which indicated Resident 12's cognition was moderately impaired. Resident 12 required extensive assistance of 2 staff with bed mobility and toileting and of 1 staff for personal hygiene and dressing. The resident did not walk and required limited assistance of one staff for locomotion on and off the unit. Resident 12 was identified as at risk for developing pressure ulcers and had two stage 3 pressure ulcers. Review of Resident 12's admission MDS dated [DATE] CAA (Care Area Assessment) revealed pressure ulcer was triggered to be careplanned. However, the documentation revealed the resident's actual problem was a venous stasis ulcer (wounds that are occur due to improper circulation). Review of Resident 12's admission Braden assessment dated [DATE] revealed a score of 16. A score of 18 or below according to the directions on the form indicated the resident was at risk for developing a pressure sore. On 11-16-17 a Braden Assessment was completed with a score result of 14. Review of the Wound Data Collection form dated 11-20-17 for Resident 12 revealed the initial data of the left buttock wound described as 2.5 x 2 cm (centimeter) area with 3 open areas with yellow tissue and open areas measured 0.8 x 0.7 cm; 0.5 x 0.4 cm; and 0.2 x 0.2 cm. The wound bed was described as 100% slough (tissue that is yellow or white in appearance and adheres to the ulcer bed in strings or thick clumps or is mucinous) with minimum amount of drainage. Review of the Wound RN (Registered Nurse) assessment dated [DATE] revealed the left buttock wound was assessed to be a stage 3 pressure ulcer. Review of the Wound Data Collection form dated 2-5-18 for Resident 12 revealed the left buttuck wound measured at 1 x 1.2 x 0.1 cm. Review of the Wound Data Collection form dated 1-22-18 revealed the right buttock had a wound which measured 05. x 0.2 x 0.1 cm Review of the Wound RN assessment dated [DATE] revealed the wound on the right buttock was a stage 2 pressure ulcer. Review of the Wound Data Collection form dated 2-5-18 revealed the right buttock pressure ulcer measured 0.1 x 0.1 x 0.1 cm Observation on 02-01-18 at 7:34 AM of LPN-E (Licensed Practical Nurse) performing the wound care to the two pressure ulcers on Resident 12's right and left buttocks. Left buttock pressure ulcer was approximately 1 cm round in size open with white rounded smooth edges with pink granulated tissue without any drainage. Right buttock pressure ulcer was approximately 0.5 cm round in size open with white rounded smooth edges with pink granulated tissue without any drainage. Resident 12 denied any pain when the left buttock pressure ulcer was treated but complained of pain with treatment of [REDACTED]. Interview on 02-15-18 at 12:54 PM with Resident 12 revealed most of the time the pressure sores do not hurt but occasionally the right buttock pressure sore does cause pain. Observation on 01-29-18 at 10:42 AM of Resident 12's bed revealed no air mattress or air overlay on the bed to help relieve pressure to the buttock pressure wounds when the resident was laying down. Observation on 01-29-18 at 10:42 AM revealed a cushion in the resident's wheelchair but the resident's bed was absent of an air mattress or air overlay to help reduce pressure when the resident laid in bed on (gender) buttocks. Review of the undated Physician orders [REDACTED]. Review of Resident 12's careplan revealed a plan of care was not revised and entered onto the careplan regarding the stage 3 pressure ulcer on the left buttock until 12-05-17. The interventions listed were 1) needs pressure relieving foam/gel cushion in wheelchair 2) treatment per Physician order [REDACTED]. Interview on 02-01-18 at 2:03 PM with the MDS Coordinator revealed on admission resident had venous stasis ulcers on legs, wounds on toes, and did not have pressure ulcers. The facility did not address the resident sitting on a personal pillow in the resident's wheelchair until the resident developed the first pressure ulcer on the left buttock. Then they worked with the resident to have the resident sit on a professinal pressure relieving cushion but it took time as the resident was noncompliant at first. The resident now was fully complaint but recently developed the 2nd pressure ulcer on the right buttock. The MDS Coordinator confirmed the absence of documentation on the careplan or the Kardex (tool used to communicate to the nurse aides for resident cares) about other interventions to relieve pressure to the buttocks such as encouraging the resident to lay down during the day or trialing an air mattress on the bed. Interview on 02-05-18 with the DON (Director of Nursing) revealed the DON reviewed the chart and also could not find any documentation where any other interventions were initiated to help prevent the development of the pressure ulcers from ever starting when first identified upon admission as at risk for developing pressure ulcers.

Licensure Reference Number 175 NAC 12-006.05 (8) Based on observation, interview, and record review; the facility failed to ensure residents were not physically restrained. This failure affected 1 of 3 sampled residents (Resident 1) whose restraint contributed to an injury during a fall. The facility census was 30. Findings are: An observation on 12/14/2016 at 2:15 PM revealed a full body mechanical lift was used to transfer Resident 1 from a wheelchair (w/c) to the resident's bed. The resident followed verbal cues to unfasten a waist belt of the w/c and reminded the staff members to unstrap (gender) feet from the foot pedals prior to lifting the resident out of the w/c. An interview on 12/14/16 at 2:20 PM with Resident 1 revealed the resident was unable to remove the straps from (gender) feet without assistance from the staff. A review of a facility investigation titled ABUSE, NEGLECT OR MISAPPROPRIATION dated 11/28/16 revealed, on 11/24/16, Resident 1 leaned forward in the w/c to move a trash can out of the way. The seat belt attached to the w/c was unfastened and the resident's body slid forward out of the w/c. Resident 1 was found seated on the foot rests of the w/c with both feet strapped to the foot rests. The resident was sent to the emergency room and was found to have sustained a fracture to the right lower leg. A review of the Care Plan (CP) for Resident 1, last reviewed on 11/10/16, revealed no documentation related to the use of foot straps on the w/c. The CP indicated concerns related to [MEDICAL CONDITION], deconditioning, and lower extremity weakness. Resident 1 was dependant upon staff for bed mobility, transfers, locomotion off unit, and dressing. Resident 1 had a weak core and exhibited difficulty sitting up straight in a w/c. The resident used a multipositioning w/c to aide in posture and received a new electric tilt w/c in Oct/2016. An entry dated 10/2016 indicated a w/c seat belt was in place, documenting I can remove it myself it's not a restraint. The Social Services area of the CP indicated Resident 1 had a Guardian in place and [DIAGNOSES REDACTED]. A review of the Social Services area of the medical record for Resident 1 revealed no documentation related to informed consent or authorization for the use of restraints. A review of the facility's Policy for Restraints reviewed/approved on 12/19/16 revealed Physical Restraint use was defined as any physical or mechanical device used to involuntarily restrain the movement of the whole or a portion of a resident's body. It may restrict a person's freedom of movement, physical activity or normal access to his/her body. All patients requiring restraints must be restrained in the least restrictive manner when alternatives to restraints are ineffective, and the resident and/or family will be consulted and an Authorization/Refusal for Use of Restraints form will be signed. Consultation with appropriate health professionals such as occupational or physical therapists in the use of less restrictive devices must be documented in the medical record prior to using physical restraints. Clinical justification for using restraints is specifically addressed in the patient's record and reassessed at least quarterly or with change of condition. Documentation will support interventions tried as an alternative to restraint use. Postural Support Devices that are used to protect the patient are exempt from restraint guidelines and may include: bedrails, table top chairs, protective nets, helmets, and mechanisms such as orthopedic appliances, braces, w/cs or other appliances and/or devices used to posturally support the patient An interview on 12/19/2016 at 11:27 AM with the facility's Occupational Therapist (OT) revealed the foot straps were in place on Resident 1's new w/c related to the need to keep the resident's feet in alignment/proper position. The OT reported the facility had not considered the foot straps to be restraints as Resident 1 had no functional use of the resident's feet and could not move them on (gender) own. No other interventions were attempted related to positioning of Resident 1's feet on the w/c foot rests. An interview on 12/19/2016 at 1:11 PM with Licensed Practical Nurse B revealed the facility had not obtained a signed Authorization/Refusal for Use of Restraints form for Resident 1's lap safety belt or the straps for the foot rests as the devices had not been identified by the facility as restraints.