Every finding on record at Milford Meadows Care Center

The facility failed to ensure that all opened food items in the kitchen were sealed and dated and that the dishwasher provided required level of sanitation. This practice had the potential to impact all residents who consume food prepared and served by the facility. The facility census was 68.Nebraska Licensure Reference Number 175 NAC 12-006.11E and NAC 12-007.01(A) The findings are: A.Review of facility policy on Food Safety Requirements, dated 01/2024 revealed that the facility stores all food in accordance with professional standards for food service safety. - Procedure D.b.ii: All staff who may provide food or fluids to residents of the facility will be educated. This education will include: 3. requirements for covered containers or secure wrapping 4. proper labeling and dating of each item Observation of facility kitchen on 7/6/26 at 8:10AMInspection of dry storage revealed: - Open and unsealed box of raisins, undated. - Open and unsealed 5-pound (lb) Box of buttermilk biscuit mix, undated - Open 32-ounce (oz) bottle imitation vanilla, undated - Opened 12-lb container of chocolate icing with brown smears along sides, undated - Open 10-lb bag of pasta, sealed but undated - Sealed container of alfredo sauce with sicky substance spilled on top 2. Inspection of walk-in cooler revealed: - Open one-gallon container of lime juice, undated - Open 32-oz lemon juice, undated - Opened 10-lb plastic jug of BBQ sauce, undated - Cheese slices, wrapped but undated - Opened bottle of Italian salad dressing, undated 3. Inspection of walk-in freezer revealed - Opened bag of croissants, sealed but undated - Open container of chicken breast patties, unsealed and undated An Interview of Kitchen Manager (KM) at 8:25 AM on 7/6/2026 revealed it is their expectation that anything open will be labeled, dated and sealed. B.Record review of facility policy on Food Safety Requirements, dated 01/2024, revealed that any person working in the kitchen is responsible to adhere to the food safety requirements. Many factors contribute to foodborne outbreaks in facilities, including: - Contaminated Equipment - Equipment can become contaminated in various ways, including improper sanitation. Page 6 of this Policy indicates the facility is to provide safe and sanitary storage, preparation and distribution of food in accordance with professional standards for food service safety. - Nursing home residents risk serious complications from foodborne illness because of their compromised health status. Sanitary conditions must be present in health care food service settings to promote safe food handling. CMS recognizes the U.S. Food and Drug Administration's Food Code and the Centers for Disease Control and Prevention's food safety guidance as national standards to serve food in a safe and sanitary manner. Record review of State Operation Manual, Appendix PP dated 7/23/2025, 483.60(i) revealed recommendations according to the U.S. Department of Health and Human Services, Public Health Services, FDA Food Code: Low Temperature Dishwasher (chemical sanitization): - Wash 120 degrees Fahrenheit; and - Final Rinse 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse.Chemical sanitization requires greater controls than hot water sanitization. If explicit instructions are not provided by the manufacturer, the recommended sanitization concentrations are as follows: - Chlorine 50-100 ppm minimum 10 second contact time.Improper test strips yield inaccurate results when testing for chemical sanitation. An interview with KM on 7/06/2026 at 8:30 AM revealed that facility dishwasher utilizes chemical sanitation but manufacturer's guidelines for the dishwasher were not available at time of interview. KM states the facility does not keep sanitation log; however, they checked the dishwasher daily. KM checked chemical sanitation concentration in Surveyor's presence and the result on the test strip was the lightest color listed on the bottle's result legend, indicating 10 ppm (parts per million) of chlorine. It was noted that the strips utilized for this test expired on 1/01/2026.KM obtained a new package of sanitation monitoring strips which expired 1/01/2028 and re-tested the dishwater sanitation. The reading was very low. The color was lighter than the lowest rating on the bottle, indicating a reading of less than 10 ppm of chlorine.KM checked the chemicals which feed into the dishwasher and noted that the level of fluid in one container was very low. KM stated that this container would be removed and a full replacement obtained from storage. After adjustment of chemicals for dishwasher, KM was asked to check the sanitization level of the dishwasher. The sanitization rechecked by KM and chlorination found to be approximately 75 ppm. KM stated that Eco Labs, the company that provides the chemicals for the kitchen, was scheduled to come 7/07/2026 and that company checked things during the visit.Administrator (ADM) was informed of concerns regarding the sanitization of the dishes and presence of expired test strips on 7/07/2026 at 3:30 PM. ADM stated that the dishwasher had been a problem for a while now.Observation of facility kitchen on 7/08/2026 at 7:15 AM revealed that a sanitation log was now posted for monitoring chemical concentration for dishwasher sanitation. The log had an entry for 7/08/2026, a reading of 75 ppm. Observation of facility kitchen on 7/09/2026 at 7:40 AM revealed an entry on the sanitation log for 7/09/2026 with a reading of 100 ppm.KM was interviewed on 7/09/2026 at 7:40AM. KM showed this surveyor test strips provided by Eco Lab following the visit on 7/08/2026. The strips had a color legend that allowed for more consistent recognition of chemical level concentration. However, these strips were observed to be expired as of 10/1/2025. The expiration date on the bottle was reviewed with KM. KM confirmed that these strips were expired and obtained alternate strips for sanitation monitoring that were not expired. KM stated that they would follow up with Eco Labs to obtain more strips that are not expired. ADM verified that Eco Labs had been in on 7/08/2026 to look at the dishwasher and that the company representative came to the facility every month for maintenance of the machine. ADM stated Eco Labs can provide a history or these visits. Eco Lab Representative (ECR) for facility arrived at facility at 9:45 AM on 7/09/2026 and was interviewed in presence of ADM. ECR confirmed the facility had received monthly visits to ensure the dishwasher was in proper working order, including chemical levels for sanitization. ECR confirmed that the test strips given to facility on 7/08/2026 were likely expired stated I didn't check the date. ECR showed surveyor digital copies of facility visit reports for the past year. During interview with ADM on 7/09/2026, use of expired sanitation strips and dishwasher sanitation were discussed. Survey findings from three recent surveys reviewed with ADM, all of which had concerns regarding dishwasher sanitation. ADM confirmed that the dishwasher did not provide sanitation when chlorination levels are not maintained.

Based on observation, interview, and record review the facility failed to follow infection prevention standards for hand hygiene during wound care for one (Resident 28) of four sampled residents. Facility identified census of 68. Licensure Reference Number 175 NAC 12-006.18(B)(D) A record review of Resident 28's admission Record revealed that Resident 28 was admitted [DATE] with a diagnosis of urinary retention (a condition when the bladder doesn't empty) requiring the resident to have a catheter to drain the bladder.Record review of Resident 28's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 05/18/2026, revealed the following:-Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 (which indicated the resident is competent).-Resident 28 was admitted with a urinary catheter.-Resident 28 needed assistances with personal hygiene cares. A record review of Resident 28's Care Plan Report revealed Resident 28 had a suprapubic catheter and was being followed by the Urologist. A further review revealed Resident had enhanced barrier precautions (wearing a disposable gown, gloves, and mask when providing catheter cares or changing linens). Record review of Resident 28's Order Summary dated 07/07/2026 at 8:57 AM revealed an order for DYNA-HEX 4% solution (a skin cleaner that is effective in lowering the bacteria on the skin) to clean the suprapubic insertion site twice a day. An observation on 07/08/2026 at 10:07 AM to 10:10 AM of Licensed Practical Nurse (LPN)-F providing wound care for Resident 28 revealed to following:-LPN-F entering room with bedside table on wheels, germicidal wipes in a container, and a split 2x2 gauze dressing. -LPN-F wiped down the bedside table to hold the suprapubic cares supplies and then put a gown and gloves on without performing hand hygiene.-LPN-F opened gauze 4x4 dressings and put foaming Hibiclens (an equal substitution for DYNA-HEX 4%) on the dressing and proceeded to wipe the suprapubic catheter (a tube inserted into the bladder to drain urine which is accessed in the lower abdomen) with two different 4x4 gauze dressings. No rinsing of the wound was done. -LPN-F removed gloves and put new ones on without performing hand hygiene.-LPN-F placed a split 2x2 gauze dressing on top of the tube at the insertion site.-LPN-F took off gloves, did not perform hand hygiene, and reached into shirt pocket under the gown and got a pen. LPN-F marked the 2x2 gauze dressing with a date, time and LPN-F's initials.-LPN-F took gown off and then did hand hygiene. Interview on 07/08/2026 at 10:14 AM with LPN-F confirmed hand hygiene should have been done before and after gloves are put on or taken off. Interview on 07/09/2026 at 12:20 PM with Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed hand hygiene needs to be done before and after glove changes.

Licensure Reference Number 175 NAC 12-006.04 (B)(ii) Based on record review and interviews, the facility failed to ensure that yearly continuing education was completed for one Certified Nurse Aide (CNA)-C of five sample employees. The facility census was 68. Findings are:Record review of CNA-C's employee file revealed missing yearly continuing education for 2025.A record review of Centers for Medicare & Medicaid Services Code of Federal Regulations Title 42 S483.95(g) revealed nurse aides are required to have no less than 12 hours of continuing education each year.An interview on 07/08/2026 from 12:12 PM to 12:25 PM with Human Resources Director (DHR) confirmed CNA-C did not complete required yearly continuing education.An interview on 07/09/2026 at 12:50 PM with Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed CNA-C's employee file was missing required yearly continuing education.

The facility failed to ensure that hot foods were served at 135 degrees Fahrenheit or higher and cold foods were served at 41 degrees Fahrenheit or lower for residents receiving room trays. This practice has the potential to impact all facility residents receiving room trays. The facility census was 68.Nebraska Licensure Reference Number 175 NAC 12-006.11D The findings are: Interview with Resident 20 on 7/06/2026 revealed resident reported that food was often cold.Interview with Resident 27 on 7/06/2026 revealed resident reported that food was not very good and stated Jello warm and melty, portions are too small, oatmeal needs a straw to drink it, and hot dogs are not warm in the middle.Interview with Resident 40 on 7/06/2026 revealed resident reported that food was not so good.Interview with Resident 52 on 7/06/2026 revealed resident report that food was not good. Portions are not large enough and there is no coffee.Interview with Kitchen Manager (KM) on 7/07/2026 at 9:30 AM revealed room trays were prepared at the end of posted mealtimes for the dining room. Room trays are prepared for residents who did not receive a meal in the dining room. A request was made for a test room tray for lunch and for KM to check temperatures of the food items when served.Record review of facility policy on Food Safety Requirements, reviewed 01/2024 revealed that: - Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause food borne illness. - Potentially Hazardous Foods require time/temperatures control for safety to limit the growth of pathogens - Several factors may influence the growth of bacteria - Time in conjunction with temperatures controls are critical. The longer food remains in the danger zone, the greater risks for growth of harmful pathogens - Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure for residents. Review of posted mealtimes for Milford Meadows Care Center revealed that Breakfast is served from 7:00 AM to 8:30 AM, Lunch is served from 11:30 AM to 1:00 PM and Dinner is served from 5:00 PM to 6:30 PM. This document also states that an Anytime Menu will be available during posted mealtimes. Review of the separate Anytime Menu revealed a variety of cold cereals, side items and main course offerings available for residents to order in lieu of the items on the regularly scheduled menu. Observation of room tray cart for 100 hall revealed that cart with test tray went out from kitchen to the unit at 1:00PM on 7/07/2026. Test tray was delivered to the surveyors at 1:57 PM and temperature checked by KM. Temperatures results were as follows: - Chicken, 87 degrees Fahrenheit - Potatoes, 81 degrees Fahrenheit - Vegetables, 87.4 degrees Fahrenheit - Beverages were not refrigerated on cart, however these were not checked for temperature During testing of tray, KM confirmed that the cart for hallway 100 was sent out of the kitchen at 1:00 PM, and test tray had been sitting for approximately 1 hour. There were 2 other unpassed trays remaining on the cart at the time. KM believed that these residents may have refused their lunch on that day. Food was tasted by surveyors for palatability at 2:00 PM on 7/07/2026. Mixed vegetables were found to lack seasoning and were very soft. Potatoes were found to be very spicy and likely not palatable for some residents. The chicken sandwich was cold, and the fried chicken patty was not crunchy. Interview of Administrator (ADM) on 7/07/2026 at 3:30 PM conducted. ADM asked about presence of food borne illness in building. ADM confirmed that there had not been any food borne illnesses in the facility. However, ADM shared that there was an outbreak of Norovirus in March of 2026. ADM was informed of the results of the test tray temperatures and confirmed that the temperatures did not meet facility expectations. Observation of breakfast room tray cart on Unit 100 at was available 8:45 AM on 7/8/2026. KM was requested to check temp of remaining trays on the cart at 9:20 AM. While a tray was being removed to check temperatures, a staff member accidentally tipped cart and 2 remaining trays fell out of cart and on to floor of Unit 100. KM did check temperature of two items which were not spilled: - glass of chocolate milk, 48.2 degrees Fahrenheit - bowl of cream of wheat cereal, 109.6 degrees Fahrenheit At time the temperatures were checked, KM confirmed that these temperatures did not meet facility policy on Food Handling Requirements.

Licensure Reference Number 175 NAC 12-004(F)(i)(5) Based on observation, record review, and interview, the facility failed to notify the provider of a urine culture and sensitivity (C&S, a lab result identifying the organism growing and medication the organism is sensitive to in a urine sample) for Resident 35. This affected 1 of 2 residents sampled for urinary tract infections (UTI-an infection in any part of the urinary system, including the kidneys, bladder, ureters [tubes that lead from the kidneys to the bladder], and urethra [tube that drains the bladder to the outside of the body]). The facility census was 68.Findings are:A record review of Resident 35's admission Record printed 07/07/2026 revealed the facility admitted Resident 35 on 12/12/2018 with diagnoses of cerebral palsy (a group of conditions that affect movement, balance and posture), quadriplegia (form of paralysis that affects all four limbs, plus the torso), urinary incontinence (inability to control the bladder), and a history of urinary tract infections.A record review of Resident 35's Progress Notes from 06/21/2026 to 07/09/2026 revealed the following notes:- 06/25/2026 at 3:50 PM indicating the nurse had observed light red urine in Resident 35's toilet.- 06/26/2026 at 1:03 PM that the provider was notified and ordered a urinalysis (UA-a urine test to check for a UTI) with a C&S.- 06/27/2026 at 00:05 AM that the urine sample was obtained.- 06/29/2026 at 10:33 AM that the UA results were received, forwarded for a C&S, and placed in the provider's box for review.-06/29/2026 at 1:35 PM that the provider reviewed the UA and would wait for the culture.There was no further documentation of the UA or C&S until 07/08/2026 at 2:05 PM when an antibiotic was ordered.A record review of Resident 35's UA lab report revealed the specimen was collected, received, and reported on 06/27/2026, and that the specimen was forwarded for culture and sensitivity. Further review revealed the document was acknowledged by the provider on 06/29/2026 with a note that the provider would treat when C&S results.A record review of Resident 35's C&S lab report of urine revealed the specimen was collected and received on 06/27/2026 and reported on 6/29/2026. The results revealed that Resident 35 had a UTI, identified the organism growing and provided medication options for treatment. Further review revealed the document was acknowledged by the provider on 07/08/2026 with treatment orders given.An observation on 07/06/2026 at 10:36 AM revealed the water in Resident 35's toilet was light red.An interview on 07/07/2026 at 2:50 PM with the Director of Nursing (DON) confirmed there was no documentation of notifying Resident 25's provider of the C&S results.An interview on 07/08/2026 at 1:48 PM with the Regional Nurse Consultant (RNC) confirmed that the provider had not been notified of Resident 35's urine C&S until 07/08/2026.An interview on 07/09/2026 at 11:01 AM with the DON confirmed that Resident 35's urine C&S should have been reported to the provider as soon as it came back from the lab.

Based on record reviews and interviews, the facility failed to provide written notice of transfer and notification of the bed hold policy to Resident 11 or their representative and to Resident 70 or their representative upon hospitalization. This affected 2 of 2 residents reviewed for hospitalization. The facility census was 68.Findings are:A record review of the facility's Transfer and Discharge from the Facility Policy dated 1-2024 revealed the following:- Notice will be provided to the resident or their representative at least 30 days before they are discharged or transferred, in writing and in a form and manner they understand.- In an emergency, the notice should be issued as soon as practicable when the transfer or discharge is required by the resident's urgent medical condition.- The notice should include date and location of transfer, reason for transfer, and information about the right to appeal.- A copy of the notice will be sent to the state long-term-care ombudsman's office.The policy did not contain information about bed holds. A.A record review of Resident 11's admission Record printed 07/07/2026 revealed the facility admitted Resident 11 on 04/18/2019 and the resident had diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy) and heart failure.A record review of Resident 11's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 04/27/2026 revealed a Brief Interview for Mental Status (BIMS- 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) score of 15, indicating the resident was cognitively intact.A record review of Resident 11's Clinical Census page printed 07/07/2026 revealed the resident was hospitalized from [DATE] to 05/11/2026, from 05/17/2026 to 05/21/2026, and from 06/14/2026 to 06/16/2026.An interview 07/06/2026 at 11:15 AM with Resident 11 revealed they did not recall being informed of the facility's bed hold policy or provided with a written notice of transfer.A record review of the Client Uploaded Files tab of PointClickCare (PCC, the electronic health record used by the facility) printed 07/08/2026 revealed a Resident Notice of Transfer or Discharge and a Bed Hold Notice. Both documents had an effective date of 06/14/2026 and an upload date of 06/15/2026. Further review of the tab revealed no other saved transfer or bed hold notices. The facility was unable to provide documentation of written notice of transfer and notification of the bed hold policy being provided to Resident 11 or their representative for the hospitalizations on 05/07/2026 or 05/17/2026.An interview on 07/08/2026 at 11:13 AM with the Director of Nursing (DON) confirmed the facility did not have documentation of written notice of transfer and notification of the bed hold policy being provided to Resident 11 or their representative for the hospitalizations on 05/07/2026 or 05/17/2026. B.A record review of Resident 70's admission Record printed 07/07/2026 revealed the facility admitted the resident on 04/17/2028 and the resident had diagnoses of quadriplegia (form of paralysis that affects all four limbs, plus the torso), high blood pressure, and profound intellectual disabilities.A record review of Resident 70's Progress Notes from 04/01/2026 to 07/09/2026 revealed the following notes:-04/05/2026 at 1:39 PM the charge nurse had sent the resident to the hospital for continued seizures and emergency medical services was there to transport the resident to the hospital.-04/05/2026 at 7:04 PM that the resident had returned to the facility from the hospital with a diagnosis of pneumonia (a lung infection).-04/19/2026 at 9:30 PM the resident was sent to the hospital for difficulty breathing.-04/23/2026 at 2:17 PM the facility received a call that the resident was changing to comfort cares and being transferred to the hospital's hospice unit.A record review of Resident 70's Clinical Census page printed 07/07/2026 revealed the resident was hospitalized on [DATE] and the facility stopped billing on 04/23/2026.The facility was able to provide documentation of written notice of transfer and notification of the bed hold policy being provided to Resident 70's representative on 04/05/2026.The facility was unable to provide documentation of written notice of transfer and notification of the bed hold policy being provided to Resident 70 or their representative for the hospitalization on 04/19/202.An interview on 07/08/2026 at 11:13 AM with the DON confirmed they did not have documentation of written notice of transfer and notification of the bed hold policy being provided to Resident 70 or their representative for the hospitalization on 04/19/2026.

Licensure Reference Number 175 NAC 12-006.09 Based on observations, interviews and record review, the facility failed to follow wound care and fluid restrictions according to provider orders for one (Resident 28) of four sample residents. The facility identified a census of 68. Findings are: A.A record review of Resident 28's admission Record revealed that the resident was admitted to the facility on [DATE] with diagnosis urinary retention (a condition when the bladder doesn't empty) requiring the resident to have a catheter to drain the bladder. A record review of Resident 28's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 05/18/2026, revealed a Brief Interview for Mental Status (BIMS, 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) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. A record review of Resident 28's Care Plan Report revealed Resident 28 had a suprapubic catheter (a thin flexible tube surgically inserted through a small lower abdominal incision directly into the bladder to drain urine) and was being followed by the Urologist. A record review of Resident 28's Order Summary Report dated 07/07/2026, revealed the resident was to have wound care at the suprapubic insertion site twice a day using DYNA-HEX 4% (a skin cleaner that is effective in lowering the bacteria on the skin). The facility supplied Hibiclens, which is an equal substitution for DYNA-HEX 4%. A record review of the Hibiclens bottle labeled with Resident 28's information revealed the following directions for use:-Rinse the area with water.-Apply Hibiclens to area and wash gently.-Then rinse the area thoroughly. An observation on 07/08/2026 at 10:07 AM to 10:10 AM of Licensed Practical Nurse (LPN)-F providing wound care for Resident 28 revealed to following:-LPN-F wiped the suprapubic catheter insertion site with Hibiclens foam applied to 4x4 gauze pads. This step was repeated.-No rinsing prior to applying the Hibiclens or after. Interview on 07/08/2026 at 10:14 AM with LPN-F confirmed rinsing Resident 28's suprapubic catheter insertion site should have been rinsed prior to washing with Hibiclens and then rinsing after the washing was completed. Interview on 07/09/2026 at 12:20 PM with Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed LPN-F should have followed Hibiclens directions, rinsing the area with water, washing with Hibiclens, and then rinsing the area with water. B.A record review of Resident 28's admission Record revealed that the resident was admitted to the facility on [DATE] with diagnosis congestive heart failure (a condition when the heart muscle is weakened or stiff and doesn't pump the blood efficiently) which causes fluid to pool in the residents legs, lungs, and abdomen. A record review of Resident 28's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 05/18/2026, revealed a Brief Interview for Mental Status (BIMS, 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) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. A record review of Resident 28's Care Plan Report printed on 07/07/2026, revealed Resident 28 had high blood pressure and congestive heart failure. The record review revealed Resident 28 should be monitored for increased leg swelling, given heart medications, and resident's weights as ordered by the provider. A record review of Resident 28's Order Summary Report dated 07/07/2026, revealed resident had a 1440 milliliter (mL) a day fluid restriction, ordered date was 11/07/2025, and was to be documented every shift. Record review of Resident 28's previous 30 days Meal Intake and Fluids report revealed the following fluid intakes:-1670 mL on 06/09/2026-1894 mL on 06/12/2026-1552 mL on 06/15/2026-1670 mL on 06/16/2026-2200 mL on 06/17/2026-2130 mL on 06/22/2026-2570 mL on 06/23/2026-2290 mL on 06/24/2026-2030 mL on 07/01/2026 An observation of Resident 28's room on 7/8/26 at 10:00 AM revealed fluids available for resident to consume were two 500 mL patient mugs full of liquids found on the bedside table and two 24-ounce (709 mL per bottle) diet mountain dew soda on the resident's windowsill ledge. Interview on 07/08/2026 at 10:14 AM with Licensed Practical Nurse (LPN)-F confirmed Resident 28 has a 1440 mL fluid restriction and the resident makes a choice to drink more than 1440 mL each day. LPN-F confirms no charting has been completed referencing the resident's choice to refuse the 1440 mL fluid restriction and no provider notification has taken place. Interview on 07/09/2026 at 12:20 PM with Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed Resident 28's fluid intake based on the Meal Intake and Fluids report was greater than 1440 mL on the following days: 06/09/2026, 06/12/2026, 06/15/2026, 06/16/2026, 06/17/2026, 06/22/2026, 06/23/2026, 06/24/2026, 07/01/2026.

License Reference Number: 175 NAC 12-006.2(H) Based upon record review and interview, the facility failed to submit an investigation to the State Agency within five working days.The facility census was 68. FINDINGS ARE:A record review of Facility policy Notification of Changes Policy dated 5-17-2024 revealed that notification of physician and resident representative is required when an accident results in injury and may require physician intervention, when a significant change in resident condition is noted, when there is a need to alter treatment or the resident with be transferred or discharged from the facility. A record review of Facility's undated policy titled Procedure for Notification of Changes for Resident (undated) revealed that notification will occur following an accident which results in injury or may require physician intervention, a significant change in resident status, a need to alter treatment significantly, or a decision to transfer or discharge the resident from the facility. A record review of Facility's Grievance/Complaint Log revealed that the incident in question was not listed on current facility log. This document listed events from 3/21/2026 through 5/05/2026. A record review of facility's electronic medical record (EMR) revealed that Resident 1 was admitted on [DATE] with diagnoses that included anoxic brain damage (a severe, life-threatening condition caused by a complete lack of oxygen to the brain, leading to cell death within minutes) and schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms (such as delusions or hallucinations) and mood disorder symptoms (such as mania or depression)) . Further review of the EMR reveals that Resident 1 has a Brief Interview for Mental Status (BIMS) score of 9. The BIMS is a screening tool to detect cognitive impairment. A BIMS score of between 8 to 12 indicates moderate problems with thinking or memory. EMR also reveals that Resident 1 uses a wheelchair for mobility. A record review of Facility's EMR for Resident 2 revealed that they were admitted [DATE] with diagnoses that include cerebral infarction (stroke), unspecified dementia and generalized anxiety disorder. Further review of the EMR reveals that Resident 2 has a BIMS score of 12, indicating moderate problems with thinking or memory. EMR also reveals that Resident 2 uses a wheelchair for mobility. A record review of investigations previously submitted to Nebraska Department of Health and Human Services (DHHS) provided by the Administrator (Admin), revealed presence of reported altercation involving Resident 1 and Resident 2. This document, Report # 1165231, showed that Adult Protective Services was notified of the occurrence on 1/24/2026 at 4:01 PM. The document detailed a description of the incident and a summary of the investigation outcome. This document further revealed that the completed investigation was submitted to DHHS on 2/05/2026. A review of calendar for January and February 2026 reveals that 5 working days following the reported incident of 1/24/2026 would be 1/30/2026 and that 2/5/2026 is 9 working days following the event. An Interview with Admin on 5/13/2026 at 11:35 AM revealed that the Admin started a new log in March of this year. Admin searched for the logs for 2025 and earlier in 2026. However, these documents could not be produced during survey visit.

Licensure Reference Number 175 NAC 12-006.18B Licensure Reference Number 175 NAC 12-006.18D The facility failed to ensure infection control measures were followed related to lack of signage indicating 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) and the Personal Protective Equipment (PPE) required for cares on Residents 10,15, 24 , and 52, the storage of respiratory equipment for Residents 10, 15, 24, 25 and 52, mask cleaning for Resident 1's PAP, perform hand hygiene between glove changes and wear eye protection during catheter cares on Resident 52, and failed to carry clean linens away from the body to prevent the potential for cross contamination. The facility identified a census of 63. Findings are: A. An interview on 02/06/25 at 10:10 AM with Nurse Aide (NA)-O revealed that residents in EBP were identified by a yellow dot sticker on their name plate outside the room. When questioned how (gender) knew which PPE was to be worn with each resident, NA-O answered, well I know that Resident 15 has a catheter so I would wear a gown and gloves when emptying (gender) catheter. When questioned how visitors know that PPE they need to wear, NA-O was unable to answer this. An interview on 02/06/25 at 10:50 AM with Licensed Practical Nurse (LPN)-P confirmed that EBP signage was not posted in the room and voiced that only the PPE supplies needed to care for that patient were placed into the yellow bag hanging in each EBP room. When questioned how visitors knew what PPE was necessary for resident in EBP, LPN-P voiced that visitors did not come down to resident rooms and visited in the lobby or solarium area. An interview on 2/06/25 at 12:35 PM with the Assistant Director of Nursing (ADON) confirmed that visitors do go to the resident rooms. A record review of the facility policy titled Infection Control (Enhanced Barrier Precautions) dated 5/2024 contained the following guidance: Procedures: 1. Appropriate signage for type of precaution will be posted on room door. B. An observation on 2/06/25 at 10:53 AM revealed NA-O carrying a stack of linens into a resident room while carrying linens up against (gender) body. An interview on 2/06/25 at 10:54 AM with LPN-P confirmed that staff were to carry linens away from their body and not up against their chest. An observation on 2/06/25 at 11:27 AM revealed Medication Aide (MA) -M carrying a stack of linens into a resident room while carrying linens up against (gender) body. An interview on 2/06/25 at 11:27 AM with MA-M confirmed that linens should not be delivered to resident rooms while being held against staff's body. MA-M confirmed that linens where to be carried in a bag and away from the body. An interview on 2/6/25 at 1:21 PM with the facility Assistant Director of Nursing (ADON) confirmed that linens were to be carried away from staff's body and not up against clothing and that EBP signs should be posted in the resident rooms to indicate what PPE should be used with cares. A record review of the facility policy titled Laundry (Linen Pass) with a revision dated of 4/18 revealed it did not contain any guidance related to carrying linens and touching against the body. 47406 C) Record review of Resident 52's Admission record dated 2/6/25 revealed admission was 10/6/22. Observation on 2/5/25 at 3:06 PM revealed Resident 52's catheter tubing had slight cloudy urine. Record review of Resident 52's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 11/29/24 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 15. -Section G: Maximum assist with toileting hygiene. -Section H: indwelling catheter Record review of Resident 52's Physician Orders dated 2/10/25 revealed: -Change suprapubic catheter every 30 days. -Acetic Acid Solution 0.25 %, use as directed to flush suprapubic catheter as needed, flush liquid 60 milliliters saline as needed. -Bacitracin ointment 500/gram, apply topically to suprapubic site twice daily. Record review of Resident 52's Medical diagnosis dated 2/6/25 revealed: Pyuria, Obstructive and Reflux uropathy, Poor urinary stream, Personal history of (corrected) Hypospadias, and Retention of urine. Observation on 2/10/25 at 10:22 AM with RN-D performing suprapubic (SP) catheter cares with Resident #52. RN-D donned gown and 3 pairs of gloves without washing hands prior. RN-D removed the old SP catheter dressing. RN-D then removed the top pair of gloves and threw into trash without hand hygiene. RN-D cleansed SP catheter insertion site with an alcohol wipe, then wiped the skin surrounding the catheter where the tape and dressing was with a skin prep. RN-D removed the top set of gloves, then donned another pair over the top of the existing pair and applied Bacitracin ointment 500 gram at SP catheter site. RN-D applied a split gauze around catheter tubing and secured with paper tape. RN-D took off top pair of gloves and put on a new pair of gloves with no hand hygiene. RN-D cleansed the catheter tubing that was exposed with alcohol wipes from outside of the new dressing. RN-D removed the top gloves and flushed the catheter with Acetic Acid Solution 0.25%. RN-D did not wear goggles or a face shield during the catheter flush. RN-D attached the catheter to the catheter strap and doffed gloves. RN-D performed hand hygiene x 20 seconds. Interview with Resident 52 on 2/10/25 at 10:34 AM revealed that the staff do not clean the catheter tubing very often. Interview on 2/10/25 at 11:00 AM with the Assistant Director of Nursing confirmed that the RN should have cleaned the catheter tubing prior to applying the dressing, wear only 1 pair of gloves at a time, change gloves and preform hand hygiene when removing the gloves, and to wear goggles/shield when flushing the catheter. Record review of Indwelling Catheter Policy dated 1/20 revealed: Sunrise will assist each individual admitted to this facility with the right to become involved in their own care and to provide the services to reach their highest possible practicable, physical and psychosocial level they so choose. And indwelling catheter is not used unless there is valid medical justification for catheterization and the catheter is to be discontinued as soon as clinically warranted. Because of the risk of substantial complications with the use of indwelling urinary catheters, they should be reserved primarily for short term decompression of acute urinary retention. Sunrise Country Manor will refer the Lippincott Manual for insertion, ongoing care and removal protocols. protocols. Record review of Hand Hygiene Policy undated revealed: -Wet hands with water; -Apply enough soap to cover all hand surfaces; -Rub hands palm to palm; -Write palm over left dorsum with interlaced fingers and vice versa; -Palm to palm with fingers interlaced; -Backs of fingers to opposing palms with fingers interlocked; -Rotational rubbing of left thumb clasped in right palm and vice versa; -Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa; -Rinse hands with water; -Dry hands thoroughly with a single use towel; -Used towel to turn off faucet; -Your hands are now safe. Your 5 moments for hand hygiene: -Before touching a patient. -Before clean/aseptic procedure. -After body fluid exposure risk. -After touching a patient. -After touching patient surroundings. Hand hygiene and medical glove use: -The use of gloves does not replace the need for cleaning your hands. -Hand hygiene must be performed when appropriate, regardless of the indication for glove use. -Remove gloves to perform hand hygiene, when an indication occurs while wearing gloves. -Discard gloves after each task and clean your hands. Gloves may carry germs. -Wear gloves only when indicated according to standard and contact precautions; otherwise they become a major risk for germ transmission. Record review of Enhanced Barrier Precautions education dated 1/14/25 revealed: -Used for anyone with (MDRO's) colonized multidrug resistant organisms. -Used with anyone who has a device: central line, urinary catheter, feeding tube, tracheostomy. -Between standard and contact precautions. Use only when performing high contact resident care. -Includes perform hand hygiene and includes a gown and gloves with high contact care delivery. -Dressing, showering, transferring, providing hygiene, changing linens, changing briefs or toileting. Record review of Infection Control (Precautions) Policy dated/revised 4/24 revealed: -It is the policy of Sunrise Country Manor to provide a safe and sanitary environment for residents, visitors and employees. Standard precautions will be practiced by all staff and should be used for all resident cares at all times. Sunrise Country Manor follows the guidance for Standard and Transmission-based precautions and intensified interventions as recommended by the APIC manual Infection Preventionist guide to long term care, as well as by the Centers for Disease Control. -Standard Precautions are Based on the principle that blood, all body fluids and secretions, excretions, (not including sweat), non-intact skin or lesions, and mucous membranes may contain transmissible infectious organisms. Standard precautions included hand hygiene and use of gloves, gown, mask and eye protection or face shield, depending on the anticipated exposure. Refer to the Facilities Policy on Personal protective Equipment. Standard precautions also include safe injection practices. -Hand Hygiene: Perform hand hygiene with soap and water when hands are visibly soiled. Unless hands are visibly soiled, an alcohol based hand rub is preferred over soap and water in most clinical situations. Refer to visual guidance provided by World Health Organization on how to hand rub or how to hand wash and how to hand wash. Clean your hands using an alcohol based hand rub or wash. With soap and water for the following clinical indications: -Before and after having direct contact with the patient (taking a pulse or blood pressure, performing physical examination, lifting the patient in bed). -Before performing an aseptic task. Example placing an indwelling device or handling invasive medical devices. -Before moving from work on a soiled body site to a clean body site on the same patient. -After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings or contaminated surfaces. -If hands will be moving from a contaminated body site to a clean body site during patient care. -Immediately after glove removal. Gloves: For contact with blood, body fluids, secretions, excretions, and contaminated items; for touching mucous membranes or non-intact skin: for contact with intact skin when infection risks are identified. 3. Change gloves during patient care if the gloves will move from a contaminated body site example peroneal area to a clean body site example face. 4. Remove gloves after contact with a patient and or the surrounding environment. Including medical equipment using proper technique to prevent hand contamination. Mask Rye Protection and Face Shields: During procedures likely to generate splashes or sprays of Blood or body fluids or the splatter of debris. D) Record review of Resident 1's Admission records dated 2/6/25 admission was 12/9/22. Interview with Resident 1 on 2/5/25 at 12:50 PM revealed that resident changes the oxygen (O2) when [gender] thinks it needs changed. Resident 1 stated the CPAP (Continuous Positive Airway Pressure -a treatment that uses mild air pressure to keep your breathing airways open) mask it is not cleaned much. Record review of Resident 1's Physician Orders dated 2/10/25 revealed: -Weekly CPAP/Bi-Level/Auto PAP cleaning, hand wash mask, nasal pillows, and tubing with dawn dish soap and water, Rinse thoroughly, air dry. -Oxygen 3 Liters, titrate with activity to keep sats above 90%. -Oxygen nasal cannula/mask, replace nasal cannula/mask weekly -Oxygen tubing, replace oxygen tubing every 28 days. -Daily CPAP/Bi-level/auto pap cleaning, wipe mask with damp cloth to remove debris. Empty chamber, fill chamber with soapy warm water and shake vigorously, rinse, air dry. - Distilled water add distilled water per manufacture recommendations to BiPAP and humidifier. Record review of Resident 1's Medical diagnosis dated 2/6/25 revealed: Chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, and obstructive sleep apnea. Record review of Resident 1's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 11/12/24 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 15. - Behavior present for inattention. -Section E: delusions, rejection of care 4 to 6 days. -Section G: dependent for oral hygiene and toileting hygiene -moderate assist with bathing -independent with upper body dressing, lower body dressing, footwear, personal hygiene, repositioning and transfers. -Section O: O2, Non-invasive Mechanical Ventilator Observation on 2/5/25 at 12:50 PM Resident 1's O2 concentrator revealed: 4 liters and the O2 tubing is not dated. O2 tubing that is in an open sack on top of the concentrator dated 1/2024. The CPAP mask was lying on the bed unused, and had many whitish specks of debris inside the mask and the outside of the mask has yellow-light tannish hard debris on the plastic of the mask. The CPAP tubing was light yellowish approximately 10 inches down the tubing from the mask. The O2 tubing that resident 1 is using is hardened from the cannula to around the ears. Observation on 2/6/25 at 9:20 AM Resident 1's O2 concentrator revealed: 4 liters and the O2 tubing is not dated. O2 tubing that is in an open sack on top of the concentrator dated 1/2024. The CPAP mask was lying on the bed unused, and had many whitish specks of debris inside the mask and the outside of the mask has yellow-light tannish hard debris on the plastic of the mask. The CPAP tubing was light yellowish approximately 10 inches down the tubing from the mask. The O2 tubing that resident 1 is using is hardened from the cannula to around the ears. Interview on 2/6/25 at 10:45 AM with RN-D confirmed that the inside of CPAP mask had whitish dry substance, and the outside has yellow-light tannish debris on the plastic mold of mask and approximately 10 inches of tubing from the mask was light yellow. The O2 tubing was hard from nares to around ears and I will change it. RN-D said the CPAP gets cleaned weekly on night shift and we should be wiping it clean every day, and I didn't. Interview on 2/6/25 at 11:20 AM with the Assistant Director of Nursing revealed that the staff should be cleaning the CPAP mask every day and weekly cleaning with soap and water, CPAP mask must be placed in a storage bag, date the O2 tubing, and change the O2 cannula weekly. Record review of Respiratory Care Policy dated 2/20 revealed: Respiratory care service at Sunrise Country Manor (i.e. oxygen therapy, breathing exercises, CPAP/BiPAP, nebulizers/metered dose inhalers, tracheostomy cares) will be provided with a physician's order consistent with professional standards of practice. -Cleaning Schedule: Mask, nasal pillows, and tubing-wipe daily with damp cloth or alcohol-free mask wipe. Headgear, mask, and tubing - wash weekly in a mixture of warm water and small amount of liquid dishwashing detergent or baby shampoo. Rinse thoroughly, air dry and reassemble. Documentation received titled All Nursing Staff- Oxygen, CPAP/BiPAP, Nebulizers dated 5/1/24 revealed: -If a resident wears oxygen continuously, when you get them up in the morning, after you complete their morning cares, have the med aide or the nurse unhook their tubing from the concentrator and roll it up or hook it up to the portable. -If the resident does not wear the oxygen continuously, take the cannula/mask off and roll it up and put the cannula/mask/tubing in the oxygen storage bag that is attached to the oxygen concentrator. Turn the oxygen concentrator off. -If you walk into their room, and their oxygen tubing is not in the oxygen storage bag, please roll it up and place it in the bag. -The CPAP/BiPAP mask must be placed in the storage bag. -Date tubing's on oxygen, and nebulizers when changed. 45641 E) A record of the facility's All Nurses Respiratory Equipment Change/Storage notification dated 2/7/25 revealed oxygen nasal cannulas (a tube that fits in the nose to deliver oxygen), masks on the concentrators (a machine used to purify oxygen), and portable canisters must be rolled up and placed in their bag on the concentrator, or portable on their wheelchair or walker when they are not using them. A record review of Resident 25's Clinical Census dated 02/10/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 25's Medical Diagnosis dated 02/11/2025 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Shortness of breath, Obstructive Sleep Apnea (OSA), History of Pneumonia, and Morbid Obesity (severely overweight). A record review of Resident 25's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/03/2024 revealed the resident had a Brief Interview for mental Status (BIMS)(a score of a residents cognitive abilities) of 15 which indicated the resident was cognitively aware. The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with person hygiene, substantial/maximal assistance with upper body dressing, and was dependent on staff for toileting, bathing, lower body dressing, and footwear. The resident was on oxygen therapy while a resident. A record review of Resident 25's Transition Orders And Information For The Continuation Of Patient Care dated 12/30/2021 revealed an oxygen order for 2-4 liter per minute (L/M). An observation on 02/05/2025 at 2:50 PM revealed Resident 25 was not in the resident's room and the oxygen nasal cannula was draped over the concentrator and the prongs that go in the nose were touching the floor. An observation on 02/10/2025 at 11:28 AM with Licensed Practical Nurse (LPN)-A revealed Resident 25's wheelchair was located in the hallway with the oxygen nasal cannula draped over the arm of the wheelchair and the nasal prongs that go in the resident's nose were touching the tire and wheel of the wheelchair 1 inch from the floor. There was a bag that the nasal cannula should have been placed in attached to the handle of the wheelchair. In an interview on 02/10/2025 at 11:28 AM, LPN-A confirmed Resident 25's nasal cannula was draped over the arm and touching the wheel and tire of the wheelchair and should not have been.

Licensure Reference Number 175 NAC 12-006.11(E) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure the final cooking temperatures (temps) of the food were obtained to prevent the potential for foodborne illness. The facility also failed to ensure the dishwashing machine temps were greater than 120 degrees Fahrenheit (F) during the wash and rinse cycles, the ceiling fan and light covers were free from debris, and food temperatures were taken following microwaving food to prevent the potential for foodborne illness. This had the potential to affect all residents in the facility that consumed food from the kitchen. The facility census was 63. Findings are: In an interview on 02/11/2025 at 2:11 PM, the facility's Administrator confirmed there was only 1 resident in the facility that did not consume (eat) food from the kitchen. A. A record review of the United States Department of Agriculture's (USDA) Safe Minimum Internal Temperature Chart dated 05/11/2020 revealed that safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. [NAME] all food to the following minimum temperatures as measured with a food thermometer before removing food from the heat source. Beef, Pork, Veal & Lamb Steaks, chops, roasts 145 degrees F Ground Meats 160 degrees F Ground Poultry 165 degrees F Ham, fresh or smoked (uncooked) 145 degrees F Fully Cooked Ham (to reheat) USDA inspected 140 others 165 degrees F All Poultry 165 degrees F Eggs 160 degrees F Fish & Shellfish 145 degrees F Leftovers 165 degrees F Casseroles 165 degrees F https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/safe-temperature-chart A record review of the facility's Steam Table Temperature Log sheets dated 12/09/2024 - 02/09/2025 revealed there was 1 meat, 1 starch, 1 vegetable, and 1 dessert row on the log sheet, it did not reveal areas to record temperatures of the the mechanically altered diets such as puree (blended to a pudding-like consistency) and mechanical soft (blended to a easy to eat consistency). The log sheets did reveal the following: 12/09/2024 there were no dinner cooking or holding temps recorded. 12/10/2024 through 12/13/2024 there were no dinner hold temps recorded. 12/14/2024 through 12/15/2024 there were no cooking or holding temps recorded for any meals. 12/16/2024 through 12/19/2024 there were no dinner hold temps recorded. 12/18/2024 there were no lunch holding temps recorded. 12/20/2024 there were no dinner cooking or holding temps recorded. 12/21/2024 through 12/22/2024 there were no cooking or holding temps recorded for any meals. 12/23/2024 through 12/24/2024 there were no dinner cooking or holding temps recorded. 12/25/2024 through 12/26/2024 there were no cooking or holding temps recorded for any meals. 12/27/2024 there were no dinner cooking or holding temps recorded. 12/28/2024 through 12/29/2024 there were no cooking or holding temps recorded for any meals. 12/30/2024 the only dinner temp recorded was a vegetable cooking temp. 12/31/2024 there were no lunch holding temp or dinner cooking or holding temps recorded. 01/01/2025 through 01/03/2025 there were no dinner cooking or holding temps recorded. 01/04/2025 through 01/05/2025 there were no cooking or holding temps recorded for any meals. 01/06/2025 there were no dinner holding temps recorded. 01/07/2025 through 01/08/2025 there were no lunch or dinner holding temps recorded. 01/09/2025 through 01/10/2025 there were no dinner holding temps recorded. 01/11/2025 through 01/12/2025 there were no cooking or holding temps recorded for any meals. 01/13/2025 through 01/17/2025 there were no dinner holding temps recorded. 01/15/2025 there were no lunch holding temps recorded. 01/18/2025 through 01/19/2025 there were no cooking or holding temps recorded for any meals. 01/20/2025 through 01/24/2025 there were no dinner holding temps recorded. 01/25/2025 through 01/26/2025 there were no cooking or holding temps recorded for any meals. 01/27/2025 through 01/31/2025 there were no dinner holding temps recorded. 02/01/2025 through 02/02/2025 there were no cooking or holding temps recorded for any meals. 02/06/2025 there were no cooking temps recorded. A record review of the facility's undated, un-named menus for 02/02/2024 through 02/15/2025 revealed there was a meat dish prepared for the noon and main meals everyday except the main meal on 02/05/2025 was vegetable chili. An observation on 02/06/2025 from 9:14 AM through 12:38 AM revealed the facility Cook-B prepared the lunch meal that included Beef Stroganoff, Sauteed Zucchini, Noodles, and Pineapple Upside Down Cake. Following the meal preparation, Cook-B pureed the meal items and placed in a small steam pan which was then placed on the steam table, and then blended the mechanical soft and placed in a medium sized steam pan which was then placed on the steam table. The Beef Stroganoff, and the Sauteed Zucchini were removed from the oven and placed on the steam table. The noodles were prepared on the stove in batches through the meal service and dumped in a large steam pan on the steam table. At 11:08 AM Cook-B started plating the food and the Dietary Aides (DA) delivered the food to the residents in the Dining Room. Once the residents in the Dining Room were all served, at 11:58 PM, Cook-B temped the main pan of Beef Stroganoff, Sauteed Zucchini, and Noodles and recorded on the Steam Table Temperature Log. The observation did not reveal final cooking temps were taken from the main menu items, the pureed items, or the mechanical soft items prior to being served to the residents to ensure the food items were at a safe serving temperature. In an interview on 02/06/2024 at 12:00 PM, Cook-B confirmed Cook-B did not check the final cooking temperature of any of the food items prior to being served to the residents and should have. In an interview on 02/06/2025 at 2:11 PM, the Dietary Manager (DM) confirmed that Cook-B should have temped the final cooking temperatures of all food prior to serving the food to the residents to ensure it was safe to consume. B. A record review of the facility's Cleaning (Dishes) policy dated 7/2018 revealed the staff was to check temperature during the dishwashing procedures to determine if wash and rinse temperatures were being maintained and that a wetting agent and chemical sanitizer was being dispensed. A record review of the [NAME] Hot Water Sanitizing Upright Door Dishmachine Installation And (&) Operation Manual dated 07/10/2006 for model ES-2000HT INTL, page number 2, revealed the wash minimum temperature was 150 degrees F and the rinse minimum temperature was 180 degrees F. A record review of the undated, un-named ECOLAB sticker on the side of the dish sanitizer revealed Minimum (min) wash temp 120 degrees F, Min rinse temp 120 degrees F, Recommended Incoming water temperature was 140 degrees F. Min chlorine was 50 parts per million (ppm). An observation on 02/06/2025 from 10:20 AM to 12:38 PM revealed Cook-B completed pureed the Pineapple Upside Down Cake in the Robot Coupe blender and used a scoop to put a measured amount in 3 bowls. Cook-A then took the blender container and blade to the 3-campartment sink and sprayed it out. Cook-A placed the container parts and blade on a plastic rack and placed into the dish machine, pressed the button to start, and walked back into the kitchen. The observation revealed the wash temp only reached 78 degrees F, and the rinse temperature only reached 108 degrees F. An observation of the undated, un-named ECOLAB sticker on the side of the dish sanitizer revealed Minimum (min) wash temp 120 degrees F, Min rinse temp 120 degrees F, Recommended Incoming water temperature was 140 degrees F. Min chlorine was 50 parts per million (ppm). Cook-B then returned to the dishwashing room to get the blender parts, washed hands, returned to the food prep area and put the blender together. Cook-B then put 6 scoops of the Sauteed Zucchini in the blender and pureed, then scooped into a medium sized steam pan. Cook-B took the blender container and parts to the dishroom and sprayed out, placed the container and parts on a plastic rack, placed into the dishwasher, started the dishwasher and went back to the kitchen. The observation revealed the wash temp only reached 92 degrees F, and the rinse temperature reached 121 degrees F. An observation on 02/05/2025 at 7:40 AM revealed a sign on the front of the dishwashing machine that revealed: dish machine must be between 120-140. If temp not reading between 120-140 must run machine until it reaches a min of 120. In an interview on 02/06/2025 at 2:11 PM, the DM confirmed that Cook-B should have watched and ensured the dishwashing machine reached a temperature of at least 120 degrees F. C. A record review of the facility's Cleaning & Sanitization policy dated 1/08 revealed the staff would ensure a clean and sanitary environment for the preparation and storage of food by regular cleaning and maintaining kitchen surfaces. An observation on 02/05/2025 at 7:40 AM with the DM revealed the 6 black metal light covers above the drink station of the kitchen with a moderate amount of a gray fuzzy substance on them. An observation on 02/06/2025 at 12:38 PM with the DM revealed the ceiling fan above the dishwashing machine had a moderate amount of a gray fuzzy substance on it and the fan was running. In an interview on 02/05/2025 at 7:40 AM, the DM confirmed the 6 black metal light covers above the drink station of the kitchen with a moderate amount of a gray fuzzy substance on them and they should have been clean. In an interview on 02/06/2025 at 12:38 PM, the DM confirmed the ceiling fan above the dishwashing machine had a moderate amount of a gray fuzzy substance on it and the fan should have been clean. D. A record review of the Nebraska Food Code dated 07/21/2016 revealed Ready to Eat foods that had been processed and packaged in a food processing plant shall be heated to a temperature of at least 135 degrees F. An observation on 2/6/2025 at 11:33 AM revealed Cook-B opened a can of Campbell's soup and poured into a bowl. Cook-F then placed the bowl of soup in the microwave for 1 minute. When the microwave alerted it was done, Cook-B took the bowl of soup out of the microwave and served directly to the Resident 4 without temping the bowl of soup. An observation on 2/6/2025 at 11:41 AM revealed DA-C opened a can of Campbell's soup and poured into a bowl. DA-C then placed the bowl of soup in the microwave for 1 minute. When the microwave alerted it was done, DA-C took the bowl of soup out of the microwave and served directly to the Resident 24 without temping the bowl of soup. In an interview on 02/06/2025 at 12:00 PM, Cook-B confirmed Cook-B and DA-C microwaved soup and delivered directly to residents without temping and should have to ensure the food was safe to eat. In an interview on 02/06/2025 at 2:11 PM, the DM confirmed Cook-B and DA-C should have temped the food after microwaving and before delivering to the residents.

Licensure Reference Number 175 NAC 12-006.05(S) Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and review, the facility failed to ensure that comfortable sound levels were maintained in the facility to protect the residents' right to be treated with consideration, respect, and the choices of the residents. The facility census was 63. Findings are: A record review of the Resident Rights policy dated 9/2019 revealed the facility would make every effort to assist each resident in exercising their rights to ensure that the resident is always treated with respect, kindness, and dignity. A record review of the facility's Resident Handbook dated January 2024 revealed Resident Rights were included and the residents had the right to be treated with consideration, respect, dignity, and reasonable accommodation of one's needs and preferences. A record review of the un-named Resident 36 complaint dated 02/10/2025 revealed the resident was admitted to the facility on [DATE] and around the date of 08/04/2024 the resident complained to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that Resident 52's music in the lobby was too loud. A record review of the following residents' Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) revealed: -Resident 52's 11/19/2024 MDS revealed a Brief Interview for mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) of 15/15, which indicated the resident was cognitively intact. -Resident 54's MDS dated [DATE] revealed a BIMS score of 8/15, which indicated the resident had moderately impaired cognition. -Resident 218 did not have a MDS but their 02/09/2025 Skilled Evaluation revealed the resident was alert and oriented x 3. -Resident 31's 12/24/2025 MDS revealed a BIMS score of 15/15, which indicated the resident was cognitively intact. -Resident 58's 11/26/2024 MDS revealed a BIMS of 14/15, which indicated the resident was cognitively intact. -Resident 42's 12/10/2024 MDS revealed a BIMS of 13/15, which indicated the resident was cognitively intact. -Resident 16's 10/22/2024 MDS revealed a BIMS of 13/15, which indicated the resident was cognitively intact. -Resident 36's 10/22/2024 MDS revealed a BIMS of 15/15, which indicated the resident was cognitively intact. An observation on 02/06/2025 from 7:00 AM through 9:53 AM revealed there was very loud music playing that could be heard upon entering the front door of the facility. The music was located in the sitting area across from the nurse's station where all 3 halls came together and could clearly be heard at the far end of all 3 hallways that contained resident rooms. An observation on 02/06/2025 at 7:11 AM revealed the following: -room [ROOM NUMBER] had the door open and a resident sleeping in bed 1. -room [ROOM NUMBER] had the door closed and a resident in bed 1 was trying to sleep. -rooms [ROOM NUMBERS] had the door closed and residents in bed trying to sleep. -room [ROOM NUMBER] had the door open and a resident sleeping in the recliner. -room [ROOM NUMBER] had the door open and a resident in bed 1 attempting to sleep in bed. -room [ROOM NUMBER] had the door closed and a resident was trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 was trying to sleep. -room [ROOM NUMBER] had the door closed and the residents were trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 1 was trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 was trying to sleep. -rooms [ROOM NUMBER] had the room doors closed and residents trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 was sleeping. -room [ROOM NUMBER] bed 1 and 2 had residents in bed trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 had the lights off but was awake. Further observation on 02/06/2025 at 9:53 AM revealed Residents 52 and 54 were in the sitting area across from the nurse's station where all 3 halls came together. Resident 52 was singing with the music into a microphone and Resident 54 was unintelligibly (unable to understand) also singing in the microphone. An observation on 02/10/2025 from 7:05 AM through 9:37 AM revealed there was very loud music playing that could be heard upon entering the front door of the facility. The music was located in the sitting area across from the nurse's station where all 3 halls came together and could clearly be heard at the far end of all 3 hallways which contained resident rooms. At 9:07 AM, Resident 52 had a microphone in hand and was singing to the song. At 9:37 AM, Resident 54 was unintelligibly singing into the microphone. An observation on 02/10/2025 at 7:50 AM revealed the following: -room [ROOM NUMBER]'s door was closed and had a sign on the door that revealed do not disturb. I prefer to be left alone from: 9pm - 8 am. -room [ROOM NUMBER]'s door was open and a resident sleeping in bed 1. -room [ROOM NUMBER]'s door was closed. -room [ROOM NUMBER], 303, and 304 had the doors closed. -room [ROOM NUMBER] had the door closed and the resident laying in bed attempting to sleep. -room [ROOM NUMBER]'s door was closed, and the resident was lying in bed attempting to sleep. -room [ROOM NUMBER]'s door was closed, and the residents were in bed trying to sleep. An observation beginning on 02/11/2025 at 6:48 AM revealed the music in the sitting area was turned to a reasonable level and by 6:56 AM the volume had gradually increased to a very loud level that could be heard at the far end of all 3 halls. At 9:38 AM, Resident 54 was unintelligibly singing in the microphone and 9:42 AM, Resident 52 was singing into the microphone. In an interview 02/06/2025 at 7:21 AM, the Assistant Director of Nursing (ADON) was at the nurse's station and confirmed the music was playing very loudly. The ADON confirmed the resident playing the music was Resident 52 but that Resident 52 does not play the music that loud everyday and that only 1 resident has complained about it. In an interview on 02/06/2025 at 7:55 AM, Resident 218 in room [ROOM NUMBER] confirmed the loud music did bother the resident and the resident had to try and keep the door to their room closed due to the noise. In an interview on 02/06/2025 at 7:57 AM, Resident 31 in room [ROOM NUMBER] confirmed that when the music was that loud in the mornings, it did disturb the resident and made it hard to sleep. In an interview on 02/06/2025 at 8:02 AM, Resident 42 in room [ROOM NUMBER] confirmed the loud music did disturb the resident and the resident could not sleep in due to the noise. In an interview on 02/06/2025 at 8:36 AM, Resident 16 in room [ROOM NUMBER] confirmed their room door was kept closed as soon as their roommate left because the loud music drove this resident nuts. Resident 16 stated they had tried to speak to Resident 52 about it and Resident 52 said the resident can play the music as loud as the resident wants if it was after 6 AM. Resident 16 confirmed Resident 54's singing was horrible. Resident 16 confirmed the resident had talked to the administration about it and nothing had been done about it. Resident 16 confirmed the music would be fine if it were quieter, but it was way too loud. Resident 16 confirmed the resident was unable to keep their room door shut until their roommate, Resident 23, had been gotten up and taken out of the room due to the roommate had seizures and the staff wanted the door left open. In an interview on 02/10/2025 at 9:28 AM, Resident 36 in room [ROOM NUMBER] confirmed the resident wanted to sleep in but the music was too loud, especially when the door was open. The resident confirmed the resident complained about the music noise level to the administration when the resident moved in to the facility and nothing was done about it. The resident confirmed the resident does not like when Resident 54 just yells in the microphone. Resident 36 confirmed the resident just keeps their room door closed and turns up their television to try and drown it out. In an interview on 02/10/2025 at 10:47 AM, the ADON confirmed Resident 36 had complained about the loud music but did not want to complete a grievance form. The ADON was unaware of another resident complaining about the loud music. In an interview on 02/10/2025 at 3:47 PM, the facility's Administrator confirmed that the music was played too loudly early in the mornings.

Licensure Reference Number 175 NAC 12-006.05(S) Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and review; the facility failed to ensure that the food and beverages were not served to residents with disposable dishware and cutlery to protect the residents' rights to be treated with dignity and to preserve a homelike environment. This affected the 25 facility residents who received their meals in their rooms. The facility census was 63. Findings are: A record review of the Resident Rights policy, dated 9/2019 revealed the facility would make every effort to assist each resident in exercising their rights to ensure that the resident was always treated with respect, kindness, and dignity. A record review of the facility's Resident Handbook, dated January 2024 revealed Resident Rights were included and the residents had the right to be treated with consideration, respect, dignity, and reasonable accommodation of one's needs and preferences. A record review of the facility's undated Residents who eat in their room list revealed the highlighted residents were residents who ate in their rooms, for a total of 25 residents. The list included residents who resided in room [ROOM NUMBER]-2, 103-2, 105-2, 107-2, 108-2, 109-1, 110-1, 111-1, 113-1, 113-2, 115-2, 202-2, 203-1, 207-1, 207-2, 208-2, 209-1, 209-2, 214-1, 301, 303, 304-2, 307-1, and 311-1. An observation on 02/06/2025 at 12:46 PM revealed room trays were being delivered to residents' rooms with the food and beverages in Styrofoam containers and packs of plastic utensils. An observation on 02/11/2025 at 1:02 PM revealed room trays were being delivered to residents' rooms with the food and beverages in Styrofoam containers and packs of plastic utensils. In an interview on 02/06/2025 at 2:11 PM, the Dietary Manager (DM) confirmed resident room trays were always served in Styrofoam containers. In an interview on 02/10/2025 at 3:47 PM, the facility's Administrator confirmed that food and beverages delivered to the resident's room were served in Styrofoam containers and per the regulation should not have been.

Based on interview and record review the facility failed to ensure behavior monitoring was completed to support the use of multiple psychotropic medications (drugs that affect the brain and nervous system, influencing mood and behavior) for one (Resident 17) of two sampled residents. The facility identified a census of 63. Findings are: A record review of the facility policy titled Charting (Behaviors) with a last revision date of 1/20 revealed the following guidance related to the documentation of resident behaviors: Procedure: 1. All staff are responsible for the documentation of any observed behaviors. a. Nursing Assistants should document behaviors in the POC (Point of Care) system under the specific resident. b. Nurses and members of the Inter-disciplinary team (IDT) should document daily behaviors in PCC: i. Create a note under the Behavior category. This should include details of the behavior and the attempted interventions, including the outcome of those interventions. 1. New interventions need to be tried and documented. Non-pharmacological interventions should always be tried first. A record review of the Admission Record printed on 2/6/25 revealed Resident 17 had been admitted into the facility on [DATE] with a primary diagnosis of right above the knee amputation. A record review of the Significant Change Minimum Data Set (MDS, completed when a resident has had an improvement or a decline in 2 areas of activities of daily living (ADL's)) dated 12/13/24, Section C revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15 which indicated Resident 17 was cognitively intact. A record review of the Medication Administration Record (MAR) dated February 2025 revealed Resident 17 was taking the following psychotropic medications that affect mood and behaviors: -Buspirone (a medication used to treat anxiety disorder) 5 milligrams (mg) one tablet by mouth three times daily (TID) for anxiety disorder. -Duloxetine (a medication used to treat depression, anxiety and chronic muscle pain) 60 mg by mouth daily for major depressive disorder. -Lexapro (a medication used to treat depression and anxiety disorder) 20 mg by mouth daily at bedtime for major depressive disorder. -Lamictal (a medication used to treat seizures and bipolar disorder) 100 mg by mouth daily for bipolar disorder. -Ativan (a medication used to treat anxiety and seizure disorders) 1 mg by mouth every bedtime for anxiety. -Ativan 0.5 mg every 6 hours as needed (PRN) for anxiety. A record review of a document titled Admission Medication Regimen Review dated 8/29/24 for Resident 17 contained the following guidance: Residents receiving psychoactive medications should have ongoing behavior monitoring, diagnosis, target behaviors identified, and side effect monitoring. Med(s) to be monitored: Buspirone, Lexapro, Ativan, Duloxetine, and Trazadone. A record review of a document titled Note to Attending Physician/Prescriber dated 7/26/24 revealed a request for a dose reduction of the psychotropic medications for Resident 17 was declined by the physician with a note stating no gradual dose reduction (GDR) due to psychiatric instability, which would support the need for monitoring and documentation of behaviors. An interview on 2/6/25 at 2:08 PM with the Assistant Director of Nursing (ADON) revealed that the facility's process related to behavior documentation was that the nurse aides (NAs) would document the behavior in the Point Click Care (PCC), (the facility's electronic medical record system) Task charting (where a check list of behaviors that the staff can choose from is documented along with all Activities of Daily Living (ADL's)) and then were to report the behaviors to the charge nurse to document in the Progress Notes for that resident, to include interventions provided and effectiveness of the interventions. A record review of the Task: Behavior charting covering the prior 30 days (1/12/25 through 2/9/25), revealed Resident 17 had displayed wandering behavior on 1/18/25, 2/1/25, 2/8/25, and 2/9/25, with no correlating Progress Note. An interview on 2/10/25 at 1:22 PM with the ADON, after review of the Task: Behavior charting covering the prior 30 days and the correlating Progress Notes, confirmed that the charting did not relay details of the behaviors to explain what wandering looked like for Resident 17 and did not relay any interventions or redirections provided for Resident 17, and should have. The interview with the ADON also confirmed that the behavior documentation for Resident 17 did not support the use of the 6 psychotropic medications currently being used. An interview on 2/11/25 at 7:00 AM with Medication Aide (MA)-R confirmed that the NA's will document resident behaviors in the PCC Task charting and then report those behaviors to the Charge Nurse to documents further details in the Progress Notes. An interview on 2/11/25 at 7:04 AM with Registered Nurse (RN)-D confirmed that the process related to behavior charting was that the NA's would document the type of behavior displayed in the PCC Task charting and report the behavior to the Charge Nurse to documents further details and interventions in the Progress Notes.

Licensure Reference Number 175 NAC 12-006.09H Based on observation, interview, and record review, the facility failed to cleanse the resident's wounds prior to applying treatment and failed to cleanse another wound in a circular motion from the center of the wound outward for 1 (Resident 9) of 4 sampled residents. The facility census was 63. Findings are: A record review of the NursingEducation.org's article Nurse Insights: What Are the Best Practices for Wound Care in Nursing? dated 01/18/2024 revealed the best practice for cleaning a wound is to clean around the wound using the prescribed solution. This is done by gently wiping in a circular motion from the center of the wound outward. https://nursingeducation.org/insights/wound-care/ A record review of Resident 9's Clinical Census dated 02/11/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 9's Medical Diagnosis list dated 02/11/2025 revealed the resident had diagnoses of Non-pressure chronic (long term) ulcer (wound) on the right foot, Non-pressure chronic (long term) ulcer (wound) on the left foot, Type 2 Diabetes Mellitus (uncontrolled blood sugar), Abnormal coagulation (blood clotting), and Venous insufficiency (poor blood flow in the veins). A record review of Resident 9'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 12/31/2024 revealed the resident had a Brief Interview for mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15 which indicated the resident was cognitively intact. The resident was independent for most activities of daily living (ADLs) except bathing and eating. The resident had diabetic ulcers and was receiving wound care. A record review of Resident 9's Care Plan with an admitted [DATE] revealed the resident had a focus area for actual impairment to skin integrity (condition of the skin's barrier) and interventions that included to avoid scratching and keep body parts from excessive moisture, educate on causes, encourage good nutrition and hydration, and treatments as ordered by the provider. A record review of Resident 9's Physician's Orders dated 02/11/2025 revealed on 05/01/2024 the provider ordered wound care to the right plantar (sole of the foot). The order was to apply a double layer of Therabond (a [NAME] plated wound dressing) moistened with tap water and cover with Mepilex (a foam absorbent dressing) on Mondays, Wednesdays, and Fridays. Mupirocin (an antibiotic ointment used to treat skin infections) ointment 2 percent (%) ointment, apply to open areas on the legs daily with dressing changes. A record review of the facility's Resident Listing Report dated 12/27/2024 through 01/16/2025 revealed on 01/16/2025 Resident 9 had a right plantar wound that was 1 centimeter (cm) long, 0.8 cm wide, and had no depth. A record review of the facility's Weekly Skin Observation Tool dated 02/07/2025 revealed Resident 9 had a diabetic right plantar wound the was 1.5 cm long, 0.8 cm wide, and had no depth. The wound bed had granulation (reddish connective tissue on the surface of a healing wound). The wound drainage was serosanguinous (thin, watery, pale, red/pink drainage) and there was 25% dressing saturation. The resident was seeing a wound care provider for this wound. In an observation on 02/10/2025 at 12:00 PM revealed Licensed Practical Nurse (LPN)-A performed hand hygiene (cleaning), donned (put on) a gown and gloves, and took a 4 inch by 4 inch (4x4) dressing that was soaked in wound wash and cleansed the right plantar wound by rubbing from toes to mid-foot across the wound multiple times. The observation did not reveal LPN-A used a circular motion specific to the wound when cleansing the right planter wound. LPN-A took a dry 4x4 and rubbed around and between the resident's toes on the right foot, then from toes to mid-foot over the right planter wound to dry the wound. The observation did not reveal LPN-A used a clean, dry, 4x4 when drying the right plantar wound after drying the toes. LPN-A then doffed (removed) gloves, performed hand hygiene, applied new gloves, removed a piece of Therabond that was soaking in a cup of water, folded, applied to the right plantar wound and applied Mepilex over the wound. LPN-A doffed gloves, performed hand hygiene, donned new gloves, applied a small amount of Mupirocin to LPN-A's gloved right fingers, and rubbed across all 5 wounds multiple times on the shin (front part) of the left leg. The observation did not reveal LPN-A treated each of the 5 scabbed wounds separately on the shin of the left lower leg or cleansed prior to Mupirocin being applied. LPN-A then doffed gloves, performed hand hygiene, donned gloves, applied a small amount of Mupirocin LPN-A's gloved right fingers, and applied to a scabbed area on the resident's right medial malleolus (bony projection on each side of the ankle). The observation did not reveal the wound on the right medial malleolus was cleansed prior to the treatment being applied. LPN-A doffed gown and gloves and disposed of all supplies without further concern. In an interview on 02/10/2025 at 12:00 PM, LPN-A confirmed LPN-A did not cleanse the wounds due to the resident had a shower that morning. LPN-A confirmed LPN-A cleansed the right plantar wound in an up and down motion and should have done a circular motion from the center of the wound out. In an interview on 02/10/2025 at 3:47 PM, the Assistant Director of Nursing (ADON) confirmed LPN-A should have cleansed and treated Resident 9's wounds per best practice and should not have dried the wound on the right plantar with the same 4x4 used to dry around the toes.

Licensure Reference Number 175 NAC 12-006.09D2b Based on record review, observation, and interview; the facility failed to monitor a pressure ulcer for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 61. Findings are: Record review of Resident 4's face sheet revealed the resident admitted to the facility 11/30/2020. Record review of a late entry progress note for Resident 4 by Registered Nurse (RN)-J revealed the following Late entry for 2/24, treatment completed to right leg lotion applied, noticed a large piece of lose dry skin hanging from the heal. assessing the area there is a 5 cm x 5 cm purple mushy area on his heal. Applied a merplix to protect the heal. Fax to MD and skin assessment done today. Record review of a fax cover sheet dated 2/26/2024 to Resident 4's practitioner revealed Resident 4 Has a fluid filled area 5.0 Centimeters (CM) X 5.0 CM to the right heel, Possible Pressure related. The facility staff requested a treatment order for the right heel. Record review of a returned fax with the sent date of 2/26/24 revealed the Family Nurse Practitioner (FNP) signed the requested order and faxed back to the facility on [DATE]. The order was received 30 days after the Resident 4 initially had a fluid filled blister identified on the right heel. Record review of Resident 4's Braden score (is a standardized, evidence-based assessment tool commonly used in health care to assess and document a resident's risk for developing pressure injuries) assessed on 2/26/24 revealed the score was 15. A Braden score of 15 is considered a moderate risk for potentially developing a pressure wound. Record review of Resident 4's Advanced Practice Registered Nurse-H's (APRN-H) encounter dated 4/18/2024 revealed Resident 4 had the right heel pressure ulcer listed as a stage 3 (STAGE III Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.) The APRN-H assessed the measurements as L: (Length) 2.0 cm (Centimeters), W: (Width) 2.0 cm, D: (Depth) 0.1 cm. The ARPN described the wound with 100% granulation tissue (Granulation tissue is new connective tissue and microscopic blood vessels that form on the surface of a wound during the healing process) and moderate (Serosanguineous) sero/sang drainage with an odor. Record review of an encounter sheet for Resident 4 dated 5/9/2024 by APRN-H revealed the measurements for the right heel were L: 3.2 cm by W:3.2 cm, D: 0.1 cm, and granulation tissue is 25% with slough (dead tissue, cream or yellow in color) at 75% of the wound bed. The drainage from the wound was documented as moderate sero/sang with an odor, and peri wound (the area around the wound) as macerated (softening and breakdown of the skin as a result of prolonged exposure to moisture). The encounter sheet dated 4/18-2024 revealed Resident 4's APRN-H identified evidence of infection and wound status as having decline. Record review of a fax cover sheet for Resident 4 dated 5/16/24 reveled APRN-H diagnosed Resident 4 with a wound infection and to start Metronidazole (an anti-biotic medication) 500 milligrams (mg) ,twice a day for 7 days. Observation on 5/21/24 at 7:15 AM of dressing change to Resident 4's right heel completed by Registered Nurse-E (RN-E) revealed RN-E removed the dressing. Further observation revealed the dressing was saturated with sero/sang fluid. The area around the wound was macerated and approximate measurements were 3.0 CM by 3.0 CM. RN-E completed the dressing change as ordered to Resident 4's right heel. Interview on 5/21/24 at 11:30 AM was conducted with the Director of Nursing (DON). During the interview the DON verified there were not measurements for Resident 4's right heel wound from 4/18-5/9/24. The DON revealed the staff nurses should measure the wounds weekly when they are completing the weekly skin observation. The DON confirmed that the facility was not following the skin policy and procedure. The DON confirms the wound deteriorated when the wound nurse did not round at the facility. Interview on 5/21/24 at 11:30 AM with the Assistant Director of Nursing (ADON) revealed that the nurse's taking care of the Resident 4, should have been measuring the wound and notifying the practitioner if the wound was declining. The ADON confirms the wound deteriorated when the wound nurse did not round at the facility. Interview on 5/21/24 with Licensed Practical Nurse-F (LPN-F) reveals that LPN-F rounded with the wound nurse weekly. LPN-F verified the wound nurse had not been at the facility between 4/19-5/8/24. LPN-F confirmed the wound deteriorated when the wound nurse did not round at the facility. Record review of the facility's skin policy and procedure dated 1/20 reveled that residents will receive care consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless clinically unavoidable. Resident with pressure ulcers will receive necessary treatments and services to promote healing, prevent infection and prevent new ulcers from developing. Procedure of this policy confirms that the nursing staff will follow procedures if skin integrity issues that are noted. The nursing staff will obtain measurements for each skin integrity issue, update the responsible party, update the provider, and obtain orders.

Licensure Reference Number175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to prevent the potential for food borne illness related to low dishwasher temps. This had the potential to affect 65 of 66 residents who receive food from the kitchen. The facility failed to monitor remvoal of room trays this affected Resident 59. The facility identified a census of 66. Findings are: An observation on 03/27/24 at 07:45 AM revealed that facility dishwasher was a hot water and chemical sanitization system. The observation revealed a dishwasher temperature for the wash cycle that read 100 degrees F. The observation revealed that the face of the temperature dial on the dishwasher read 120 degrees F. The observation revealed a rinse temperature of 110 degrees F. The observation of the dishwasher temperatures during the wash and the rinse cycles was observed and verified by the CDM and confirmed to not be meeting sanitization requirements on 03/27/24 at 7:55 AM. An observation on 3/27/24 at 2:10 PM, accompanied by Cook-B, revealed a dishwasher temperature of 110 degrees on the wash cycle and 130 degrees on the rinse cycle. An interview on 3/27/24 at 2:10 PM with the CDM, confirmed that the facility had had no food borne illnesses within the facility. During the observation on 3/27/24 at 2:10 PM, Cook-B, reported that the DM had placed a call to ECO-Lab (a company that provide services systems that specialize in treatment, purification, cleaning, and hygiene of water sanitization appliances). A second run of the dishwasher wash cycle revealed a temperature of 118 degrees F. An interview on 3/27/24 at 3:10 PM the CDM revealed that Eco-Lab had been in the building and stated that the booster to the dishwasher was throwing error codes and that the booster had been reset. A record review of the document titled ECOLAB, Extra Service Request dated 3/27/24 at 3:51 PM revealed the following information: -Request Description: not reaching temperature. -Service Comments: Reset booster heater and consistently started getting the right temperature. An observation on 3/28/24 at 9:55 PM accompanied by the CDM, revealed a dishwasher temperature of 110 degrees on the wash cycle and 120 degrees on the rinse cycle after 2 cycles runs. An observation on 4/1/24 at 10:48 AM, during meal preparation with Cook-F, revealed a dishwasher temp of 120 degrees during the wash cycle and 138 degrees during the rinse cycle. The observation on 4/1/24 at 10:48 AM, revealed a sign taped onto the dishwasher directing all staff to run the dishwashing cycle two times to ensure it met required temperatures. 47312 C. Review of Resident 59's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 3/5/24, revealed the following: -a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 3 indicating the resident was severly cognitively impaired. -a diagnosis of Dementia without Behavioral Disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -is independent with eating An observation on 3/28/24 at 8:03 AM revealed Resident 59 sitting on [gender] bed with a bed side tray placed in front of [gender] with Styrofoam container on it. Resident 59 opened the container and revealed meatloaf, sweet potatoes and a mix of carrots, cauliflower, and broccoli inside it. An interview on 3/28/24 at 8:03 AM Resident 59 confirmed that it was meatloaf, sweet potatoes and a mix of cauliflower, carrots and broccoli in the Styrofoam container. An interview on 3/28/24 at 8:17 AM with Medication Aide (MA)-J revealed that the Styrofoam container contained the meal from the previous evening. MA-J confirmed that the container should not have been on Resident 59's bed side tray still. Review of the facility policy, Dining (Room Trays), dated 1/2020, revealed the following: -3. The nursing assistant is expected to monitor room trays by returning to the resident's room in a timely manner to check on the resident.

Licensure Reference Number 175 NAC 12-006.09D6(7), 175 NAC 12-006.17B, 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to perform hand hygiene upon entering resident's room, after emptying a used bed pan, before setting up resident's meal tray in room, and prior to exiting the resident's room for Resident 3 and failed to ensure cleaning and storage of respiratory equipment was done in a manner to prevent potential cross-contamination for Resident 2, Resident 13, and Resident 19. The facility census was 66. How many sampled? Findings are: A. An observation on 3/28/2024 at 1:08 PM in Resident 3's room revealed NA-D (Nursing Assistant) knock and enter the resident's room with lunch meal in hands. NA-D put the food down on the resident's bedside table, put gloves on, and removed a used bed pan from the resident's bed and emptied it in the bathroom. NA-D came out of the bathroom, removed [gender] gloves and put new gloves on and proceeded to set up the resident's lunch directly on her bed per resident's request. NA-D was headed to the door and asked the resident if she was good and removed [gender] gloves. NA-D took some used Styrofoam cups off her bedside table and emptied them in the bathroom sink, turned the light on and left the room. Observed NA-D go into the hopper room (a separate room to dispose of dirty items and clean dirty equipment) to dispose of the cups and came out of the hopper room and picked up another room tray off a medication cart and delivered to another resident's room and set their meal up for them. NA-D then went to the dining room. No hand hygiene was observed to be performed during this time. An interview on 3/28/2024 at 1:18 PM with NA-D when asked of when [gender] would perform hand hygiene, NA-D revealed as [gender] looked down the hallway and said after the bed pan was emptied before setting the resident's lunch up and after removing dirty gloves. NA-D also confirmed that hand hygiene should have been done when entering the resident's room and prior to leaving the room as there was increased risk of cross contamination when other tasks were completed without doing any hand hygiene. An interview on 3/28/2024 at 1:20 PM with the ADON (Assistant Director of Nursing) revealed NA-D should have performed hand hygiene upon entering the resident's room, after emptying the used bed pan before setting up the resident's lunch and upon exiting the resident's room. The ADON further confirmed that hand hygiene needs to be performed any time gloves are removed and was not done and should have been done. ADON further revealed there was no specific policies for hand hygiene and glove usage, but does have policies for Nursing Assistant Procedures. A record review of the facility policy Nursing Assistant Procedures last revised 4/2018 which had attached procedures from the Nebraska Health Care Association dated 2019 revealed how to wash hands, how to change gloves, and how to handle soiled equipment. Review of the handwashing procedure states to rub all surfaces of the hands continuously for at least 20 seconds, rinse, and dry hands. Review of the procedure for handling soiled equipment stated to wash and dry hands thoroughly, apply gloves, hold, and carry soiled equipment away from clothing, clean soiled equipment (bedpan, urinal, etc.) with cold water and appropriate disinfectant per facility policy, remove gloves and dispose in proper container, wash and dry hands thoroughly, and return cleaned equipment to appropriate storage area. There was no information on when to perform hand hygiene or when to exchange gloves. 42861 B. A record review of the document titled Admission Record printed on 3/28/24 revealed that the facility had admitted Resident 13 on 6/19/20 with a primary diagnosis of a TBI (Traumatic Brain Injury). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 2/22/24, Section C revealed no 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) score for Resident 13. The record review revealed Section C did contain the following questions related to cognitive patterns: C0700 Seems or appears to recall after 5 minutes with an answer of 1. Memory problem. C1000 Made decisions regarding tasks of daily life with an answer of 3. Severely impaired. An observation on 03/27/24 at 8:31 AM revealed Resident 13 was noted to have a bag hanging on the oxygen (o2) concentrator (which is a machine that takes air from your surroundings, extract oxygen and filter it into a purified oxygen for you to breathe) which was next to the heater and the bag was melted down one side. The observation revealed o2 tubing attached to the portable tank on the w/c (wheelchair) was not stored in the bag attached to the w/c. The nasal cannula (a device that delivers oxygen throught a tube and into your nose) was noted to be touching the outside of the bag and was not being used to store the oxygen tubing which was attached to the portable tank. The observation revealed a bag of candy in the bag provided for oxygen tubing storage. An observation on 3/28/24 at 10:37 AM revealed Resident 13 to be sitting in the hallway outside of the dining room and did not have oxygen on. When asked why (gender) did not have o2 on, the facility Administrator then directed MA-G to retrieve Resident 13's nasal cannula from (gender) room. MA-G returned with oxygen tubing and allowed the connector (the piece of oxygen tubing that connects to either the oxygen conentrator or portable tank) end to fall onto the floor while applying the cannula and then connected the connector end that had touched the floor to the portable tank. An observation on 3/28/24 at 10:46 AM revealed Resident 13's oxygen tubing which was still connected to the concentrator was being stored in the melted bag. An interview with RN-H on 3/28/24 at 10:47 AM after observation of the tubing attached to Resident 13's concentrator, confirmed the bag had melted and tubing was still being stored in the melted bag and confirmed that the bag should be changed. The interview with RN-H confirmed that the facility policy was to change oxygen tubing once weekly and store in the blue bag on the back of the wheelchair and the clear bag attached to the concentrators. A record review of the facility policy titled Equipment Sanitation (Oxygen) dated 2/20, reads as follows: Care of Cannula/Mask: Replace cannula/mask weekly. Care of tubing: Replace oxygen tubing once per month. C. A record review of the document title Admission Record printed on 3/28/24 revealed Resident 19 had been admitted into the facility on [DATE] with a primary diagnosis of Bacteremia (bacteria in the blood) and a secondary diagnosis of acute and chronic respiratroy failure (an acute exacerbation or decompensation of chronic respiratory failure recognized by worsening symptoms and increasing treatment needs). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/30/24, Section C revealed no 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) score for Resident 19. The record review revealed Section C did contain the following questions related to cognitive patterns: C0700 Seems or appears to recall after 5 minutes with an answer of 1. Memory problem. C1000 Made decisions regarding tasks of daily life with an answer of 1. Modified independence - some difficulty in new situations only. An observation on 03/27/24 at 2:50 PM revealed Resident 19's CPAP (continuous positive airway pressure - a machine that provides air at a pressure just high enough to prevent the collapse of your airway, often used to treat sleep apnea) mask to be attached to the tubing and draped over the nightstand, no bag present for storage of the mask and the mask was noted to be lying face down touching the nightstand. An observation on 03/28/24 at 8:56 AM revealed Resident 19's CPAP on nightstand, undated, with the mask still attached to tubing and resting face down touching the nightstand. An interview on 03/28/24 at 10:55 AM with RN-H when questioned regarding process for respiratory equipment cleaning and storage, voiced I wiped out (gender) CPAP mask with one of theses this morning, pointing to a container of disinfectant wipes. When asked if the equipment was taken apart, cleaned and dried, RN-H voiced night shift is to clean/soak them. During an interview on 03/28/24 at 10:55 AM with RN-H present, Resident 19 voiced that the CPAP mask had not been cleaned or soaked on the night shift. An observation on 04/01/24 at 2:19 PM revealed Resident 19's CPAP mask to still be attached to the tubing and draped over nightstand with face mask touching the nightstand. An interview with LPN-I on 04/01/24 at 2:19 PM after an observation of the CPAP equipment confirmed that Resident 19's CPAP mask and tubing was not being stored per facility expectations. LPN-I further confirmed that the mask and tubing was to be stored in a bag. A record review of the facility policy titled Respiratory Care and dated 10/13, regarding the cleaning and storage of respiratory equipment, revealed it follows the guidance from Northwest Respiratory (the respiratory supply vendor for the facility) which was on pages 27-28 of the Northwest Respiratory Services guide provided to the facility: -Northwest Respiratory Services guide, page 27, titled Cleaning your CPAP/Bi-Level Equipment read as follows: Daily Cleaning 2. Wipe the portion of the mask that comes in contact with your skin with a damp cloth or alcohol-free wipe. This removes most skin oil from the mask. 3. Empty any remaining water from the humidifier chamber. 4. Fill the chamber with soapy water and shake vigorously. 5. Rinse the chamber with clean water. 6. Air dry. The record review of the undated Northwest Respiratory Services guide, page 27, titled Cleaning your CPAP/Bi-Level Equipment revealed it did not contain guidance related to the storage of equipment once cleaned. 50348 D. A record review of the facility's Equipment Sanitation (Oxygen) policy dated 5/23 revealed that the staff should wipe off oxygen concentrators with a clean damp cloth for cleansing, replace oxygen cannula and masks weekly and replace oxygen tubing once per month. A record review of facility's Respiratory Care policy dated 10/13 revealed that the facility will follow the guidelines provided by vendor Northwest Respiratory Service regarding use and cleaning of CPAP/BIPAP (Continuous Positive Airway Pressure/Bilevel (varied) Positive Airway Pressure) (a machine that is used to treat sleep apnea or obstructive sleep apnea) equipment. The following information was revealed in the Northwest Respiratory Service Manual referenced on page 27, labeled Cleaning your CPAP/Bi-Level Equipment: cleaning of the CPAP/BIPAP mask should be completed daily with damp cloth or alcohol wipe. Also, that weekly mask and tubing cleaning of headgear, mask and tubing with soap and water then air dry. A record review of facility's Respiratory Care policy dated 10/13 revealed that the facility will follow the guidelines provided by vendor Northwest Respiratory Service regarding use and cleaning of nebulizer (a medication delivery device that produces a fine mist for inhalation into lungs) equipment. The following information was found in the Northwest Respiratory Service Manual on page 22 and labeled Cleaning Your Nebulizer: the nebulizer should be disassembled and rinsed with warm water daily and then after allowing to air dry. A weekly disinfection of the nebulizer is to be completed with 1:3-part white distilled vinegar to water, and every 2 weeks the nebulizer is to be replaced with a new one. A record review of Resident 2's Face Sheet, dated 4/1/24, revealed that Resident 2 admitted on [DATE]. A review of Resident 2's Physician Orders dated 3/28/24 revealed the following: replace nebulizer set weekly, label new set with the date every Friday night shift, cleanse nebulizer and rinse after each use, replace oxygen nasal cannula weekly, and oxygen tubing every 28 days. A review of March 2024 Treatment Administration Record (TAR) revealed on 3/22/24 the nebulizer was not replaced due to equipment not available, and that nebulizer cleaning was not on the TAR. Further review revealed that there was no mention of the CPAP or the cleaning schedule on the TAR. An observation on 3/27/24 at 9:46 AM of Resident 2's room revealed: the nebulizer treatment equipment was without a date of last change marked, the mask was discovered with debris, the CPAP tubing and mask had a yellowish tint and debris covering the coils on the inside of the tubing, and the water reservoir was empty with brownish film on the inside. An observation 03/28/24 on 10:46 AM of Resident 2's room revealed: the nebulizer treatment equipment remained undated. The nebulizer mask continued to have debris, and the CPAP tubing as well as mask have a yellowish tint and debris lining the coils on the inside of the tubing. The water reservoir remained empty with brownish film on the inside of the container. A bottle of distilled water dated 11/14 was found located on the floor in front of the bedside table. An interview on 3/28/24 at 10:48 AM, Resident 2 revealed that the resident puts the CPAP on without assistance from staff at night, as well as throughout the day. Resident 2 also revealed that the CPAP tubing and mask had not been changed since before admitted . An observation on 4/1/24 at 10:00 AM of Resident 2's room revealed that the nebulizer tubing was dated and initialed, the CPAP tubing and mask continued to have debris on inner part of tubing and the tubing was a discolored yellowish appearance. The mask had a smeared, oily substance on the inside of the mask. The water reservoir on the CPAP machine was dry with a brownish film on the inside. An interview on 4/1/24 at 10:15 AM, the ADON confirmed the discoloration and debris in Resident 2's CPAP tubing, and that all the respiratory supplies should be cleaned, changed, and dated per policy. An interview on 04/01/24 at 10:25 AM, the DON confirmed that there was no mention of Resident 2's CPAP cleaning on the TAR.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review; the facility failed to maintain equipment and personal property in good condition as evidenced by: dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of a tube feeding pole, and grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player for 1 (Resident 6) of 1 sampled residents. The facility census was 66. Findings are: An observation on 3/28/24 at 8:06 AM of Resident 6's room revealed the following: dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of the tube feeding pole, and grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player. An observation on 4/1/24 at 8:52 AM of Resident 6's room revealed the following: dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of the tube feeding pole, and grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player. Review of the paper titled Resident 6 Tube Feeding, undated, revealed that nurses are to wipe off the TF (tube feeding) pump and pole with disinfecting wipes when the TF/water bag is changed. In an interview on 4/1/24 at 8:38 AM with Nursing Assistant (NA)-A revealed that housekeeping is to clean the dresser and dust the bed side tray, suction machine, nebulizer machine and CD player and nurses are to clean the tube feeding pole. NA-A confirmed the presence of the dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of the tube feeding pole, and the grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player. In an interview on 4/01/24 at 8:40 AM with Licensed Practical Nurse (LPN)-B confirmed that nurses are to clean the tube feeding pole and it had not been cleaned. In an interview on 4/1/24 at 8:46 AM with Housekeeper (HSKP)-C revealed that there is no set schedule or documentation for when resident rooms are to be cleaned. HSKP-C confirmed the presence of light beige-colored streaks on top of and down the front of the dresser and the dust on the bed side tray, suction machine, nebulizer machine and CD player. HSKP-C further confirmed that the dresser, bed side tray, suction machine, nebulizer machine and CD player had not been cleaned recently. In an interview on 4/1/24 at 12:54 PM the Assistant Director of Nursing (ADON) confirmed that there is no policy regarding the cleaning of personal property or equipment.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected a Level II PASARR (Preadmission Screening and Resident Review-that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level 2 screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by Medicaid) for 1 (Resident 7) of 1 sampled resident. The facility census was 66. Findings are: Review of Resident 7's admission record revealed that [gender] admitted to the facility on [DATE]. Review of Resident 7's PASARR Level 2 Outcome-Notification of NF (nursing facility), dated 4/4/17, revealed that Resident 7 met the PASARR criteria for a Level 2 evaluation for MI. Review of Resident 7's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 11/14/23, revealed that the question at A1500: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was marked No. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual v1.17.1, dated October 2019, revealed the following: -Code yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition An interview on 4/2/24 at 10:17 AM the MDS Coordinator confirmed that the question at A1500 should have been marked yes due to Resident 7 having a MI. An interview on 4/2/24 at 12:01 PM the Assistant Director of Nursing confirmed that the facility had no policy related to coding of the MDS.

Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new PASARR (Preadmission Screening and Resident Review-that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level 2 screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by Medicaid) screen was completed related to a new mental health diagnosis for 1 (Resident 59) of 1 sampled resident. The facility census was 66. Findings are: Review of Resident 59's Admission Record, dated 3/27/24, revealed a new diagnosis of Unspecified Psychosis not due to a Substance or known Physiological Condition (a mental disorder characterized by a disconnection from reality with an unknown cause) was added on 10/10/23. Review of Resident 59's PASARR-Notice of Level 1 Screening Outcome, dated 3/30/23, revealed that Resident 59 had no signs of serious MI, IDD, or a related condition and that no further clinical review or onsite evaluation was needed. Review of Resident 59's electronic health record (EHR) revealed no other completed PASARR screens. An interview on 3/28/24 at 4:00 PM, the Business Office Manager (BOM) confirmed that a Level 2 PASARR screen should have been completed and had not been after the new mental health diagnosis was added on 10/10/23. An interview on 4/1/24 at 12:58 PM the Assistant Director of Nursing (ADON) revealed that there is no policy regarding when a new PASARR screen should be completed. The ADON confirmed that there should be new PASARR screen completed when a new mental health diagnosis is added to a resident's diagnosis list.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a (6) Based on interview and record review, the facility failed to notify one resident's (Resident 2) physician of a fall with injury in order to not delay treatment. The facility census was 67. Findings are: Review of Resident 2's History of Present Illness dated 8/24/14 revealed that the resident had increased weakness, multiple falls, and was not eating or drinking well. The resident was not caring for self at home with having physical decline in multiple areas. The resident's Discharge [DIAGNOSES REDACTED]. Review of Resident 2's Quarterly MDS (Minimum Data Set: a federally mandated comprehensive tool used for care plans) revealed that the resident had a BIMS (Brief Interview for Mental Status) of 9 (8-12 is moderately cognitively impaired). The resident's Total Severity Score for mood was 2 (1-4 is minimal depression). The resident had delusions and displayed other behaviors one to three days weekly. The resident required supervision with bed mobility and transfers. The resident was independent with ambulation and locomotion with the use of a walker. The resident required limited assistance with toileting. The resident had balance issues, but was able to correct on own. The resident was frequently incontinent of urine, but was not on a toilet plan. The resident had pain rated at a 7. The resident had shortness of breath with exertion, sitting, and lying down. The resident had two falls since the last MDS with no injury. The resident took antianxiety medication, antidepressants, and anticoagulants (blood thinners). The resident did not receive therapy or restorative services. Review of Resident 2's IDPN (Interdisciplinary Progress Notes) revealed: -On Saturday, 7/25/15 at 5 PM, the IDPN stated At 1135 Res (resident was witnessed by staff losing (resident) balance while trying to sit in (resident) chair at the DR (dining room) table. (Resident) leaned up against the wall and slid down it onto the floor landing on (resident's) bottom. No injuries noted. Denies pain 2 A (assists) (with) hoyer (mechanical lift) used to get res off of floor . The resident's physician was notified via fax at 12:55 PM. -On Sunday, 7/26/15 at 5:45 AM, the resident was on the floor sitting by the resident's bed and claimed missed the edge. The resident denied pain. The resident was assisted to standing position then ambulated to bed. The physician was faxed. -On 7/26/15 at 9:30 PM, the resident complained of pain to the lower back and received as needed pain medication. The resident had one assist with activities of daily living. -On 7/27/15 at 10 AM, no injuries noted from falls. -On 7/27/15 at 12:30 PM, the resident refused breakfast and lunch. Eating cookies and crackers in the resident's room. -On 7/27/15 at 6 PM, the resident refused dinner, room tray was offered, and the resident refused. The resident had increased difficulty standing and grimaced when the resident did stand. The resident denied pain. Nurse's Order to offer as needed Tylenol TID (three times daily). -On 7/28/15 at 9 AM, it was noted that the resident had a 9 cm (centimeter) dark purple bruise to the right side of the resident's lower back. The resident reports that when the resident fell on [DATE] the resident hit the resident's back. The resident's physician was notified by fax. -On 7/29/15 at 2 AM, the resident was found sitting outside in the courtyard by staff at 12 AM. The resident claimed that the resident had been outside for four hours due to not being able to stand from a chair independently. The resident had increased confusion. A fax was sent to the physician to obtain an x-ray. -On 7/29/15 at1 PM, the resident refused to get out of bed for breakfast and lunch. The resident complain of left side of back, hip and leg pain. Fax sent to the resident's physician for an x-ray. -On 7/29/15, received a telephone order from a physician to send the resident to Seward emergency room for an x-ray. -On 7/29/15 at 10 PM at 6:30 PM, the resident returned from the hospital with a [DIAGNOSES REDACTED]. Review of Resident 2's Physician Faxes revealed: -A fax dated 7/25/15 stated that the resident was noted sitting on the floor in the dining room due to the resident missing the chair. The resident's vital signs (blood pressure, temperature, pulse, respirations) were within normal limits and no injuries were noted. The physician noted this but did not date the signature. The nurse noted on 7/28/15, three days after the resident's fall. -A fax dated 7/26/15 revealed that the resident noted to be sitting on the floor due to missing the edge of the bed. The resident's vital signs were within normal limits and no injuries were found. The physician noted the fax two days after the resident's fall. -A fax dated 7/28/15 let the physician know that the resident had a 9 cm x 1 cm dark purple bruise on the resident's right lower back. The resident stated that when the resident fell on [DATE] the resident hit the resident's back. The physician noted this on 7/28/15. The physician was not notified that for two days the resident required assistance with cares, had pain, refused meals, and that the nursing staff placed the resident on Tylenol as needed TID. -On 7/29/15, the physician was notified that that the resident fell twice over the weekend and refused to get out of bed. The resident was complaining of leg and rib pain. The facility asked to x-ray the resident's hips and legs. The physician responded that the resident needed to be seen on 7/29/15. Interview with LPN (Licensed Practical Nurse) A on 8/13/15 revealed that when a resident falls the family was notified as soon as possible and a fax was sent to the physician if there was no injury.

Licensure Reference Number 12-006.09D7b Based on observations, record review and staff interview; the facility failed to conduct assessments of repeated falls and failed to identify and implement interventions to prevent resident injuries incurred after falls for two of four sampled residents (Resident 2 and 3). Facility census 67. Findings are: A. Review of Resident 3's medical record revealed the resident sustained [REDACTED]. Resident 3 was admitted to the facility in July 2012. Resident 3's [DIAGNOSES REDACTED]. Review of the facility fall log, facility fall investigations and fall tracking log for Resident 3 on 8/13/15 for June, July and August 2015 revealed the resident had experienced 9 falls with one emergency room encounter for head injury and one hospitalization for a fractured femur: - Fall on 6/1/15 at 10:40 am - resident trying to toilet - alarm sounding. Care Plan reviewed no new interventions. Reminded staff to assist to toilet every 2 hours and prn ( as needed). - Fall on 6/5/15 at 12:30 am - resident self transferring to restroom, had bowel movement noted in toilet. All intervention appropriate. Continues to ambulate in room unattended. Bed alarm is working. On the evening of 6/5/15 resident was witnessed to stand at 7:30 pm, lost balance and fell in room by television. No apparent injuries. - Fall on 6/29/15 at 6:30 am - resident incontinent of bowel and urine. Attempted to self transfer to wheelchair which was by closet lost balance and fell hitting head. Care plan reviewed all interventions appropriate. No recent changes. - Fall on 7/3/15 at 1:45 am - resident had been in bed was found on the floor by bathroom. Assessed by nurse on duty assisted off of floor toileted and put back in bed. All interventions in place. Resident needed to use bathroom. - Fall on 7/4/15 at 2:45 am - resident was walking from bed to bathroom. All interventions in place. No current changes. Self transferring. - Fall on 7/7/15 at 9:10 pm - alarm heard and resident was found on the floor by the door to the room. Two assist to stand and placed in wheelchair. Denies injury. Reminded to use call light. - Fall on 7/14/15 at 9:41 am - resident left on toilet alone/unattended, alarm was off. Resident walked with pants down and fell . Care plan reviewed, all interventions appropriate at this time. No current changes noted. Left alone on toilet, self transferred. Staff educated. - Fall on 7/19/15 at 8:30 pm - resident transferred from wheelchair unassisted. Locks were not in-place. Wheelchair rolled out from residents grasp and resident fell to floor. Staff reported brakes did not lock while self transferring. Anti-roll back fixed on 7/21/15. Received order for Urinalysis, lab work and X-ray of Right knee. Negative for injury. Sent to emergency room secondary to pain. admitted to hospital with fracture. Review of Nursing notes from 7/19/2015 revealed resident refused any assessment for injury said was going to bed. Family notified and Doctor faxed (report of fall). On 7/20/15 one entry noted voices no complaints at 11:00 am. On 7/21/15 - at 8:30 am Staff trying to get resident up for the day and resident hollering with cares. Right knee inner aspect bruised and swollen. X-ray of knee ordered. 11:00 am call placed to physician for increased hollering - resident sent to emergency room . Family notified. 4:00 pm - Hospital called and reported the resident was being admitted for femoral neck fracture. Further review of Nursing Notes: Resident 3 returned to facility on 7/25/15 following displaced Right femoral neck fracture and 37 staples intact following surgical repair. Resident was oriented to person only and was agitated and reported pain. Resident was ordered to have abductor pillow placed between legs and velcro in place to keep proper hip alignment for healing of fractures. On the morning of 7/31/15 - Resident refused breakfast. At lunch, Resident was in dining room and pushed self away times two from table - the second time resident fell out of wheelchair on to floor hitting right temple on floor and landing on right side . Resident was sent to Emergency for x-ray of right hip and scan of head due to fall. On 7/31/15, resident was provided with tilt and space wheelchair for positioning needs. Interview with Nurse K on 8/13/15 revealed that a bowel and bladder assessment was not completed until 7/27/15 after resident returned from hip fracture injury. No new interventions were added specifically for the resident for toileting needs after six of the nine falls were related to toileting needs, self toileting or self transferring. B. Review of Resident 2's Admitting History and Physical dated 8/24/14 revealed that the resident had increased weakness, multiple falls, not eating or drinking well. The resident was not caring for self at home with having physical decline in multiple areas. The resident's Discharge [DIAGNOSES REDACTED]. Review of Resident 2's Quarterly MDS (Minimum Data Set: a federally mandated comprehensive tool used for care plans revealed that the resident had a BIMS (Brief Interview for Mental Status) was 9 (8-12 moderately cognitively impaired. The resident's Total Severity Score for mood was 2 (1-4 minimal depression). The resident had delusions and displayed other behaviors one to three days weekly. The resident required supervision with bed mobility and transfers. The resident was independent with ambulation and locomotion with the use of a walker. The resident required limited assistance with toileting. The resident had balance issues, but was able to correct on own. The resident was frequently incontinent of urine, but was not on a toilet plan. The resident had rate pain rated at a 7. The resident had shortness of breath with exertion, sitting, and lying down. The resident had two falls since the last MDS with no injury. The resident took antianxiety medication, antidepressants, and anticoagulants (blood thinners). The resident did not receive therapy or restorative services. Review of Resident 2's Incident Log revealed that the resident fell three times in June 2015 resulting twice with injuries and two times in July 2015 resulting in a trip to the emergency room . Review of Resident 2's Physician Faxes revealed: -A fax dated 6/22/15 revealed that the resident had abrasions to the left forearm from a fall. -A fax dated 6/28/15 revealed that the resident fell in the courtyard on 6/27/15 and the resident had two abrasions. The staff would monitor the resident. -A fax dated 7/25/15 stated that the resident was noted sitting on the floor in the dining room due to the resident missing the chair. The resident's vital signs (blood pressure, temperature, pulse, respirations) were within normal limits and no injuries were noted. The physician noted this but did not date the signature. The nurse noted that on 7/28/15, three days after the resident's fall. -A fax dated 7/26/15 revealed that the resident noted to be sitting on the floor due to missing the edge of the bed. The resident's vital signs were within normal limits and no injuries were found. The physician noted the fax two days after the resident's fall. -A fax dated 7/28/15 let the physician know that the resident had a 9 cm x 1 cm dark purple bruise on the and legs. The physician responded that the resident needed to be seen on 7/29/15. The resident stated that when the resident fell on [DATE] the resident hit their back. -On 7/29/15 the physician was notified that that the resident fell twice over the weekend and refused to get out of bed. The resident was complaining of leg and rib pain. The facility asked to x-ray the resident's hips. Review of Resident 2's IDPN (Interdisciplinary Progress Notes) revealed: -On 6/7/15 at 8 AM the resident was found on the floor in the room after attempting to ambulate independently. The resident was incontinent of urine and the resident was attempting to get a new brief from the closet. The resident lost the resident's balance and fell . There were no injuries. -On 6/27/15 at 9:50 PM the resident was found sitting on the sidewalk in the courtyard at 7:45 PM stated was walking and tripped on sidewalk and fell on to the resident's bottom. The resident had an abrasion to the right wrist measuring 4 cm (centimeters) by 4 cm. and an abrasion to the left eyebrow that measured 1 cm by 1 cm. -On 7/25/15 at 5 PM stated At 1135 Res (resident) was witnessed by staff losing (resident) balance while trying to sit in (resident) chair at the DR (dining room) table. (Resident) leaned up against the wall and slid down onto the floor landing on (resident's) bottom. No injuries noted. Denies pain. -On 7/26/15 at 5:45 AM the resident was on the floor sitting by the resident's bed and claimed missed the edge. The resident denied pain. -On 7/26/15 at 9:30 PM the resident complained of lower back pain and was given Tylenol. The resident required one assist with activities of daily living. -On 7/27/17 at 12:30 PM the resident refused breakfast and lunch eating cookies and crackers in room. -On 7/27/15 at 6 PM the resident refused dinner and refused a room tray. The resident had increased difficulty with standing. The resident grimaced when the resident stool. The resident denied pain. The nurse put in an order for [REDACTED]. -On 7/28/15 at 9 AM the resident had a 9 cm (centimeter x 1 cm dark purple bruise to right side of lower back. The resident reported that it happened during the fall on 7/25/15. The resident hit the resident's back. The resident's physician was notified by fax. -On 7/29/15 at 2 AM the resident was found sitting outside in the courtyard at 12 AM and stated that the resident was unable to stand from chair independently. -On 7/29/15 at 1 PM the resident refused to get out of bed for breakfast and lunch. The resident complained of left side back, hip, and leg pain. The resident fell on [DATE] and 7/26/15 and was found outside at 2 AM on 7/29/15. The resident had increased confusion. A fax was out to the resident's physician for an x-ray. -On 7/29/15 at 1:25 PM a telephone order was received to send the resident to Seward emergency room for an evaluation. -On 7/29/15 at 2:20 PM the resident was sent to the hospital for evaluation at the emergency room . -On 7/29/15 at 10 PM the resident returned to the facility with a [DIAGNOSES REDACTED]. Review of Resident 2's Care Plan dated 12/9/2014 revealed: -There were no fall preventions added for 6/22/15 or 6/27/15. -After the resident's falls on 7/25/15 and 7/26/15, an intervention was added to give the resident Tylenol routinely due to hesitation with standing and transfers and to check the resident's ears due to falls. Review of Resident 2's facility's Significant Change Watch List revealed: -On 6/29/15 the resident had a new onset of falls and was harder for the resident to get out of a chair. The resident's sleeping had increased during the day and the resident had lost interest in everyday activities. The facility was to monitor for a significant change in condition. -On 7/13/15 the nursing staff was to check into the resident's condition for a possible acute illness. The Rehab Nurse LPN (Licensed Practical Nurse) reported that the resident would benefit from increased assistance with activities of daily living if the resident would accept it. The resident's activities of daily living scores remained the same. -On 7/21/15, Therapy reported that the resident was participating with physical and occupational therapies and was showing improvement with transfers. -On 7/27/15 the Rehab Nurse reported three days last week of resident being resistive with therapy. The resident fell twice due to trying to sit down on chair/ edge of bed. -On 7/29/15 the resident was sent to the hospital for evaluation due to recent onset of rib pain recent falls, reluctance to get up out of bed and decreased appetite. -On 7/30/15 the resident had a [DIAGNOSES REDACTED]. The resident had walked independently with a walker before. Interview on 8/13/15 at 11:33 AM with LPN A revealed that the resident did not have an alarm. The resident had refused to walk to the dining room. The resident had been refusing to walk. The resident wanted to go in the wheelchair. The resident preferred to spend all of the resident's time outside and got upset when the resident came in. The resident did not attempt to stand up independently anymore. The resident complained of right rib pain. Interview with the Rehab Nurse RN (Registered Nurse) and Rehab Nurse LPN on 8/13/15 at 2:05 PM revealed that the resident has had a general decline in condition. The resident was having a harder time getting out of bed and sitting down. The resident did not like asking for help. The resident generally did not use the call light. The resident will usually holler out or just come out and ask for help. The resident was having a progression in Dementia with the resident's brain not able to tell the resident's legs to stand up. The resident had received Physical and Occupational therapies and the resident was not always cooperative. The therapists thought the resident was having cognitive problems getting to the brain to get the legs to respond. During the family, resident, and facility meeting the resident requested to discontinue physical and occupational therapies. The resident was started on a walk to dine program and restorative program. The meeting with the resident and family on 8/4/15 resulted in the following interventions: 1. Remind to use call light and walker-dressing in room; 2. the resident's walker was checked and fixed. The NA (Nurse Aides) were to walk the resident outside; Give the resident Tylenol routinely (nursing order); and Check the resident's ears secondary to falls while attempting to sit. Observation of Resident 2's care on 8/13/15 at 3:50 PM revealed: that NA (Nurse Aide) K and NA L placed a gait belt around the resident's waist. The resident was seated in the resident's wheelchair. The resident asked what the gait belt was for. The NA explained they were going to assist the resident to bed. The resident stated that the resident could do it by self. The resident stood up strongly on own with both NA K and L assisting with gait belt pivot transfer onto the bed. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 8/13/15 at 3:15 PM revealed that they had a meeting with Resident 2 and the family. The DON felt that using the wheelchair would lessen the resident's fall. The resident was using the call light to ask for assistance to toilet. The ADON felt the resident was having a harder time getting out of a regular chair alone.

Licensure Reference Number:175 NAC 12-006.09D7 Based on observation, staff and resident interviews and review of facility and resident records; the facility failed to complete an investigation of causal factors for a fall from a wheelchair and identify interventions for providing transportation via wheelchair in a safe manner for 1 (Resident 1) of 3 sampled residents. Facility census was 72. Sample size was 3. Findings are: admitted for Resident 1 to current facility was on 01/22/2010 Review of the MDS (Minimum Data Set: A federally mandated comprehensive assessment tool used for care planning) dated 06/28/2011 as a Quarterly Review Assessment revealed: -[DIAGNOSES REDACTED]. -No behavioral symptoms present; -Functional Status: required extensive assistance for bed and transfer assist of one staff, did not ambulate in room or hallway, required extensive assist of one staff for locomotion in a wheelchair, required extensive assist of one staff for dressing and toileting and required limited assist of one staff for provision of personal hygiene, required physical help in part of bathing; -Balance during transition/walking: only stable with human assistance while moving on/off the toilet and transfer into a wheelchair. Not able to walk; -Functional limitation in range of motion: impairment on one side in upper and lower extremity; -Mobility devices include: wheelchair; -Falls since admission include: one fall with no injury and one fall with minor injury; -Received antipsychotic and antidepressant medications on a daily basis. Review of the MDS Assessment with reference date of 07/22/2011 done for a significant change in status revealed changes in the following: -Additional/New Diagnosis: [REDACTED]. -Functional Status: required extensive assistance for bed and transfer assist from two staff; -No transfer, ambulation or locomotion during this time; -Toileting required total assist of two staff; -No mobility out of bed during this assessment period; -Functional limitation in range of motion: impairment on one side in upper extremity and impairment on both sides in lower extremities; -Fracture related to a fall in the past 6 months was "1". Review of the RESIDENT (Resident 1) INCIDENT REPORT of 07/18/2011 revealed: -Staff was pushing resident in w/c (wheelchair) when (gender's) blanket and foot got caught under the chair. Resident 1 leaned forward to pull up the blanket, then fell forward on to the floor. Resident 1 complained of severe left hip pain. -Order obtained to be seen in the ER (emergency room ; -Resident condition at the time of incident: medications taken included: psychotropic's/antipsychotic's, diuretics, analgesics/narcotics; -Medical risk factors possibly related to incident: a history of seizures, [DIAGNOSES REDACTED] and sensory limitations. Review of the OCCUPATIONAL THERAPY EVALUATION/PLAN OF CARE REVEALED: -Start Date: "03/16/2011 to 04/22/2011: Functional Independence with wheelchair skills: (Resident 1) uses (right) side only. Unable to maintain an upright posture without support of w/c positioning device." Safety: "Addressed (nursing) concerns with sideway leaning. Vendor has been contacted and is unable to adapt chair further (without) restraint. Criteria for safe bending established with (Resident 1). (Resident 1) is not lean further that looking past body. Nursing agrees to assist with cuing." Start Date: 07/18/2011 to 07/22/2011 revealed: -"Medical History includes: fracture of neck of femur, late effects of acute polio[DIAGNOSES REDACTED], Osteoarthrosis involving multiple sites, muscle weakness." -"Reason for referral: (Patient had a traumatic (left) femural (fracture)..that has made a significant decrease in (gender) (functional) ability. Exacerbation of disease resulting in change of function." Review of PHYSICAL THERAPY EVALUATION/PROGRESS NOTES for 07/18/2011 to 07/22/2011 revealed that "Transfer with slide board is difficult to provide transfer back to bed due to bed not being able to lowered further and the required immobility/stationary stability of the left leg/hip. Physical Therapy has decided that pre-skills for sliding board transfers are needed before a second attempt is made for a transfer." Review of the CARE PLAN for Resident 1 on 08/15/2011 revealed: -An entry on 07/18/11 identified: "I am at risk for falls related to poor safety awareness and poor understanding of physical movement of my wheelchair. I have a history of attempting t pick things up from the floor in my w/c and not asking for help." -GOAL of 07/18/2011 was "I will be free from injury related t of falls." -APPROACHES 07/18/2011 included "ask for assistance, use my grabber for objects that fall to the floor, sit up straight in w/c, do not lean over to reach things on floor while in my wheel chair." INTERVIEW with Occupation Assistant on 08/15/2011 at 1:30PM revealed: -Clarify physician orders [REDACTED]. -Resident 1 could not have any movement in affected leg since surgery. -Issues that compromise transfer were: bariatric bed, weight and not being able to get the resident from the w/c back into the bed using the slide board (uphill). -Resident would be seen today by surgeon for evaluation. When the resident could be approved to use a Hoyer lift then there would not be a problem for transferring. Interview with: Resident 1 at 08:00AM on 08/15/2011 revealed: -"I can't get out of bed now because of my hip; I had surgery. The blanket with tags was wrapped around me. I was going to the bath house. It got tangled up in the wheels and I fell out trying to get it out." -"The blanket was lying across me and it got caught in the small wheel (front wheel of chair). The left leg/foot was up on the foot pedal. The left leg is the one that I can't use (post polio[DIAGNOSES REDACTED]). I use my right foot/right hand to propel myself. The left leg is the one I don't use and it is the one that is broken. I went forward in the chair and fell out trying to get the blanket out. The right leg is my good side." INTERVIEW: 08/15/2011 at 12:00PM with the Administrator and ADON (Assistant Director of Nursing) revealed: -The night nurse wrote in the nurses notes about the incident. -No interview was done with the night aide or night nurse about the incident. -No interview was conducted with the resident at the time or upon return to the facility about how the incident happened. -Positioning in the w/c with adaptive devices for positioning and mobility was not addressed in the care plan nor addressed in the care plan after the incident. -The Plan of Care did not address mobility in the wheelchair that had been long term use of a leg splint on the left leg and left foot pedal for support when in the w/c. Resident 1 was able to use right foot/leg and arm/hand to propel independently. -The use of a seat belt device for safety/positioning was discussed with Resident 1 a long time ago but refused its use. - Both the Administrator and ADON acknowledged that the investigation was not complete to identify causal factors, in specific the use of a lap blanket as a potential hazard, and to determine interventions to prevent recurrent fall accidents. They also acknowledged that the Plan of Care did not reflect the current needs, identify interventions or accommodations for safety post fall from wheelchair for Resident 1.