Every finding on record at Ridgewood Rehabilitation & Care Center

Licensure reference number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure 1 resident (Resident 33) out of 3 residents sampled, signed a SNF (Skilled Nursing Facility) ABN (Advanced Beneficiary Notice) and NOMNOC (Notice of Medicare Non-Coverage) prior to when the facility determined services would no longer qualify as covered under Medicare. The facility census was 62. Findings are: Record review of a progress note dated 03/11/2026 at 1729 revealed that the Social Services Director (SSD) contacted Resident 33's Power of Attorney (POA- a trusted person to make decisions on behalf of another person) to inform them that 03/11/2026 would be the last covered day (LCD- the final calendar day that Medicare paid for an individual's SNF care and after which the resident was responsible for out-of-pocket costs). Record review revealed that Resident 33's SNF ABN (a form that informed patients that Medicare may deny coverage for items or services and required the patient to assume financial responsibility if they chose to proceed) was provided to the resident and signed on 03/13/2026. Record review revealed that Resident 33's NOMNOC (a form given to patients who used Medicare covered services when covered care was ending and explained how to file an expedited appeal if they disagreed with the discharge) was provided to the resident and signed on 03/13/2026. An interview with the SSD on 06/03/2026 at 11:30 AM confirmed that Resident 33 did not sign the SNF ABN or NOMNOC until 3/13/26 which was two days after the LCD. The SSD confirmed that the POA could not sign the SNF ABN or NOMNOC in person and had not given verbal permission when they spoke on the phone about the LCD.

Licensure reference number 175 NAC 12-006.11(E) Based on record review, observation, and interview, the facility failed to ensure kitchen staff performed hand hygiene to prevent potential cross contamination during food preparation and the facility failed to properly store opened food in the satellite kitchen to prevent a possible food born illness. The facility census was 62. Findings are:Record review of the Nebraska Food Code 2-301.14 dated 2022 revealed the following:Food employees should clean their hands and exposed portions of their arms before engaging in food preparation and:(F) during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks (G) when switching between working with raw food and working with ready-to-eat food (H) before donning (putting on) gloves to initiate a task that involved working with food (I) after engaging in other activities that contaminated the hands. Record review of Facility Hand Hygiene Competency revised 12/2019 revealed hands should be washed:-after handling contaminated items -before and after gloving An observation of the satellite walkway refrigerator on 06/01/2026 at 8:19 AM revealed the following: -an open half gallon of chocolate milk with no open date-a pitcher of a light-colored brown liquid with no date and no label -an open water bottle with no date-two uncovered glasses filled with an orange liquidAn observation of the satellite kitchen refrigerator on 06/01/2026 at 8:23 AM revealed the following: -two bottles of unlabeled and undated dressings-one opened, unsealed, undated bag of hashbrowns An observation on 06/02/2026 at 10:29 AM of Culinary Assistant-A (CA-A) was of the preparation of sauteed shrimp, as followed: -CA-A did not perform hand hygiene prior to gloves being donned (put on)-all seasonings were measured out and placed in the pan-CA-A touched the shrimp to put it in the pan-CA-A doffed (removed) their gloves, no hand hygiene was performed, CA-A then used utensils to stir the shrimp-CA-A cleaned all of the spices off of the counter, then cleaned the kitchen counter with a re-usable towel that had been draped and damp over the sink-CA-A completed hand hygiene for 20 seconds-CA-A did not don gloves, CA-A then transferred cooked the shrimp to separate container An alternate no garlic plate was completed immediately as followed:-all seasonings were measured out-CA-A used the remaining raw shrimp and without gloves, placed them into the pan-no hand hygiene was completed, CA-A then put away the remaining seasonings, touched the refrigerator, and cleaned the counter with the previous re-usable towel An interview on 06/01/2026 at 8:23 AM with Culinary Assistant-B (CA-B) confirmed the open, undated, and unlabeled items in the satellite kitchen. The CA-B confirmed that the items in the refrigerator should have been dated, labeled, and sealed. An interview on 06/02/2026 at 10:50 AM with CA-A confirmed that they did not complete hand hygiene after touching the shrimp and after doffing their gloves on two separate occasions. An interview on 06/03/2026 at 11:14 AM with the Dietician revealed that there was no policy for food storage.

Licensure Reference Number 175 NAC 12-006.18(B)Based on record review, observation, and interview, the facility failed to follow infection control standards of practice regarding hand hygiene and glove use during wound care for Resident 13 and Resident 6. This affected 2 of 3 residents observed for wound care. The facility census was 62.Findings are: A record review of the facility's Hand Hygiene Competency dated 12/2019 revealed the following: -hand hygiene should be done after touching a resident or their belongings, after any contact with body fluids, after handling contaminated items, before and after gloving, and between changing gloves. -when using soap and water to perform hand hygiene, staff should wet hands, apply soap and rub hands together for a full 20 seconds, then rinse well without touching the inside of the sink or the faucet, leave the water running, dry hands well with paper towels, and use a clean paper towel to turn off the water. -when using hand sanitizer to perform hand hygiene, staff should rub all surfaces of the hand until dry. The procedure should take 20-30 seconds. A record review of the facility's Surgical wound dressing application revised 05/19/2025 revealed the dressing change should be done as follows: -perform hand hygiene-put on gloves-loosen and remove the soiled dressing-discard the dressing in an appropriate receptacle. -remove and discard your gloves-perform hand hygiene-prepare the sterile field (germ-free workspace used during medical procedures to prevent infections) and supplies-perform hand hygiene-put on sterile gloves-clean the wound in a circular motion-use each pad or applicator only once-pat the wound dry with sterile gauze-apply a new dressing-remove and discard gloves-perform hand hygiene. A. A record review of Resident 13's admission Record printed 06/02/2026 revealed the facility admitted Resident 13 on 04/28/2026 and the resident had diagnoses of renal tubule-interstitial disease (inflammation and swelling inside the kidneys that affects the kidneys' ability to process fluids and waste) and bladder cancer. A record review of Resident 13's Baseline Care Plan – V2 dated 04/28/2026 revealed the resident had nephrostomy tubes (thin tubes that go into the kidneys through the back and drain into a bag) present on admission. A record review of Resident 13's Order Summary Report dated 06/02/2026 revealed an order to change the nephrostomy tube dressings weekly on Wednesday and as needed for excessive drainage. The order specified that was a sterile dressing change. An observation on 06/03/2026 from 11:45 AM to 12:20 PM of the Infection Preventionist (IP) performing bilateral (both sides) dressing changes of Resident 13's nephrostomy tubes. The IP put a gown and mask on outside the resident's room, then entered the room and positioned the resident. The IP washed their hands with soap and water for five seconds, put their hands under the running water, then turned the faucet off with their bare hand before obtaining paper towels to dry their hands. The IP then set up the sterile field and supplies, put on sterile gloves, removed and discarded the dressing on the left side, then removed and discarded gloves and performed hand hygiene using hand sanitizer. The IP started to rub the hand sanitizer in, then waved their hands in the air to dry. IP then put on a new pair of sterile gloves, cleaned around the tube site, and used the new dressing to fan the area. Applied the securing device and covered the area with a transparent adhesive dressing, then removed their gloves, washed their hands with soap and water for 15 seconds, turned the water faucet off with their bare hand before obtaining paper towels to dry their hands, then waved their hands in the air. The IP then set up the sterile field and supplies, put on sterile gloves, removed and discarded the dressing on the right side, then removed and discarded the gloves and performed hand hygiene using hand sanitizer. The IP rubbed hands together, then waved hands in the air, then rubbed hands together again. The IP started to put on the left sterile glove, said it was too sticky, and put it back on the sterile field. The IP then washed their hands with soap and water for seven seconds, put their hands under the running water, then turned the faucet off with their bare hand before obtaining paper towels to dry their hands. The IP then put on the same pair of sterile gloves, cleaned around the site, applied the securing device and covered the area with a transparent adhesive dressing. The IP then removed their gown and gloves, did hand hygiene with soap and water for 25 seconds, then turned the faucet off with their bare hand before obtaining paper towels to dry their hands. An interview on 06/04/2026 at 12:22 PM with the IP confirmed that they should have turned off the water faucet with a paper towel and did not, that handwashing should be done for at least 20 seconds, and that waving their hands in the air was not the correct way to dry them. B. Record review of facility competency document titled Hand Hygiene Competency revised 12/2019 revealed that hands should be washed: -before each resident contact -after a resident is touched or their belongings are handled -after any contact with body fluids -after handling contaminated items (linens/garbage/briefs) -before and after gloving Record review of facility competency titled Wound dressing application undated revealed that staff should: -remove the old dressing and discard -remove and discard soiled gloves -perform hand hygiene -put on new gloves -clean the wound -remove gloves and then perform hand hygiene -put on new gloves An observation on 06/03/2026 from 9:08 AM to 9:27 AM of Licensed Practical Nurse-C (LPN-C) who completed wound care on Resident 6. The observation of the wound care was as followed: -LPN-C donned (put on) a gown and gloves and entered Resident 6's room with supplies-a barrier was placed on the ground and the old dressing was removed-LPN-C did not change their gloves-the wound was cleaned four different times with ascorbic acid (a standard wound cleanser) soaked gauze, a new gauze was used each time, then dried with a dry gauze-LPN-C then used the soiled gloves to move the resident curtain, doffed (removed) the gloves, completed hand hygiene for 20 seconds but did not have paper towels, doffed gown, did not complete hand hygiene after touching the gown-LPN-C then left the room and obtained more supplies, upon re-entry to resident room, LPN-C donned a new gown and gloves -LPN-C applied cream to the wound with the gloved finger -LPN-C applied two ABD dressings (a very thick, highly absorbent medical pad), kerlix wrap (a type of soft, stretchy medical gauze bandage), and tape -LPN-C did not date or place their initials on the dressing -LPN-C removed the dirty supplies, doffed the gown and gloves -LPN-C then completed hand hygiene for 20 seconds but did not have paper towels An interview on 06/03/2026 at 9:28 AM with LPN-C confirmed that gloves were not changed after the removal of the dirty dressing and before cleaning the wound. LPN-C confirmed that glove change should be completed from dirty to clean. An interview on 06/04/2026 at 7:56 AM with the Administrator confirmed that the expectation of a dressing change would be to remove gloves, perform hand hygiene, and apply new gloves after removing the soiled dressing prior to cleaning the wound and applying a clean dressing.

Licensure reference number 175 NAC 12.006.04(B)(ii)(1) Based on record reviews and interviews the facility failed to ensure staff had the required 12 hours of in-service training for 2 nursing assistants (2 out of 5 sampled) staff. This had the potential to affect all residents in the facility. The facility census was 57. Findings are: Record review of NA-D's Relias (a company that provides healthcare training/education) training hours revealed 8.59 hours of education for the last year (2024). Record review of NA-E's Relias training hours revealed 11.05 hours of education for the last year (2024). Record review of employee names with their hire date revealed NA-D's hire date was 7/11/13 and NA-E's hire date was 12/17/22. Record review of employee's education training for the past year, found NA-D and NA-E did not have the required 12 hours of education yearly. Interview with the IP/SD (Infection Preventionist/Staffing Development) on 1/21/25 at 2:32 PM revealed the facility's year for nurses' aides 12-hour education is from January 1st to December 31st. Interview with the IP/SD on 1/22/25 at 11:04 AM confirmed that NA-D and NA-E did not have 12-hours of education training completed for 2024.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure the microwave, refrigerator, and freezer in the Life Enrichment (activities) kitchen were clean. The facility census was 57. Findings are: A record review of the facility's kitchens Deep Cleaning schedule revealed the microwave and refrigerator/freezer should have been cleaned daily. A record review of the facility's requested last 2 months of the Life Enrichment kitchen's Weekly Cleaning logs dated 11/21/2024 - 01/21/2025 did not reveal they had been completed. An observation on 01/15/2025 at 8:10 AM revealed the Life Enrichment kitchen's microwave had multi-colored food splatters and debris throughout and the residential refrigerator/freezer bottoms and drawers contained food drippings and debris. An observation on 01/15/2025 at 1:36 PM with the facility's Registered Dietician (RD) revealed the Life Enrichment kitchen's microwave had multi-colored food splatters and debris throughout and the residential refrigerator/freezer bottoms and drawers contained food drippings and debris. In an interview on 01/22/2025 at 10:29 AM, the facility's Administrator confirmed 10-12 residents consume food from the Life Enrichment kitchen. In an interview on 01/15/2025 at 1:36 PM with the facility's RD confirmed the Life Enrichment kitchen's microwave had multi-colored food splatters and debris throughout and the residential refrigerator/freezer bottoms and drawers contained food drippings and debris and should have been clean.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on interviews and record reviews the facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) machine for 1 (Resident 11) of 4 sampled residents. The facility census was 57. Findings are: Record review of Resident 11's Clinical Census dated 1/16/25 revealed admission to facility was 12/16/24. Record review of Resident 11's Medical Diagnoses dated 1/15/25 revealed Obstructive Sleep Apnea. Record review of Resident 11's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/20/24 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 9 which indicates moderate cognitive impairment. -Section O Non-invasive Mechanical Ventilator. Record review of Resident 11's Physician's orders dated 1/16/25 revealed: -CPAP on every HS (hour of sleep) for sleep apnea, per home settings, on at HS, off in AM, every morning and at bedtime for Sleep apnea On HS; Off AM Record review of Resident 11's Physician orders, care plan, treatment administration record dated 1/16/25 revealed there were no settings for resident's CPAP. Interview with ADON on 1/21/25 at 9:25 AM revealed that ADON that there was no settings for Resident 11's CPAP. Record review of the facilities Your CPAP/Bi-Level Unit undated education revealed no instructions regarding the CPAP settings.

Licensure Reference Number 175 NAC 12-006.10 Based on observation, interview, and record review, the facility failed to provide rational and justification to extend 1 (Resident 30) of 5 sampled resident's as needed (PRN) Alprazolam (Xanax)(an anti-anxiety medication) beyond 14 days. The facility census was 57. Findings are: A record review of the facility's Psychoactive Medication and Medication Regimen Review Management Standard dated 09/2024 revealed that an indication for use was: the identified, documented clinical rational for administering a medication based upon an assessment of the resident's condition. An unnecessary drug was when a drug was ordered for an excessive duration, or without adequate indications for its use, or without adequate monitoring. A record review of Resident 30's Clinical Census dated 01/16/2025 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital on 08/23/2024 and returned to the facility on [DATE]. A record review of Resident 30's Medical Diagnosis dated 01/11/2025 revealed the resident had diagnoses of Anxiety Disorder, Pain, Dementia (confusion) without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), and Pneumonia. A record review of Resident 30's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/29/2024 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 supervision and assistance with oral hygiene (cleaning), partial/moderate assistance for upper body dressing, and substantial/maximal assistance with toileting, bathing, lower body dressing and footwear. The resident had Anxiety and was on an antianxiety medication. A record review of Resident 30's Care Plan with an admitted [DATE] revealed a focus area of uses psychoactive medications (medications that alter mood and perception) related to Anxiety and an intervention of antianxiety adverse effects - monitor/document/report PRN: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, light-headedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, and blurred vision. Unexpected side effects: mania (extreme mood swings), hostility, rage, aggressive behavior, and hallucinations. Attempt non-pharmacological interventions prior to administering PRN psychoactive medications. A record review of Resident 30's Order Summary Report dated 01/16/2025 revealed the resident had physician orders for: Alprazolam Oral Tablet 0.5 milligram (MG) 2 times per day (BID) for Anxiety **Time of administration specifically ordered by PCP (Primary Care Physician or Provider)** Prescriber Written 08/30/2024 Alprazolam Oral Tablet 0.5 MG give 1 tablet by mouth every 8 hours as needed for Anxiety for 6 Months **May take two hours after scheduled dose of administration** Prescriber Written 08/30/2024 and set to end 02/28/2025 A record review of the facility's Physician Visit/Communication Form dated 08/30/2024 revealed the facility notified the physician that Resident 30 and the resident's spouse requested Xanax at 10:00 AM, at bedtime, and PRN. The physician agreed, signed, and dated the form, but did not include rational as to why the resident needed the PRN Xanax for more than the allowed 14 days. A record review of Resident 30's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated November 2024 - January 2025 revealed the facility administered PRN Xanax to the resident on the following dates: 11/21/2024 11/08/2024 11/02/2024 11/01/2024 12/02/2024 - No documented out of character behaviors 12/05/2024 - Documented out of character behaviors 01/11/2025 - No documented out of character behaviors 01/13/2025 - No documented out of character behaviors 01/16/2025 - Documented out of character behaviors A record review of Resident 30's Behavior/Intervention Monthly Flow Record Dated November 2024 did not reveal the resident had documented behaviors on: 11/21/2024 11/08/2024 11/02/2024 A record review of Resident 30's Progress Notes Dated 01/22/2025 did not reveal the resident had documented behaviors on: 11/21/2024 11/08/2024 11/02/2024 12/02/2024 01/11/2025 01/13/2025 An observation on 01/15/2025 at 11:43 AM revealed Resident 30 was sitting in a recliner in the room. Resident was very pleasant and appeared calm and in no distress. An observation on 01/16/2025 at 8:41 AM revealed Resident 30 was sitting in the room straightening the blankets on the bed. Resident appeared calm and in no distress. In an interview on 01/22/2025 at 10:49 AM, the facility's Administrator confirmed the Administrator reviewed Resident 30's progress notes and behavior monitoring, and the physician communication forms related to the PRN Xanax order. The Administrator confirmed the physician did not document rational for ordering Xanax PRN for greater than 14 days and should have. The Administrator confirmed behaviors were not documented to justify the use for the Xanax that was administered on the following dates and there should have been: 11/21/2024 11/08/2024 11/02/2024 12/02/2024 01/11/2025 01/13/2025

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review, observations and interviews, the facility failed to ensure 2 residents (Resident 5 and 36) out of 4 sampled residents were free of a significant medication error. The facility census was 57. Findings are: A. A record review of the facility's Oral Drug Administration policy dated 5/20/24 revealed: -Verify the order on the patient's medication administration record by checking it against the practitioners orders. -Check the expiration date on the medication. -Visually inspect the medication for particles, discoloration, or other loss of integrity -Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors. An observation on 01/16/25 at 8:07 AM revealed the Registered Nurse (RN) opened the narcotic drawer from the medication cart and taking one Phenobarbital 32.4 mg pill out of the medication pack (A blister pack is a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) and put the Phenobarbital pill in a plastic medication cup. The RN then signed out the Phenobarbital and took the Phenobarbital pill to Licensed Practical Nurse (LPN-A). The LPN-A put the medication cup with the Phenobarbital pill in the medication cart for Resident # 5. LPN-A signed (genders) name besides the RN in the narcotic book for the Phenobarbital. An observation on 1/16/25 at 8:15 with the LPN-A revealed that the LPN-A administered the Phenobarbital to Resident #5 per peg tube (a thin, flexible tube surgically inserted through the abdominal wall and into the stomach as an alternative route for delivering nutrition, fluids, and medications directly into the stomach). An interview on 1/16/25 at 8:30 AM with the RN confirmed that (gender) should not have pulled the Phenobarbital out of the medication pack unless that nurse was going to be giving the medication themselves. RN confirmed that (gender) should not have given the Phenobarbital to the LPN-A . An interview on 1/16/25 at 8:30 AM with the LPN-A confirmed that (gender) did administer the Phenobarbital to Resident # 5. LPN-A confirmed that (gender) did not remove the Phenobarbital from the narcotic drawer. The LPN-A confirmed (gender) did not compare the label with the medication record. The LPN-A confirmed that this is the normal practice with giving Resident # 5 medications. An interview on 01/16/25 at 1:34 PM with Infection Preventionist/Staff Development (IP/SD) confirmed that the expectations during a medication pass is that the nurse who is pulling the medication out of the narcotic box is the nurse who is administrating the medication. The nurse pulling the medications out of a narcotic box should not give the narcotic to another nurse to administer. 47406 B. Record review of Resident 36's Clinical Census admission was 1/7/22. Record review of Resident 36's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/6/24 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 11, which indicates moderate cognitive impairment. -Section N: Indicates that the resident is Hypoglycemic (has low blood sugar) . Record review of Resident 36's Diagnosis list dated 1/16/25 revealed Type 2 Diabetes Mellitus without complications. Record review of Resident 36's Physician's orders dated 1/16/25 revealed: - Basaglar KwikPen Subcutaneous Solution Pen-injector 100 Unit/ML (Insulin Glargine) Inject 50 units subcutaneously at bedtime for diabetes. -NovoLOG Injection Solution 100 Unit/ML (Insulin Aspart) Inject 6 units subcutaneously before meals for diabetes, administer with sliding scale-Fiasp Flex pen equivalent. -NovoLOG Injection Solution 100 Unit/ML (Insulin Aspart), Inject as per sliding scale: 151-200 = 4; 201 - 250 = 8; 251 - 300 = 10; 301 - 350 = 12; 351 - 425 = 15; 426 - 500 = 18; 501 - 650 = 20; 651 - 800 = 22 notify Dr. if blood sugar below 50 and above 400, subcutaneously four times a day for diabetes. Administer with scheduled dose= Fiasp Flex pen equivalent Observation on 1/16/25 at 12:09 PM of Resident 36's insulin administration and obtaining BS (blood sugar) by LPN-B. LPN-B obtained the BS from right forefinger after cleansing with alcohol wipe with results 367. LPN-B prepared 6 units Novolog and 15 units sliding scale Novolog totaling 21 units without priming needle and gave in resident's left lower abdomen after cleansing with alcohol wipe. Interview on 1/16/25 at 12:12 PM with LPN-B revealed that [gender] was taught to prime the insulin pen the first time the pen was opened and did not have to prime after that for any other times used. Interview on 1/21/25 at 11:56 AM with Interim DON revealed that the nurse needed to prime the pre-filled insulin pens prior to setting the dose at each administration to ensure that the correct amount of insulin is administered. Record review of Pre-filled Insulin Pen Competency Policy dated 1/2020 revealed: Important notes: Use a new needle for each injection, making sure it is completely attached to the pen before priming, setting the dose and injecting the insulin. Procedure Step: 10. To prime the pen, make sure the arrow is in the center of the dose window. (If you do not see the arrow in the center of the dose window, push in the injection button fully and turn the dose knob until the arrow is seen in the center of the dose window.) 11. Pull the dose knob out in the direction of the arrow until a 0 is seen. 12. Turn the dose knob clockwise until the number 2 is seen. (If the number dialed is too high, simply turn the dose knob backward until the number 2 is seen.) 13. Hold the pen with the needle pointing straight up, tapping the clear cartridge holder so any air bubbles collect near the top. Push the injection button completely using thumb. Keep pressing and continue to hold the injection button firmly. A stream of insulin should come out of the tip of the needle. (If the stream of insulin does not come out, repeat above steps. If after 6 attempts a stream of insulin does not come out the tip of the needle, change the needle. If still unable to get insulin flowing out of the needle, do not use the pen and contact pharmacy).

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure food in the Life Enrichment refrigerator and freezer were labeled with the resident's name and dated. The facility census was 57. Findings are: A record review of the facility's Visitor Food policy revealed that food stored for residents needed to be labeled, dated, and stored safely in designated area per facility policy following the food safety guidelines for personal food. An observation on 01/15/2025 at 8:10 AM revealed the Life Enrichment (activities) kitchen residential refrigerator/freezer contained: 1 plastic container of grapes not labeled, dated, or sealed 1 purple/pink/white cake light covered in plastic wrap not labeled, dated or sealed 1 plastic wrapped white cheese that had a resident's name first name on it, no date 1 sealed package of beef snack sticks that had a resident's first name on it, no date 1 container Coffee Ice Cream with a resident's first name on it, no date 1 container Rocky Road Ice cream had a resident's first name on it, no date 1 container Vanilla Bean ice cream had a resident's first name on it, no date An observation on 01/15/2025 at 1:36 PM with the facility's Registered Dietician (RD) revealed the Life Enrichment kitchen residential refrigerator/freezer contained: 1 plastic container of grapes not labeled, dated, or sealed 1 purple/pink/white cake light covered in plastic wrap not labeled, dated or sealed 1 plastic wrapped white cheese that had a resident's name first name on it, no date 1 sealed package of beef snack sticks that had a resident's first name on it, no date 1 container Coffee Ice Cream with a resident's first name on it, no date 1 container Rocky Road Ice cream had a resident's first name on it, no date 1 container Vanilla Bean ice cream had a resident's first name on it, no date An observation on 01/16/25 08:37 AM revealed the Life Enrichment (activities) kitchen residential refrigerator/freezer contained: 1 pack of white cheese in a plastic wrap labeled with a resident's first name, no date 1 pack of beef meat sticks labeled with a resident's first name, no date In an interview on 01/15/2025 at 1:36 PM with the facility's RD confirmed the Life Enrichment kitchen residential refrigerator/freezer contained: 1 plastic container of grapes not labeled, dated, or sealed 1 purple/pink/white cake light covered in plastic wrap not labeled, dated or sealed 1 plastic wrapped white cheese that had a resident's name first name on it, no date 1 sealed package of beef snack sticks that had a resident's first name on it, no date 1 container Coffee Ice Cream with a resident's first name on it, no date 1 container Rocky Road Ice cream had a resident's first name on it, no date 1 container Vanilla Bean ice cream had a resident's first name on it, no date The RD confirmed the items should have been sealed, labeled with the resident's name, and dated with the date it was placed in the refrigerator/freezer and was not.

Licensure reference number 175 NAC 12-006.17 Based on observations, record reviews, and interviews, the facility failed to ensure Resident 11's catheter drainage bag was off the floor, ensure staff wore gloves when touching Resident 4's catheter tube, use infection control technique when removing cleansing wipes, provide activities of daily living cares for Resident 4 without performing hand hygiene, and failed to clean Resident 2, 22, and 50's nebulizer kits to prevent potential cross contamination. The facility census was 57. Findings are: A. Record review of Resident 4's Clinical Census dated 1/16/25 revealed resident admitted to the facility on [DATE]. Observation of Resident 4 on 01/15/25 at 9:45 AM revealed slightly cloudy urine in catheter tubing. Record review of Resident 4's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/20/24 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 13, which indicated that the resident's cognition is intact. Record review of Resident 4's physician's orders dated 1/16/25 revealed: -Macrobid Oral Capsule 100 mg (milligram), Give 100 mg by mouth two times a day for Urinary Tract Infection until 01/21/2025 - Start Date- 01/14/2025. -Change indwelling catheter monthly and PRN(as needed) inability to drain every day shift starting on the 1st and ending on the 1st every month for wound healing. Medical justification/diagnosis: Nonhealing wound related to constant moisture form incontinence Indwelling catheter: Catheter size 16fr/30cc balloon Irrigate as needed. -Catheter cares two times a day related to Type 2 Diabetes Mellitus with Hyperglycemia. Interview on 1/21/25 at 10:50 AM with LPN-B revealed Resident 4's catheter was placed on 12/31/24 to assist with promoting wound healing. Observation of catheter cares for Resident 4 on 1/21/25 at 8:33 AM by NA-C revealed the following. NA-C had gown and gloves on when surveyor arrived in room. NA-C removed resident's pullup (incontinence product) and placed the catheter drainage bag on the foot of bed. NA-C took a cleansing wipe out of the wipes container using the contaminated glove. NA-C wiped left groin with wipe and turned it over and cleansed the right groin, then threw it away in the trash. NA-C took another wipe out of container using the same glove and cleansed underneath meatus opening and perineal care, then threw the wipe away. NA-C took another wipe using the same glove and wiped around catheter tubing at meatus opening and threw wipe away. NA-C took another wipe from container with same glove and cleansed catheter tube from meatus down about 4 inches and threw the wipe away. NA-C assisted putting a new pullup on. NA-C removed [gender] gloves without performing hand hygiene and assisted resident to sit up on edge of bed and put on pants. NA-C placed a gait belt on resident and transferred the resident into wheelchair using walker. NA-C placed the catheter drainage bag under the wheelchair in the privacy bag while touching the catheter tubing without gloves on. NA-C took gown off and pushed resident into bathroom. NA-C touched [gender] own hair. NA-C did not perform hand hygiene. NA-C handed resident a comb, hearing aids and eyeglasses. NA-C took resident to the dining room for breakfast without performing hand hygiene. Interview with interim DON on 1/21/25 at 11:00 am confirmed that staff should not take a cleansing wipe out of the wipe container using a contaminated glove, pick up catheter tubing without gloves, touch their own hair or do other activities of daily living without hand hygiene, and that staff should wash hands when finished with catheter cares and when removing gloves. Interview with NA-C on 1/21/25 at 11:20 AM confirmed NA-C should not take a cleansing wipe out of the wipe container using a contaminated glove, touch their own hair, do other activities of daily living without hand hygiene, and needed to wash hands when finished with catheter cares and when removing gloves. Record review of facility's Handwashing Competency policy dated 8/2013 revealed: When to wash hands: -After touching a resident or handling their belongings -Whenever hands are soiled -After any contact with body fluids -After handling contaminated items (linens/garbage/briefs, etc.) -Before and after gloving -Whenever indicated Record review of facility's Foley Catheter Care Competency policy revised 7/2009 revealed: Procedure Step: 12. Remove gloves and wash hands. Record review of Enhanced Barrier Precautions (EBP) policy dated 4/12/24 revealed: Definitions: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs the use of gown and glove use during high contact resident cares. High contact resident care activities include: -Providing hygiene -Dressing -Transferring -Changing briefs or assisting with toileting -Device care or use for central lines including PIIC lines, urinary catheters, feeding tubes, tracheostomy tubes B. Record review of Resident 11's Clinical Census dated 1/16/25 revealed resident admitted to the facility on [DATE]. Observation on 1/15/25 at 1:07 PM of Resident 11's catheter drainage bag tubing had dark yellow urine with sediment. Record review of Resident 11's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/20/24 revealed: -Section C: BIMS 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 9 which indicates moderate cognitive impairment. -Section H: urinary catheter. Record review of Resident 11's Physician's orders dated 1/16/25 revealed: - Foley catheter coude- replace Foley monthly, catheter cares every shift, gets changed at urology per wife. Record review of Resident 11's Medical Diagnosis dated 1/16/25 revealed Obstructive and Reflux Uropathy (refers to a condition where urine flow is blocked within the urinary tract). Observation on 1/21/25 at 7:45 AM with NA-C for catheter cares for Resident 11 revealed the following. NA-C had gown and gloves on when surveyor entered room. Resident walked to the bathroom with walker and sat on toilet. NA-C took the catheter bag off the walker and placed it on the bare floor. NA-C did not do hand hygiene or apply new gloves. NA-C took a cleansing wipe from the wipes container and was touching the edges of the container, cleansed the right groin and turned the wipe over and cleansed the left groin. NA-C took another wipe from container with the same glove and cleansed resident's genital area. NA-C took a cleansing wipe from the wipe container touching the edges of the container and cleansed catheter tubing from meatus down tubing approximately 4 inches. NA-C placed the catheter bag onto walker and assisted resident with new pull up. NA-C performed hand hygiene with soap and water for 18 seconds. Interview with interim DON on 1/21/25 at 11:00 AM revealed that staff is to keep the catheter bag off the floor, not use contaminated gloves to take cleansing wipes from the wipes container. Interview with NA-C on 1/21/25 at 11:21 AM confirmed [gender] should have kept the catheter bag off the floor and not use the same gloves to take cleansing wipe from the wipe container. Interview with Administrator on 1/21/25 at 1:55 AM revealed that the facility did not have a Catheter policy. Record review of Foley Catheter Care Competency education dated 7/2009 revealed: 10. Check the drainage tubing and bag to ensure proper positioning and drainage. Record review of Resident Handwashing Competency policy dated 8/2013 revealed: When to wash hands: -After touching a resident or handling their belongings -Whenever hands are soiled -After any contact with body fluids -After handling contaminated items (linens/garbage/briefs, etc.) -Before and after gloving -Whenever indicated Record review of Enhanced Barrier Precautions (EBP) policy dated 4/12/24 revealed: Definitions: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs the use of gown and glove use during high contact resident cares. High contact resident care activities include: -Providing hygiene -Dressing -Transferring -Changing briefs or assisting with toileting -Device care or use for central lines including PICC (peripherally inserted central catheter) lines, urinary catheters, feeding tubes, tracheostomy tubes (a tube inserted into the windpipe through a surgcally created opening in the neck). 48271 C. A record review of the facility's Nebulizer Therapy (medication delivered to the resident's lungs), small volume policy dated November 17, 2017, revealed after the nebulizer treatment, staff were to rinse the nebulizer with sterile water and allow it to air-dry, or discard it after the treatment. A record review of Resident 50's Order Summary Report dated 01/21/2025 revealed the resident had physician orders for: -Ensure O2 tank is off and has O2 for the morning and (REPLACE if empty!) every evening shift for nursing order. -DuoNeb Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally via nebulizer four times a day for shortness of breath, prescriber written 11/13/2024. An observation on 01/15/2025 at 8:18 AM revealed Resident 50's nebulizer kit was laying on the bedside table with a residual amount of medication in it and facial oils on the mask. An observation on 01/15/25 at 08:19 AM revealed Resident 50's oxygen concentrator was on in the bathroom and oxygen tubing was hanging over chair in room. Resident 50 was sitting in the dining room. An observation on 01/16/25 at 10:15 AM revealed Resident 50's nebulizer kit was laying on the bedside table with a residual amount of medication in it and facial oils on the mask. An observation on 01/16/25 at 08:30 AM revealed Resident 50's oxygen concentrator was on in the bathroom and oxygen tubing was hanging over chair in room. Resident 50 was sitting in the dining room. An observation on 1/21/25 at 8:51 AM revealed Resident 50's oxygen concentrator was in the bathroom still running and oxygen tubing was draped over the chair. An observation on 1/21/25 at 8:51 AM revealed that Resident 50's nebulizer kit was laying on the bedside table with a residual amount of medication in it and facial oils on the mask. An interview on 1/21/25 at 11:00 AM with the ADON confirmed that the nebulizer mask had residual medication amount in the medicine cup and the medicine cup should be cleaned after each use and it wasn't cleaned after use. ADON confirmed that the oxygen concentrator should be turned off when not in use and it was not turned off when not in use. ADON confirmed that Resident 50 changes from the oxygen concentrator to the oxygen portable tank themselves and places the oxygen tubing over the chair. 45641 D. A record review of the facility's Nebulizer Therapy (medication delivered to the resident's lungs), small volume policy dated November 17, 2017, revealed after the nebulizer treatment, staff was to rinse the nebulizer with sterile water and allow it to air-dry, or discard it after the treatment. A record review of Resident 2's Order Summary Report dated 01/21/2025 revealed the resident had physician orders for: DuoNeb Solution 0.5-2.5 (3) milligrams (MG)/3 milliliter (ML), (Ipratropium-Albuterol)(a medication used to relax the muscle around the tubes in the lungs) 1 vial inhale orally via nebulizer every 6 hours as needed for cough, shortness of breath, prescriber written 05/28/2024 DuoNeb Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally via nebulizer three times a day for cough, shortness of breath, prescriber written 01/08/2025 An observation on 01/15/2025 at 11:53 AM revealed Resident 2's nebulizer kit was laying on the bedside table with a residual amount of medication in it and facial oils on the mask. An observation on 01/21/2025 at 10:43 AM revealed Resident 2's nebulizer kit was laying on top of the nebulizer machine on the bedside table with a residual amount of medication in it and facial oils on the mask. An observation on 01/21/2025 at 11:02 AM with the facility's Assistant Director of Nursing (ADON) revealed Resident 2's nebulizer kit was laying on top of the nebulizer machine on the bedside table with a residual amount of medication in it and facial oils on the mask. In an interview on 01/21/2025 at 11:02 AM, the facility's ADON confirmed Resident 2's nebulizer kit was laying on top of the nebulizer machine on the bedside table with a residual amount of medication in it and facial oils on the mask and it should have been cleaned after the treatment. E. A record review of the facility's Nebulizer, small volume policy dated November 17, 2017, revealed after the nebulizer treatment, staff was to rinse the nebulizer with sterile water and allow it to air-dry, or discard it after the treatment. A record review of Resident 22's Order Summary Report dated 01/21/2025 revealed the resident had physician orders for: DuoNeb Solution 0.5-2.5 (3) MG/3 ML, 1 vial inhale orally via nebulizer every 6 hours as needed for cough, shortness of breath, prescriber written 05/23/2024 DuoNeb Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally via nebulizer two times a day for cough, shortness of breath, mucus, prescriber written 09/27/2024 An observation on 01/15/2024 at 10:01 AM revealed Resident 22's nebulizer kit was laying on the bed with a small amount of medication remaining in the cup and facial oils on the mask. An observation on 01/21/2025 at 10:51 AM revealed Resident 22's nebulizer kit was draped over the oxygen concentrator (a machine used to purify oxygen) with a residual amount of medication in the cup. An observation on 01/21/2025 at 10:57 AM with the ADON revealed Resident 22's nebulizer kit was draped over the oxygen concentrator with a residual amount of medication in the cup. In an interview on 01/21/2025 at 10:57 AM, the ADON confirmed Resident 22's nebulizer kit was draped over the oxygen concentrator with a residual amount of medication in the cup and was not clean. The ADON's expectation was after the nebulizer treatment, the staff would clean, dry, and place the nebulizer kit in a bag.

Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review, the facility failed to ensure items stored in the facility's refrigerators and freezers were labeled and dated, ensure kitchen staff performed handwashing for at least 20 seconds, ensure floors in the dry storage and walk-in refrigerator and freezer were clean, and failed to test the sanitizing solution in the sanitizing bucket to prevent potential foodborne illness. This had the potential to affect 59 of the facility's 60 residents that consumed food from the kitchen. The total facility census was 60. Findings are: A. A record review of the facility's undated Labeling and Dating Foods (Date Marking) revealed in the dry storage, individual items would be marked with the date the item was received into the facility. Refrigerated and freezer storage items would be re-dated with a use by date once opened. Prepared food items should be discarded if it doesn't have a specific manufacturer date and has been refrigerated for 7 days, leftover for more than 72 hours, or expired. An observation on [DATE] at 7:52 AM kitchen revealed: -1 opened white plastic container of chicken base on the prep table shelf not dated -1 opened bag of mozzarella cheese in the reach-in refrigerator un-dated -1 opened bag of dry mashed potatoes closed with tape on the dry shelf next to the reach-in refrigerator not dated -Walk-In Refrigerator: -1 each 18-quart clear container with lid had an orange substance in in not labeled or dated -1 opened and taped closed bag of shredded lettuce not labeled or dated -1 opened and taped shut bag of cabbage not labeled or dated -1 opened and taped shut bag of shredded carrots not labeled or dated -1 opened bag of Sysco Reliance Whipped Topping not dated -2 opened containers Resers Deli Salads not dated -1 opened container Len's Classic [NAME] not dated -Locked Dry Storage: -1 opened bag and closed with tape Pasta La [NAME] Enriched Noodle Product not dated -1 opened bag and closed with tape Pasta La [NAME] Macaroni Product not dated An observation on [DATE] at 8:42 AM with the facility's cook revealed the all the items list above were not labeled or dated. In an interview on [DATE] at 8:42 AM, the facility's cook confirmed the above listed items had been opened and not been labeled or dated. In an interview on [DATE] at 12:01 PM, The facility's Registered Dietician (RD) confirmed all the items listed above should have been labeled or dated after being opened. B. A record review of undated Visitor Food policy revealed food stored for the residents needed to be labeled and dated and stored safely in the designated area. A record review of the facility's undated, unnamed sign located on the front of the side-by-side refrigerator/freezer revealed: All items in the freezer and refrigerator must be in a covered container and have a name and date. No metal cans are allowed. All open food/leftovers will be thrown away after 3 days or after the expiration date on the container. An observation on [DATE] at 9:56 AM revealed the side-by-side refrigerator/freezer in the North dining room of the Cardinal unit contained: -a bowl covered with plastic wrap labeled with a resident's name and room number was not dated -1 green cup with a white lid did not reveal a name or date -1 opened pop bottle labeled Fanta Orange had a sticky note with a resident's 1st name but no date -1 ice cream cake labeled with a resident's 1st name; last initial was dated ,d+[DATE] -1 cup of a frozen orange frozen substance was not labeled or dated In an interview on [DATE] at 10:16 AM, the RD confirmed the RD observed the items in the side-by-side refrigerator/freezer and the items where not labeled and dated correctly and should have been. C. A record review of the facility's undated Handwashing Techniques revealed the staff should wet hands, apply soap, and scrub hands and arms vigorously for 20 seconds, then rinse. Food handlers must wash hands before start work and after, after using the restroom, when handling raw food, and after touching hair, face, or body, etc. Food handlers should change their gloves before beginning a different task and after handling ready to eat food. A record review of the Handwashing Competency dated ,d+[DATE] revealed the facility staff should have wet hands, apply soap and lather, and rubbed hands together for a full 20 seconds. Staff should have performed handwashing after handling contaminated items and before applying and after removing gloves. An observation on [DATE] at 10:30 AM revealed the facility's Cook tested the temperature (temped) the chicken breast, wiped the thermometer (temp) probe, performed handwashing for 12 seconds and applied gloves. The Cook then performed mechanical process of the chicken, covered with foil, labeled, removed gloves and placed the pan on the steam table prior to preparing chicken broth without handwashing. The Cook then applied gloves, did not perform handwashing, and pureed the chicken breast. The Cook disassembled the blender and ran the blender parts through the dish sanitizer, removed the parts and applied gloves without handwashing, and re-assembled the blender. The Cook then pureed the cauliflower and dumped in a steam pan, covered with foil, labeled and dated, placed in the warmer, got the stuffing, temped the stuffing, got a steam pan from the dishwashing room, went a got food from the walk-in refrigerator, applied gloves, and dumped the stuffing in the blender, all without handwashing. Pureed the stuffing and dumped the blender of stuffing in the steam pan, removed gloves, cover the steam pan with foil, labeled and dated, and put the steam pan in the warmer, without handwashing. In an observation of food preparation on [DATE] at 9:00 AM revealed the Cook changed gloves 5 times during the food preparation process without handwashing. In an interview on [DATE] at 11:20 AM, the RD confirmed the Cook should have applied soap and lathered for at least 20 seconds during food temping and preparation and before and after glove changes. D. An observation on [DATE] at 7:52 AM revealed the floor in the walk-in refrigerator had a gray coating and multiple 2-[NAME] cart tracks through the gray fuzzy substance. The walk-in freezer floor had a gray fuzzy substance on it with scattered frozen French fries and drippings from the meat. The floors in the locked dry storge room had a gray fuzzy substance on them and multiple 2-[NAME] cart tracks from the door to the can racks. In and interview with the Cook on [DATE] at 8:42 AM, the Cook confirmed the Cook observed the floors in the walk-in refrigerator, walk-in freezer, and locked dry storage floors were dirty and should have been clean. In an interview on [DATE] at 11:20 AM, the RD confirmed the floors in the walk-in refrigerator, walk-in freezer, and locked dry storage floors were dirty and should have been clean. E. A record review of the undated EcoLab's Sink and (&) Surface Cleaner Sanitizer Test Strips How-to Guide revealed the Dodecyl Benzene Sulfonic Acid (DDBSA)(a sanitizing chemical) of the Sink & Surface Cleaner Sanitizer should have been between 272 and 700 parts per million (PPM). An observation on [DATE] at 8:27 AM revealed the Cook took a rag from the sanitizing bucket and wiped the prep table but did not reveal the Cook tested the sanitizing buckets for the active range of DDBSA. A record reveal of the kitchen's logbooks with multiple dates, did not reveal a log for the testing of the sanitizing bucket. In an interview on [DATE] at 8:27 AM, the Cook confirmed she had wiped the food preparation table with a rag from the sanitizing bucket. The cook confirmed the Cook does not test the dilution of the sanitizing bucket and has not tested since re-hired in [DATE] and should have tested the dilution of the bucket to ensure the sanitizer was effective. In an interview on [DATE] at 11:20 AM, the RD confirmed the kitchen sanitizing bucket should have been tested twice a day and was not.

Licensure Reference Number 175 NAC 12.006.17B Based on observation, interview, and record review, the facility failed to ensure the oxygen concentrator's (a machine used to deliver purified oxygen) cabinet filters were present and clean for 4 residents (Residents 2, 4, 31, and 60) of 5 sampled residents, ensure 2 residents (Residents 2 and 60) of 2 sampled resident's positive airway pressure device (PAP) masks were cleaned daily, and ensure 1 resident (Resident 20) of 2 sampled resident's PAP filter was clean. The total facility census was 60. Findings are: A. A record review of the undated Platinum Series XL, 5, 10 Operators Manual revealed there were cabinet filters on both sides of the unit that should have been removed and cleaned at least once a week. https://www.invacare.com/product_files/1106664.pdf A record review of Resident 2's Order Summary Report dated 02/13/2024 revealed orders of: BiPAP (a machine used to treat sleep apnea) at night with oxygen at 2 liters per minute (l/m) and External Filter: Rinse weekly (Saturdays), let dry and Replace every evening shift Sat. A record review of Resident 2's Treatment Administration Record (TAR) dated [DATE], [DATE], and [DATE] revealed the order of: External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat was marked completed every Saturday, and was last marked completed Saturday 02/10/2024. The TAR revealed Resident 2 used the oxygen every night the resident was at the facility. An observation on 02/07/2024 at 9:24 AM revealed Resident 2 had an Invacare Platinum XL oxygen concentrator in the room that was connected to the PAP and the cabinet filters on each side of the unit were missing. An observation on 02/07/2024 at 1:36 PM revealed Resident 2 had an Invacare Platinum XL oxygen concentrator in the room that was connected to the PAP and the cabinet filters on each side of the unit were missing. In an interview on 02/07/2024 at 1:36 PM, Resident 2 confirmed the oxygen concentrator and PAP was used every night. An observation on 02/08/2024 at 1:27 PM revealed Resident 2 had an Invacare Platinum XL oxygen concentrator in the room that was connected to the PAP and the cabinet filters on each side of the unit were missing. An observation on 02/12/2024 at 7:16 AM revealed the Invacare Platinum XL oxygen concentrator was in the hall by Resident 2's door and the cabinet filters on the unit were missing. In an interview on 02/12/2024 at 7:16 AM, Resident 2 confirmed the staff changed the oxygen concentrator that was in the room because they told [gender] that it didn't have filters. In an interview on 02/08/2024 at 01:27 PM, RN-B confirmed the staff cleaned the filters on the oxygen concentrators every Saturday on the night shift. When the staff took an oxygen concentrator out of the room, the staff should have cleaned the unit and cleaned and replaced the filters. In an interview on 02/12/2024 at 12:47 PM, Registered Nurse (RN-A) confirmed Resident 2's Invacare Platinum XL oxygen concentrator did not have the cabinet filters. In an interview on 02/12/2024 at 1:50 PM, the Assistant Director of Nursing (ADON) confirmed the Invacare Platinum XL oxygen concentrator was in Resident 2's room and it did not have the external cabinet filters and should have. The ADON confirmed the external cabinet filters should have been cleaned and replaced every week. The ADON confirmed the internal filter was very gray and fuzzy and should not have been. B. A record review of the undated Platinum Series XL, 5, 10 Operators Manual revealed there were cabinet filters on both sides of the unit that should have been removed and cleaned at least once a week. https://www.invacare.com/product_files/1106664.pdf A record review of Resident 4's Order Summary Report dated 02/12/2024 revealed orders of: Apply oxygen at 0.5 - 2 l/m as needed at hours of sleep (HS) and remove in the morning after the breathing treatment and External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat for infection prevention. A record review of Resident 4's TAR dated [DATE] and [DATE] revealed the order of: External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat for infection prevention was marked completed every Saturday, and was last marked completed Saturday 02/10/2024. The Tar revealed the resident did have the oxygen applied on: -02/01/2024 -02/02/2024 -02/03/2024 -02/04/2024 -02/06/2024 -02/07/2024 -02/08/2024 -02/12/2024 An observation on 02/07/2024 at 9:42 AM revealed Resident 4 had an Invacare Platinum XL oxygen concentrator in the room that had a nasal cannula (NC)(a tube used to deliver oxygen to the nose) and the cabinet filters on each side of the unit were missing. An observation on 02/08/2024 at 7:22 AM revealed Resident 4 had an Invacare Platinum XL oxygen concentrator in the room that had a NC and the cabinet filters on each side of the unit were missing. In an interview on 02/08/2024 at 01:27 PM, RN-B confirmed the staff cleaned the filters on the oxygen concentrators every Saturday on the night shift. In an interview on 02/12/2024 at 12:47 PM, Registered Nurse (RN-A) confirmed Resident 4's Invacare Platinum XL oxygen concentrator did not have the cabinet filters. In an interview on 02/12/2024 at 1:34 PM, the Assistant Director of Nursing (ADON) confirmed the Invacare Platinum XL oxygen concentrator was in Resident 4's room and it did not have the external cabinet filters and should have. The ADON confirmed the external cabinet filters should have been cleaned and replaced every week. The ADON confirmed the internal filter was very gray and fuzzy and should not have been. C. A record review of Resident 31's Order Summary Report dated 02/08/2024 revealed orders of: Apply oxygen at 1-3 liters per minute as needed and External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat. A record review of Resident 31's Treatment Administration Record (TAR) dated [DATE] and [DATE] revealed the order of: External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat was marked completed every Saturday, and was last marked completed Saturday 02/10/2024. The TAR did not reveal the resident was using oxygen. An observation on 02/07/2024 at 9:24 AM revealed Resident 31 had an oxygen concentrator was on and the Resident had the NC in the nose. The oxygen concentrator was set at 1 liters per minute (l/m). The cabinet filter on left side of the unit was missing. In an interview on 02/07/2024 at 10:32 AM, Resident 31 confirmed [gender] used the oxygen most days when the [gender] felt it was needed. An observation on 02/08/2024 at 7:50 AM revealed Resident 31 had an oxygen concentrator was on and the Resident had the NC in the nose. The oxygen concentrator was set at 1 l/m. The cabinet filter on left side of the unit was missing. In an interview on 02/08/2024 at 01:27 PM, RN-B confirmed the staff cleaned the filters on the oxygen concentrators every Saturday on the night shift. In an interview on 02/12/2024 at 12:47 PM, Registered Nurse (RN-A) confirmed Resident 31's oxygen concentrator did not have the cabinet filter. In an interview on 02/12/2024 at 1:34 PM, the Assistant Director of Nursing (ADON) confirmed Resident 31's oxygen concentrator was being used by Resident 31, and it did not have the external cabinet filter and should have. The ADON confirmed the external cabinet filters should have been cleaned and replaced every week. D. A record review of the undated Invacare Perfecto2 V Oxygen Concentrator manual revealed there were cabinet filters on both sides of the unit that should have been removed and cleaned at least once a week. https://www.invacare.com/product_files/1106664.pdf A record review of Resident 60's Clinical Census dated 02/08/2024 revealed the Resident was admitted to the facility on [DATE]. A record review of Resident 60's Order Summary Report dated 02/08/2024 revealed orders of: 4 l/m of oxygen bled into CPAP every HS and did not reveal an order to clean and replace the oxygen concentrator filter. A record review of Resident 60's TAR dated [DATE] revealed the Resident's oxygen was applied every night 02/06/2024 - 02/12/2024. An observation on 02/07/2024 at 12:31 PM revealed Resident 60 had an Invacare Perfecto2 V oxygen concentrator in the room that was connected to the PAP and the cabinet filter was coated with a gray fuzzy substance. An observation on 02/08/2024 at 7:25 AM revealed Resident 60 had an Invacare Perfecto2 V oxygen concentrator in the room that was connected to the PAP and the cabinet filter was coated with a gray fuzzy substance. In an interview on 02/08/2024 at 7:25 AM, Resident 60 confirmed the oxygen and PAP were used nightly. In an interview on 02/08/2024 at 1:27 PM, RN-B confirmed the staff cleaned the filters on the oxygen concentrators every Saturday on the night shift. In an interview on 02/12/2024 at 12:47 PM, Registered Nurse (RN-A) confirmed Resident 31's oxygen concentrator's cabinet filter was observed and had a gray fuzzy substance on it In an interview on 02/12/2024 at 1:34 PM, the Assistant Director of Nursing (ADON) confirmed Resident 60's oxygen concentrator was being used by the Resident, and the external cabinet filter had a gray fuzzy substance on it and it should have been cleaned. The ADON confirmed the external cabinet filters should have been cleaned and replaced every Saturday night. E. A record review of the facility's undated Your Continuous Positive Airway Pressure (CPAP)/Bi-Level Unit (machines used to treat sleep apnea) policy revealed the portion of the mask that comes in contact with the skin should have been wiped daily with a cloth to remove skin oils from the mask. A record review of Resident 2's Order Summary Report dated 02/13/2024 did not reveal orders to clean the PAP or supplies. An observation on 02/07/2024 at 9:24 AM revealed Resident 2's PAP mask was laying on the sheets in the bed and had an only film on the mask seal (the part of the mask that comes in contact with the skin). An observation on 02/07/2024 at 1:36 PM revealed Resident 2's PAP mask was draped over the bedside table and there was an oily film on the mask seal. In an interview on 02/07/2024 at 1:36 PM, Resident 2 confirmed the [gender] was wearing the PAP every night, was not sure what it was supposed to be set at, and the staff cleans the mask weekly, but not wiped off daily. An observation on 02/08/2024 at 7:47 AM revealed Resident 2's PAP mask was in the black infection control bag and had an oily film on the mask seal. An observation on 02/12/2024 at 7:16 AM revealed Resident 2's PAP mask was draped over the bedside table and had an oily film on the mask seal. In an interview on 02/08/2024 at 01:27 PM, RN-B confirmed the staff only cleaned the PAP masks weekly on the day shift and it was not completed every day. In an interview on 02/13/2024 at 11:31 AM, the ADON confirmed the staff only cleaned PAP supplies weekly and the mask was not being wiped off daily and should have been per the policy. F. A record review of the facility's undated Your Continuous Positive Airway Pressure (CPAP)/Bi-Level Unit (machines used to treat sleep apnea) policy revealed the portion of the mask that comes in contact with the skin should have been wiped daily with a cloth to remove skin oils from the mask. A record review of Resident 60's Clinical Census dated 02/08/2024 revealed the Resident was admitted to the facility on [DATE]. A record review of Resident 60's Order Summary Report dated 02/08/2024 did not reveal orders to clean the PAP or supplies. An observation on 02/07/2024 at 12:32 PM revealed Resident 60's PAP mask was draped over the bedside table with an oily film on the mask seal. An observation on 02/08/2024 at 7:35 AM revealed Resident 60's PAP mask was draped over the bedside table with an oily film on the mask seal. In an interview on 02/08/2024 at 7:35 AM, Resident 60 confirmed the facility's staff had not cleaned the mask or wiped off the seal since the Resident was admitted . In an interview on 02/08/2024 at 01:27 PM, RN-B confirmed the staff only cleaned the PAP masks weekly on the day shift and it was not completed every day. In an interview on 02/13/2024 at 11:31 AM, the ADON confirmed the staff only cleaned PAP supplies weekly and the mask was not being wiped off daily and should have been per the policy. G. A record review of the facility's undated Your Continuous Positive Airway Pressure (CPAP)/Bi-Level Unit (machines used to treat sleep apnea) policy revealed that the filter maintenance would depend on the model the resident had, and it would be specific to the manufacturer's recommendations. A record review of the undated ResMed AirSense 10 User Guide revealed the air filter should have been checked and replaced at least every 6 months and the air filter was not washable or reusable. https://document.resmed.com/documents/products/machine/airsense-series/user-guide/airsense-10-device-with-humidifier_user-guide_amer_eng.pdf A record review of Resident 2's Order Summary Report dated 02/13/2024 revealed orders of: BiPAP (a machine used to treat sleep apnea) at night with oxygen at 2 liters per minute (l/m) and External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat. A record review of Resident 2's Treatment Administration Record (TAR) dated [DATE], [DATE], and [DATE] revealed the order of: External Filter: Rinse weekly (Saturdays), let dry Replace every evening shift Sat was marked completed every Saturday, and was last marked completed Saturday 02/10/2024. The TAR revealed Resident 2 used the BiPAP every night the resident was at the facility. An observation on 02/07/2024 at 9:24 AM revealed Resident 2's PAP filter had a gray fuzzy substance on it. An observation on 02/07/2024 at 1:36 PM revealed Resident 2's PAP filter had a gray fuzzy substance on it. In an interview on 02/07/2024 at 1:36 PM, Resident 2 confirmed [gender] was wearing the PAP every night, was not sure what it was supposed to be set at and was not sure that the staff had ever changed the filter. An observation on 02/08/2024 at 7:47 AM revealed Resident 2's PAP filter had a gray fuzzy substance on it. An observation on 02/12/2024 at 7:16 AM revealed Resident 2's PAP filter had a gray fuzzy substance on it. In an interview on 02/08/2024 at 01:27 PM, RN-B confirmed the staff were to clean filters and change the tubing weekly, every Saturday night. In an interview on 02/12/2024 at 1:50 PM, the ADON that the ADON observed the PAP filter and it had a gray fuzzy substance on it and that it should have been cleaned and changed, but had not been.

Licensure Reference Number 175 NAC 12.006.05(21) Based on observation, interview, and record review, the facility failed to ensure secretions (a substance discharged from the body) were controlled to maintain the dignity of 1 (Resident 4) of 1 sampled resident. The facility census was 60. Findings are: A record review of Resident 4's Admission Record dated 02/12/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 4's Medical Diagnosis dated 02/12/2024 revealed the resident had diagnoses of Cerebral Palsy, Unspecified (disorders that affect a person's ability to move and maintain balance and posture), Dysphagia, Oropharyngeal Phase (swallowing difficulties due to items get stuck in the back of the mouth), Neonatal Aspiration of Amniotic Fluid and Mucus with Respiratory Symptoms (inhaled fluids during birth), Acquired Deformity of the Chest and Ribs, Other Disorders of the Lung, and Muscle Wasting and Atrophy (loss of muscle tissue). A record review of Resident 4's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/01/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 99 which indicated the resident was unable to complete the interview. The resident was dependent on staff for all activities of daily living including oral and personal hygiene (cleaning). The MDS did not reveal the resident had a suction machine. A record review of Resident 4's Care Plan with an admitted [DATE] revealed the resident had Focus areas of potential risk for infection related to dependance for personal care, tube feeding, swallowing issues/aspiration risk, and potential for complications related to presence of enteral nutrition feeding tube and Dysphasia and an intervention was head of bed elevated at least 30 degrees as tolerated to reduce the risk of aspiration. An observation from the hallway on 02/07/2024 at 9:02 AM revealed Resident 4 was sitting in a wheelchair in the resident's room with a long, thick strand of secretions coming from the Resident's mouth and extended to the Resident's lap and Resident 4 had a weak cough and audible rhonchi (congested sounds heard without a stethoscope). Resident 4 had a towel that covered the chest and abdomen (stomach area) that was held by a cable around the neck with clips on both sides. Resident 4 had a suction machine in the room that did not have the canister or tubing set up on it. An observation from the hallway on 02/07/2024 at 11:21 AM revealed Resident 4 was sitting in a wheelchair at the nurse station with a long, thick strand of secretions coming from the Resident's mouth and extended to the Resident's lap. Resident 4 had a towel that covered the chest and abdomen that was held by a cable around the neck with clips on both sides. Resident 4 had a suction machine in the room that did not have the canister or tubing set up on it. An observation from the hallway on 02/08/2024 at 7:22 AM revealed Resident 4 was sitting in a wheelchair in [gender]'s room with a long, thick strand of secretions coming from Resident 4's mouth and extended to the Resident's lap. Resident 4 had a towel that covered the chest and abdomen that was held by a cable around the neck with clips on both sides. Resident 4 had a suction machine in the room that did not have the canister or tubing set up on it. An observation from the hallway on 02/08/2024 at 11:35 AM revealed Resident 4 was sitting in a wheelchair at the nurse station with a long, thick strand of secretions coming from the Resident's mouth and extended to the Resident's lap. Resident 4 had a towel that covered the chest and abdomen that was held by a cable around the neck with clips on both sides. Resident 4 had a suction machine in the room that did not have the canister or tubing set up on it. An observation from the hallway on 02/12/2024 at 11:21 AM revealed Resident 4 was sitting in a wheelchair at the nurse station with a long, thick strand of secretions coming from the resident's mouth and extended to the resident's lap. Resident 4 had a towel that covered the chest and abdomen that was held by a cable around the neck with clips on both sides. Resident 4 had a suction machine in the room that did not have the canister or tubing set up on it. A record review of Resident 4's Clinical Physician Orders dated 02/12/2024 revealed Resident 4 had an order of: May suction orally as needed (PRN) for secretions every 1 hours as needed. An observation from the hallway on 02/12/2024 at 11:21 AM revealed Resident 4 was sitting in a wheelchair at the nurse station with a long, thick strand of secretions coming from the resident's mouth and extended to the resident's lap. Audible rhonchi could be heard, and Resident 4 had a towel that covered the chest and abdomen that was held by a cable around the neck with clips on both sides. Resident 4 had a suction machine in the room that did not have the canister or tubing set up on it. In an interview on 02/12/2024 at 12:47 PM, Registered Nurse (RN)-A confirmed there were Yankauer oral suction tips (a tool used to suction oropharyngeal secretions to prevent aspiration) in the room, but there was not a suction canister or tubing to make the machine usable. RN-A confirmed Resident 4 had an order to suction orally every hour if needed for secretions, but they do not do that. They only do that when Resident 4 choked during oral care. RN-A confirmed the thick secretions from the mouth to the lap was common for Resident 4 and that was why the staff kept the towel on the Resident. An observation on 02/13/2024 at 8:58 AM of Resident 4's morning cares revealed the resident had a large amount of thick oral secretions the extended to the lap and the resident had a suction machine in the room with the supplies on the bottom shelf and not hooked up to the suction machine. RN-B completed oral cares and wiped the resident's mouth with a towel but did not orally suction the Resident and [gender] still had audible rhonchi. In an interview on 02/13/2024 at 8:58 AM, RN-B confirmed Resident 4 had a large amount of thick oral secretions. RN-B confirmed that was normal for the Resident and the Resident has always just had the towel on the chest and abdomen. The family was aware, and the family provided the towel clips that go around the neck to protect the resident's clothing. RN-B confirmed the suction equipment and supplies were available and needed put together, but the staff only suctioned the Resident when [gender] choked during oral cares. RN-B confirmed that Resident 4 would not refuse oral suctioning while in the Resident's room. In an interview on 02/12/2024 at 4:07 PM, the Assistant Director of Nursing (ADON) confirmed the ADON observed Resident 4 in a wheelchair at the nurse's station with thick secretions from the mouth to the lap. The ADON confirmed that was normal for Resident 4 and the staff did not orally suction unless the Resident was choking. The ADON confirmed it could be a dignity issue, but it was normal for Resident 4. The ADON confirmed the suction equipment was not set up and ready to go if Resident 4 had an emergency or the staff wanted to suction the Resident's secretions. In an interview on 02/13/2024 at 11:37 AM, the Administrator confirmed the excessive thick secretions for Resident 4 was normal for the resident and the staff had not attempted to orally suction the resident throughout the day to see if it would decrease the secretions that escaped from the mouth. The administrator confirmed it could be considered a dignity issue and the facility did not know how the resident actually felt about the excessive secretions and the clothing protector.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility failed to follow standards of practice pertaining to notification of physician and treatment of blood sugars less than (<) 60 for Resident 17. The facility census was 56. Findings are: A. A review of Resident 17's face sheet revealed that Resident 17 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus without complications (a condition that affects the way the body processes blood sugar). A review of Resident 17's current orders, dated 1/5/23, revealed an order to: -Notify MD (Medical Doctor) for blood sugar greater than (>) 450 or <60. A review of Resident 17's blood sugars revealed that Resident 17's blood sugar was <60 on: -5/7/22 at 12:20 PM, blood sugar reading: 59 -7/24/22 at 8:31 AM. blood sugar reading: 57 -8/3/22 at 12:15 PM, blood sugar reading: 58 -12/16/22 at 7:42 AM, blood sugar reading: 59 A review of Resident 17's electronic medical record revealed no notification was provided to the physician on 5/7/22, 7/24/22, 8/3/22 at 12:15 PM, and 12/16/22. A review of the facilities Hypoglycemia/Hyperglycemia (hypoglycemia-low blood sugar, hyperglycemia-high blood sugar) Management plan, dated 2/2018, revealed the following: -All insulin dependent diabetics must have physician ordered blood sugar parameters (high and low) listed on their MAR, as to when the physician needs to be notified. An interview, on 1/5/23 at 1:04 PM, the Director of Nursing (DON) confirmed that the physician should have been notified and was not notified on 5/7/22, 7/24/22, 8/3/22, and 12/16/22 that Resident 17's blood sugars had been <60. B. A review of the facility's Hypoglycemia/Hyperglycemia plan, dated 2/2018, revealed the following: -Please refer to the following documents created by the American Diabetes Association for the assessment and treatment of Hypoglycemia and Hyperglycemia. A review of the American Diabetes Association guide to treatment of hypoglycemia revealed the following: -1. Consume 15-20 grams of glucose or simple carbohydrates; 2. Recheck your blood glucose after 15 minutes; 3. If hypoglycemia continues, repeat; 4. Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two away. A review of Resident 17's electronic medical record revealed that Resident 17 had not been provided 15-20 grams of glucose or simple carbohydrates on 7/24/22, 8/3/22 at 12:15 PM, and 12/16/22. The review further revealed Resident 17's blood sugar had not been rechecked on 5/7/22, 7/24/22, 8/3/22 at 12:15 PM, and 12/16/22. In an interview, on 1/5/23 at 4:16 PM, the DON confirmed that staff should have followed and had not followed the American Diabetes Association guide to treatment of hypoglycemia to treat Resident 17's blood sugars that had been <60 on 5/7/22, 7/24/22, 8/3/22 at 12:15 PM, and 12/16/22.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation and interview, the facility failed to serve meals in a manner that prevents potential food borne illness related to bare hand food contact and bare hand contact with the eating surface of plates and utensils. The facility also failed to maintain the cleanliness of cabinet surfaces and dry storage containers. This had the potential to affect all residents that ate food prepared in the facility kitchen and ate in the 100 hall dining area. The facility identified a census of 71. FINDINGS ARE: A. An observation on 08/25/21 at 12:13 PM during the dining service revealed NA-K (nurse aide) to pick up a sandwich with ungloved hands and hand the sandwich to Resident 64. During the observation on 08/25/21 at 12:13 PM, it was noted that NA-K served a plate with ungloved thumbs touching the eating service of that plate. NA-K had been observed picking up a spoon by the eating service of the spoon and then proceeded to feed a resident with that spoon. An observation of the noon dining service on 08/26/21 at 12:17 PM revealed NA-F served plates with ungloved thumbs on the eating surface of the plate for 3 different residents. The observation revealed a resident had requested silverware which NA-F grabbed by the feeding surface of a fork and knife and then handed to the resident. The observation during the noon dining service on 08/25/21 revealed NA-K did not perform hand hygiene between assisting different residents. The observation during the noon dining service on 08/26/21 revealed NA-F to complete assisting a resident with their meal and then placed a cloth mask on the resident's face without performing hand hygiene. 08/26/21 at 11:00 AM Observation in the kitchen by the stainless steel table with drawers and shelves revealed the outside of the drawers and on top of the shelf had a sticky oily residue over the front and the lower shelf. There was oil, sitting on a tray that had several bottles of oil and butter. The bottles were setting in the oil on the tray. On top of the dry storage for flour and sugar, it was sticky and oily as well. 08/30/21 at 10:50 AM Observation in the kitchen of the stainless steel table with drawers and shelves; continued to reveal the outside of the drawers and on top of the shelf a sticky oily residue over the front and the lower shelf. There was oil, sitting on a tray that had several bottles of oil and butter. The bottles were setting in the oil on the tray. 08/30/21 at 1:10 PM Interview with the administrator, revealed the expectation that these items should be clean and not sticky, and that there should be a cleaning schedule in the dietary department for these items.

Licensure Reference Number 175 NAC 12-006.11D Based on observation and interview, the facility failed to ensure that hot foods were maintained at a palatable temperature. This had the potential to affect 19 residents that ate in the memory care unit dining area. The census was 71. Findings are: On 08/25/21 at 3:15 PM, interview with Resident 30, revealed food was cold some times. On 08/25/21 at 3:45 PM, interview with Resident 57, revealed many times food is cold. On 08/25/21 at 4:00 PM, interview with Resident 65, revealed cold food that the resident couldn't eat. On 08/30/21 at 10:50 AM, observation in the kitchen revealed Cook D took the temperature of the chicken patty at 190, green beans at 188, and potatoes and gravy at 190. On 08/30/21 at 10:55 AM, interview with Cook D revealed the temperatures for the food were within range and hot enough. On 08/30/21 at 1:05 PM, observation in the memory support unit revealed the administrator completed serving trays to the residents. The Administrator made a plate of food and checked the temperature of the food items. The temperature of the chicken patty was 118 degrees, the green beans were 120 degrees and the potatoes and gravy was 126 degrees. On 08/30/21 at 1:10 PM, interview with the Administrator whom was assisting with meals, revealed the temperatures of the meal were cold and not palatable to eat.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.4C3a(6) Based on interview and record review, the facility failed to notify the physician of a change of condition related to elevated blood pressures for 1 resident (Resident 30) of 5 sampled. The facility identified a census of 71. FINDINGS ARE: A record review of the Order Summary for Resident 30, revealed Resident 30 had been receiving the following medications for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] HCl Tablet 20 MG Give 1 tablet by mouth in the afternoon related to ESSENTIAL (PRIMARY) HYPERTENSION after lunch - [MEDICATION(S)] HCl Tablet 40 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION A record review conducted on 08/30/21 of the blood pressures for Resident 30 for the last 60 days revealed blood pressures as follows: 8/30/2021 08:00 182 / 80 mmHg Sitting l/arm 8/29/2021 18:00 148 / 77 mmHg Other 8/29/2021 08:00 133 / 62 mmHg Other 8/28/2021 18:00 154 / 71 mmHg Other 8/28/2021 08:00 144 / 72 mmHg Other 8/28/2021 02:30 170 / 65 mmHg 8/27/2021 10:28 163 / 104 mmHg Sitting r/arm 8/27/2021 07:28 163 / 104 mmHg Sitting r/arm 8/26/2021 20:00 154 / 78 mmHg Sitting l/arm 8/26/2021 08:00 177 / 69 mmHg Sitting l/arm 8/25/2021 20:00 170 / 84 mmHg Other 8/25/2021 08:00 182 / 80 mmHg Sitting l/arm 8/24/2021 18:00 133 / 63 mmHg Other 8/24/2021 09:09 158 / 94 mmHg Sitting r/arm 8/24/2021 09:04 158 / 94 mmHg Sitting r/arm 8/23/2021 18:00 168 / 77 mmHg Other 8/23/2021 07:02 192 / 91 mmHg Sitting l/arm 8/22/2021 18:00 174 / 82 mmHg Other 8/22/2021 08:00 216 / 80 mmHg Sitting l/arm 8/21/2021 18:00 180 / 83 mmHg Other 8/21/2021 08:00 186 / 65 mmHg Sitting l/arm 8/20/2021 07:00 178 / 82 mmHg Other 8/19/2021 21:42 152 / 74 mmHg Sitting r/arm 8/19/2021 08:00 179 / 73 mmHg Other 8/18/2021 20:00 125 / 70 mmHg Sitting l/arm 8/18/2021 07:54 174 / 78 mmHg Sitting l/arm 8/17/2021 08:00 191 / 75 mmHg Sitting l/arm 8/16/2021 08:00 163 / 64 mmHg Sitting l/arm 8/15/2021 10:00 158 / 68 mmHg Sitting r/arm 8/14/2021 20:00 137 / 87 mmHg Standing l/arm 8/14/2021 14:08 132 / 62 mmHg 8/13/2021 08:01 181 / 76 mmHg Sitting l/arm 8/13/2021 08:00 181 / 76 mmHg Sitting l/arm 8/12/2021 10:50 118 / 70 mmHg Sitting r/arm 8/11/2021 08:00 186 / 84 mmHg Sitting l/arm 8/10/2021 08:00 148 / 71 mmHg Other 8/9/2021 12:16 164 / 72 mmHg Sitting l/arm 8/8/2021 10:29 117 / 71 mmHg Sitting r/arm 8/7/2021 10:37 161 / 98 mmHg Sitting r/arm 8/6/2021 07:48 170 / 67 mmHg Sitting l/arm 8/5/2021 20:00 168 / 64 mmHg Sitting l/arm 8/5/2021 08:00 185 / 63 mmHg Sitting l/arm 8/4/2021 08:00 179 / 74 mmHg Sitting l/arm 8/3/2021 15:59 161 / 64 mmHg 8/2/2021 16:23 132 / 92 mmHg Sitting r/arm 8/1/2021 08:00 176 / 69 mmHg Sitting l/arm 7/31/2021 08:00 161 / 69 mmHg Sitting l/arm 7/30/2021 07:15 159 / 97 mmHg Sitting r/arm 7/29/2021 16:12 149 / 64 mmHg 7/28/2021 20:00 159 / 84 mmHg Sitting l/arm 7/28/2021 08:00 169 / 80 mmHg Sitting l/arm 7/27/2021 08:00 173 / 67 mmHg Other 7/26/2021 07:34 184 / 74 mmHg Sitting l/arm 7/25/2021 08:00 172 / 68 mmHg Other 7/24/2021 08:00 144 / 60 mmHg Other 7/23/2021 11:46 145 / 60 mmHg Sitting r/arm 7/22/2021 22:51 154 / 84 mmHg Sitting l/arm 7/22/2021 07:10 166 / 78 mmHg Sitting l/arm 7/21/2021 07:40 162 / 74 mmHg Sitting r/arm 7/20/2021 20:00 136 / 66 mmHg Sitting l/arm 7/20/2021 08:32 171 / 63 mmHg 7/19/2021 13:00 172 / 66 mmHg Other 7/18/2021 06:26 170 / 68 mmHg 7/17/2021 09:26 137 / 54 mmHg 7/16/2021 20:00 120 / 64 mmHg Sitting l/arm 7/16/2021 07:34 173 / 69 mmHg Sitting l/arm 7/15/2021 20:00 130 / 68 mmHg Sitting l/arm 7/14/2021 07:08 165 / 70 mmHg 7/13/2021 10:18 143 / 81 mmHg Sitting r/arm 7/12/2021 08:31 125 / 76 mmHg Sitting l/arm 7/11/2021 18:00 120 / 64 mmHg Other 7/10/2021 18:00 143 / 62 mmHg Other 7/10/2021 07:03 172 / 72 mmHg Sitting r/arm 7/9/2021 18:00 140 / 55 mmHg Other 7/9/2021 07:25 154 / 75 mmHg Sitting l/arm 7/8/2021 23:08 148 / 90 mmHg Sitting r/arm 7/8/2021 10:39 168 / 104 mmHg Sitting r/arm 7/7/2021 20:00 148 / 62 mmHg Lying l/arm 7/7/2021 07:22 187 / 63 mmHg Sitting l/arm 7/6/2021 18:56 140 / 60 mmHg Sitting r/arm 7/6/2021 07:00 140 / 62 mmHg 7/5/2021 19:30 150 / 54 mmHg Sitting r/arm 7/5/2021 06:30 170 / 74 mmHg Sitting r/arm 7/5/2021 05:30 152 / 64 mmHg Lying r/arm 7/4/2021 14:44 158 / 71 mmHg 7/3/2021 20:00 138 / 72 mmHg Sitting l/arm 7/3/2021 08:00 141 / 67 mmHg Sitting r/arm 7/2/2021 21:03 114 / 69 mmHg Sitting r/arm 7/2/2021 09:31 140 / 78 mmHg Sitting r/arm 7/2/2021 07:18 163 / 74 mmHg Sitting r/arm 7/1/2021 07:58 146 / 86 mmHg Sitting r/arm A record review of the listed blood pressures for the last 60 days revealed elevated blood pressures on 07/08/21 and twice on 08/27/21. A record review of the Progress Notes dated 07/07/21 through 08/30/21 revealed that on 07/08/21 Resident 30 had displayed lethargy and low oxygen saturation levels along with a blood pressure reading of 168/104. The record review revealed a fax had been sent to the physician regarding the oxygen levels but no mention or follow up related to the elevated blood pressure. A record review of the Progress Notes dated 07/07/21 through 08/30/21 revealed that on 08/27/21 a blood pressure of 163/104 had been obtained at 06:00 AM with no physician notification. A record review of the Progress Notes dated 07/07/21 through 08/30/21 revealed that on 08/27/21 the blood pressure for Resident 30 remained at a reading of 163/104 at 10:28 AM with no physician notification or follow up assessment. An interview on 8/31/21 at 10:08 AM with the DON (Director of Nursing) confirmed physician notification had not occurred with the elevated blood pressures for Resident 30. During the interview with the DON, the DON reported (gender) planned to review the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 8/31/21 at 12:50 PM with Licensed Practical Nurse[LPN]-J, confirmed no awareness of the facility policy related to when to report abnormal vital signs, voicing I would need to check on what the policy says. During the interview, after review of blood pressures documented by LPN-J, LPN-J that the resident's blood pressure should have been rechecked.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1b Based on observation, record review and interview, the facility failed to provide encouragement and cueing related to eating for Resident 25. The sample size was 23. The facility identified a census of 71. FINDINGS ARE: An observation of noon dining on the 100 hall on 08/25/21 at 12:06 PM revealed Resident 25 had been sleeping at the table with food present in front of the resident. Observation at 12:15 PM of Resident 25 revealed the resident had been aroused and encouraged to eat by tablemate not by the staff present in the dining room. An observation during the noon meal service on 08/26/21 at 12:32 PM revealed Resident 25 sleeping at the table with the meal present in front of (gender). The observation revealed Resident 25 had been aroused and encouraged to eat by the tablemate and not by the staff. The observation revealed no food had been consumed by Resident 25 other than dessert. During the observation it had been noted that NA-F (nurse aide) had stopped assisting another resident and approached Resident 25 questioning if (gender) was ready to return to (gender) room. The observation revealed NA-F had not encouraged Resident 25 to eat more nor offered substitute foods prior to (gender) leaving the dining room. Observation on 08/26/21 at 12:32 PM revealed that while in the dining room, no staff member encouraged Resident 25 to eat nor offered substitute foods when seeing the resident's poor oral intake. A record review conducted on 08/26/21 of the weights for Resident 25 revealed a weight loss of 5 pounds (2.2%) in the last 3 weeks. An interview conducted on 08/26/21 at 03:15 PM with the ADON (Assistant Director of Nursing) after review of the weight list for Resident 25 revealed that Resident 25 had not triggered for a weight loss thus far due to the timing being only 3 weeks at this point and not 4.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on interview and record review, the facility failed to develop and implement a Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) related to Hypertension (also known as high or raised blood pressure) for Resident 30. The sample size was 35. The facility identified a census of 71. FINDINGS ARE: A record review of the admission demographic information for Resident 30 revealed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the undated CCP for Resident 30 revealed no problem/goal/interventions related to essential hypertension. An interview on 8/31/21 at 10:08 AM with the DON (Director of Nursing) confirmed the CCP for Resident 30 did not contain the problem related to Hypertension.

Based on record review and interview, the facility failed to ensure a new PASRR (Pre-Admission Screening and Resident Review) review had been completed after a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The total sample size was 35 and the facility census was 71. Findings are: A. Review of Resident 34's Admission PASRR was completed on 9/5/17 as a level 1 and had come with the resident from a different facility. The rationale documented on the level 1 screen determined that Resident 34 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Gender] had no indication for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A negative screen was approved. Should there be an exacerbation related to mental illness or a discrepancy in the reported information, a status change should be submitted to Ascend for further evaluation. Record review of Resident 34's Admission Face Sheet printed on 8/31/21 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 34 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 34's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was ordered to start on 9/17/20. Record review of Resident 34's admission Minimum Data Set [MDS: a federally mandated comprehensive assessment tool used for care planning] dated 5/7/19 section A1500 for PASRR was marked 0 for no which revealed that Resident 34 was not considered by the State level 2 PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS identified Resident 34 to have current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident 34's most recent annual MDS dated [DATE] section A1500 for PASRR was marked 0 for no which revealed that Resident 34 was not considered by the State level 2 PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS identified Resident 34 to have current Psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 34's Electronic Medical Record revealed that a new PASRR had not been completed since admission on 5/1/19. The resident received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/30/21 at 2:56 PM with the facility Social Services Designee confirmed that Resident 34 had received a new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Licensure reference number 175 NAC 12-006.09D4 Based on observation, record review and interview; the facility failed to provide restorative services (exercise programs designed to prevent decline in mobility) in order to prevent a physical decline for 2 residents (Residents 36 and 34) and to prevent an increase in discomfort for 1 non mobile resident (Resident 32). The facility census was 73. Findings are: A. An observation on 05/29/18 at 03:23 PM, revealed Resident 36 seated in an electric wheelchair. Both feet were contracted (decrease in range of motion) and the resident had a left hand splint in place. Record review revealed a Restorative Care Plan initiated on 8/11/17. The Goal was to have no decline in condition with a review date of 6/27/18. Restorative referral program note for mobility exercises revealed the resident was to have Upper Extremity activity x 20 minutes and Upper Body dress MODA, Lower Body dress dependent, Transfers EZ stand. Joint restrictions. This was signed by OTR/L but not dated . Physician order [REDACTED]. Interview on 05/31/18 at 01:12 PM with Restorative Aide (RA) - I, revealed the RA was unable to do restorative related to being assigned to bathe residents. Interview on 06/04/18 at 12:08 PM with the DON (Director of Nursing) and the Administrator confirmed that there was a lack of staffing regarding restorative. Interview on 06/04/06/04/18 at 03:18 PM with Therapy Staff Member F confirmed that the resident had a decline in condition. There was a new contracture to Resident 36's neck related to not doing stretches in Restorative. There was a decline in condition to the lower extremities related to not wearing the braces and the hand contracture was worse. Resident 36 was currently on Therapy case load related to the decline in condition . B. An observation on 05/29/18 at 1:33 PM, revealed Resident 34 seated in a recliner in the resident's room with their feet elevated. A pillow was positioned behind the resident's head, and appeared to be forcing the head forward. An observation on 05/30/18 at 10:12 AM revealed Resident 34 seated in a soft chair in the resident's room. The resident's neck was noted to be in what appeared to be a chronically flexed position with their head forward facing downward. A review of the MDS (a mandatory comprehensive assessment tool used for care planning) assessments for Resident 34, dated 1/3/18 and 3/30/18 indicated the resident required extensive assistance for transfers, bed mobility, dressing, toileting, and personal hygiene. Minimal assistance was needed for ambulation (walking) and eating. The assessments indicated no changes in functional ability. A review of an undated Care Plan, for Resident 34, revealed the resident was admitted to the facility on [DATE]. The care plan included no documentation related to the resident's stooped posture or contracted neck. An intervention indicating Restorative program as indicated was initiated on 8/1/17, related to a Focus of history and/or has a potential for falls also initiated on 8/1/17. A review of a PHYSICIAN VISIT/COMMUNICATION FORM dated 5/22/18, revealed an order for [REDACTED]. An interview on 6/5/18 at 11:30 AM with Occupational Therapist (OT)-N revealed Resident 34 had been on therapy service 2/7/18-4/3/18 related to the resident's abnormal posture and contracted neck. The OT reported a functional maintenance (restorative exercise) program had been put into place and included pictures of recommended techniques for positioning management to be implemented when the resident was lying down. The OT went on to say that Resident 34's spouse was requesting therapy again as the Resident's functioning ability had decreased related to posture and neck positioning. A review of Resident 34's electronic medical record revealed no documented evidence the facility implemented a functional maintenance or restorative exercise program. On 06/05/18 at 11:04 AM, an interview with the DON (Director of Nurses) revealed the therapy recommendations for neck stretching and positioning for Resident 34, had not been implemented prior to receipt of new therapy orders on 5/22/18. C. An observation of morning cares on 5/31/17 at 7:25 AM, for Resident 32, revealed the resident was dependent upon staff for repositioning, transfers, dressing, toileting, and grooming. Resident 32 was able to feed self with set up and minimal assistance. A tilt in space (mechanisms to allow repositioning) type wheelchair was used for positioning and mobility. A review of an undated care plan for Resident 32 revealed the resident was admitted to the facility on [DATE]. A focus, initiated on 4/8/17, indicated the resident had a potential for alteration in comfort related to [MEDICAL CONDITION] (a disease with symptoms including muscle rigidity, tremors, and changes in speech and gait), dementia, decreased mobility, and depression. Documented interventions for the focus did not include restorative or range of motion (The full movement potential of a joint, usually its range of flexion and extension) exercises to prevent further decline in mobility. A focus, initiated on 4/7/17 and revised 1/7/18, indicated Resident 32 had a History and/or had a potential for falls related to: Confusion, Impaired gait/balance, Impaired vision/hearing, Incontinence, Medications, Poor communication/comprehension, and unaware of safety needs. An intervention, initiated on 4/7/17, documented Restorative program as indicated. The intervention had not been revised and did not indicate need related to the resident's decreased mobility. An interview on 06/04/18 at 12:08 PM, with the DON and Administrator revealed the facility had identified that there was a lack of staff scheduled to complete Restorative Programs as recommended. The DON confirmed Resident 32 had not been receiving Restorative Services for range of motion exercises.

Lincensure Reference Number: 175 NAC 12-006.09D2a; 175 NAC12-006.09D2b Based on Observation, Interview and Record review; the facility failed to identify causal factors and implement interventions to prevent a pressure sore from occurring for 1 resident. (Resident 4) and failed to implement interventions to facilitate wound healing and prevent the potential for reoccurrence for 2 residents (Resident 3 and 4) Sample size was 15 plus 8 non sampled residents. The facility census was 59. Findings are: A. Review of Resident 4's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 7/12/09 revealed Resident 4 had full loss of Range of Motion (the ability to move a joint) of hands and fingers and no pressure sores present. Review of facility policy titled Skin and Wound Management Standard dated 8/2009 revealed "A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing." The policy defined Avoidable as "the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate." Review of Interdisciplinary Progress Notes for Resident 4 revealed that on 9/20/09, the nurses' noted that the resident's right hand "between fingers, tip of thumb and palm irritated, raw, red." and had a "foul odor". Review of Resident 4's Medical Record revealed no Pressure Ulcer Record for September 09. Review of Occupational Therapy Daily Encounter Note for Resident 4 dated 9/29/09 revealed the resident was fitted with and staff instructed to put palm protector in right hand "to prevent skin to skin contact". Review of Resident 4's Interdisciplinary Progress Notes revealed the area was healed. However, the interdisciplinary progress note on 10/8/09 revealed "Hand still red c (with) open areas". Review of Pressure Ulcer Record for Resident 4 dated 10/13/09 revealed a Stage 2 Pressure Ulcer (partial thickness skin loss caused by pressure) measuring 1.2 cm (centimeters) by 1.0 cm with bright red surrounding skin color. Review of Pressure Ulcer Record for Resident 4 dated 10/16/09 revealed Resident 4 was discontinued from occupational therapy secondary to pressure ulcers resolving with use of palm guard. Review of Resident 4's Pressure Ulcer Record dated 10/23/09 revealed a Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle) measuring 1.7cm by .8 cm with an odor. Review of Resident 4's care plan revealed the problems statement dated 10/31/2008 of Potential for skin breakdown with the following interventions: Carrot (a device designed to gently and gradually alleviate contractures in the fingers and hand) or wash cloth to R (right) hand at all times. Palm protector to L (left) hand at all times for prevention. However, there was no mention of palm protector to right hand as recommended by the Occupational Therapist. Review of Resident 4's current care plan last updated on 7/15/10 revealed no problem statement regarding risk for skin breakdown and no interventions to prevent the reoccurrence of a pressure area. Observations of Resident 4 on 8/2/10 at 11:30 a.m. revealed that the Carrot was partially in the resident's right hand allowing skin to skin contact and pressure. No palm guard was observed in either hand. Interview on 8/2/10 at 11:40 a.m. with Nursing Assistant (NA)-B during restorative Passive Range of Motion (PROM-exercises done for a person that help keep joints and muscles as healthy as possible) exercises revealed that the resident frequently did not keep the carrot in place. Observations of Resident 4 on 8/3/10 at 10:30 a.m. revealed that the Carrot was partially in Residents right hand allowing skin to skin contact and pressure. No palm guard was observed in either hand. Interview with ADON (Assistant Director of Nursing) on 8/3/10 at 10:30 a.m. revealed that the only padding used for Resident 4's right hand was the carrot. Review of Resident 4's Pressure Ulcer Record dated 12/23/09 revealed "Pressure area is from where 1st finger of R) (right) hand lays on knuckle" the site was defined as the 3rd finger knuckle of the right hand. The area was assessed as a Stage 2 (partial thickness skin loss caused by pressure). The record revealed that the pressure sore was healed on 12/28/09. Review of Resident 4's Pressure Ulcer Record dated 12/23/09 revealed "Pressure area is from where 1st finger of R) (right) hand lays on knuckle." The site was defined as the 4th finger knuckle of the right hand. The area was assessed as a Stage 2 (partial thickness skin loss caused by pressure). The record revealed that the pressure sore was healed on 12/28/09. Review of physician orders [REDACTED]." Observation of Resident 4 during restorative exercises on 8/2/10 at 11:30 a.m. revealed that Resident 4's first finger of the right hand lays tightly over the second finger of the right hand with no padding in place. Observations of Resident 4 on 8/3/10 at 10:30 a.m. revealed no padding between Resident 4's first and second fingers of the right hand as ordered. Interview with ADON on 8/3/10 at 11:30 a.m. revealed that the only padding used for Resident 4's right hand was the carrot. B. Review of Resident 3's Care Plan revealed an updated incontinence problem on 7/26/10 of, "3 stage 2 open areas to coccyx." Under approaches was..."turning schedule,...., last up and first down, ..." The Care Plan also revealed an updated nutrition problem on 7/26/10 stating, "9.9 lbs 6.5% weight loss in 30 days." Under approaches was..."Beneprotien" (A concentrated source of protein that can be mixed with foods and beverages and aides in wound healing..) Observation was made on 8/3/10 at 8:30 AM of Resident 3 eating breakfast. Resident 3's red juice had a clouded appearance with pieces of a white substance in it. Nursing Assistant K who was assisting Resident 3 to eat was asked what was in the juice and responded that it was Beneprotien. Observations were made of Resident 3's meals on 7/28/10 at 11:55 AM, 7/29/10 at 9:10 AM and 12:55 PM, and 8/2/10 at 8:20 AM. At all of these observations thickened juice was served to Resident 3 but no supplement (Beneprotien) had been added. On 8/3/10 at 1:15 PM when asked if the Beneprotien had been missed at those meals Cook H stated, "Probably." Review of the facility's SKIN AND WOUND MANAGEMENT STANDARD dated 8/09 on page 806 item 3. "Repositioning. Residents should be repositioned at least every two hours while in bed. Residents should be repositioned every hour while up in a chair........Lay resident down as appropriate between meals and cue staff to position resident off their back with naps and rest periods....." During the initial tour of the facility on 7/28/10 at 9:30 AM LPN L stated that Resident 3 was to be the last up for meals and the first down after meals because of skin breakdown on Resident 3's coccyx. Observation was made on 7/28/10 at 11:50 AM of Resident 3 seated at the dining room table while other residents were still being escorted to the meal. At 2:05 PM, Resident 3 was observed in a chair at a table in the main common area. Resident 3 was observed in the same position in the same area at 2:20 PM. At 2:50 PM Resident 3 was in bed positioned on the left side. On 8/2/10 Resident 3 was observed laying on back in bed at 3:10 PM, 3:52 PM and at 4:00 PM. At 4:00 PM the Director of Nursing (DON) confirmed that Resident 3 should be positioned from side to side and would "tell the girls to position Resident 3 on (gender) side."